This document provides an overview of epilepsy, including its history, epidemiology, classification, symptoms, investigation, treatment, and psychiatric complications. Some key points include: - Epilepsy is a common neurological disorder affecting 20-40 million people worldwide. - Seizures are classified as either generalized or partial based on where they originate in the brain. Common types include tonic-clonic, absence, myoclonic, and complex partial seizures. - Investigations include EEG, MRI, and PET to help determine the seizure type and focus. Genetic factors are also important in some cases. - Treatment involves anti-epileptic drugs to control seizures, with older drugs including phenytoin and

1. EPILEPSY Moderator –Dr.M.Gowri Devi Presenter- Dr.K.SudhaRani

2. HISTORY Hippocrates –disease of brain Bromides -1st.treatment Emilkraeplin- predisposition to psychosis

3. EPIDEMIOLOGY 20-40 million people world wide Prevalence-0.63% Incidence-0.05% Male: female-equal 12-20% familial >75%- before 18 yrs.

4. DEFINITION Epileptic seizure-sudden involuntary behavioral events associated with excessive or hyper synchronous electrical discharge in brain Ictus Inter ictal period Peri ictal Epilepsy Status epilepticus

5. CLASSIFICATION GENERALISED Tonic-clonic Absence-typical atypical Myoclonus Atonic/akinetic Tonic Clonic Unclassified PARTIAL Simple partial-motor somato sensory autonomic psychic Complex partial -sps progress to loc -begin with loc Partial with sec.general. -withsps - with cps

6. GRAND MAL Abrupt onset with loc No aura or warning signs Occasional prodromata Tonic clonic phases Symmetrical involvement Followed by sleep or confusion Amnesia for attack-retrograde

7. ABSENCES TYPICAL Generalized Sets in childhood Loses contact for 4-5 sec. Momentarily dazed, stops speaking, becomes immobile Pale ,fixed gaze Posture, balance maint. absence with automatism ATYPICAL Longer duration Change in muscle tone Occurs in pt.s with developmental delay Occurs with other types Inter ictal eeg abnormal

8. ATONIC Involves posture Precipitates muscle relaxation Few seconds No after effects Seen with absences , grandmal MYOCLONIC Sudden shock like movement Neck, arms, shoulder Fall if legs, trunk involved Very short time

9. PARTIAL Begins in some part of brain Implies structural lesion Preceded by aura Symptomatology depends on area of origin Simple partial –consciousness retained -motor -sensory -simple &special -Autonomic -psychic Complex partial

10. TEMPORAL LOBE EPILEPSY Most common cps Psychiatric symptoms most common Focal discharge spreads to limbic system Onset early Family h/o seizures h/o febrile seizures Often intractable Aetiology –birth injury,anoxia

11. AURA Autonomic-epigastric aura Perceptual-distortions, perceptions Cognitive-speech thought memory Affective-anxiety, fear, depression ICTUS Behavior arrest Stare Unilateral posturing Automatism POST ICTAL Disorientation, memory loss, dysphasia

12. INVESTIGATION EEG-spenoidal,foramenovale electrodes Unilateral ,bilateral spikes inter ictal spikes &waves MRI-small lobe,small hippocampus Hypometabolism –PET Hypoperfusion-SPECT Treatment-surgery

13. SPECIAL FORMS Reflex epilepsy Tonic seizures Gelastic epilepsy Autonomic epilepsy West syndrome Lennexgestaut syndrome landau kleffner syndrome Ramsay hunt syndrome

14. AETIOLOGY Idiopathic Birth injury, congenital malformation Post traumatic Post infective Cerebro vascular disease Cerebral tumour Degenerative disorders Drugs &toxins Metabolic causes

15. drugs Alkylating agents (e.g., busulfan, chlorambucil) Antimalarials (chloroquine, mefloquine) Antimicrobials/antivirals -lactam and related compounds Quinolones Acyclovir IsoniazidGanciclovir Anesthetics and analgesics MeperidineTramadol Local anesthetics Dietary supplements Ephedra (ma huang) Gingko Immunomodulatory drugs Cyclosporine OKT3 (monoclonal antibodies to T cells) TacrolimusInterferons Psychotropics Antidepressants Antipsychotics Lithium Radiographic contrast agents Theophylline Sedative-hypnotic drug withdrawal Alcohol Barbiturates (short-acting) Benzodiazepines (short-acting) Drugs of abuse Amphetamine Cocaine Phencyclidine Methylphenidate Flumazenila

