Epilepsy

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Epilepsy

  1. 1. Epilepsy Dr. Osman Sadig Bukhari
  2. 2. <ul><li>- Epileptic seizures are manifestations of abnormal synchronous cerebral discharge. </li></ul><ul><li>- Epilepsy is the liability to recurrent seizures </li></ul>
  3. 3. <ul><li>Pathophysiology </li></ul><ul><li>1- Inhibitory neurotransmitters e.g GABA prohibit spontaneous cerebral discharges. Reduction in this inhibitory system excites the </li></ul><ul><li>genesis of seizure activity. </li></ul><ul><li>2- Excitatory neurotransmitters also exist e.g Ach, glutamic acid & aspartate. </li></ul>
  4. 4. <ul><li>Classification of epilepsy </li></ul><ul><li>Epilepsy is classified according to the clinical pattern into: </li></ul><ul><li>1- generalized epilepsy </li></ul><ul><li>2- partial or focal seizures </li></ul>
  5. 5. <ul><li>1- Generalized epilepsy There is wide spread abnormal electrical brain discharge with loss of consciousness </li></ul><ul><li>- Tonic- clonic seizure (grand mal) </li></ul><ul><li>- Petit mal seizure (absence seizu) </li></ul><ul><li>- Myoclonic seizures </li></ul><ul><li>- Akinetic or atonic seizures </li></ul><ul><li>- Tonic seizures. </li></ul>
  6. 6. <ul><li>2- Partial or focal seizures seizure activity is localized to a part of one hemisphere. - Focal motor seizures originating in the motor cortex </li></ul><ul><li>- Focal sensory seizures originating in the sensory cortex </li></ul><ul><li>- Psychomotor seizures originating in the </li></ul><ul><li>medial temporal lobes (temporal lobe epilepsy) </li></ul><ul><li>- Visual seizures originating in the occipit </li></ul><ul><li>lobes. </li></ul>
  7. 7. <ul><li>* simple partial seizures describes seizures </li></ul><ul><li>without loss of consciousness </li></ul><ul><li>* complex partial seizures describes partial seizures seizures when the pat become unaware * Partial seizures may be secondarily generalized </li></ul>
  8. 8. <ul><li>Generalized seizures </li></ul><ul><li>- Most common </li></ul><ul><li>- Generalized from onset or secondarily generalized indicating the focal origin of the seizure & hence most likely structural brain damage (accompanying </li></ul><ul><li>aura) </li></ul>
  9. 9. <ul><li>1-Tonic- clonic seizures (grand mal) </li></ul><ul><li>- Prodromal phase with irritability or unease hours to days before za seizures </li></ul><ul><li>- Aura indicate za focal origin of za seizure </li></ul><ul><li>(hallucinations, limb jerking, deja- vu) - Tonic phase : due to very rapid motor cortical discharge accompanied by a cry, fall, loss of consciousness, cyanosis and incontinence of urine & rarely faeces lasting few seconds. </li></ul>
  10. 10. <ul><li>- Clonic phase : due to less rapid and gradual slowing of discharge with violent jerking of all limbs accompanied by frothing, tongue biting & incontinence lasting 1-5 minutes. </li></ul><ul><li>- Post ictal phase : seizures are self limitting leaving za pat confused, drowsy or unconscious with flaccid limbs & jaw, extensor planter, HA, abn behavior for minutes to hours </li></ul>
  11. 11. <ul><li>2- Typical absence seizure (Petit mal) </li></ul><ul><li>- usually in childhood </li></ul><ul><li>- invariably benign </li></ul><ul><li>- the child ceases activity, stares & fails to </li></ul><ul><li>respond to commands </li></ul><ul><li>- accompanied by 3/sec spike & wave EEG. </li></ul><ul><li>- attacks last a matter of seconds, but many may occur each day - few muscles may twitch but rarely the child falls </li></ul>
