2. DefinitionDefinition
Defined as 2 or more unprovokedDefined as 2 or more unprovoked
seizuresseizures
Not a single disease, but aNot a single disease, but a
manifestation of underlying brainmanifestation of underlying brain
dysfunctiondysfunction
Single or occasional seizures (eg:Single or occasional seizures (eg:
febrile fits) and those occuring duringfebrile fits) and those occuring during
acute illness should not beacute illness should not be
considered as epilepsyconsidered as epilepsy
3. EpidemiologyEpidemiology
Epilepsy is the most common seriousEpilepsy is the most common serious
neurological diseaseneurological disease
The lifetime prevalence of a singleThe lifetime prevalence of a single
non-febrile seizure is 2–5%non-febrile seizure is 2–5%
The prevalence is slightly higher inThe prevalence is slightly higher in
males and in those in lowermales and in those in lower
socioeconomic groupssocioeconomic groups
4. AetiologyAetiology
The causes of epilepsy vary worldwide andThe causes of epilepsy vary worldwide and
with age.with age.
The aetiology may be multifactorial, and isThe aetiology may be multifactorial, and is
unknown in about two- thirds of patientsunknown in about two- thirds of patients
Community-based surveys in the UK showCommunity-based surveys in the UK show
the following common aetiologies:the following common aetiologies:
• cerebrovascular disease (15%)cerebrovascular disease (15%)
• cerebral tumours (6%)cerebral tumours (6%)
• alcohol-related (6%)alcohol-related (6%)
• post-traumatic (2%)post-traumatic (2%)
5. In the UK, refractory epilepsy is mostIn the UK, refractory epilepsy is most
commonly caused bycommonly caused by
• hippocampal sclerosishippocampal sclerosis
• malformations of cortical developmentmalformations of cortical development
• small foreign tissue lesions (vascularsmall foreign tissue lesions (vascular
malformations, hamartomata and low-grademalformations, hamartomata and low-grade
gliomas)gliomas)
Neurocysticercosis and other infectiousNeurocysticercosis and other infectious
causes are common in developing worldcauses are common in developing world
More than 200 disorders showing aMore than 200 disorders showing a
Mendelian pattern of inheritance featureMendelian pattern of inheritance feature
epilepsy among their manifestations, butepilepsy among their manifestations, but
these account for only about 1% of casesthese account for only about 1% of cases
6. Pathology and pathogenesisPathology and pathogenesis
Reciprocal corticothalamic interaction isReciprocal corticothalamic interaction is
probably important in the generation ofprobably important in the generation of
generalized seizuresgeneralized seizures
Local excitation–inhibition imbalance is theLocal excitation–inhibition imbalance is the
likely basis of partial seizureslikely basis of partial seizures
Modern pathological studies are beginningModern pathological studies are beginning
to define the structural limits of suchto define the structural limits of such
changeschanges
Functional imaging studies will also con-Functional imaging studies will also con-
tribute, with the eventual aim of rationaltribute, with the eventual aim of rational
drug designdrug design
7. DiagnosisDiagnosis
The first step is to establish theThe first step is to establish the
diagnosis of epilepsy.diagnosis of epilepsy.
