This document defines seizures and epilepsy, describes different types of seizures, and outlines evaluation and treatment approaches. It summarizes that seizures are caused by sudden bursts of electrical activity in the brain, epilepsy is defined as two or more unprovoked seizures, and evaluation involves medical history, physical exam, EEG, and sometimes neuroimaging to classify seizures and determine underlying causes and treatment.

1. Seizure & Epilepsy

2. Definitions

3. SeizureA sudden surge of electrical activity in brain that usually affects how a person feels or acts for a short time.Some seizures can hardly be noticed, while others are totally disabling.

4. EpilepsyA condition that affects central nervous system (CNS)had at least 2 seizures not caused by some known medical condition like alcohol withdrawal or extremely low blood sugar.not indicate anything about the cause of the seizures, what type they are, or how severe they are.

5. Momentary loss of consciousness Fit Faint Fake

6. Transient loss of consciousnessHistory and PhysicalWitness accountDéjà vuJamais vuAphasiaOlfactory auraEpigastric sensationTongue bitingPost event deliriumFocal neurodeficitLight-headednessSweatingProlonged standingPrecipitants eg.micturitionChest painPalpitationSlow heart rateLow blood pressureAphasiaDeliriumHead turnAutomatismPosturingConvulsionPostictal deliriumMyoclonus or convulsionafter pallor,sweating and collapsePallorSweatingSlow pulseLow BPConvulsive syncopeSeizureSyncopeSyncopeSeizure

9. Nonepileptic causes for spellsPhysiologicTremorVasovagal syncopeCardiac arrhythmiasMigraineMedication adverse effectsTransient ischemic attacksAutonomic dysfunction

10. Nonepileptic causes for spellsPsychologicAnxietyPanic attacksMood disorderPersonality disorderPsychosisSomatiform illnessPsychogenic seizures

11. Phase of seizuresPreictal phase or aura or warningIctal phase : simple or complex partial or generalized tonic-clonic seizurePostictal phaseor recovery period : last from seconds to minutes to hours

12. Precipitants of seizure Sleep and lack of sleep Drugs and alcohol Intercurrent illness : infection, electrolyte imbalance Menstruation Stress and worry Other precipitants-reflex epilepsy

13. Classification of seizurePartial (focal, localized) seizuresGeneralized seizures (convulsive or non-convulsive)Unclassified epileptic seizures

14. Partial (focal, localized)seizuresSimple partial seizures (preserved consciousness) Complex partial seizures (impaired consciousness) Partial seizures evolving to secondarily generalized seizures

15. Simple partial seizures (preserved consciousness)With - motor signs - somatosensory or special sensory systems - autonomic symptoms or signs - psychic symptoms

16. Complex partial seizures (impaired consciousness) - Simple partial onset followed by impairment of conscious - With impairment of consciousness at onset

17. Partial seizures evolving to secondarily generalized seizures - Simple partial seizures evolving to generalized seizures - Complex partial seizures evolving to generalized seizures - Simple partial seizures evolving to complex partial seizures evolving to generalized seizures

18. Generalized seizures (convulsive or nonconvulsive)- Absence seizures Typical absences Atypical absences- Myoclonic seizures- Clonic seizures- Tonic seizures - Tonic-clonic seizures - Atonic seizures (astatic seizures)

19. Unclassified epileptic seizures - Neonatal seizures - Recurrent status epilepticus - Rare or ‘isolated’ seizures

20. Epileptic seizureAll clinical andlaboratory dataneuroimagingSeizuredescription and EEGEtiologySeizuretype (s)

21. SeizureIdiopathic Generalized epilepsy likelyFeatures of focal epilepsyEpilepsy or PNESProvoked seizuresTreat cause +/- AEDEEGEEGMRI/CT brainVideo EEGPNES=psychogenic non-epileptic seizuresAED=antiepileptic drug

22. Laboratory investigationCBC FBS, BUN, CreatinineElectrolyte , Liver function test , Ca+2 Mg+2Electro-encephalography (EEG)Video EEGNeuroimaging : CT Scan, MRI, MR Spect, PETSpecial investigation : ammonia, lactate, pyruvate etc.

