This slide was prepared for teaching purpose to medical students. It contain information from different books and medical journals. please inform if any of the information given need to be changed.
This slide was prepared for teaching purpose to medical students. It contain information from different books and medical journals. please inform if any of the information given need to be changed.
Coma is defined and the anatomy of consciousness explained. The various levels of arousal, AVPU scale and Glasgow Coma Scale described. The differential diagnosis of coma discussed are coma with & without focal deficits and the meningitis syndrome.
The various aspects of history discussed in details. The examination part includes the general examination, Brainstem reflexes, motor functions with the signs of lateralisation and meningeal irritation signs.
The basic lab investigations, Imaging and special investigations like CSF examination, EEG discussed.
Elevated intracranial pressure and its management explained.
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Coma is defined and the anatomy of consciousness explained. The various levels of arousal, AVPU scale and Glasgow Coma Scale described. The differential diagnosis of coma discussed are coma with & without focal deficits and the meningitis syndrome.
The various aspects of history discussed in details. The examination part includes the general examination, Brainstem reflexes, motor functions with the signs of lateralisation and meningeal irritation signs.
The basic lab investigations, Imaging and special investigations like CSF examination, EEG discussed.
Elevated intracranial pressure and its management explained.
Intracerebral hemorhage Diagnosis and managementRamesh Babu
About ICH - Diagnosis and management, Discussed the clinical presentation, evaluation, radiological features and management including recent guidelines
This PPT focuses on the diagnosis and treatment of the primary headache disorders, with special emphasis on migraine, the headache most likely to bring patients to physicians and pharmacists. warning signs of the ominous headache, which, although rare, can herald a life-threatening condition. Clinical characteristics of the primary headache types, migraine, tension-type headache, and cluster headache, are described
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This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
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is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
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This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
2. Introduction
Seizure
an abnormal, excessive, paroxysmal discharge of the
cerebral neurons
5–10% of the population will have at least one
seizure, with the highest incidence occurring in
early childhood and late adulthood
Epilepsy
a chronic condition characterized by recurrent,
unprovoked seizures
if a patient has 2 or more seizures, he/she is diagnosed
as having epilepsy
Incidence 0.3–0.5%
Prevalence 5–30 persons per 1000.
4. Syncope
A transient loss of consciousness due to brief interruption of blood
supply to the brain.
Convulsive movements of the extremities may follow some prolonged
episodes.
Vasovagal syncope
secondary to fear, pain or unpleasant sights such as blood or
medical procedures.
Reflex syncope
coughing, micturition, defecation or Valsalva’s maneuver.
Other causes, especially in the elderly,
orthostatic hypotension and cardiac arrhythmias.
Clinical presentation
dizzy/light-headed
fullness in ears
Nauseous
often gradual graying or blurring of the vision.
5. Syncope contd..
Patients who fall tend to go down more “gracefully” than those
with seizures
Stereotypical provoking factors such as
prolonged periods of standing in the heat,
sight of blood,
micturition, or
abruptly assuming an erect posture after prolonged
recumbence.
The absence of an aura , tongue bite, urinary incontinence and
prolonged tonic-clonic activity in the presence of a provoking
factor would be more suggestive of syncope.
6. Transient Ischemic Attacks
TIA result from temporary interruption of blood
supply in the distribution of a cerebral vessel.
“Negative symptoms” such as numbness and
weakness are more likely to manifest as compared
to the “positive symptoms” (stiffness and twitching)
seen with seizures.
Patients will likely have risk factors for
cerebrovascular disease such as hypertension,
diabetes and/or coronary artery disease.
7. Migraines
A classic migraine with visual aura, nausea/vomiting and
pounding hemicranial headache can be differentiated easily from
a seizure based on history alone.
However, migraines presenting with isolated symptoms such as
vertigo, episodic vomiting (cyclic vomiting), visual changes and
aphasia with/without headaches can be a challenge.
