1. WELCOME

2. EPILEPSY
the “sacred disease’’
By
Basil

3. Introduction
The brain normally contain millions of
neurons interacting through electrical
discharges .
If these interactions misfire it can cause
series of problem in the brain.
It can cause changes in the way person
feels, think, and moves. Those changes
are called seizure

4. History of epilepsy
References to epilepsy date back to ancient
times and mystical explanation continued
until 18th century.
Hippocrates wrote the first book on epilepsy
in 400 BC.
He believed that epilepsy is a curse or sign
from the GOD.
In 1494 it was believed that seizure is a
characteristics of witches. The prosecution
that followed resulted in 2 lack deaths.

5. In 1890 one of the neurologist John
Hughlings Jackson defined seizure as an
occasional excessive and disorderly
discharge of nerve tissue on the muscle
tissue.
In 1912 first seizure medication
Phenobarbitone was created as a sedative
but soon it was found useful for seizure and
it is still using today.
1929 the German Psychiatrist Horns Burger
invented the Electro Encephalo Gram
(EEG) provided the first recording of
epileptic discharge from brain.

6. • In 1930 Gibbs co-related the clinical
evidence of epilepsy EEG findings.
• Even in 20th century some state has the low
that ―Those With Epilepsy Shall Not Wed‖ .
But luckily this practice was ended.
• 1997 FDA approved a device ― The Vagus
Nerve Stimulator‖ to treat partial epilepsy in
adults.
• Napoleon, Julius Caesar, and Jonty Rhodes
are some prominent personalities who
suffered due to epilepsy.

7. Seizure
• Seizure the word came from a Latin word
sacire means -to take possession of
• Seizure is a paroxysmal uncontrolled
electrical discharge of neurons in the brain
that interrupts normal functioning, leading to a
sudden, violent involuntary series of
contractions of a group of muscle.

8. DEFINITION
• Seizure is a clinical syndrome caused by an
electrical event that is characterized by
hyper excitability and hyper synchronization
of large group of neurons in the brain.
• Seizure is a medical disorder in which too
many brain cell become excited at the same
time.
• This can cause unexpected changes in the
behavior, motor activity, sensation, or
consciousness.

10. • Seizure is like an electrical storm in the
brain.
• The end of the seizure is the transition
back to the individuals normal stage.
• Seizure may occur spontaneously
without any cause.
• A seizure typically goes on for a few
seconds to a few minutes.

11. In adults metabolic disturbances that
cause seizure include
 Acidosis
 Electrolyte imbalance
 Hypoglycemia
 Hypoxia
 Alcohol and barbiturate withdrawal
 Dehydration.

12. Extracranial disorders that cause seizure
are
• Heart, lung, liver, or kidney diseases
• Systemic lupus erythematosus.
• Diabetes mellitus
• Hypertension
• Septicemia

13. What is Epilepsy?
[Epilepsia- (Greek)- seizure]
Epilepsy is a chronic disorder of abnormal,
recurrent, excessive, and self terminating
electrical discharge from neurons.
Spontaneously recurrent seizure more than
one time is called as epilepsy.
The periods between seizures can vary
widely and can be measured in minutes,
hours, days, weeks, months, or even
years.

14. • However there is repetitive seizure activity at
some time in the future regardless of the
interval.
• Clinically epilepsy is recurring seizure in
which there is disturbance in some type of
behavior ( motor, sensory, autonomic, or
consciousness.)
• To count it as epilepsy seizure should have
to appear spontaneously without an
immediate precipitating factor.
• Seizure resulting from systemic or metabolic
disturbance are not considered as epilepsy.

15. Epidemiology
• About 1% of the world population has
epilepsy.
• Around 60 million people in the world
are affected by epilepsy.
• Every individual have 1% life time risk
to develop epilepsy.
• Incidence of epilepsy is 1 in 100 people
in India.

16. • Every year one lack more cases get
added.
• 30% of the epilepsy cases are of
uncontrollable or persistent.
• The greatest number of people with
newly diagnosed epilepsy will be among
children under the age of two years and
the elderly over the age of 60 years.
• The children who have Parents with
epilepsy are having 5- 20% chance to
develop epilepsy.

17. more common in

18. Etiology and risk factors
Seizure is a symptom of numerous
disorders, but in 70% of sufferers
the cause remains unclear
(idiopathic) despite careful history
taking,clinical examination and
investigation!

19. Common causes
• The risk factors for developing seizure
can be broadly classified under three
headings.
• 1- Metabolic or Chemical Imbalance.
• 2- Structural defects
• 3- Infections or Inflammatory reactions.