  12. 12. <ul><li>- always idiopathic & not due to acquired lesions </li></ul><ul><li>- may progress to grand mal later in life. </li></ul><ul><li>- atypical absence attacks may be caused by partial seizure of temp origin without 3/ sec EEG pattern. </li></ul>
  13. 13. <ul><li>3- Myoclonic seizures </li></ul><ul><li>jerky muscle movements </li></ul><ul><li>4- Akinetic or atonic seizures </li></ul><ul><li>- seizures with sudden loss of tone, </li></ul><ul><li>and loss of consc & fall (drop attacks) </li></ul><ul><li>5- tonic seizures </li></ul><ul><li>- stiffness without following jerking </li></ul><ul><li>movements. </li></ul>
  14. 14. <ul><li>Partial seizures </li></ul><ul><li>- It arise focally & may spread </li></ul><ul><li>- the nature of za seizure depends on the </li></ul><ul><li>cortical area affected (site of origin of seizure) </li></ul><ul><li>- accompanied by an aura which is a warning for an impending seizure e.g hallucinations, limb jerking or tingling, abnormal behaviour </li></ul>
  15. 15. <ul><li>1- Focal motor seizures </li></ul><ul><li>- originate in za motor cortex </li></ul><ul><li>- causes localized twitching </li></ul><ul><li>- usually starts at za angle of za mouth or in za thumb or index finger spreading to involve za whole limb (Jaksonian) which may be temporarily paralyzed (Todd’s paralysis - Versive seizures wz conjugate gaze deviation away from za site of lesion implies frontal epileptic </li></ul>
  16. 16. <ul><li>focus & may become secondarily generalized. </li></ul><ul><li>2- Focal sensory seizures </li></ul><ul><li>- originate in za sensory cortex causing focal sensory symptoms </li></ul><ul><li>- manifested as tingling & electric sensation in the contra lateral side. Sensory jaksoni seizure may follow. </li></ul>
  17. 17. <ul><li>3 - Psychomotor seizures </li></ul><ul><li>- Also called temporal lobe seizures </li></ul><ul><li>- arise from za medial temporal lobe </li></ul><ul><li>- manifest as alteration of mood, memory and perception </li></ul><ul><li>- it may remain partial or secondarily </li></ul><ul><li>generalized to tonic- clonic seizure. - simple seizures may be accompanied by Deja- vu (unde familiarity) or Jamais- vu (unreality), complex hallucinations </li></ul>
  18. 18. <ul><li>of sounds, smell, taste or vision, emotional changes and visceral sensation (epigastric pain and nausea). - Complex partial seizures may be </li></ul><ul><li>preceded by aura lasting sec or minutes followed by impairment of awareness for several min when za pat may stare, unresponsive to questions with automatism (lip </li></ul>
  19. 19. <ul><li>smaking, swallowing). </li></ul><ul><li>Tonic- clonic seizures may follow. </li></ul><ul><li>4- Visual seizures </li></ul><ul><li>- originate in za visual cortex </li></ul><ul><li>- manifest as simple visual hallucinations </li></ul><ul><li>or formed visual hallucinations which arises anteriorly in the temporal lobe </li></ul>
  20. 20. <ul><li>Aetiology of epilepsy </li></ul><ul><li>1- idiopathic in generalized seizures with FH in 40% </li></ul><ul><li>2- Metabolic: </li></ul><ul><li>- hypoglycemia - hyperglycemia </li></ul><ul><li>- porphyria - hypoCa - hypoNa - renal failure - hepatic failure. </li></ul>