A detailed history of previous attacks
Certain triggers (caffeine, sleep withdrawal, chocolate)
Family history of migraines
Empirical treatment with antiepileptic/anti-migraine medications
may clarify the diagnosis in some instances
8. Pseudoseizures and Hysterical
Seizures
Pseudoseizures are paroxysmal attacks of non-
epileptic etiology
waxing and waning movements during a single attack
prolonged tonic-clonic activity without postictal
disorientation
non-rhythmic pelvic thrusting
non-physiological evolution of symptoms such as motor
activity spreading from one hand to the other without first
affecting the ipsilateral face or leg.
9. Classification of seizure
Seizures may be either focal or generalized.
Focal seizures
originate within networks limited to one cerebral hemisphere
Focal seizures with or without impairment of cognition
Generalized seizures
arise within and rapidly engage networks distributed across both
cerebral hemispheres.
Focal seizures are usually associated with structural
abnormalities of the brain.
In contrast, generalized seizures may result from cellular,
biochemical, or structural abnormalities that have a more
widespread distribution.
10.
11. FOCAL SEIZURES
Arise from a neuronal network either discretely
localized within one cerebral hemisphere or more
broadly distributed but still within the hemisphere
Focal seizures with or without dyscognitive features
(“simple focal seizures” and “complex focal seizures”)
Focal seizures can also evolve into generalized seizures
(focal seizures with secondary generalization)
Interictal EEG
often normal or may show brief discharges termed
epileptiform spikes, or sharp waves.
12. Focal Seizures Without
Dyscognitive Features
Focal seizures can cause motor, sensory, autonomic, or psychic
symptoms without impairment of cognition
Ictal EEG
abnormal discharges in a very limited region over the appropriate area of
cerebral cortex if the seizure focus involves the cerebral convexity
Focal motor seizures
abnormal motor movements may begin in a very restricted region such as
the fingers and gradually progress (over seconds to minutes) to include a
larger portion of the extremity
“Jacksonian march”
spread of seizure activity over a progressively larger region of motor cortex.
Localized paresis (Todd’s paralysis) may occur for minutes to many hours in
the involved region following the seizure
Seizure may continue for hours or days
epilepsia partialis continua
13. Focal Seizures Without
Dyscognitive Features
Focal seizures may also manifest as changes in
somatic sensation (e.g., paresthesias)
Vision (flashing lights or formed hallucinations)
Equilibrium (sensation of falling or vertigo), or
Autonomic function (flushing, sweating, piloerection).
Focal seizures arising from the temporal or frontal cortex may also
cause alterations in hearing, olfaction, or higher cortical function
(psychic symptoms)
sensation of unusual, intense odors (e.g., burning rubber or kerosene) or
sounds (crude or highly complex sounds)
epigastric sensation that rises from the stomach or chest to the head
Fear
sense of impending change, detachment, depersonalization, déjá vu
illusions that objects are growing smaller (micropsia) or larger (macropsia).
These subjective, “internal” events that are not directly observable by
someone else are referred to as auras.
14. Focal Seizures with
Dyscognitive Features
Transient impairment of the patient’s ability to maintain normal contact with the
environment
unable to respond appropriately to visual or verbal commands during the seizure
impaired recollection or awareness of the ictal phase
1. Aura (i.e., a focal seizure without cognitive disturbance)
2. Sudden behavioral arrest or motionless stare
3. Automatisms
involuntary, automatic behaviors
very basic behaviors such as chewing, lip smacking, swallowing, or “picking”
movements of the hands
more elaborate behaviors such as a display of emotion or running.
4. The patient is typically confused following the seizure
Transition to full recovery of consciousness may range from seconds up to an hour.
Anterograde amnesia
Postictal aphasia
15. EVOLUTION OF FOCAL SEIZURES
TO GENERALIZED SEIZURES
Tonic-clonic variety
Focal seizures arising from a focus in the
frontal lobe
H/O of preceding aura
16. GENERALIZED SEIZURES
Arise at some point in the brain but
immediately and rapidly engage neuronal
networks in both cerebral hemispheres
17. Typical Absence Seizures
Sudden, brief lapses of consciousness without loss of postural control
Typically lasts for only seconds
No postictal confusion
Subtle, bilateral motor signs such as
rapid blinking of the eyelids
chewing movements
small-amplitude, clonic movements of the hands.