Type of seizure, syndromicType of seizure, syndromic
classification and aetiology mustclassification and aetiology must
then be determined forthen be determined for
complete characterization and optimcomplete characterization and optim
um managementum management
8. Establishing the diagnosisEstablishing the diagnosis
Epileptic seizures are paroxysmal events,Epileptic seizures are paroxysmal events,
often with impairment of awarenessoften with impairment of awareness
Symptoms may include generalized con-Symptoms may include generalized con-
vulsive movements, drop attacks,vulsive movements, drop attacks,
transient focal motor or sensory attackstransient focal motor or sensory attacks
(including facial and eye movements),(including facial and eye movements),
pychic experiences, episodic phenomenapychic experiences, episodic phenomena
in sleep and prolonged confusional statesin sleep and prolonged confusional states
Diagnosis of epilepsy is clinicalDiagnosis of epilepsy is clinical
9. An eyewitness account is almost essentialAn eyewitness account is almost essential
– there is no substitute for a detailed– there is no substitute for a detailed
history from the patient and a witness, norhistory from the patient and a witness, nor
for direct observation of an attack whenfor direct observation of an attack when
possiblepossible
Ask specifically about:Ask specifically about:
• the circumstances of the episodethe circumstances of the episode
• patterns of occurrencepatterns of occurrence
• preceding symptoms that may localizepreceding symptoms that may localize
seizure origin or suggest other conditionsseizure origin or suggest other conditions
• timing, pattern and tempo of evolution oftiming, pattern and tempo of evolution of
symptomssymptoms
• reported behaviour before, during and afterreported behaviour before, during and after
the eventthe event
Investigations are needed onlyInvestigations are needed only
occasionally to establish the diagnosis, butoccasionally to establish the diagnosis, but
help in managementhelp in management
10. Differential diagnosis of epilepsyDifferential diagnosis of epilepsy
SyncopeSyncope (secondary anoxic movements which(secondary anoxic movements which
may be brief, small or irregular may occur)may be brief, small or irregular may occur)
• VasovagalVasovagal
• MicturitionMicturition
• PosturalPostural
• Vascular disordersVascular disorders
• RespiratoryRespiratory
• CardiacCardiac
Cardiac disordersCardiac disorders
• ArrhythmiasArrhythmias
• Aortic or mitral stenosisAortic or mitral stenosis
• CardiomyopathiesCardiomyopathies
• Other obstructive conditions (e.g. myxoma)Other obstructive conditions (e.g. myxoma)
12. Type of seizureType of seizure
Partial seizuresPartial seizures begin focally in thebegin focally in the
cortex. Such seizures maycortex. Such seizures may
secondarily become generalized,secondarily become generalized,
involving the whole of the cortexinvolving the whole of the cortex
Generalized seizuresGeneralized seizures, in contrast,, in contrast,
involve much of the cortex bilaterallyinvolve much of the cortex bilaterally
from the outset, and usually causefrom the outset, and usually cause
immediate loss of consciousnessimmediate loss of consciousness
13. Generalized tonic-clonic seizureGeneralized tonic-clonic seizure
• May occur spontaneously or following a partialMay occur spontaneously or following a partial
seizureseizure
• May be heralded by a cry, followed by loss ofMay be heralded by a cry, followed by loss of
consciousnessconsciousness
• Falling to the ground with spasm of limbsFalling to the ground with spasm of limbs
• Deepening cyanosis in the tonic phaseDeepening cyanosis in the tonic phase
• Subsequent clonic phase is marked bySubsequent clonic phase is marked by
Stertorous breathingStertorous breathing
Jerky limb convulsion of increasing amplitude andJerky limb convulsion of increasing amplitude and
decreasing frequencydecreasing frequency
• Tongue biting, incontinence of urine and faecesTongue biting, incontinence of urine and faeces
may occurmay occur
• The seizure is typically followed by coma withThe seizure is typically followed by coma with
an ascending consciousness level, then byan ascending consciousness level, then by
confusion, headache, aching limbs and a desireconfusion, headache, aching limbs and a desire
to sleep, before complete recoveryto sleep, before complete recovery
14. Absences:Absences:
• Generalized seizuresGeneralized seizures