  21. 21. <ul><li>3- drugs & toxins: - alcohol abuse & withdrawal - tricyclic AD - MAOs - cocaine - phenothiazines - benzodiazepine withdrawal 4- Structural brain disease: </li></ul><ul><li>- cerebral trauma (birth trauma, RTA, surgery </li></ul><ul><li>- vascular (stroke, AV malformation) </li></ul>
  22. 22. <ul><li>- cerebral tumours </li></ul><ul><li>- intracranial infections ( meningitis, encephalitis, cerebral abscess, Tb, HIV, cystocercosis) </li></ul><ul><li>- cerebral inflammation (MS, SLE, sarcoidosis) </li></ul>
  23. 23. <ul><li>Factors triggering seizures </li></ul><ul><li>1- sleep deprivation </li></ul><ul><li>2- emotional stress </li></ul><ul><li>3- physical & mental exhaustion </li></ul><ul><li>4- pyrexia & infections </li></ul><ul><li>5- drugs & alcohol withdrawal </li></ul><ul><li>6- withdrawal of anti convulsants </li></ul><ul><li>7- flickering lights & TV screen </li></ul><ul><li>8- rarely loud noises, hot bathes, music and reading. </li></ul>
  24. 24. <ul><li>Diagnosis of epilepsy </li></ul><ul><li>1- history from the pat and/or a reliable eye witness documenting seizures and characterizing its type & time of onset is the most important </li></ul><ul><li>- recognition of a precipitating cause </li></ul><ul><li>- FH of epilepsy </li></ul><ul><li>- tongue biting, frothing, urine incontinence </li></ul><ul><li>cyanosis, loss of consc </li></ul><ul><li>- post ictal symptoms </li></ul>
  25. 25. <ul><li>2- general medical ex (epiloia, bruits over neck & skull, paresis, traum </li></ul><ul><li>3- CBC & ESR, blood urea & E, B sugar, ser Ca, LFT, serology for syphilis & HIV, </li></ul><ul><li>4- CXR, skull XR, ECG </li></ul><ul><li>5- EEG: routine & 24hr ambulatory. Always abnormal during a seizures. Normal inter ictal EEG does not exclude epilepsy </li></ul>
  26. 26. <ul><li>6- CT & MRI brain sp in: </li></ul><ul><li>- late onset seizures (after 20) </li></ul><ul><li>- focal epilepsy at any age </li></ul><ul><li>- if EEG shows focal seizure source </li></ul><ul><li>- if control of seizures is difficult </li></ul><ul><li>* Immaging is not indicated in tonic- clonic </li></ul><ul><li>seizures wz FH & wzout aura & in typical petit mal wz classical EEG. </li></ul>
  27. 27. <ul><li>D. diagnosis of generalized seizures </li></ul><ul><li>- Epilepsy - syncope </li></ul><ul><li>- cardiac dysrrhythmias </li></ul><ul><li>- hypoglycemia </li></ul><ul><li>- migraine </li></ul><ul><li>- TIAs </li></ul><ul><li>- brain stem ischemia </li></ul><ul><li>- sleep walking </li></ul><ul><li>- pseudo seizures (hysterical) </li></ul>
  28. 28. <ul><li>Management of epilepsy </li></ul><ul><li>1- General </li></ul><ul><li>- Explain za nature of za disease & dispel any misconceptions </li></ul><ul><li>- advice to comply wz TR, avoid precipitating events and accept restrictions (fire, water, working machinery and work above ground level) - uncontrolled epileptics should not drive </li></ul>
  29. 29. <ul><li>Or operate machinery unless well controlled for 3yrs or seizures only nocturnal for 3yrs. 2- Immediate care of seizures </li></ul><ul><li>- Move za pat away from danger sites. </li></ul><ul><li>- Ensure airway & suitable positioning after seizure </li></ul><ul><li>- prevent tongue biting </li></ul><ul><li>- Call for medical help if there is recurrent seizure or if it continue for > 5minutes </li></ul><ul><li>- High conc. of oxygen if seizure is prolonged </li></ul>