23. Electroencephalogram

24. What value is the EEG?Add weight to the clinical diagnosis

25. Aid classification of epilepsy

26. Detection of the structural brain lesion.EEG30 minute interictal EEG –useful when clinical suspicion of epilepsyTiming is importantWithin 24 hr of generalized convulsion: 50% have abnormal EEG First 48 hr: 21-34% have epileptiform activitySleep EEG or sleep-deprived EEG might increase diagnostic yield

27. Normal EEG

28. Primary generalized epilepsy—ictal EEG

29. Primary generalized epilepsy- interictal EEG

30. Burst of generalized spike and wave discharges—typical absence seizure

31. EEG monitoring

32. Video MonitoringHelpful in determining nature of seizure disorder (epilepsy, convulsive syncope, or psychogenic seizures)

33. Indication for neuroimaging in patients with seizuresPartial seizure Late onset unprovoked seizure (age > 25) Unexplained neurological signs Focal slow waves EEG poor control or new symptoms / signs

34. NeuroimagingIn the absence of trauma: CT and MRI brain for patients presenting with suspected first unprovoked seizure or with a focal neurological deficit.MRI is preferable for looking for neuronal migrational disorders, major malformations, vascular anomalies, tumors

35. The causes of epilepsyGenetic factorCongenital abnormalitiesTrauma and the effect of craniotomyCNS infectionCerebrovascular diseaseCerebral tumorsAlzheimer’s disease and other degenerative disease Others

36. Neurocysticercosis

37. Cerebral infarction

38. Intracerebral hemorrhage

39. Brain tumor or metastasis

40. Lt mesial temporal sclerosis

41. Cortical dysplasia

42. 52 year old woman with intractable seizurePET scan

43. PET using F-18 FDG-- Decreased FDG uptake in both temporal lobes, right worse then left but otherwise relatively symmetric

44. What to do?Generalized seizureLoosening the patient’s clothingLower the patient gently to the floor, turn them onto their side and cushion headNothing is put into the mouthRemove any items that could cause injury

45. What to do? ---Generalized seizureWhen the seizure is over, allow the patient to rest or sleepIf they are able to return to their feet, help them homeObtain medical help if they continue to experience breathing problems once the seizure is over, or if the seizure lasts a long time(over 10 mins), or when another attack quickly follows the first

46. What to do?Partial seizuresStay with the patients throughout the seizureProtect them from any dangerous objectTaking care not to restrain them in anyway

47. First aids

48. Treatment

49. จะต้องให้ยากันชักหรือไม่?รักษาไม่รักษาผลข้างเคียงของยาโอกาสจะชักซ้ำ

50. Choose a drug : considering the following factorsThe seizure type and prognosis Age The possibility of pregnancy Toxicity Drug interaction Price

51. RISK OF RECURRENT SEIZUREThe recurrence risk follow a first unprovoked seizure 27%-52%50% recurrence occur within 6 months over 80% within 2 years of initial seizurestwice as likely to have another seizure if you have a known brain injury or brain abnormality.

52. RISK OF RECURRENT SEIZURE(cont)If you do have two seizures, there's about 80% chance that you'll have more.

53. Factors predictive of a high rate of seizure recurrence after the first unprovoked seizureAbnormal neurologic status by NE or imaging

54. EEG abnormalities (especially epileptiform)

55. Partial seizuresCounseling before treatment1. Aims of treatment2. Prognosis and duration of the expected treatment3. Importance of compliance4. Side effects

56. Starting antiepileptic treatmentProspective risks Usual clinical Factors that may modify of epilepsy practice usual practice Single seizure No treatment Progressive cerebral disorder (clinically Dx) Clearly epileptic EEG 2 or more seizure Monotherapy Seizures widely separated (clinically Dx) in time (> 1 year) Identified precipitating, factors (eg, drugs, alcohol,reflex stimuli) Probability of poor compliance (eg, personality disorder) Attitude of patients/parents

57. MoreAntiepileptic drugs20PregabalinLevetiracetamOxcarbazepineTiagabineFosphenytoin15TopiramateGabapentinFelbamateLamotrigineZonisamide10VigabatrinSodium ValproateCarbamazepineBenzodiazepinesEthosuximide5PhenytoinPrimidonePhenobarbitalBromide0184018601880190019201940196019802000Calendar yearAntiepileptic Drug Development

58. First-line choice of AEDs according to seizure type

59. Advantages of MonotherapyBetter seizure controlReduced side effectsAbsence of drug interactionsReduced teratogenic effectsBetter complianceReduced cost of medicationImproved quality of life