• May be simply aMay be simply a sudden, brief cessationsudden, brief cessation
or slowing of activity, with rapid returnor slowing of activity, with rapid return
to normalityto normality
• Accompanied by 3Hz spike and waveAccompanied by 3Hz spike and wave
EEG activityEEG activity
• Atypical absences show slower or poorlyAtypical absences show slower or poorly
formed spike-wave EEG activity; theyformed spike-wave EEG activity; they
may be more prolonged than typicalmay be more prolonged than typical
absencesabsences
15. Epileptic myoclonic jerksEpileptic myoclonic jerks
• usually a sudden flexion movement ofusually a sudden flexion movement of
the armsthe arms
• generalized seizuresgeneralized seizures
• occur in various syndromesoccur in various syndromes
• They are not usually associated withThey are not usually associated with
loss of consciousness, unlessloss of consciousness, unless
accompanied by absencesaccompanied by absences
16. Partial seizures:Partial seizures:
• occur in a wide variety of formsoccur in a wide variety of forms
• Consciousness is not impaired in simpleConsciousness is not impaired in simple
partial seizurespartial seizures
• Complex partial seizures are defined byComplex partial seizures are defined by
impaired consciousness, which mayimpaired consciousness, which may
occur from the outset or may evolveoccur from the outset or may evolve
from a simple partial seizurefrom a simple partial seizure
• automatisms may also occurautomatisms may also occur
17. Partial seizuresPartial seizures
• temporal lobe origintemporal lobe origin
abnormal taste or smell experiencesabnormal taste or smell experiences
rising epigastric sensationrising epigastric sensation
autonomic changesautonomic changes
psychic phenomena such as fear,psychic phenomena such as fear, déjà vudéjà vu andand jamaisjamais
vuvu
• Frontal seizuresFrontal seizures
frequent, bizarre and brief with rapid recovery offrequent, bizarre and brief with rapid recovery of
consciousnessconsciousness
commonly, version of eyes or head and unilateral orcommonly, version of eyes or head and unilateral or
bilateral limb movement or posturing occurbilateral limb movement or posturing occur
may be mistaken for non-epileptic attacks ormay be mistaken for non-epileptic attacks or
paroxysmal movement disordersparoxysmal movement disorders
18. Partial seizuresPartial seizures
• Parietal seizuresParietal seizures
characterized by positive sensory orcharacterized by positive sensory or
paraesthetic symptoms, or by painparaesthetic symptoms, or by pain
• Occipital seizures:Occipital seizures:
positive, possibly coloured visualpositive, possibly coloured visual
phenomena in the contralateral visual field,phenomena in the contralateral visual field,
or loss of visionor loss of vision
19. AutomatismsAutomatisms
• semi-purposeful release phenomenasemi-purposeful release phenomena
• can occur in complex partial seizures orcan occur in complex partial seizures or
prolonged absencesprolonged absences
• clinical differentiation is thereforeclinical differentiation is therefore
difficultdifficult
• They includeThey include
lip-smackinglip-smacking
SwallowingSwallowing
fidgeting with the handsfidgeting with the hands
more complex behaviours includingmore complex behaviours including
vocalization, speech and wanderingvocalization, speech and wandering
20. Status epilepticusStatus epilepticus
• occur in series, or without interruptionoccur in series, or without interruption
• Any recognized seizure type may occur inAny recognized seizure type may occur in
series or status, usually in patients known toseries or status, usually in patients known to
have epilepsyhave epilepsy
• Generalized tonic-clonic status epilepticus isGeneralized tonic-clonic status epilepticus is
the most dramatic, and is a medicalthe most dramatic, and is a medical
emergencyemergency
• the most common causesthe most common causes
anti-epileptic drug withdrawalanti-epileptic drug withdrawal
non-compliancenon-compliance
MeningitisMeningitis
EncephalitisEncephalitis
cerebral tumorcerebral tumor
abscess (particularly frontal)abscess (particularly frontal)
alcohol withdrawalalcohol withdrawal
21. • Complex partial status epilepticus mayComplex partial status epilepticus may
manifest with pro- longed periods ofmanifest with pro- longed periods of
confusion and disorientation, associatedconfusion and disorientation, associated
with automatic activity for which there iswith automatic activity for which there is
amnesiaamnesia