20. Metabolic or Chemical Imbalance
• Hypoglycemia.
• Hyperglycemia
• Hypocalcaemia
• Hyponatremia
• Hypoxia
• Uremia
• Toxins
• Drugs intoxication or withdrawal.
• Alcohol consumptions
• Hyperthermia

21. Structural defects
• Gliotic scars
• Post traumatic
• Post infraction
• Post infections
• Congenital malformation
• Vascular malformations
• Brain tumors ( primary or metastatic)

22. Infections or Inflammatory reactions.
• Meningitis
• Encephalitis
• Brain abscess
• Syphilis
• Systemic lupus erythematosus .
• Neurocysticercosis ( parasitic infection
of the CNS)

23. OTHER CAUSES
• Genetic factors(hereditary)/mutations
• Other diseases like
• Alzheimer's disease
• Dementia
• Kidney Failure
• Liver Failure
• Heart Failure

24. The risk factors classified
according to age group
• In young adults-
• Trauma
• Alcohol withdrawal
• Illicit drug use
• Brain tumor

25. • Above 35 yr and older-
• Cerebrovascular disease
• Alzheimer’s disease
• Neurodegenerative disease
• Metabolic disorder
• Brain tumor
• Alcohol withdrawal

28. Common triggers
• Stress
• Sleep deprivation
• Boredom
• Alcohol
• Missing tablets
• Menstruation
• Photosensitivity (TV/flicker)
• Missed meals/hypoglycaemia
• Sudden loud noise
• Street drugs
• Particular odour

34. PATHOPHYSIOLOGY
• Ropper and Brown explains that there is three
sets of disturbances present before a seizure
activity.
• 1-A population of pathologically excitable
neurons.
• 2- A reduction in the activity of normal
inhibitory gamma- aminobutyaric acid(GABA).
• 3-An increase in excitatory glutaminergic
activity through recurrent connections to
spread the discharge(hyper synchronization of
neurons).

36. PATOPHYSIOLOGY
Due to etiological factors
Alteration in normal chemical and structural
environment of brain neurons
Scarring of brain tissue (gliosis)
A group of abnormal neurons forms in the brain
(seizure focus)

37. The neurons present in the seizure focus are
hypersensitive neurons and their cytoplasmic
membrane are highly permeable(hyper excitable).
This increased permeability renders them
susceptible to activation by triggering factors
Any stimulus that causes depolarization of the cell
membrane of these neurons induce spontaneous
firing of electrical impulse

38. Once the intensity of seizure discharge exceeds a
certain point or seizure threshold, it spreads by
physiologic pathways to involve adjacent or
distant areas of the brain
It spreads to the adjacent, cortical, and thalamic
brain stem nuclei.
This activity spread to involve the whole brain
then a generalized seizure occurs causing muscle
contraction and loss of consciousness.

39. There are some inhibitory centers in the brain which
act as counter regulatory mechanism
These inhibitory neurons of the cortex, anterior
thalamus, and basal ganglion nuclei becomes active
and slows the neuronal electrical discharge
(diencephalo cortical inhibition)
This interrupting the seizure and produce
intermittent contraction and relaxation phase
(clonic phase)

40. As epileptogenic neurons are exhausted and the
inhibitory process builds up the seizure stops and
paralysis of neurons of epileptogenic focus occurs.
This leads to Todd’s post epileptic paralysis.
Todd’s paralysis is a temporary focal weakness or
paralysis following a partial or generalized seizure
that can last for up to 24 hours.

41. • Several ligand-gated ion channels have been
linked to some types of frontal and
generalized epilepsies.
• Epilepsy is linked to mutations of the genes
which code for sodium channel proteins;
these defective sodium channels stay open
for too long thus making the neuron hyper-
excitable.

42. • Glutamate, an excitatory neurotransmitter,
may thereby be released from these
neurons in large amounts which — by
binding with nearby glutaminergic neurons
— triggers excessive calcium (Ca2+)
release in these post-synaptic cells.
• Such excessive calcium release can be
neurotoxic to the affected cell

43. • The hippocampus, which contains a large
volume of just such glutaminergic neurons is
especially vulnerable to epileptic seizure,
subsequent spread of excitation, and
possible neuronal death.
• Another possible mechanism involves
mutations leading to ineffective GABA (the
brain's most common inhibitory
neurotransmitter) action.

