Epilepsy is characterized by recurrent unprovoked seizures caused by abnormal neuronal activity in the brain. Key questions in evaluating epilepsy include determining seizure type, identifying underlying causes or syndromes, selecting appropriate anti-epileptic drug treatment, and determining criteria for stopping treatment or pursuing surgical options. Diagnosis involves a detailed history and examination, as well as EEG and potentially MRI to classify the epilepsy syndrome and guide management.

1. Epilepsy
Recurrent unprovoked seizures

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

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

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

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

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

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

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

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

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

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

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

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

14. Surgery
Refractory epilepsy with
symptomatic localization

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

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