• Absence status epilepticus often occurs in theAbsence status epilepticus often occurs in the
context of learning disability orcontext of learning disability or de novode novo inin
older individualolder individual
may be associated with confusion, disorientationmay be associated with confusion, disorientation
or cognitive slowingor cognitive slowing
• Epileptia partialis continuaEpileptia partialis continua
focal (usually motor) status epilepticus, often reflectsfocal (usually motor) status epilepticus, often reflects
underlying structural abnormalities, and may beunderlying structural abnormalities, and may be
unremitting for months or years despite treatmentunremitting for months or years despite treatment
with anti-epileptic drugswith anti-epileptic drugs
22. ExaminationExamination
The presence of neurological signs (e.g. hemiparesis,The presence of neurological signs (e.g. hemiparesis,
dysphasia, field defect, papilloedema) may lateralize ordysphasia, field defect, papilloedema) may lateralize or
localize a structural lesionlocalize a structural lesion
Dysmorphism and learning disability may reflect aDysmorphism and learning disability may reflect a
chromosomal disorderchromosomal disorder
progressive features (e.g. dementia, ataxia, worseningprogressive features (e.g. dementia, ataxia, worsening
myoclonus) suggest a neurodegenerative disordermyoclonus) suggest a neurodegenerative disorder
Cutaneous stigmata of the neurocutaneous disordersCutaneous stigmata of the neurocutaneous disorders
should always be soughtshould always be sought
A cardiovascular examination should be performed at firstA cardiovascular examination should be performed at first
presentationpresentation
The pupils may dilate during a seizureThe pupils may dilate during a seizure
other features may help lateralize the focusother features may help lateralize the focus
• dysphasia indicates dominant hemisphere onsetdysphasia indicates dominant hemisphere onset
• Unilateral automatisms are ipsilateral and unilateral dystoniaUnilateral automatisms are ipsilateral and unilateral dystonia
contralateral to a temporal lobe focuscontralateral to a temporal lobe focus
23. Classification of syndromesClassification of syndromes
Syndromic classification incorporatesSyndromic classification incorporates
• Seizure typeSeizure type
• AetiologyAetiology
• PrecipitantsPrecipitants
Sydromic diagnosis may guide treatment andSydromic diagnosis may guide treatment and
prognosisprognosis
International league against epilepsy (ILAE)International league against epilepsy (ILAE)
classificationclassification
• Two principle categeries are localization related andTwo principle categeries are localization related and
generalisedgeneralised
• These are subdivided idiopathic, symptomaticThese are subdivided idiopathic, symptomatic
(underlying structural abnormality) and cryptogenic(underlying structural abnormality) and cryptogenic
(structural abnormalities suggested, but not(structural abnormalities suggested, but not
demonstrated)demonstrated)
24. probably 50% of epilepsies are generalized andprobably 50% of epilepsies are generalized and
50% are localization-related, most commonly50% are localization-related, most commonly
temporal in origintemporal in origin
The importance of classification is illustrated byThe importance of classification is illustrated by
the syndrome of juvenile myoclonic epilepsythe syndrome of juvenile myoclonic epilepsy
• This idiopathic generalized epilepsy is characterized byThis idiopathic generalized epilepsy is characterized by
myoclonic jerks, tonic- clonic seizures and typicalmyoclonic jerks, tonic- clonic seizures and typical
absencesabsences
• begins in the second decadebegins in the second decade
• provoked by sleep deprivation, alcohol and fatigue, andprovoked by sleep deprivation, alcohol and fatigue, and
usually occur in the morningusually occur in the morning
• EEG in untreated patients is characteristicEEG in untreated patients is characteristic
• The condition is lifelong, and though most patientsThe condition is lifelong, and though most patients
become seizure-free on treatment with valproate, therebecome seizure-free on treatment with valproate, there
is a high risk of recurrence of seizures if treatment isis a high risk of recurrence of seizures if treatment is
withdrawnwithdrawn
• Recognition of this syndrome thus has importantRecognition of this syndrome thus has important
implications, and hence the value of a syndromicimplications, and hence the value of a syndromic
diagnosis.diagnosis.