44. During seizure there is drastic increase in
cellular respiration and glycolysis. This
markedly increased demand for ATP, (the
major direct source energy in the brain) the
brain depends mainly on the metabolism of
glucose for the production of phosphate
bonds necessary for ATP.
 Cerebral blood flow to the brain also
increased to meet the increased oxygen
demand.

45. Increased metabolic activity in contracting
skeletal muscle often can result in
hypoxemia and hypoglycemia particularly
during status epilepticus.
A rapid decrease in ATP and glucose with
increased level of lactate following seizure.
This produce energy deficit, hypoxia,
cellular exhaustion, and selected cellular
destruction.

46. Phases of seizure
1- The prodromal phase
 This refers to symptoms, such as a
headache or feeling of depression, that
precede a seizure by hours
 Some people have vague feeling one
or two days prior to the seizure that
something is going to happen.

47. 2- The aural phase
Breeze (Greek word)
It is a premonitory sensation or warning experienced
at the beginning of a seizure, which the patient
remembers.
An aura may be gustatory, visual, auditory, or
visceral experiences.
 unusual sounds
 unusual taste(metallic taste)
 disturbed vision(flashing lights)
 rising thoughts
 unusual smell(burning rubber)

49. • In complex partial seizure the person may
feel
• déjà vu—new experiences appear familiar,
jamais vu—familiar things appear foreign
• Forced thinking may occur in seizure
involving temporal lobe.
• Some may feel rising of body
• Some person may feel fear and panic.
• There are some other strange feeling which
is difficult to explain.

50. Physical symptoms of aura are
 dizziness
 headache
 lightheadedness
 numbness
 upset stomach
 tingling sensation
• Aura usually occur seconds to minutes
before a seizure
• If a patient has an aura it usually the same
experience each time.

51. 3- The ictal phase
 ― Ictus ― is a Latin word means seizure.
 It proceeds with full seizure activity.
 In this phase there is abnormal electrical
discharge from the brain cause alteration in
sensation, movement, behavior and
consciousness.

52. 4- The postictal phase
 It is the period immediately after a
seizure has occurred
 The end of the seizure is the
transaction back to the individual
normal stage.
This can last to seconds to hours.
The person may have headache,
muscle soreness, sore tongue or cheek.
The person may be tired and sleep for
long hours

53. EPILEPSY -
CLASSIFICATION
PARTIAL SEIZURES (FOCAL
SEIZURES)
GENERALISED SEIZURES

56. PARTIAL SEIZURES (FOCAL
SEIZURES)
• It begins with an electrical discharge in one
limited area of the brain.
• Partial seizure begin in a specific region of the
cortex as indicated by the EEG changes and by
clinical manifestations.
• Partial seizure may be confined to one area of
the brain and remain partial or focal in nature.
• The impact of partial seizure depends on where
in the brain it originates and how it spread

58. Partial seizures are again divided
in to,
Simple partial seizures.
Complex partial seizures.
Partial seizures evolving to
secondary generalized seizure.

59. Simple partial seizures.
The awareness is preserved
The memory is preserved.
The consciousness is preserved.
If all these are preserved then we call the
partial seizure as simple partial seizure.
In simple partial seizures, only a finger or
hand may shake or the mouth may jerk
uncontrollably

60. • The person may talk unintelligibly, may
be dizzy, and may experience unusual
or unpleasant sights, sounds, odors, or
tastes, but without loss of
consciousness.
• They may involve motor, sensory,
autonomic, or psychic phenomena or a
combination of these.

61. Focal motor seizure
• Symptoms depend on the motor region
activated.
• May remain focal or may spared to
other areas on the motor strip, a
process called march, this type of
seizure called jacksonian seizure.

62. • If a seizure spread along the motor strip the
switching can watch along with the different
parts of the body. It is called as jacksonian
march.
• For example the seizure may begins in the
fingers of one side and march to the hand,
wrist, forearm, and arm of the same side of
the body.
• Focal motor attack may cause head to turn
to one side opposite epileptic foci.

64. • Todd’s paralysis may result and may lasts
for minutes to hours.
• Continuous focal motor seizure is called
Epilepsia Paralysis Continua
FOCAL SENSORY SEIZURE
Arise from cortical sensory strip
Usually feel like numbness, tingling
sensation, spatial disorientation etc.
Auditory seizures with various sounds,
gustatory sensation like metallic taste or
primary tastes(salty, sweet, sour, or bitter).

65. • Occipital lobe contains brain cell responsible
for vision . Seizure in the occipital lobe can
produce flashing lights and visual
hallucination.
• Some patients have the feelings of floating
sensation or vertigo.
• Autonomic seizures
• Autonomic seizures are common, evoking
changes in autonomic activity (e.g., altered
heart or breathing rate, sweating) or visceral
sensations (e.g., in abdomen or chest).