  30. 30. <ul><li>3 - Anticonvulsant therapy </li></ul><ul><li>- TR with anticonvulsants is required in all pats except those with seizures that can be avoided (photogenic, alcohol withdrawal) and not usually indicated from za 1 st seizure or infrequent seizures </li></ul><ul><li>- Definitely indicated after za 2 nd seizure and after a single unprovoked seizure in pats with strong FH & very abnormal EEG. </li></ul>
  31. 31. <ul><li>- May be given prophylactically after head injury and following brain surgery </li></ul><ul><li>- Anticonvulsants stabilize neuronal cell membrane inhibiting neuronal discharge and spread by enhancing the activity of inhibitory N/Ts (GABA) and inhibiting excitatory N/Ts. </li></ul><ul><li>- Use simple regimens to ensure compliance </li></ul>
  32. 32. <ul><li>- Begin anticonvulsants with a single drug and gradually build up the dose to therapeutic response or to max tolerated dose </li></ul><ul><li>- Monotherapy controls seizures in 80% </li></ul><ul><li>- If monotherapy is not effective change to </li></ul><ul><li>another drug of diff group & gradually </li></ul><ul><li>withdraw the 1 st drug. </li></ul><ul><li>- Combination therapy is needed in some </li></ul>
  33. 33. <ul><li>- Dose adjusted to achieve max effect at times when seizures liable to occur. </li></ul><ul><li>- Note drug interactions wz hepatic enzyme </li></ul><ul><li>inducing anticonvulsants & OCP, anti coagulant </li></ul><ul><li>- Treat if there is underlying pathology </li></ul><ul><li>- Pats should keep a diary of seizures . </li></ul><ul><li>- Withdrawal of anticonvulsants may be </li></ul><ul><li>considered after 3 years free of seizures andshould be gradual. </li></ul>
  34. 34. <ul><li>Anticonvulsants </li></ul><ul><li>1 st line drugs </li></ul><ul><li>- phenytoin - carbamazepine (oxycarbazepine) - sod valporate - clonazepam </li></ul><ul><li>- phenobarbitone - primidone - ethosuximide </li></ul>
  35. 35. <ul><li>2 nd line drugs </li></ul><ul><li>- lamotrigine </li></ul><ul><li>- gabapentin - vigabantin </li></ul><ul><li>- topiramate </li></ul><ul><li>- felbamate </li></ul><ul><li>- levetriacetam </li></ul><ul><li>- tigabine </li></ul>
  36. 36. <ul><li>Guidelines for selection of anticonvulsants </li></ul><ul><li>seizure type drug preference order </li></ul><ul><li>Pry tonic- clonic valporate , carbamazepine </li></ul><ul><li>phenytoin, barbiturates </li></ul><ul><li>2ry tonic- clonic carbamazepine , phenytoin </li></ul><ul><li>valporate, barbit, lamotrigine </li></ul><ul><li>partial seizures carbamazepine , phenytoin </li></ul><ul><li>valporate, clonazepam, lamotri </li></ul><ul><li>typical absences ethosuximide , valporate </li></ul><ul><li>myoclonic/ valporate , clonazepam </li></ul><ul><li>akinetic </li></ul>
  37. 37. <ul><li>* phenytoin is membrane stabilizer & 90% </li></ul><ul><li>albumin bound </li></ul><ul><li>* sod valporate inhibits GABA transaminase </li></ul><ul><li>and 90% albumin bound </li></ul><ul><li>* phenytoin, carbamazepine & barbiturates are </li></ul><ul><li>hepatic enzyme inducers </li></ul><ul><li>* 2 nd line drugs are effective for partial or </li></ul><ul><li>secondarily generalized seizures </li></ul><ul><li>* surgery for refractory partial seizures e.g </li></ul><ul><li>resection of the ant. part of non dominent temporal lobe abolishes temporal lobe epilepsy in 60% </li></ul>