Associated with a group of genetically determined epilepsies
onset usually in childhood or early adolescence
main seizure type in 15–20% of children with epilepsy
EEG
generalized, symmetric, 3-Hz spike-and-wave discharge that begins and
ends suddenly, superimposed on a normal EEG background
18. Atypical Absence Seizures
Lapse of consciousness
longer duration
less abrupt in onset and cessation
More obvious motor signs
EEG
generalized, slow spike-and-wave pattern with a frequency
of ≤2.5 Hz
Diffuse or multifocal structural abnormalities of the
brain
signs of neurologic dysfunction such as mental retardation
Less responsive to anticonvulsants
19. Generalized, Tonic-Clonic
Seizures
Main seizure type in ~10% of all persons with epilepsy
Most common seizure type resulting from metabolic derangements
The seizure usually begins abruptly without warning,
Vague premonitory symptoms in the hours leading up to the seizure
distinct from the stereotypic auras associated with focal seizures that
generalize.
Tonic contraction of muscles throughout the body
muscles of expiration and the larynx
loud moan or “ictal cry.”
Respirations are impaired
Secretions pool in the oropharynx
Cyanosis
jaw muscles
biting of the tongue
Marked enhancement of sympathetic tone
increases in heart rate, blood pressure, and pupillary size
20. Generalized, Tonic-Clonic
Seizures
After 10–20 s
Clonic phase
superimposition of periods of muscle relaxation on the tonic
muscle contraction.
periods of relaxation progressively increase until the end of the
ictal phase, which usually lasts no more than 1 min.
Postictal phase
Unresponsiveness, muscular flaccidity, and excessive salivation
that can cause stridorous breathing and partial airway obstruction
Bladder or bowel incontinence
Postictal confusion
Headache, fatigue, and muscle ache
21. Generalized, Tonic-Clonic
Seizures
EEG
tonic phase
progressive increase in generalized low-voltage fast
activity, followed by generalized high-amplitude, polyspike
discharges
clonic phase
high-amplitude activity is typically interrupted by slow waves
to create a spike-and-wave pattern
postictal EEG
diffuse slowing that gradually recovers as the patient
awakens
Brief tonic seizures lasting only a few seconds
Lennox-Gastaut syndrome
22. Atonic Seizures
Sudden loss of postural muscle tone lasting 1–2 s
Consciousness is briefly impaired
No postictal confusion
EEG
brief, generalized spike-and-wave discharges followed
immediately by
diffuse slow waves that correlate with the loss of muscle
tone
Atonic seizures are usually seen in association with
known epilepsy syndromes.
23. Myoclonic Seizures
Myoclonus is a sudden and brief muscle contraction that may involve
one part of the body or the entire body.
Physiologic form of myoclonus
sudden jerking movement observed while falling asleep.
Pathologic myoclonus
metabolic disorders
degenerative CNS diseases
anoxic brain injury
Myoclonic seizures are considered to be true epileptic events because
they are caused by cortical dysfunction.
EEG
bilaterally synchronous spike-and-wave discharges synchronized with the
myoclonus
Myoclonic seizures
juvenile myoclonic epilepsy
24.
25. Epilepsy syndromes
Epilepsy syndromes are disorders in which
epilepsy is a predominant feature
There is sufficient evidence (e.g., through
clinical, EEG, radiologic, or genetic
observations) to suggest a common
underlying mechanism
26.
27.
28.
29. Juvenile myoclonic epilepsy
(JME)
Generalized seizure disorder of unknown cause
Appears in early adolescence
1. Bilateral myoclonic jerks that may be single or repetitive
most frequent in the morning after awakening and can be provoked by
sleep deprivation.
