1. Epilepsy
Recurrent unprovoked seizures

2. Seizure
Transient symptoms/signs of
abnormal, excessive,
synchronous neuronal activity in
the brain

3. Epilepsy- questions?
 1- seizure?
 2- seizure-type?
 3- fits a syndrome?
 4- identifiable cause?
 5- anti-epileptic drug (AED)?
 6- when to stop treatment?
 7- surgery?

4. History of event
 Frequency
 Timing
 Duration
 Triggers
 Warning
 Color change- pallor, cyanosis
 Alteration in consciousness
 Motor phenomena
 Associated s/s- incontinence, injury
 Symptoms following attack- post-ictal

5. Differential diagnosis
 Pseudoseizure- psychiatric
 Syncope- cardiac or neurological
 Movement disorder
 Migraine
 Transient ischemic attack
 Metabolic disorders- hypoglycemia
 Anoxia/hypoxia

6. Seizure type
 Partial-
 Simple- no LOC
 Complex- focal onset with LOC
 Secondary generalization
 Generalized- all have LOC
 Tonic, clonic, tonic-clonic-grand mal
 Absence-petit mal
 Atonic
 Myoclonic

7. Common epilepsy syndromes
 Nocturnal frontal lobe epilepsy
Childhood onset, nocturnal, seizures- complex motor movements/vocalizationn
 Benign rolandic epilepsy
Late childhood, nocturnal, simple partial seizures involving face
 Benign occipetal epilepsy of childhood
Childhood onset, seizures with visual symptoms- scotoma/blindness
 Childhood absence epilepsy
Childhood, absence seizures, EEG- 3 Hz spike-wave discharges
 Juvenile myoclonic epilepsy
Teenagers, early morning myoclonic jerks, EEG- 4-6 Hz generalized spike-wave discharges
 Lennox-Gastaut syndrome
MR + GTC seizures + EEG- 2 Hz slow spike-wave pattern
 Temporal lobe epilepsy
Teenage onset, complex partial seizures, poor response to AED
 West syndrome
MR + infantile spasms + EEG- hypsarrythmia

8. Causes
 Neonates & infancy- hypoxia,
congenital abnormalities, infection,
trauma
 Early childhood- febrile seizures,
epilepsy syndromes
 Adolescence & adults- CNS infection,
trauma, tumors, drug abuse
 Older adults- CVA, degenerative
disorders, tumors

9. Investigation
 Glucose, Electrolytes, Calcium, Creatinine
 12 lead ECG
 MRI- to identify structural abnormalities, if
 Onset <2 years or adulthood
 Focal onset by history, examination, EEG
 Refractory seizures
 EEG-
 Helps support diagnosis of epilepsy
 Helps determine seizure type/epilepsy syndrome
 Helps determine risk of recurrence
 Supported by sleep EEG, photic stimulation & hyperventilation

10. Treatment
 AED- anti-epileptic drugs
 Goals- no seizures & no side-effects
 Monotherapy preferred
 Single AED effective in ~50%
 ~70% controlled with 2 drugs
 ~20% have breakthrough seizures despite
best AEDs
 Vagus nerve stimulation as adjunct in
refractory epilepsy, not for surgery

11. When to start AED?
 Generally after 2nd
seizure- recurrence ~75%
 After 1st
seizure (recurrence ~1/3rd
)- if
 Individual has neurological deficit
 EEG shows unequivocal epileptic activity
 Brain imaging shows a structural abnormality
 Unacceptable risk of recurrence
Some choose not to take AEDs after knowing all
risks & benefits

12. What first-line AED?
 GTC- carbamazepine-C, lamotrigine-L,
Na valproate-V, topiramate-T
 Absence- ethosuximide-E, L, V
 Myoclonic- V
 Tonic- L, V
 Atonic- L, V
 Partial- C, L, V, T

13. When to stop?
 A collective decision based on epilepsy
syndrome, prognosis, lifestyle
 Withdrawl only after 2 years of seizure free
period
 One drug at a time, withdrawn over 2-3
months
 Benzodiazepines & barbiturates withdrawl
may cause withdrawl symptoms
 Seizure recurrenceback to last dose

14. Surgery
Refractory epilepsy with
symptomatic localization

15. Status epilepticus
 Seizures without recovery of consciousness
in between
 ~20% mortality
 Commonest cause- poor compliance with
AED
 Ensure A.B.C
 Rx- Lorazepam/Diazepam(Fos)Phenytoin
 Once controlled- find cause &
institute long-term AEDs

16. Women & epilepsy
 Women on AED planning pregnancy- folic
acid supplementation
 Teratogenicity- maximum with Na valproate
 Pregnant woman on AED- US at 18-20 weeks
to detect structural fetal defects
 Ensure compliance with AED to avoid a
seizure during pregnancy
 Do not change an effective AED
 Breast-feeding to be encouraged