66. Psychic seizures
• Psychic seizures affect how we feel, think,
and experience things.
• Patients may report a "dreamy state,"
transitional between waking and
unconsciousness.
• Psychic seizures can alter language function,
perception or memory.

67. • They can also evoke spontaneous
emotions (e.g., fear, anxiety, or
depression), altered perceptions of time
(time slowing down or speeding up)
• Altered perceptions of familiarity;(déjà
vu—new experiences appear familiar,
jamais vu—familiar things appear
foreign), depersonalization (feeling one
is not oneself), derealisation (the world
seems unreal, dream-like), or autoscopy
(viewing one's body from outside).

68. Complex partial seizures
The consciousness
The awareness
The memory
If any of the above factors are absent we
call the partial seizure as complex
partial seizure.
These are often called as psychomotor
seizures.

69. • The person either remains motionless or
moves automatically but in appropriative for
time and place.
• This will leads to a moment to moment
world. During this time the person may
repeat the same phrase or action over and
over in an automatic way not recognizing
the repetition. This automatic activity is
called as automatisms.

70. • Automatic movements (automatisms) are
common and involve the mouth (e.g., lip
smacking, chewing, swallowing), upper
extremities (e.g. fumbling, picking),
vocalization/verbalization (e.g., grunts,
repeating a phrase), or complex acts (e.g.,
shuffling cards).
• More dramatic automatisms occasionally
occur (e.g., screaming, running, pelvic
thrusting).

71. • Others just freeze and steer blankly
without any movement.
• Some time the person may experience
excessive emotions of anger, fear,
elation, or irritability.
• Complex partial seizures usually last
from 15 seconds to 3 minutes.
• After the seizure, postictal confusion is
common, usually lasting less than 15
minutes, although other symptoms,
such as fatigue, may persist for hours.

72. • Whatever the manifestation the person
does not remember the episode when it
is over and what they did.
• Later the memory start working again
except for a gap during the seizure.
• The location of the discharging focus is
usually in the temporal lobe, hence it is
known as temporal lobe seizure.

73. • If the temporal lobe seizure spreads to both
temporal region then the manifestation
include
• Pause in activity
• Confusion
• Temporary memory loss and
• Fragmentary automatic robot like
activity

74. Partial seizures evolving to
secondary generalized seizure
• It begins as a Partial seizure may spread to involve
the entire brain, culminating in a generalized tonic-
clonic seizure
• The abnormal electrical activity may spread to
involve other areas of the brain, to cause a tonic
clonic seizure.
• This may result in a transient residual neurologic
deficit postictally.
• This is called as Todd’s paralysis (focal weakness)

75. GENERALIZED SEIZURES
• It is characterized by hyper
synchronized electrical activity of the
neuron throughout the brain.
• Generalized seizure occur when the
misfiring of the nerve cell occur over the
entire brain at the same time.
• Because the entire brain is affected at
the onset of the seizure there may be
no warning or aura.

76. Generalized tonic-clonic seizure
Absence seizure
Myoclonic seizure
Tonic seizure
Clonic seizure
Atonic seizure
Generalized seizures is classified
again in to

77. Tonic – Clonic seizure (grand mal)
A prodromal period of irritability and tension may
precede the seizure activity.
Tonic-clonic seizures usually last 30–120 seconds.
The tonic clonic seizure begins with a sudden loss
of consciousness .
The tonic phase there is a major contraction
(increased tones) of the voluntary muscle.
The body stiffens with legs and arms extended.
If the person is standing he will fall in to the ground.
The jaw snaps shut and the tongue may be bitten.

78. • A shrill cry may be heard because of the
forcible exhalation of the air through the
closed vocal cord as the thoracic muscle
initially contract.
• The pupil may dilate and unresponsive to
light.
• During the tonic phase the person may
apnic and may appear pale and dusty.
• This tonic phase may last for 10- 20
seconds.

79. • The clonic phase begins with gradual transition
from the tonicity of the tonic phase.
• The clonic phase is characterized by violent
rhythmic muscular contractions accompanied by
strenuous hyperventilation.
• The eyes roll, and there is excessive salivation
which frothing from the mouth.
• Profuse sweating and rapid pulse are common.
• The clonic jerking gradually subsides in frequency
and amplitude over a period of about 30-40
seconds
• The bladder or bowel control may loose as the
muscle relaxes.