Consciousness is preserved unless the myoclonus is especially severe.
2. Many patients also experience generalized tonic-clonic seizures
3. Up to one-third have absence seizures.
Although complete remission is relatively uncommon, the seizures
usually respond well to appropriate anticonvulsant medication.
There is often a family history of epilepsy, and genetic linkage studies
suggest a polygenic cause
30. Lennox-Gastaut syndrome
Occurs in children
Triad:
1. Multiple seizure types
generalized tonic-clonic, atonic, and atypical absence seizures
2. EEG
slow (<3 Hz) spike-and-wave discharges and a variety of other
abnormalities; and
3. Impaired cognitive function in most but not all cases.
Associated with CNS disease or dysfunction from a variety of causes
De novo mutations
Developmental abnormalities
Perinatal hypoxia/ischemia
Trauma
Infection
Unfortunately, many patients have a poor prognosis
underlying CNS disease
severe, poorly controlled epilepsy.
31. Mesial temporal lobe epilepsy
(MTLE)
Most common syndrome associated with
focal seizures with dyscognitive features
High resolution MRI
hippocampal sclerosis
Refractory to treatment with anticonvulsants
but responds well to surgical intervention
32. History
1. When did you experience the first seizure in your life?
2. Do you experience some kind of a warning or unusual feeling at
the onset, or immediately preceding the seizure?
3. What happens during the seizure?
4. What happens immediately following the seizure?
5. Is there a diurnal variation?
6. Are there any known triggering factors?
7. What is the seizure frequency?
8. What has been the maximum seizure-free period since the
seizure onset?
9. Is there more than one kind of seizure?
10. Has the patient sustained injuries related to the seizures?
11. What is the frequency of visits to the emergency department?
33. 1. When did you experience
the first seizure in your life?
Early neonatal period
perinatal insults
metabolic disorders, and
congenital malformation.
Generalized seizures tend to present in early
childhood or teenage years
Elderly with new onset seizures
structural pathology such as a stroke or brain
tumor
34.
35.
36. 2. Do you experience some kind of a
warning or unusual feeling at the
onset, or immediately preceding the
seizure?
The warning symptoms that are perceived at the onset
of a seizure are called “aura.”
An aura actually indicates that the seizure is focal in
origin.
Temporal lobe epilepsy
déjà vu
epigastric sensation,
Parietal lobe epilepsy
Paresthesias
Occipital lobe epilepsy
visual distortions
transient blindness
37. 3. What happens during the
seizure?
Is there head or eye deviation to one side?
Seizures originating from the frontal eye fields may cause head and eye
deviation to the contralateral side
Is there excessive eye blinking at the onset?
Occipital lobe seizures can present with excessive blinking at the onset,
negative visual symptoms or visual distortions
If automatisms (defined as involuntary, organized sequences of
movement that are not causally related to the external environment)
occur, are these more pronounced on one side?
Temporal lobe seizures are often manifested with lip smacking and other
oral and alimentary automatic behavior
most pronounced in the ipsilateral extremity, along with dystonic posturing of
the contralateral arm
Does the patient bite his tongue or lose control of the bladder function?
more often seen with generalized seizures
38. 4. What happens immediately
following the seizure? Postictal
period
Generalized tonic-clonic seizure
postictal sleep
disorientation and lack of awareness of the surroundings
Hemiparesis or hemiplegia following a seizure
(Todd’s paralysis)
focal seizure
Aphasia with otherwise normal awareness
language areas in the dominant hemisphere.
Absence seizures
brief or no postictal disorientation
39. 5. Is there a diurnal variation?
Tonic-clonic and myoclonic seizures seen in
primary generalized epilepsies
more common on awakening or in early morning.
Temporal lobe seizures
occur any time.
Certain frontal lobe seizures
nocturnal presentation
40. 6. Are there any known
triggering factors?
Sleep deprivation
Flickering lights
Menses
Alcohol consumption
Non-compliance of medication
Use of antihistamines
Stress
Fever
Exercise
41. 7. What is the seizure
frequency?