  38. 38. <ul><li>Individual anticonvulsants </li></ul><ul><li>Phenytoin </li></ul><ul><li>- 50 & 100mg formulations </li></ul><ul><li>- adult daily dose 200- 400mg, usually single dos </li></ul><ul><li>- SE= gum hypertrophy, hirsutism, acne, facial coarsening, cerebellar syndr, sedation, megaloblastic anaemia, fever, skin rash, SLE, L. adenopathy, dyskinesias, periph N, </li></ul><ul><li>osteomalacia </li></ul>
  39. 39. <ul><li>- other uses= trigeminal and glossopharyngeal N, </li></ul><ul><li>lightening pain of T. dorsalis, arrhythmias, painful N in DM, herpes, MS, D. myotonica </li></ul>
  40. 40. <ul><li>Carbamazepine </li></ul><ul><li>- tabs of 200mg </li></ul><ul><li>- adult daily dose= 200- 1200mg in 2-3 doses </li></ul><ul><li>SE= cerebellar syndr, sedation and confusion, diplopia, hepatotoxicity, hypoatremia, rash blood dyscrasias </li></ul><ul><li>- other uses= painful N including DM, herpes and trigeminal neuralgia and in psychiatry. </li></ul>
  41. 41. <ul><li>Sodium valporate </li></ul><ul><li>- tabs of 200 & 500mg </li></ul><ul><li>- adult dose= 400- 1200mg in divided doses </li></ul><ul><li>- SE= GIT, drowsiness, hepatic toxicity, Wt gain tremors, thrombocytopenia, alopecia. </li></ul>
  42. 42. <ul><li>Barbiturates </li></ul><ul><li>- includes phenobarbitone and primidone </li></ul><ul><li>- now less commonly used, but cheaper and used for all types of epilepsy except petit mal </li></ul><ul><li>- SE= sedation, drowsiness, cerebellar syndrome, dependence, rash, hyperactivity </li></ul>
  43. 43. <ul><li>Clonazepam </li></ul><ul><li>- tabs of 1, 2mg </li></ul><ul><li>- adult daily dose= 1-6mg in divided doses for all types of epileps </li></ul><ul><li>- SE= drowsiness, irritability, behaviour changes, ataxia </li></ul>
  44. 44. <ul><li>Ethosuximide </li></ul><ul><li>- tabs of 250mg </li></ul><ul><li>- only for petit mal </li></ul><ul><li>- daily dose= 100-1500mg </li></ul><ul><li>- SE= GIT, HA, lethargy, unsteadiness, urticaria, blood dyscrasias. </li></ul>
  45. 45. <ul><li>Second line drugs </li></ul><ul><li>Mainly used as 2 nd line drugs for partial and secondarily generalized epilepsy </li></ul><ul><li>- Lamotrigine: 100-500mg in divided doses. </li></ul><ul><li>sedation, ataxia, dyspepsis and </li></ul><ul><li>skin rash are SE </li></ul><ul><li>- Gabapentin : 900-1800mg. Sedation, Wt gain, ataxia & nystagmus are SE </li></ul>
  46. 46. <ul><li>Withdrawal of anticonvulsants </li></ul><ul><li>- should only be tried 3 years after complete </li></ul><ul><li>control of seizures & should be gradual over </li></ul><ul><li>6-12 months. </li></ul><ul><li>- classical absences in children carry best </li></ul><ul><li>prognosis for successful withdrawal </li></ul><ul><li>- In adults 20% relapse during withdrawal and </li></ul><ul><li>another 20% in the following 5 years. </li></ul><ul><li>- Relapses are more likely in seizures beginning in adult life & severe prolonged seizures, major epilepsy & very abn EEG. </li></ul>
  47. 47. <ul><li>Females, epilepsy & anticonvulsants </li></ul><ul><li>- fertility is reduced in epileptics ? Ovarian abn </li></ul><ul><li>- teratogenic effects of anticonvulsants ? Counselling for pregnancy </li></ul><ul><li>spinal canal defects , hare lip & cleft palate </li></ul><ul><li>are za commonest defects, sp in 1 st trimester </li></ul><ul><li>- use monotherapy with 1 st line drug, best is </li></ul><ul><li>carbamazepine + folic acid + vit K po a week </li></ul><ul><li>before delivery </li></ul><ul><li>- failure of contraception : increase dose of OCP </li></ul><ul><li>or alternative contraception. - No CI to breast feeding </li></ul>