25. Classification of epilepsy (abbreviatedClassification of epilepsy (abbreviated
ILAE)ILAE)
Generalized epilepsies andGeneralized epilepsies and
syndromessyndromes
• Idiopathic with age-related onsetIdiopathic with age-related onset
• Benign neonatal familial convulsions• Benign neonatal familial convulsions
• Benign neonatal convulsions• Benign neonatal convulsions
•• Benign myoclonic epilepsy in infancyBenign myoclonic epilepsy in infancy
• Childhood absence epilepsy• Childhood absence epilepsy
•• Juvenile myoclonic epilepsyJuvenile myoclonic epilepsy
•• Epilepsy with generalized tonic-clonicEpilepsy with generalized tonic-clonic
seizures on awakeningseizures on awakening
26. Generalized epilepsies andGeneralized epilepsies and
syndromessyndromes
• Symptomatic or cryptogenicSymptomatic or cryptogenic
West syndromeWest syndrome
Lennox–Gastaut syndromeLennox–Gastaut syndrome
Epilepsy with myoclonic-astaticEpilepsy with myoclonic-astatic
seizuresseizures
Epilepsy with myoclonic absencesEpilepsy with myoclonic absences
• SymptomaticSymptomatic
Early myoclonic encephalopathyEarly myoclonic encephalopathy
Early infantile myoclonicEarly infantile myoclonic
encephalopathy with burst suppressionencephalopathy with burst suppression
OthersOthers
27. Localization-related epilepsies andLocalization-related epilepsies and
syndromessyndromes
• Idiopathic with age-related onsetIdiopathic with age-related onset
Benign childhood epilepsy with centrotemporal spikesBenign childhood epilepsy with centrotemporal spikes
Childhood epilepsy with occipital paroxysmsChildhood epilepsy with occipital paroxysms
Primary reading epilepsyPrimary reading epilepsy
• SymptomaticSymptomatic
Epilepsy with simple partial, complex partial orEpilepsy with simple partial, complex partial or
secondarily generalized seizures arising from thesecondarily generalized seizures arising from the
frontal, parietal, temporal or occipital lobe or fromfrontal, parietal, temporal or occipital lobe or from
multiple lobes, or of unknown lobe of onsetmultiple lobes, or of unknown lobe of onset
Epilepsia partialis continuaEpilepsia partialis continua
Syndromes characterized by specific modes ofSyndromes characterized by specific modes of
activationactivation
• Unknown whether idiopathic or symptomaticUnknown whether idiopathic or symptomatic
28. Epilepsies and syndromesEpilepsies and syndromes
undetermined (focal orundetermined (focal or
generalized)generalized)
• Severe myoclonic epilepsy inSevere myoclonic epilepsy in
infancyinfancy
• Epilepsy with continuous spike-and-Epilepsy with continuous spike-and-
wave activity in sleepwave activity in sleep
• Acquired epileptic aphasiaAcquired epileptic aphasia
Special syndromesSpecial syndromes
29. InvestigationsInvestigations
All patients with a diagnosis, or possibleAll patients with a diagnosis, or possible
diagnosis of epilepsy should undergo full blooddiagnosis of epilepsy should undergo full blood
count, electrolytes (including calcium), glucose,count, electrolytes (including calcium), glucose,
liver function tests and 12-lead ECGliver function tests and 12-lead ECG
ECG is important to detect rare cases ofECG is important to detect rare cases of
prolonged QT interval presenting as seizuresprolonged QT interval presenting as seizures
(often morning generalized tonic- clonic seizures)(often morning generalized tonic- clonic seizures)
In most patients, relevant abnormalities can beIn most patients, relevant abnormalities can be
detected only by high-resolution MRIdetected only by high-resolution MRI
• MRI reveals the cause of epilepsy in 30% of patientsMRI reveals the cause of epilepsy in 30% of patients
with generalized epilepsies and in 70% of those withwith generalized epilepsies and in 70% of those with
localization-related epilepsieslocalization-related epilepsies
30. EEGEEG
• role of EEG is often misunderstoodrole of EEG is often misunderstood
• Detection of EEG abnormalities does not equate toDetection of EEG abnormalities does not equate to
epilepsy, unless the clinical context is appropriateepilepsy, unless the clinical context is appropriate
• Conversely, absence of interictal EEG abnormalities does notConversely, absence of interictal EEG abnormalities does not
exclude a diagnosis of epilepsyexclude a diagnosis of epilepsy
• In a single awake recording, only one-third of patientsIn a single awake recording, only one-third of patients
consistently show epileptiform changesconsistently show epileptiform changes
• The yield can be improved by repeating recordings in sleep orThe yield can be improved by repeating recordings in sleep or
by specific activating methods (hyperventilation, photicby specific activating methods (hyperventilation, photic
stimulation)stimulation)
• In certain conditions, EEG may be diagnostic; for example,In certain conditions, EEG may be diagnostic; for example,
generalized 3 Hz spike-and-wave activity is characteristic ofgeneralized 3 Hz spike-and-wave activity is characteristic of
some primary generalized epilepsiessome primary generalized epilepsies
• About 5% of patients with epilepsy are photosensitive. SpecificAbout 5% of patients with epilepsy are photosensitive. Specific
photoparoxysmal findings have implications with respect tophotoparoxysmal findings have implications with respect to
lifestyle and must be notedlifestyle and must be noted
• Ictal recordings are seldom made in routine practice, unless aIctal recordings are seldom made in routine practice, unless a
seizure occurs by chanceseizure occurs by chance
• In some seizures, there may be no ictal changes; this doesIn some seizures, there may be no ictal changes; this does
not exclude a diagnosis of epilepsy, particularly in simplenot exclude a diagnosis of epilepsy, particularly in simple
partial seizures and frontal lobe epilepsy.partial seizures and frontal lobe epilepsy.