80. • The patient have no consciousness and will
not remember what was happened.
• The person slowly awakes, confusion and
disorientation are common.
• Headache, muscle ache, and fatigue are
common. Sometime the person may sleep for
long hours.
• Tonic-clonic seizure occur at anytime of the
day or night, whether the patient is awake or
asleep.
• The frequency of occurrence can vary from
hours to weeks, months, or years

82. Emergency management of tonic-clonic
seizure.
• Ensure patent airway
• Assist ventilations if patient does not
breathe spontaneously after seizure.
Anticipate need for intubation if gag reflex
absent.
• Suction as needed
• Establish IV access
• Anticipate administration of AED’s to
control seizure.

83. • Monitor vital signs, level of consciousness,
oxygen saturations, pupil reactivity and
Glasgow coma scale.
• Never force an airway between a patient’s
clenched teeth.
• Give IV dextrose for hypoglycemia.

84. Absence seizure (Petit mal )
• It is characterized by 3-20 seconds of absence of
consciousness during which the child may blink rapidly
or roll the eyes or snaffle the lips .
• In absence seizure they disconnect from the world for
a few seconds and came back exactly where they left
out.
• But the child doesn't know what was happened during
those 3-20 seconds.
• It can be mistaken for day dreaming.
• This can happen about 100 times per day and it may
interfere with learning.

85. • Seizures begin and end suddenly.
• There is no warning before the seizure, and
immediately afterward the person is alert and
attentive.
• This lack of a postictal period is a key feature
that allows one to distinguish between
absence and partial complex seizures.
• Absence seizures are often provoked by
hyperventilation
• The EEG signature of absence epilepsy is
the generalized 3 Hz spike-wave discharge

86. • This is more common in children
between the age group of 4 - 14 year of
age, it may disappear during adolescent
period.
• After the seizure the child may anxious
about what was happened and the child
may need reassurance.
• This condition usually not require any
first aide.

87. Myoclonic seizure
• Myoclonic seizures involve a brief, shock-like
jerk of a muscle or group of muscles.
• These are usually so brief, last only for a
second or two.
• Epileptic myoclonus usually causes bilateral,
synchronous jerks most often affecting the
neck, shoulders, upper arms, body, and
upper legs.
 Brief loss of consciousness, may cause fall
and often occur on waking.

88. Tonic seizure
 A sudden onset of maintained increased
tone or stiffness of the extensor muscle
 They often occur during sleep.
 They are characterized by flexion at the
waist and neck, abduction and flexion or
extension of the upper extremities, and
flexion or extension of the lower extremities.
 Typical duration is 5–20 seconds.
 It involves bilateral musculature in a
symmetric or nearly symmetric manner.

89. Clonic seizure
• It is characterized by repetitive rhythmic
clonic movements that are bilateral and
symmetric.
• The EEG characteristics is symmetric
spike wave complexes.

90. Atonic seizure (“drop attack”)
• This type of seizure is also called as akinetic
seizure or epileptic drop attack.
• Atonic seizures consist of a sudden loss of
postural tone, often resulting in falls, or,
when milder, head nods or jaw drops.
• Consciousness is usually impaired and
significant injury may occur.
• Duration is usually several seconds, rarely
more than 1 minute.

91. Diagnostic evaluation
• History collection
- Birth and developmental history.
- Significant illness and injuries
- Family history
- Febrile seizures
• Seizure history.
- Precipitating factor
- Seizure description(including onset,
duration, frequency, postictal stage)

92. • Physical Examination
- Comprehensive neurological
assessment
• Other diagnostic studies includes
CBC
Urinalysis
Electrolytes
S. creatinine
Fasting blood glucose

93. Lumbar puncture
CT scan
MRI
PET scan , (Positron emission
tomography)
EEG ( video-EEG monitoring)

98. First Aid For Seizure
• During seizure
 Stay calm
 Keep the surrounding safe
 Support the victims head by placing a pillow
 Keep the person lie on their side
 Record the time period of seizure
 Make the person as safe and comfortable as
possible
 Loose tightened clothing

99. Do not shift the person unless the place is
harmful to him.
Do not put or give anything in their mouth
Keep their head inclined, so that they
don’t choke
Assess the course and nature of seizure
activity, the body parts involved in the
seizure activity and the presence of
autonomic signs.