  48. 48. <ul><li>Status epilepticus </li></ul><ul><li>- recurrent seizures without regaining consciousness & is a medical emergency </li></ul><ul><li>- over 50% occur without previous history of </li></ul><ul><li>epilepsy & precipitants (pseudo status) and include </li></ul><ul><li>- cerebral infections - trauma </li></ul><ul><li>- CV disease - toxic </li></ul><ul><li>- metabolic - febrile seizures </li></ul><ul><li>- eclampsia in childhood </li></ul><ul><li>- mortality of 10-15% from C/R failure and </li></ul><ul><li>underlying causes </li></ul>
  49. 49. <ul><li>- complications include :- aspiration pneumonia </li></ul><ul><li>- hyperpyrexia - hyperkalaemia </li></ul><ul><li>- tachycardia - hypotension </li></ul><ul><li>- syst & cerebral hypoxia & permanent brain </li></ul><ul><li>brain damage - hypoglycemia </li></ul><ul><li>- pulm HT & edema - ICP </li></ul><ul><li>- absence status : cont. distant stuporosed state </li></ul><ul><li>- epilepsia partialis continua : often due to </li></ul><ul><li>cerebral neoplasms & cortical infarcts in elderly </li></ul>
  50. 50. <ul><li>- Management of status epilepticus </li></ul><ul><li>- medical emergency & managed in ICU </li></ul><ul><li>- Speed of treatment of convulsive activity, </li></ul><ul><li>accuracy of diagnosis & need for continued </li></ul><ul><li>monitoring with C/R support is important. </li></ul><ul><li>- At home : IV diazepam 10 mg over 2 min and if </li></ul><ul><li>IV access is not available give rectal diazepam or paraldehyde. </li></ul><ul><li>- At hospital : </li></ul><ul><li>- ABC: maintain clear airway, high O2 flow and </li></ul><ul><li>check BMG </li></ul><ul><li>- IV access & commence NS </li></ul>
  51. 51. <ul><li>- 50ml 50% dextrose if hypoglycemia is suspected and 100mg thiamine IV if history of alcoholism or malnutrition </li></ul><ul><li>- IV diazepam 10 mg over 2-3 min & repeat to </li></ul><ul><li>a max of 30 mg every 10 min if necessary. If IV access is not available rectal diazepam and rectal paraldehyde are alternative. - IV clonazepam or lorazepam 4 mg over 2 min is alternative & repeated once in10 min if necessary </li></ul><ul><li>- M onitor ECG, PR, BP, temp and of O2 </li></ul>
  52. 52. <ul><li>- Take blood for glucose, U & E, Ca, Mg, FBC, </li></ul><ul><li>toxicology if appropriate, blood cultures, </li></ul><ul><li>anticonvulsants level & ABG - Look for head injury & focal N signs + full medical examination. </li></ul><ul><li>- If seizures continue start IV phenytoin (or fosphenytoin phenytoin) if pat is not already loaded: 15 mg/kg diluted to 10 mg/ml NS at a rate of 50 mg/min. If already taking phenytoin give paraldehyde 5 ml in each buttock </li></ul>
  53. 53. <ul><li>- If status continues: phenobarbitone 10 mg/kg diluted 1 in 10 distilled water at a rate of 100 mg/min -If status persist > 90 min despite all these measures, use thiopentone with </li></ul><ul><li>neuromuscular block & assisted ventilation </li></ul><ul><li>- Continuous C/R monitoring . </li></ul><ul><li>- Once seizures are controlled, determine </li></ul><ul><li>the cause & check plasma levels of </li></ul><ul><li>anticonvulsants & start oral medications. </li></ul><ul><li>- CT brain may reveal an underlying cause </li></ul><ul><li>for status </li></ul>

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