31. EEG telemetryEEG telemetry
• Indications:Indications:
Diagnosis remains in doubt despiteDiagnosis remains in doubt despite
apparently frequent seizuresapparently frequent seizures
if surgical treatment is consideredif surgical treatment is considered
• If necessary, presurgical investigationsIf necessary, presurgical investigations
(e.g. intracarotid amytal testing to(e.g. intracarotid amytal testing to
determine lateralized memory functiondetermine lateralized memory function
and language dominance, intracranialand language dominance, intracranial
EEG to determine the seizure focus) areEEG to determine the seizure focus) are
undertaken in specialist centresundertaken in specialist centres
32. More detailed investigationsMore detailed investigations
• Hypoglycaemia may need to be excluded,Hypoglycaemia may need to be excluded,
particularly in patients with early morningparticularly in patients with early morning
seizures.seizures.
• Echocardiography, ambulatory ECG, urinalysisEchocardiography, ambulatory ECG, urinalysis
for catecholamine metabolites and porphyrinfor catecholamine metabolites and porphyrin
determination may be requireddetermination may be required
Neuropsychometric, psychological andNeuropsychometric, psychological and
psychiatric assessmentpsychiatric assessment
• may be required in patients being consideredmay be required in patients being considered
for surgery, when there is concern aboutfor surgery, when there is concern about
cognitive decline, or when a non-epilepticcognitive decline, or when a non-epileptic
attack disorder is diagnosedattack disorder is diagnosed
33. Non-epileptic attack disorderNon-epileptic attack disorder
most commonly comprise eithermost commonly comprise either
• Prolonged motionlessness with preservedProlonged motionlessness with preserved
background EEG rhythms, orbackground EEG rhythms, or
• Prominent, often waxing and waningProminent, often waxing and waning
movements including asynchronous limbmovements including asynchronous limb
flailing, pelvic thrusting and opisthotonusflailing, pelvic thrusting and opisthotonus
Salivation, incontinence and injury maySalivation, incontinence and injury may
occur, but hypoxia does notoccur, but hypoxia does not
These patients usually have underlyingThese patients usually have underlying
psychological or psychiatric problemspsychological or psychiatric problems
34. Diagnosis of non-epileptic attack disorder mayDiagnosis of non-epileptic attack disorder may
require prolonged observation and EEG monitoringrequire prolonged observation and EEG monitoring
Prolactin levels rise immediately after generalizedProlactin levels rise immediately after generalized
tonic- clonic seizures and some complex partialtonic- clonic seizures and some complex partial
seizures, and return to baseline within 50 minutesseizures, and return to baseline within 50 minutes
This does not occur after absence seizuresThis does not occur after absence seizures
Serum prolactin concentrations do not generallySerum prolactin concentrations do not generally
rise significantly after non-epileptic attacks, butrise significantly after non-epileptic attacks, but
may rise after severe syncopal episodes, or onmay rise after severe syncopal episodes, or on
physical exertionphysical exertion
Ictal EEG recording may be obscured by movementIctal EEG recording may be obscured by movement
artefact, but the typical EEG changes that mayartefact, but the typical EEG changes that may
precede or succeed epileptic seizures are not seenprecede or succeed epileptic seizures are not seen
Iatrogenic complications may ensue fromIatrogenic complications may ensue from
inappropriate treatment, particularly ininappropriate treatment, particularly in
‘pseudostatus’, which is found in 25% of referrals‘pseudostatus’, which is found in 25% of referrals
of patients with apparent status epilepticus toof patients with apparent status epilepticus to
specialist unitsspecialist units
35. PrognosisPrognosis
In most (70%), remits over a period ofIn most (70%), remits over a period of
yearsyears
The risk of recurrence is greatest in theThe risk of recurrence is greatest in the
first few months after a first seizure.first few months after a first seizure.
