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  1. 1. Seizures and Epilepsy www.freelivedoctor.com
  2. 2. <ul><li>Terms seizure and epilepsy are not synonymous </li></ul>www.freelivedoctor.com
  3. 3. Seizure <ul><li>A seizure is a paroxysmal event due to abnormal, excessive, hypersynchronous discharges from an aggregate of central nrvous system (CNS)neurons. </li></ul><ul><li>Have various manifestations. </li></ul>www.freelivedoctor.com
  4. 4. Epilepsy <ul><li>Epilepsy describes a condition in which a person has recurrent seizures due to a chronic, underlying process. </li></ul><ul><li>Single seizure, or recurrent seizures due to correctable or avoidable circumstances, does not necessarily have epilepsy </li></ul>www.freelivedoctor.com
  5. 5. Causes www.freelivedoctor.com
  6. 6. <ul><li>Seizures are a result of a shift in the normal balance of exitation and inhibition within the CNS. </li></ul><ul><li>3 important clinical observations </li></ul>www.freelivedoctor.com
  7. 7. 3 clinical observations <ul><li>1.- The normal brain is capable of having a seizure under the appropriate circumstances, and there are differences between individuals in the susceptibility or threshold for seizures. </li></ul><ul><li>Fever in childrens </li></ul><ul><li>Underlying endogenous factors. </li></ul>www.freelivedoctor.com
  8. 8. <ul><li>2.- Variety of conditions that have an extremely high likelihood of resulting in a chronic seizure disorder </li></ul><ul><li>Head trauma, stroke, infections, abnormalities of CNS development. </li></ul>www.freelivedoctor.com
  9. 9. <ul><li>3.- Seizure are episodic: provocative or precipitating factor </li></ul><ul><li>Psychological or physical stress, sleep deprivation, or hormonal changes, exposure to toxic substances and certain medications. </li></ul>www.freelivedoctor.com
  10. 10. <ul><li>Inmunosupressants: </li></ul><ul><ul><li>Cyclosporine </li></ul></ul><ul><ul><li>Monoclonal antibodies to T cells </li></ul></ul>www.freelivedoctor.com
  11. 11. Drugs that can cause seizures <ul><li>Antimicrobials: </li></ul><ul><ul><li>B-lactam and related compounds </li></ul></ul><ul><ul><li>Quinolones </li></ul></ul><ul><ul><li>Isoniazid </li></ul></ul><ul><ul><li>Ganciclovir </li></ul></ul>www.freelivedoctor.com
  12. 12. Drugs that can cause seizures <ul><li>Anesthetic and antiarrhythmics: </li></ul><ul><ul><li>B- adrenergic antagonists </li></ul></ul><ul><ul><li>Local anesthetics </li></ul></ul><ul><ul><li>Clase 1 B agents </li></ul></ul>www.freelivedoctor.com
  13. 13. Drugs that can cause seizures <ul><li>Psycotropics </li></ul><ul><ul><li>Antidepressants </li></ul></ul><ul><ul><li>Antipsychotics </li></ul></ul><ul><ul><li>Lithium </li></ul></ul>www.freelivedoctor.com
  14. 14. Drugs that can cause seizures <ul><li>Radiographic contrast agents </li></ul><ul><li>Theophyline </li></ul><ul><li>Sedative hypnotic drug withdrawal </li></ul><ul><ul><li>Alcohol </li></ul></ul><ul><ul><li>Barbiturates </li></ul></ul><ul><ul><li>Benzodiazepines </li></ul></ul>www.freelivedoctor.com
  15. 15. Drugs that can cause seizures <ul><li>Drugs of abuse: </li></ul><ul><ul><li>Amphetamine </li></ul></ul><ul><ul><li>Cocaine </li></ul></ul>www.freelivedoctor.com
  16. 16. Causes According to Age <ul><li>Neonates: (<1month): </li></ul><ul><ul><li>Perinatal hypoxemia and ischemia </li></ul></ul><ul><ul><li>Intracranial hemorrhage and trauma </li></ul></ul><ul><ul><li>Acute CNS infection (meningitis) </li></ul></ul><ul><ul><li>Metabolic disturbances </li></ul></ul><ul><ul><li>Developmental disorders </li></ul></ul><ul><ul><li>Genetic disorders </li></ul></ul>www.freelivedoctor.com