102. • After the seizure
Do not restrain him after the seizure is over.
Keep the person in a safe place.
Be calm and reassuring.
Ask the person some simple questions.
Check for injuries.
Be supportive and use a calm and
reassuring voice.
Check the vital signs, and assess the
general condition

103. NEVER DO IT

104. REMEMBER!!
• SEIZURE PATTERNS ARE INDIVIDUAL,
THEREFORE RECOVERY PATTERNS
WILL DIFFER FROM ONE PERSON TO
ANOTHER.

105. COLLABORATIVE CARE
• Antiepileptic drugs(AED’s)
• Surgery
• Vagal nerve stimulation
• Psychosocial counseling

106. Antiepileptic drugs

107. Principles for AED therapy.
1- Do we need to treat the seizure with AED
therapy ?
2- Choosing the best medication for the
patient.
The factors need to consider are
 Efficacy
 Side effects
 Risk of a serious reaction
 Convenience of administration
 Cost

108. 3- Decide best AED regimen.
• The regimen of one drug is called as
Monotherapy (―Start low, increase slow―).
• Advantage of Monotherapy:
• Fewer side effects, decreased drug-drug
interactions, better compliance, and lower
costs
• Addition of a second drug is likely to
result in significant improvement in only
approximately 10 % of patients.

109. 4- Side effects need to be considered.
5- AED can be tapered.
Withdrawal may be considered if the
patient meet the below mentioned criteria
 Normal neurological examination
 Normal IQ
 Normal EEG prior to withdrawal
 Seizure- free for 2-5 yrs or longer
 The person not have had problems with
prior attempts to stop medication.

110. PHENYTOIN (Dilantin)
• Route -Well absorbed when given orally, however,
it is also available as iv. (for emergency)
• Dose -300-400 mg/day
• Indication- Used for partial Seizures & generalized
tonic-clonic seizures. But not effective for absence
Seizures
Mechanism of Action:
Membrane stabilization by blocking Na & Ca influx
into the neuronal axon or inhibits the release of
excitatory amino acids via inhibition of Ca influx.
.

111. Side effects
• Gingival hyperplasia
• Hirsutism
• Megaloblastic anemia
• Hypersensitivity reactions (mainly skin rashes and lesions,
mouth ulcer)
• Hepatitis –rare
• Fetal malformations- especially cleft plate
• Bleeding disorders (infants)
• Osteomalacia due to abnormalities in vitamin D metabolism
• Hyperglycemia
• GI Disturbances

114. CARBAMAZEPINE(Tegretol)
• Route-available as an oral form only
• Dose -200-800 mg/day (given BD as
sustained release form)
• Indication -First line drug for partial
seizures and tonic – clonic seizures.
• Action –decrease sodium and calcium ion
influx in to neuronal membranes.

115. Side Effects of Carbamazepine:
• G.I upset
• Drowsiness, ataxia and headache; diplopia
• Hepatotoxicity- rare
• Congenital malformation (craniofacial
anomalies & neural tube defects).
• Hyponatremia & water intoxication.
• Late hypersensitivity reaction (erythematous
skin rashes, mouth ulceration and
lymphadenopathy).

116. PHENOBARBITAL
(PHENOBARBITONE)
• Route- oral and IV
• Dose- 50- 150 mg/day (1-3 mg/ kg/ day).
• Indication- status epilepticus, and in
generalized seizures except absence and
partial seizures.
Mechanism of Action:
• Increases the inhibitory neurotransmitters
(eg: GABA ) and decreasing the excitatory
transmission(CNS depressant).

117. Side effects:
 Somnolence
 Confusion
 Hypersensitivity reaction
 Renal impairment
 Sedation
 Drowsiness
 Fatigue
 Depression of cognitive functioning.

118. SODIUM VALPROATE or
VALPROIC ACID
• Route – oral (available as capsule, Syrup),
and I.V
• Dose-1000- 3000 mg/ day.
• Indication -Very effective against absence
seizure. Also, effective in generalized
tonic-clonic, tonic, atonic and Myoclonic
seizures.

119. ACTION- Increase the concentration of inhibitory
neurotransmitter GABA.
Side effects
• Drowsiness
• Difficulty in thinking
• Psychotic reactions
• Nausea, vomiting and GIT disturbances
• Increased appetite & weight gain
• Transient hair loss.
• Hepatotoxicity
• Thrombocytopenia

120. TOPIRAMATE (topamax)
• Route – Oral
• Dose- 25-50 mg/ day(max-1600mg/day) at
weekly interval.
• Indication- Recently, this drug become
one of the safest antiepileptic which can
be used alone for partial and generalized
tonic-clonic, and absence seizures.
Action- Blocks sodium channels (membrane
stabilization) and also enhances the
inhibitory effect of GABA.