Response to treatment
42. 8. What has been the maximum
seizure-free period since the
seizure onset?
To determine if any specific antiepileptic drug
was more efficacious than the others.
43. 9. Is there more than one kind
of seizure?
Different seizure types
44. 10. Has the patient sustained
injuries related to the seizures?
do not have auras
do not have enough time after the aura to
take preventive measures
45. 11. What is the frequency of visits
to the emergency department?
Degree of seizure control
46. PAST MEDICAL HISTORY
Central nervous system infections such as
meningitis, encephalitis, Lyme disease,
cysticercosis.
Head injuries, especially associated with
depressed skull fracture,
intracerebral hemorrhage,
loss of consciousness
prolonged amnesia
Brain tumor
Cerebrovascular accident
47. SOCIAL HISTORY
Level of education
Job description
construction worker, heavy equipment mechanic, driver
Planning pregnancy in the near future
Teratogenicity of antiepileptic drugs
Lower efficacy of oral contraceptives with enzyme-inducing
medication (phenytoin, carbamazepine, and phenobarbital),
Alcohol use
risk factor for a first generalized tonic-clonic seizure
interact with the metabolism of the antiepileptic drugs
seizure exacerbation, especially after continued or binge
drinking.
48. FAMILY HISTORY
Specific epilepsy syndromes and Genetically
mediated neurological disorders that have
seizures as one manifestation.
Juvenile myoclonic epilepsy (JME),
Familial neonatal convulsions,
Benign rolandic epilepsy
49.
50. Examination
Asymmetries in the size of limbs or one half of the body (hemiatrophy)
perinatal cerebral insult
Marks or ulcerations on the side of tongue or oral mucous membranes
Gingival hyperplasia
Phenytoin
Dupytrens contractures
chronic use of barbiturates
Dystonic posturing of one arm on stressed gait, such as walking on the
sides of the feet
remote insult to the corticospinal tracts
Multiple bruises or injuries
falls secondary to seizures
End gaze nystagmus, diplopia and difficulty in tandem walking
toxicity related to antiepileptic medications such as carbamazepine,
phenytoin, and lamotrigine
52. INVESTIGATING THE FIRST
SEIZURE
A seizure is a symptom of an underlying
pathology.
Investigations are directed at identifying the
precipitating etiology and conditions that can
be arrested, reversed, or treated.
A detailed history and physical examination
can provide direction to the extent of
investigations
53.
54. Laboratory Investigations
Hyponatremia, hypoglycemia,
hypomagnesemia, uremia and hepatic
encephalopathy
Serum and urine toxicology should be done
when substance abuse or drug overdose is
suspected.
In newborns and young children appropriate
metabolic screen can be requested
55. Neuroimaging
CT scan
subdural hematoma, subarachnoid hemorrhage, abscess,
neoplastic processes, and other space occupying lesions.
MRI
cerebral dysplasia
mesial temporal scleroses
when history and physical examination is suggestive of
focal pathology and the CT does not show the cause
56. Electroencephalogram (EEG)
EEG tests the cerebral function rather than
structure.
Epileptiform discharges on the EEG can help
classify the seizure types
Focal and generalized slowing is reflective of focal
and generalized disturbance of cerebral function
respectively.
Focal disturbance
strokes, tumors, and abscess.
Generalized disturbance
toxic, metabolic, or diffuse structural abnormalities
57. Treatment
Treatment of underlying condition
Avoidance of precipitating factors
Antiepileptic drugs
Refractory epilepsy
58. Antiepileptic drugs
Appear to act primarily by blocking the initiation or spread of
seizures
1. Inhibition of Na+-dependent action potentials in a frequency-
dependent manner
(e.g., phenytoin, carbamazepine, lamotrigine, topiramate,
zonisamide, lacosamide, rufinamide),
2. Inhibition of voltage-gated Ca2+ channels
(phenytoin, gabapentin, pregabalin),
3. Facilitating the opening of potassium channels
(ezogabine),
4. Attenuation of glutamate activity
(lamotrigine, topiramate, felbamate),
59. Antiepileptic drugs
5. Potentiation of GABA receptor function
(benzodiazepines and barbiturates),
6. Increase in the availability of GABA
(valproic acid, gabapentin, tiagabine),
7. Modulation of release of synaptic vesicles
(levetiracetam).