60. Expected outcomes of AED therapyWell controlled 65%Unsatisfactorilycontrolled 35%MonotherapyWell controlled 10%Unsatisfactorilycontrolled 25%Add-on therapyUnsatisfactorilycontrolled 20%Well controlled 5%Multiple drug therapy

61. Managing newly diagnosed epilepsyNewly diagnosed epilepsy47%Seizure freeFirst drug13%Seizure freeSecond drugRefractorySurgical assessmentRational duotherapy

62. Adverse effect of AEDDose related

63. Idiosyncratic / allergic

64. Chronic toxicity

65. TeratogenicityOlder AEDs

66. AED interactionsCBZ : autoinduction, VPA, PHT, -PBPHT : CBZ, VPA, PB PB : CBZ, VPA, PHTVPA : CBZ, PB, PHT

67. AEDsDrug interaction with AED and other drugs: via effect on hepatic CYP450 enzyme systemPB, primidone, PHT, CBZ induce CYP enz. : Accelerate breakdown of many prescribed lipid-soluble drugs metabolized by the same system: OCP, cytotoxic, antiarrythmic, warfarinVPA is a weak CYP enz. Inhibitor: Slow clearance of other AEDs such as PHT, LTG. Newer AEDs : less likely to interfere with hepatic metabolism.GBP, LEV,PGB,VGB do not undergo hepatic metabolism

68. Newer AEDsAdjunctive treatment of refractory epilepsySome of these AEDs: LTG, GBP, OXC, TPM have also demonstrated efficacy as monotherapy

69. Effects of phenytoin levelsLevel (mg/ml) Effect0-10 Subtherapeutic10-20 Therapeutic20-30 Mild toxicity; nystagmus, mild ataxia30-40 Moderate toxicity ; ataxia prominent> 40 Severe toxicity; ataxia, conscious - ness, encephalopathy

70. Potential Causes of Treatment Resistant EpilepsyDiagnostic errors:Non-epileptic events Wrong diagnosis of seizure types/ epileptic syndrome Missing of underlying causes/lesionsPatient’s errors:Non-compliance Inappropriate life style, inappropriate metabolism

71. Potential Causes of Treatment Resistant EpilepsyTreatment errors:Wrong choice of drugs Less optimal doses of drugs Inadequate dosing schedulesAntiepileptic drug toxicity Disease itself:Treatment resistant epilepsymetabolic disorder

72. Stopping antiepileptic treatmentAbsolute requirement2-3 years free of all seizures Patient’s informed agreement

73. Factors in favourChildhood epilepsy

74. Primary generalized epilepsy

75. Absence of cerebral disorder

76. Short duration of epilepsy

77. Normal EEG

78. Non-driverAdverse prognostic factorsSymptomatic etiology, identifiable brain pathology Partial-onset seizures or Atonic seizures Late-onset or first-year epilepsy Specific epilepsy syndrome (particularly JME) Abnormal EEGs Multiple seizure types in the same patient Additional mental or motor handicap Long duration or severe epilepsy prior to treatment Poor initial response to treatment

79. Features common to the surgically privileged seizure disordersPresence of a well-circumscribed structural lesion on the MRI (lesional epilepsy)Presence of well-localized interictal epileptiform discharged on the EEGClinical features of habitual seizures indicating focal onsetAbsence of discordance between above featureFocus localized by above features is surgically accessible and involves little or no eloquent cortexAbsence of other potentially epileptogenic abnormalities

80. Status epilepticusA condition in which epileptic activity persists for 30 minutes or more

81. Common etiologies for status epilepticus in children and adolescentsIdiopathicAcute symptomaticElectrolyte disturbanceEncephalitisHead traumaRemote symptomaticPast strokeCNS infectionCerebral palsyProgressive encephalopathyTuberous sclerosisOther neurodegenerationFebrile

82. Status epilepticus management

85. Epilepsy and pregnancy Seizure control Obstetric complication Neonatal outcome

86. Neonatal outcomeRisk of seizure (3 times > normal population)developmental outcomecongenital anomalies 4-8% (2-3 times > normal population)

87. The most common malformationCongenital heart diseaseorofacial cleftneural tube defectintestinal atresiaurogenital defectsNeural tube defect