  17. 17. <ul><li>Infants and children: (> 1 month < 12 years ) </li></ul><ul><ul><li>Febril seizure </li></ul></ul><ul><ul><li>Genetic disorders </li></ul></ul><ul><ul><li>CNS infections </li></ul></ul><ul><ul><li>Developmental disorders </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Idiopatic </li></ul></ul>www.freelivedoctor.com
  18. 18. <ul><li>Adolescents: (12-18 years) </li></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Genetic disorders </li></ul></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Brain tumor </li></ul></ul><ul><ul><li>Illicit drug use </li></ul></ul><ul><ul><li>Idiopatic </li></ul></ul>www.freelivedoctor.com
  19. 19. <ul><li>Yung adults: (18-35 years) </li></ul><ul><ul><li>Alcohol withdrawal </li></ul></ul><ul><ul><li>Illicit drug use </li></ul></ul><ul><ul><li>Brain tumor </li></ul></ul><ul><ul><li>Idiopathic </li></ul></ul>www.freelivedoctor.com
  20. 20. <ul><li>Older adults: (>35 years) </li></ul><ul><ul><li>Cerebrovascular disease </li></ul></ul><ul><ul><li>Brain tumor </li></ul></ul><ul><ul><li>Alcohol withdrawal </li></ul></ul><ul><ul><li>Metabolic disorders (uremia, hepatic failure, electrolyte abnormalities, hypoglycemia) </li></ul></ul><ul><ul><li>Alzheimer`s disease </li></ul></ul><ul><ul><li>Idiopatic </li></ul></ul>www.freelivedoctor.com
  21. 21. Basic mechanism www.freelivedoctor.com
  22. 22. <ul><li>Partial seizure activy can begin in a very discrete region of cortex and then spread to neighboring regions. </li></ul><ul><ul><li>Seizure initiation phase </li></ul></ul><ul><ul><li>Seizure propagation phase. </li></ul></ul>www.freelivedoctor.com
  23. 23. Classification www.freelivedoctor.com
  24. 24. Classification <ul><li>Partial seizures </li></ul><ul><li>Primarily generalized seizures </li></ul><ul><li>Unclassified seizures </li></ul>www.freelivedoctor.com
  25. 25. <ul><li>Partial seizures </li></ul><ul><ul><li>Simple-partial seizures </li></ul></ul><ul><ul><li>Complex partial seizures </li></ul></ul><ul><ul><li>Partial seizures with secondarygeneralization </li></ul></ul>www.freelivedoctor.com
  26. 26. <ul><li>Primarily generalized seizures </li></ul><ul><ul><li>Absence (petit mal) </li></ul></ul><ul><ul><li>Tonic clonic (grand mal) </li></ul></ul><ul><ul><li>Tonic </li></ul></ul><ul><ul><li>Atonic </li></ul></ul><ul><ul><li>Myoclonic </li></ul></ul>www.freelivedoctor.com
  27. 27. <ul><li>Unclassified seizures </li></ul><ul><ul><li>Neonatal seizures </li></ul></ul><ul><ul><li>Infantile spasms </li></ul></ul>www.freelivedoctor.com
  28. 28. Partial <ul><li>Synonymous with focal </li></ul><ul><li>Activity is restricted to discrete areas of cerebral cortex. </li></ul><ul><li>Typically associated with structural abnormalities of the brain. </li></ul>www.freelivedoctor.com
  29. 29. www.freelivedoctor.com
  30. 30. Generalized <ul><li>Involve difusse regions of the brain simultaneously in a bilaterally symetric fashion </li></ul><ul><li>May result from cellular, biochemical, or structural abnormalities that have a more widespread distribution. </li></ul>www.freelivedoctor.com
  31. 31. www.freelivedoctor.com
  32. 32. Partial Seizures www.freelivedoctor.com
  33. 33. Partial Seizures <ul><li>Discrete regions of the brain. </li></ul><ul><li>Consciousness is fully preserved during the seizure ( Simple-partial seizure ) </li></ul><ul><li>Consciousness is impaired ( Complex partial seizure ) </li></ul><ul><li>Partial seizure and then spread diffusely throughout the cortex ( partial seizure with secondary generalization ) </li></ul>www.freelivedoctor.com
  34. 34. Simple-Partial Seizure <ul><li>Motor, sensory, autonomic, or psychic symptoms. </li></ul><ul><li>Without an obvious alteration in consciousness. </li></ul><ul><li>Three additional features </li></ul>www.freelivedoctor.com