~1/3rd of who suffer a single unprovoked~1/3rd of who suffer a single unprovoked
seizure have a further seizure within 5seizure have a further seizure within 5
yearsyears
~ 3/4 of those with two unprovoked~ 3/4 of those with two unprovoked
seizures suffer further seizures within 4seizures suffer further seizures within 4
yearsyears
36. The most important predictor ofThe most important predictor of
natural history is the type (ornatural history is the type (or
syndrome) of epilepsy, particularly ifsyndrome) of epilepsy, particularly if
the cause is identified or presumedthe cause is identified or presumed
Patients with malformations,Patients with malformations,
congenital abnormalities, progressivecongenital abnormalities, progressive
myoclonic epilepsies, syndromes withmyoclonic epilepsies, syndromes with
atypical absence or atonic/tonicatypical absence or atonic/tonic
seizures, or localization- relatedseizures, or localization- related
epilepsy with underlying structuralepilepsy with underlying structural
abnormalities are least likely to remitabnormalities are least likely to remit
37. Those with juvenile myoclonic epilepsyThose with juvenile myoclonic epilepsy
generally do well if kept on treatmentgenerally do well if kept on treatment
Most patients with childhood absenceMost patients with childhood absence
epilepsy, epilepsy with tonic-clonicepilepsy, epilepsy with tonic-clonic
seizures on awakening, or nonspecificseizures on awakening, or nonspecific
generalized tonic-clonic seizures who aregeneralized tonic-clonic seizures who are
otherwise neurologically normal may beotherwise neurologically normal may be
successfully weaned from drugs oncesuccessfully weaned from drugs once
remission is achievedremission is achieved
Some types of epilepsy (e.g. benignSome types of epilepsy (e.g. benign
neonatal convulsions, fifth-day seizures,neonatal convulsions, fifth-day seizures,
benign myoclonic epilepsy of infancy,benign myoclonic epilepsy of infancy,
some benign partial epilepsies, epilepsiessome benign partial epilepsies, epilepsies
precipitated by a specific mode ofprecipitated by a specific mode of
activation) may not need drug treatmentactivation) may not need drug treatment
38. MortalityMortality
epilepsy is often assumed to be benign, butepilepsy is often assumed to be benign, but
population-based studies show an increasedpopulation-based studies show an increased
standardized mortality ratio (SMR) of 2–3standardized mortality ratio (SMR) of 2–3
Seizure type may be important in determiningSeizure type may be important in determining
SMRSMR
Mortality is greatest in the first year afterMortality is greatest in the first year after
diagnosis because of the mortality associateddiagnosis because of the mortality associated
with the underlying causewith the underlying cause
Other causes of increased SMR are epilepsy-Other causes of increased SMR are epilepsy-
related accidents, suicide, non-cerebral cancersrelated accidents, suicide, non-cerebral cancers
and ‘sudden unexpected death in epilepsy’ (non-and ‘sudden unexpected death in epilepsy’ (non-
traumatic and unwitnessed death in an individualtraumatic and unwitnessed death in an individual
with epilepsy who had otherwise been previouslywith epilepsy who had otherwise been previously
well, and in whom no cause of death iswell, and in whom no cause of death is
established even after post mortem).established even after post mortem).
39. Incidence of sudden unexpected death isIncidence of sudden unexpected death is
1/200/year in refractory epilepsy and is pr1/200/year in refractory epilepsy and is pr
obably seizure relatedobably seizure related
effective treatment (including surgical)effective treatment (including surgical)
of epilepsy may reduce this risk.of epilepsy may reduce this risk.
It is important to diagnose the underlyingIt is important to diagnose the underlying
syndrome and aetiology correctly, tosyndrome and aetiology correctly, to
ensure that the most appropriateensure that the most appropriate
treatment option can be initiated promptlytreatment option can be initiated promptly