16. GENITICS Common in idiopathic Greater concordance in monozygotic Febrile seizures –risk increases 3-6 fold Risk 20%-one parent,56%-both parent CHRNA-20q 13.2-nocturnal frontal lobe epi. KCNQ2-20q13.3-benign familial neonatal con. SCNbeta-19q12.1-generalised with febrile con LGI1-10q24-AD partial epi. Form of TLE CSTB-21q22.3-progressive myoclonus epi. EPMZA-6q24-progressive myoclonus epi.

17. Aggravating factors Sleep deprivation Extreme fatigue Starvation ,mild hypoglycemia Anoxia Emotional disturbance Shock or surprise inter personal stress Tension ,anxiety, stress premenstrual

18. EPILEPSY &PSYCHIATRY 20-60% prevalence of psychiatry problems in epilepsy patients Prone to psychosis, depression, personality disorders, hyposexuality, behavior disorders Special relation with mesobasal temporal, frontal Several studies report more psychopathology in epilepsy patients 60-76% of adult epilepsies –temporal focus

19. COND. PSYCHOSIS-most clearly associated Life long prevalence-7-12% 2 fold greater risk Left sided focus more associated DEPRESSION-patients with cps & poor seizure control Behavioral disorders-personality disorder, suicidal behavior, hypo sexuality more prevalent among epilepsy patients

20. COND. Common neuropathology Ictal sub ictal discharges Absence of function Neurochemical changes Psychodynamic & psychosocial effects sleep disturbance anticonvulsants

21. AURA OF EPILEPSY Represent initial focal onset of the attack Gives information about site of origin Memory is retained Range from simple discrete sensations to complex abnormalities Pattern constant Appear abruptly Rarely occur more than few seconds

22. COND. FRONTAL LOBE PARIETAL LOBE TEMPORAL LOBE OCCIPITAL LOBE MEDIAL SURFACE

23. POSTICTAL POST ICTAL SLEEP ,CONFUSION POST ICTAL AUTOMATISM-individual retains control of posture & muscle tone but performs complex movement &actions without being aware of it Lasts longer & more complex than ictal Actions repetitive ,fumbling, clumsy Epileptic furore-wildly overactive for several min.

24. Cond. Post ictal twilight state-lasts longer hrs.to days Psychomotor retardation, vivid hallucinations, abnormal affective experiences Accompanied by marked resistance , restlessness violent reactions may occur

25. Cond. Post ictal psychosis-seperated by lucid interval Lucid interval-2-72 hrs Lasts with mean 3.5 days(16-432hrs) Grandiose or religious delusions Elevated mood ,agitation, paranoia No perceptual voices Remit spontaneously

26. INTERICTAL PERSONALITY Borderline, atypical, histrionic, mixed, dependent Gestaut- geschwind syndrome -religiosity -hypergraphia -hypermoralism -Viscosity -hyposexuality

27. PSYCHOSIS Epileptic characteristics Cps with generalization More auras, automatisms 11to15yrs.duration Recently diminished fre. Left temporal focus Mediobasal temporal Forced normalisation Paranoia of sudden onset Psychosis alternating with seizures Preserved affect Failure of deterioration Less social withdrawal Less systematization More hall.& affect sym. More religiosity More positive sym. few 1st. Rank symptoms

28. MOOD DISORDERS Most prevalent neuropsychatricdisordes Twice common than nonepileptics Psychological reaction to disability Frequent with cps left side Paraxismal irritability or agitation Good response to antidepressants cognitive aura predisposes Decrease in seizure fre.before onset Alternating depression –ect or seizure Mania, mixed rare

29. Dissociative states Dissociative identity Depersonalization Possession state Fugue state Psychogenic amnesia association not well established Multiple personality disorder-frequent eeg changes