8. Inhibiting T-type Ca2+ channels in thalamic
neurons.
ethosuximide and valproic acid
60. When to Initiate Antiepileptic
Drug Therapy
Recurrent seizures of unknown etiology or a known cause that
cannot be reversed
Patients with a single seizure due to an identified lesion such as
a CNS tumor, infection, or trauma, in which there is strong
evidence that the lesion is epileptogenic, should be treated.
Most patients with one or more of these risk factors should be
treated
an abnormal neurologic examination,
seizures presenting as status epilepticus,
postictal Todd’s paralysis,
a strong family history of seizures,
an abnormal EEG.
61.
62.
63. Antiepileptic Drug Selection
for Focal Seizures
Carbamazepine (or oxcarbazepine), lamotrigine, phenytoin, and levetiracetam
drugs of choice approved for the initial treatment of focal seizures
Carbamazepine
first-order pharmacokinetics
leukopenia, aplastic anemia, or hepatotoxicity
Oxcarbazepine
avoids an intermediate metabolite
fewer drug interactions
Lamotrigine
skin rash
Stevens-Johnson syndrome
low initial doses and slow titration
Phenytoin
long half-life
once or twice daily dosing
nonlinear kinetics
Long-term use of phenytoin
untoward cosmetic effects (e.g., hirsutism, coarsening of facial features, gingival hypertrophy) and
effects on bone metabolism
64. Antiepileptic Drug Selection
for Focal Seizures
Levetiracetam
no known drug-drug interactions
irritability, anxiety, and other psychiatric symptoms
Topiramate
focal and generalized seizures
significant psychomotor slowing and other cognitive problems
Avoid in glaucoma or renal stones
Valproic acid
is an effective alternative for some patients with focal seizures, especially when the seizures
generalize.
Gastrointestinal side effects are fewer when using the delayed-release formulation
Reversible bone marrow suppression
Hepatotoxicity
Zonisamide, tiagabine, gabapentin, lacosamide, and ezogabine
additional drugs currently used for the treatment of focal seizures with or without evolution into
generalized seizures.
Phenobarbital and other barbiturate compounds
were commonly used in the past as first-line therapy for many forms of epilepsy
sedation in adults
hyperactivity in children
subtle cognitive changes
65. Antiepileptic Drug Selection
for Generalized Seizures
Lamotrigine and valproic acid
DOC for primary generalized, tonic-clonic seizures
Topiramate, zonisamide, phenytoin, carbamazepine, and oxcarbazepine
suitable alternatives
Valproic acid
absence, myoclonic, and atonic seizures
DOC in patients with generalized epilepsy syndromes having mixed seizure types
Carbamazepine, oxcarbazepine, and phenytoin
worsen certain types of generalized seizures, including absence, myoclonic, tonic, and
atonic seizures.
Ethosuximide
uncomplicated absence seizures
not useful for tonic-clonic or focal seizures
bone marrow suppression.
Lamotrigine
epilepsy syndromes with mixed, generalized seizure types such as JME and Lennox-Gastaut
syndrome.
Topiramate, zonisamide, and felbamate
similar broad efficacy
66. Guidelines for antiepileptic
therapy
Start with one first-line drug
Start at a low dose; gradually increase dose until effective control of seizures is
achieved or side-effects develop
Optimise compliance
If first drug fails
start second first-line drug, followed if possible by gradual withdrawal of first
If second drug fails
start second-line drug in combination with preferred first-line drug at maximum
tolerated dose
If this combination fails
replace second-line drug with alternative second-line drug
If this combination fails
check compliance and reconsider diagnosis
(Are events seizures? Occult lesion? Treatment compliance/alcohol/drugs confounding
response?)