  35. 35. Three features <ul><li>“ Jacksonian march ” abnormal motor movements may begin in a very restricted region, and gradually progress (over seconds to minutes). </li></ul><ul><li>May experience a localized paresis ( todd`s paralysis ) minutes to many hours. </li></ul><ul><li>Seizure may continue for hours or days. ” epilepsia partials continua ”. </li></ul>www.freelivedoctor.com
  36. 36. Simple partial. And Aura <ul><li>Other forms of simple-partial seizures include those that cause changes in somatic sensation. </li></ul><ul><li>Some patients describe odd internal feelings. (fear, dejà vu) </li></ul><ul><li>When precede a complex-partial or secondarly generalized seizure, these simple partial seizures serve as a warning or aura. </li></ul>www.freelivedoctor.com
  37. 37. Complex-Partial Seizures <ul><li>Focal seizure activity </li></ul><ul><li>Patient is unable to respond to visual or verbal commands during the seizure and has impaired recollection or awareness of the ictal phase. </li></ul><ul><li>Frequently begin with an aura. </li></ul>www.freelivedoctor.com
  38. 38. <ul><li>The start of the ictal phase is often a sudden behaivoral arrest or motionless stare. </li></ul><ul><li>Usually acompained by automatisms. </li></ul><ul><li>The patient is typically confused following the seizure.(seconds up to an hour). </li></ul>www.freelivedoctor.com
  39. 39. Partial Seizures with Secondary Generalization <ul><li>Partial seizures can spread to involve both cerebral hemispheres and produce a generalized seizur, usually of the tonic-clonic variety. </li></ul><ul><li>Is often difficult to distinguish from a primarilly generalized tonic-clonic seizure. </li></ul><ul><li>Careful hystory identifies a preceding aura. </li></ul>www.freelivedoctor.com
  40. 40. Generalized Seizures www.freelivedoctor.com
  41. 41. <ul><li>Arise from both cerebral hemispheres simultaneously . </li></ul><ul><li>It is currently impossible to exclude entirely the existence of a focal region of abnormal activity that initiates the seizure prior to rapid secondary generalization . </li></ul>www.freelivedoctor.com
  42. 42. Generalized Seizure. <ul><li>Practically defined as bilateral clinical and electrographic events without any detectable focal onset. </li></ul>www.freelivedoctor.com
  43. 43. Generalized Seizures <ul><li>Absence Seizure (Petit Mal) </li></ul><ul><li>Atypical Absence Seizures </li></ul><ul><li>Generalized, Tonic – Clonic Seizure (Grand Mal) </li></ul><ul><li>Atonic Seizure </li></ul><ul><li>Mioclonic Seizure </li></ul>www.freelivedoctor.com
  44. 44. Absence Seizures (Petit Mal) <ul><li>Sudden brief lapses of consciousness without loss of postural control. </li></ul><ul><li>Typically last for only seconds, consiousness returns as suddenly as it was lost. </li></ul><ul><li>No postictal confusion </li></ul>www.freelivedoctor.com
  45. 45. <ul><li>Absence seizures are usually accompained by subtle, bilateral motor signs (rapid blinking of the eyelids, chewing movements, or small-amplitude clonic movements of the hands. </li></ul>www.freelivedoctor.com
  46. 46. <ul><li>Can occur hundreds of times per day. </li></ul><ul><li>Always begin in childhood (ages 4 to 8) or early adolescence. </li></ul><ul><li>Hyperventilation tends to provoke. </li></ul>www.freelivedoctor.com
  47. 47. <ul><li>Typical Absence seizure are not associated with other neurologic problems and respond well to treatment with specific anticonvulsants. </li></ul><ul><li>60 – 70 % will have a spontaneous remission during adolescence. </li></ul>www.freelivedoctor.com