121. Side effects:
• Ataxia
• Nystagmus
• Diplopia
• Weight loss
• Sedation
• Dizziness
• Fatigue
• Nausea
• Paresthesias (abnormal sensation )
• Nervousness

122. Surgery

123. SURGICAL MANAGEMENT
• A proportion of the patient's with intractable
epilepsy will benefit from surgery.
• The aim of the surgery is to carefully remove
the brain tissue that is sparkling the seizure
while leaving intact areas that control other
functions.
• Epilepsy surgery procedures:
• Curative (removal of epileptic focus) and
• palliative (seizure-related risk decrease and
improvement of the QOL)

124. Curative (resective) procedures:
 Temporal lobectomy
Lesionectomy,
Cortical resection,
Hemispherectomy.
Palliative procedures:
• Corpus callosotomy
• Vagal nerve stimulation (VNS).

125. TEMPORAL LOBECTOMY
 Seizure most commonly arising from the one or
both temporal lobe.
 Temporal lobectomy is a resective surgery
(resection= removal) in which the area of the
temporal lobe which is responsible for seizure is
surgically removed.
 In the deep front part of the temporal lobe are
located the most seizure prone structures.
 These areas are hippocampus and the amygdala
which is removed by cutting and suction.
 The CSF surrounding the brain fill the area

126. • Nausea and headache are common during post
operative period.
• The clean surgical scar will not produce seizure
most of the time.
• Temporal lobectomy is the most common and
successful type resective surgery.
• Following temporal lobectomy memory and word
finding may be affected.
• There is improvement in anxiety and depression
after temporal lobectomy.
• Some patients may experience visual problems of
right upper visual field

127. • There is 1-2% chance of stroke after
surgery
• 0.1% chance of death
• After temporal lobectomy 55- 75% are free
of seizure that impair consciousness.
• 10-30% have significant reduction of
seizure after surgery.
• However 15% of patients have no
improvement after surgery.

129. LESIONECTOMY
• Is the removal of the scar tissue or brain
lesion which is responsible for seizure.
• Lesionectomy have a stroke risk of 1-2% .
• Depending up on the position of seizure
focus there is risk of causing impairment in
language, movement , or sensation.

130. CORPUS CALLOSOTOMY
• The cerebral hemispheres are connected
internally by the corpus callosum.
• These are a broad band of white matter
containing axons that extended between the
hemispheres.
• After a partial corpus callosotomy the seizure
reduction is around 60-80% for certain seizure
types including tonic-clonic, Atonic, and tonic
seizures.
• This surgery have a slightly higher risk of stroke
or problems with attention and behavior.

132. HEMISPHERECTOMY
• Removal of half of the brain
• In the patients some of the brain function
is already impaired and the remaining will
be lost after surgery.
• This procedure will provide complete
seizure relief in 75% of patients.

134. Vagal nerve stimulation
• Is effective in treatment of partial seizures in
patients who are:
 Refractory to multiple drugs
 Sensitive to the adverse effects of antiepileptic
 Having difficulty to follow medication schedule
• In this method an electrode is surgically placed
around the left Vagus nerve in the neck.
• It is connected to a battery placed beneath the skin
in the upper chest and the battery is surgically
replaced about every 5 years.

135. • The device is programmed to deliver intermittent
electrical stimulation to the brain to reduce the
frequency and intensity of seizures.
• Intermittent stimulation is delivered every 0.3–10
minutes for 7–30 seconds, but patients who
experience a seizure warning can trigger the
device manually.
• The stimulation may interrupt synchronization of
epileptic brain wave activity.
• 30% of patients have 50% reduction of seizure by
implanting this device.

136. The adverse effects are
• Coughing
• Hoarseness
• Dyspnoea
• Tingling in the neck

140. Non Pharmacological
Methods Of Treatments.
• Lifestyle modifications,
• particularly avoidance of alcohol and sleep
deprivation, can be very important in certain
syndromes and individuals.
• Relaxation, biofeedback, and other
behavioural techniques can help a subset of
patients, especially those with a reliable aura
preceding complex partial or secondarily
generalized seizures.

141. KETOGENIC DIET
• The ketogenic diet has been used for more
than 80 years in children with severe seizure
disorders.
• It is based on the observation that ketosis
and acidosis have anti-seizure effects.
• Strict protein, calorie, and especially
carbohydrate restriction in the setting of a
high fat diet is needed for ketosis, and may
be difficult to maintain.

142. • In a minority of patients with intractable
epilepsy, staying on this diet for months
or years can result in a sustained
improvement in seizure control, rarely
even allowing withdrawal of AEDs.