Consider alternative, non-drug treatments (e.g. epilepsy surgery, vagal nerve
stimulation)
Use minimum number of drugs in combination at any one time
67. Definition of drug resistant
epilepsy
The International League Against Epilepsy (ILAE)
has proposed the following definition of drug
resistant epilepsy and suggests that this term be
used instead of the term 'refractory epilepsy'.
Drug resistant epilepsy occurs when a person has failed to
become (and stay) seizure free with adequate trials of two
seizure medications (called AEDs).
These seizure medications must have been chosen
appropriately for the person’s seizure type, tolerated by the
person, and tried alone or together with other seizure
medications
68. Surgical treatment
Temporal lobe epilepsy
resection of the anteromedial temporal lobe (temporal lobectomy)
limited removal of the underlying hippocampus and amygdala
(amygdalohippocampectomy)
Focal seizures arising from extratemporal regions
focal neocortical resection with precise removal of an identified
lesion (lesionectomy).
When the cortical region cannot be removed
multiple subpial transection
Hemimegalencephaly or other dysplastic abnormalities
Hemispherectomy or multilobar resection
Disabling tonic or atonic seizures, usually when they are part of a
mixed-seizure syndrome (e.g., Lennox-Gastaut syndrome).
corpus callosotomy
69. Surgical treatment
Vagus nerve stimulation (VNS)
Implantable device
can detect the onset of a seizure and deliver an
electrical stimulation
Responsive NeuroStimulation
Stereotactic radiosurgery,
Laser thermoablation
Deep brain stimulation (DBS)
70. When to Discontinue Therapy
Withdrawal of therapy can be attempted after 2
years of seizure free interval in a patient who meets
all of the following criteria
complete medical control of seizures for 1–5 years
single seizure type, either focal or generalized
normal neurologic examination, including intelligence
normal EEG
In most cases, it is preferable to reduce the dose of
the drug gradually over 2–3 months
Most recurrences occur in the first 3 months after
discontinuing therapy
71. Epilepsy in pregnancy
Pre-conception counselling
folic acid 5 mg daily for 2 mths before conception
Fetal malformation
Single drug
Carbamazepine and lamotrigine have the lowest incidence of major fetal malformations
Sodium valproate has relatively higher risk
Levetiracetam may be safe
Learning difficulties in children
Lower IQ with valproate
Haemorrhagic disease of the newborn
oral vitamin K 20 mg daily to the mother during the last month of pregnancy
IM vitamin K 1 mg to the infant at birth
Increased frequency of seizures
carbamazepine levels may fall in the third trimester.
Lamotrigine and levetiracetam levels may fall early in pregnancy
adjust the dose regimen
72.
73.
74.
75.
76.
77.
78. References
Davidsons principle and practice of medicine,
22nd edition
Harrisons principle of internal medicine 19th
edition
Wisconsin Medical Journal 2004
An Approach to the Evaluation of a Patient for
Seizures and Epilepsy
S. Nizam Ahmed, MD, FRCPC; Susan S.
Spencer, MD
It is of the utmost importance for a clinician to be aware of other conditions and/or episodes that may simulate seizures. In short, the first question to be addressed is: Does the episode in question represent a seizure?
Hyperventilation tends to provoke these electrographic discharges and even the seizures themselves and is routinely used when recording the EEG
Rasmussen's encephalitis, also known as chronic focal encephalitis (CFE) is a rare inflammatory neurological disease, characterized by
frequent and severe seizures,
loss of motor skills and speech,
hemiparesis (paralysis on one side of the body),
encephalitis (inflammation of the brain), and
dementia.
A 70 year old who presents with new onset seizures is likely to have structural pathology such as a stroke or brain tumor
Once the maximum seizure-free period is identified, try to determine what medications were being used at that time. This medication may be retried if other medications fail.