  48. 48. <ul><li>Atypical Absence Seizures: </li></ul><ul><ul><li>Lapse of consciousness is usually of longer duration. </li></ul></ul><ul><ul><li>Less abrupt in onset and cessation </li></ul></ul><ul><ul><li>Accompained by more obvious motor signs. </li></ul></ul>www.freelivedoctor.com
  49. 49. Generalized Tonic – Clonic Seizures (Grand Mal) <ul><li>The most common seizure type resulting from metabolic derangements. </li></ul>www.freelivedoctor.com
  50. 50. <ul><li>The initial phase of the seizure is usually tonic contraction of muscles throughout the body. </li></ul><ul><li>After 10 to 20 s. The tonic phase of the seizure typically evolves into the clonic phase, produced by the superimposition of periods of muscle relaxion on the tonic muscle contraction. </li></ul>www.freelivedoctor.com
  51. 51. <ul><li>The periods of relaxation progressively increase until the end of the ictal phase. </li></ul><ul><li>Usually last no more than 1 min. </li></ul>www.freelivedoctor.com
  52. 52. <ul><li>Postictal phase is characterized by: </li></ul><ul><ul><li>Unresponsiveness </li></ul></ul><ul><ul><li>Muscular flacciditidy </li></ul></ul><ul><ul><li>Excessive salivation </li></ul></ul><ul><ul><li>Bleadder or bowel incontinence </li></ul></ul>www.freelivedoctor.com
  53. 53. <ul><li>Patients gradually regain consciousness over minutes to hours </li></ul><ul><li>Tipically a period of postictal confusion. </li></ul><ul><li>Headache, fatigue, and muscle ache. </li></ul>www.freelivedoctor.com
  54. 54. Atonic Seizure <ul><li>Sudden loss of postural muscle tone lasting 1 to 2 s. </li></ul><ul><li>Consciousness is briefly impaired </li></ul><ul><li>Usually no postictal confusion </li></ul>www.freelivedoctor.com
  55. 55. <ul><li>Very brief seizure may cause only a quick head drop or nodding movement. </li></ul><ul><li>Longer seizure will cause the patient to collapse. (extremelly dangerous) </li></ul>www.freelivedoctor.com
  56. 56. Myoclonic Seizure. <ul><li>Sudden and brief muscle contraction that may involve one part of the body or the entire body. </li></ul><ul><li>Pathologic myoclonus is most commonly seen in association with metabolic disorders, degenerative CNS diseases, or anoxic brain injury. </li></ul>www.freelivedoctor.com
  57. 57. Unclassified Seizures www.freelivedoctor.com
  58. 58. Neonatal Seizure <ul><li>Less than 1 month of age. </li></ul><ul><li>Brief episodes of apnea, eye deviation, eye blinking, or repetitive movements of the arms and legs. </li></ul>www.freelivedoctor.com
  59. 59. Infantile Spasms <ul><li>Infants under 12 months. </li></ul><ul><li>Abrupt movements of the head, trunk, or limbs. </li></ul><ul><li>The classic spasm is a sudden flexion of the neck and abdomen with extension of the limbs. </li></ul>www.freelivedoctor.com
  60. 60. Evaluation of the patient www.freelivedoctor.com
  61. 61. Laboratory studies <ul><li>Electrolytes </li></ul><ul><li>Glucose </li></ul><ul><li>Ca </li></ul><ul><li>Mg </li></ul><ul><li>Liver and renal function test </li></ul><ul><li>Urianalysis </li></ul><ul><li>Toxicology screen </li></ul><ul><li>Lumbar puncture </li></ul>www.freelivedoctor.com
  62. 62. <ul><li>EEG </li></ul><ul><li>CT </li></ul><ul><li>MRI </li></ul><ul><li>SPECT </li></ul>www.freelivedoctor.com
  63. 63. Diferential Diagnosis <ul><li>Syncope </li></ul><ul><li>Psychological disorders </li></ul><ul><li>Metabolic disturbances </li></ul><ul><li>Migraine </li></ul><ul><li>TIA </li></ul><ul><li>Sleep disorders </li></ul><ul><li>Movement disorders </li></ul>www.freelivedoctor.com
  64. 64. Treatment www.freelivedoctor.com Partial Tonic-clonic Absence Myoclonic Atonic Carbamazepine Phenitoiin Valproic acid Lamotrigine Valproic acid Lamotrigine Ethosuximide Valproic Acid Valproic Acid