30. AGGRSSION

31. SEXUALITY Tend to be hyposexual Disturbance in arousal& lower sexual drive Exrerience impotence &frigidity s/o hypogonadichypogonadism

32. SUICIDE Risk of suicide 4-5 times high High risk with CPS of TL origin Not due to psychosocial stress In relation to-border line personality -paranoid hallucinations -agitated compunction -command hallucinations

33. MANAGEMENT CAREFUL HISTORY DETAILS OF EPISODE PHYSICAL EXAMINATION

34. INVESTIGATIONS CBP ELECTROLYTES-Ca.,Mg RBS LFT RFT CUE TOXICOLOGY EEG CT MRI PSYCHOMETRY

35. grandmal Crescendo of low voltage fast activity Tonic-generalised synchronous high amplitude spikes at 8-12/sec Clonic-spikes grouped &seperated by slow waves Low amplitude delta waves

36. Myoclonic jerk Single wave &spike complex Multiple spikes Polyspike & wave

37. Simple absence Suddenly interrupted Bilaterally synchronous Spike slow wave complexes Three per second All scalp leads

38. Differential diagnosis Seizure No ppting factor no premonitory symptoms aura + Posture variable Sudden loc Tonic clonic-30-60seconds cyanosis, frothig Disorientation ,sleep for hrs. Biting, incontinance, headache sometimes Syncope Ppt.by emotional stress, orthostatic hypertension Tiredness ,disphoria ,nausia Posture erect Gradual loc Duration seconds Pallor Disorientation ,sleep min. biting headache rare

42. OLDER DRUGS Phenytoin - 300-400mg/d-10-20mig/ml Carbomazaphine – 600-1800mg/d-6-12mig/d Valproate -750-2000mg/d-50-125mig/d Ethusuximide-750-1250mg/d-40-100mig/d Phenoberbital-60-180mg/d-10-40mig/d Prionidane -750-1000mg/d-4-12mig/d

43. Newer drugs Lamotrigine-150-500mg/d Gabapentin-900-1200mg/d Topiramate-200-4000mg/d Tiagabin-32-56mg/d Levitaracetam-1000-3000mg/d Zonisamide-200-400mg/d Oxy carbamazapine-900-2400mh/d

44. DRUG PREFERENCES

45. Status epilepticus Lorezepam-0.1-0.15mg/kg iv over 1-2 min. Repeat after 5min. If no response Consider valproate if taking Fos phenytoin20mg/kg PE150mg/min Phenytion20mg/kg iv 50mg/min. Fos phenytoin7-10mg/kg PEiv150mg/min. Phenytoin7-10mg/kg50 mg/min Valproate 25mg/kg iv No icu-phenobarbital20 mg/kg iv 60mg/min Phenobarbitone 10mg/kg iv 60 mg/min If icu iv anesthesia Pentothal propofal

46. Psychiatric complications Effective control of seizures Evaluate for AED drug toxicity Transient post ictalno treatment Atypical antipsychotics, SSRIs Start low go slow Severe depression &suicide risk-ECT Risk of lowering threshold Drug interactions

47. Non pharmocological Psycho education Systematic desensitization Operant management technique Application of abrupt external stimulus Biofeed back

48. pregnancy Risk of untreated epilepsy-5-6% Fetal anomalies-1-2% Monotherapy ,lowest possible dose Supplement folic acid 1-4mg/d Vitamin k20mg/d last two weeks To infant 1mg at birth Altered pharmacokinetics during pregnancy So monitor blood levels frequently

49. SURGERY True epileptic seizure Occuring at unaccptable frequency Atleast one seizure/week Adequate trails with 3drugs for 2 yrs. Earliest if focal pathology present age <55 yrs. Full scale IQ <70 psychiatric disease not contra indication provided cope with surgical procedure &rehabilitation

50. Temporal lobectomy-4.5-6.5 cm.of temporal neo cortex along with 2-3 cm.of hippocampus & amygdale are removed Frontal lobectomy-preserve frontal operculum of sylvian fissure Occipital lobectomy, parietal Hemispherctomy Section of corpus callosum Temporal lobotomy

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