145. Complication
1-STATUS EPILEPTICUS
Status epilepticus is defined as more than 30
minutes continues seizure activity or two or more
sequential seizure without full recovery of
consciousness between seizure .
The most common cause is an abrupt
discontinuation of antiepileptic drugs.
Other causes are fever, withdrawal from alcohol, or
sedative.
Status epilepticus may occur with frontal lobe
lesions (strokes), following head injury, drug
intoxication, metabolic disturbances or pregnancy.

146. Clinically status epilepticus present with
obvious tonic, clonic, or tonic-clonic
movements with subtle twitching of the
hand or face; or with absence of
movement.
It can occur in both convulsive and non
convulsive seizure.
Convulsive seizures can be easily
observed clinically, but partial seizures are
less obvious and very difficult to identify.

147. The most common type of status epilepticus
is tonic-clonic status epilepticus.
Higher rates among the very young and
very old.
Status epilepticus is a medical emergency
associated with significant mortality or
morbidity (20%), if not treated aggressively.
It can cause cardiopulmonary dysfunction,
hyperthermia, and metabolic imbalance can
occur , leading to cerebral ischemia and
neural death.

148. Management of status
epilepticus
• 1- ABCs of life support.
• Position the patient to avoid aspiration or
inadequate oxygenation.
• A soft plastic airway is inserted if it is possible
to do so without forcing the teeth apart.
• The airway will need to be suctioned.
• Oxygen is administered 100% through nasal
cannula.

149. • Monitor respiratory function with pulse
oximetry.
• IV access should be secured and vital signs
and neurological signs should be monitored
frequently.
• Monitor arterial blood gases as the patient
will have profound metabolic acidosis.
• Hypoglycemia should be treated by
administering 50 ml of 50% glucose.
• Hyperthermia should be corrected by
passive cooling.

150. • 2-Administrating antiepileptic drugs.
Time line
in
minutes
Drug (progression along this algorithm if
the pervious drug is not effective)
0-3 1-Lorazepam ;0.1 mg/kg IV at 2mg/minutes
4-23 2-Phenytoin 20 mg/kg in normal saline at rate
of 50mg/minutes.
22-33 3- Phenytoin (additional) 5- 10 mg/kg
37-58 4- Phenobarbital 20mg/kg IV at a 50-75
mg/min
58-68 5- Phenobarbital additional 5-10mg/kg
6- anesthesia with midazolam or protocol

151. • 3-Treating The Underlying Cause.
• Find out the underlying cause and treat the
primary problem.
• 4- Preventing Or Treating Medical
Complications.
• The patient must be moved to well equipped
ICU .
• Hypoxia, hyperthermia, hypoglycemia,
hypotension, cardiac arrhythmias, aspiration
pneumonia and myocardial infraction can
occur.

152. • Other complications of epilepsy include
• 2- Severe Injury Due To Accidents
• 3- Depression
• 4- Sudden Unexpected Death In
Epilepsy.(SUDEIP)
• This is the syndrome attached where a
person with epilepsy dies suddenly and no
other cause of death is revealed.

153. Patient education
Adhere to treatment regimen.
Regular review and health check up
Avoid alcohol
Proper diet
Proper rest and sleep
Avoid stress by practicing yoga,
meditation etc..
Never suddenly stop medication

154. Non-epileptic attack
disorder
• These are attacks which arise for
reasons other than those which cause
epilepsy. They suggest an underlying
psychological or emotional problem.
• The incidence of NEAD is higher in
women
• NEAD often begins in adolescence or
early twenties

155. • A history of previous trauma or abuse is
quite common
• Antiepileptic drugs are unhelpful
• Stress Attacks
The person is unable to cope with
certain situations. This may be specific
life events, or more general changes
such as adolescence.

156. • Distress Attacks
Feeling of slipping in and out of
consciousness. Inner distress. Attacks
occur as a way of avoiding feelings.
Often difficult and painful recovery.
Treatment:
“support without fuss”
Psychotherapy

157. Nursing diagnosis
• Ineffective breathing pattern related to
neuromuscular impairment secondary to
prolonged tonic phase as evidenced by
abnormal respiratory rate and rhythm.
• Risk for injury related to seizure activity.
.

158. • Ineffective coping related to perceived
loss of control and denial of diagnosis
as evidenced by verbalizations about
not having epilepsy.
• Ineffective therapeutic regimen
management related to lack of
knowledge about management of
seizure disorder as evidenced by
verbalization of misconception.

159. Questions?????????

160. Thank you