Epilepsy is a chronic neurological disorder characterized by recurrent seizures resulting from abnormal neuronal activity in the brain. It affects around 1% of the population. Seizures can vary from brief periods of lack of awareness to full motor convulsions. The cause is often unknown but may involve excessive glutamate signaling and reduced GABA inhibition in the brain. Epilepsy is usually treated with anti-seizure medications, though in refractory cases surgery may be an option. The goals of treatment are seizure freedom and improved quality of life with minimal side effects.

2. PRESENTED BY
Dr. Qureshi Jalib
Epilepsy

3. Definition
 A chronic neurologic disorder manifesting by repeated epileptic
seizures (attacks or fits) which result from sudden uncontrolled
discharges of neurons within the central nervous system.
 The clinical manifestations range from a major motor
convulsion to a brief period of lack of awareness. The
stereotyped and uncontrollable nature of the attacks is
characteristic of epilepsy.

4. Pathogenesis
 The 19th century neurologist Hugh lings Jackson suggested
“a sudden excessive disorderly discharge of cerebral
neurons“ as the causation of epileptic seizures.
 Recent studies in animal models of focal epilepsy suggest a
central role for the excitatory neurotransmiter glutamate
(increased in epilepsy) and inhibitory gamma amino butyric
acid (GABA) (decreased).

5. Epidemiology and course
 Epilepsy usually presents in childhood or adolescence but may
occur for the first time at any age.
 Newborns
 Early school age
 Adolescents
 Seniors

6. Epidemiology and course
 5-10% of the population suffer a single seizure at some time in
their life.
 Single seizure does not constitute epilepsy.
 0.5-1% of the population have recurrent seizures = EPILEPSY
 Two or more unprovoked seizure called epilepsy.
 70% = well controlled with drugs
 30% epilepsy at least partially resistant to drug treatments =
INTRACTABLE (PHARMACO RESISTANT) EPILEPSY.

7. Epilepsy vs epileptic syndromes
 Epilepsy is not a nosological entity – not one disease! Not
unique etiology.
 Might be a symptom of numerous disorders – symptomatic
epilepsy (tumours, inflammation, stroke, neurodegeneration).
 Sometimes the cause remains unclear despite careful history
taking,examination and investigation.

8. Classification
 The modern classification of the epilepsies is based upon the
nature of the seizures rather than the presence or absence of
an underlying cause.
 Seizures which begin focally from a single location within one
hemisphere are thus distinguished from those of a generalised
nature which probably commence in a deeper structures
(brainstem? thalami) and project to both hemispheres
simultaneously.

9. Classification
Focal/Partial seizures
• account for 80% of adult epilepsies
• Simple partial seizures
• Complex partial seizures
• Partial seizures secondarilly generalised
Generalised seizures

10. Classification
PARTIAL
- Simple partial seizures
- Complex partial seizures
- Partial seizures secondarilly
generalised
GENERALIZED
 Absence
 Myoclonic
 Atonic
 Tonic
 Tonic-Clonic

11. Seizure types and characteristics
Seizure type(Partial)
 Simple Partial(awareness is
retained)
 Motor
 Sensory
 Autonomic
 Psychological symptoms
Characteristics
 Jerking, muscle rigidity, head
turning
 Unusual sensation – touch, taste,
hearing, vision, smell
 Stomach sensation
 Memory or emotional disturbance
(Fear)

12. Seizure types and characteristics
 Partial complex (impairment
of awareness)
 Partial seizure becomes
Generalized seizure
 Automatism – lip smacking,
chewing, walking and
repetitive, stereotyped
movements
 Begin as partial and evolves
into Grand mal seizure

13. Seizure types and characteristics
Seizure type(Generalized)
 Tonic-Clonic (Grand mal)
 Absence
 Myoclonic
 Clonic
 Tonic
 Atonic
Characteristics
 Unconsciousness, convulsions,
muscle rigidity
 Brief loss of consciousness
 Irregular jerking movement
 Repetitive rhythmic jerking
movements
 Muscle stiffness, rigidity
 Loss of muscle tone

14. Differential Diagnosis
The following should be considered in the diff. dg. of
epilepsy:
Syncope attacks (when pt. is standing; results from
global reduction of cerebral blood flow; nausea,
sweating; jerks!)
Cardiac arrythmias (Prolonged arrest of cardiac rate
will progressively lead to loss of consciousness –
jerks!)
Migraine (Migraine may lead to loss of
consciousness!)

15. Differential Diagnosis
Hypoglycemia – seizures or intermittent behavioral
disturbances may occur.
Narcolepsy – inappropriate sudden sleep episodes
Panic attacks
PSEUDOSEIZURES – psychosomatic and
personality disorders

16. Treatment options
Pharmacotherapy
Non pharmacological therapy
 Surgical intervention
 Vagus nerve stimulation
 Ketogenic diet (high fat, low protein, very low
carbohydrates)

17. Treatment goals
No seizures
No side effects
Monotherapy
Once daily dosing

18. Principals of pharmacotherapy
 Use the right drug for the seizure type
 Use one drug and increase the dose until a therapeutic effect
is gained or toxicity appears (maximum tolerated dose)
 Monitor treatment including blood levels
 If required add a second drug.

19. Principals of pharmacotherapy
 If monotherapy fails use two drugs
 Review and replace the combinations used
 Add in a third drug if necessary
 Be prepared to accept that a significant reduction in seizure
frequency maybe as good as it gets.

20. Treatment
 The majority of patients respond to drug therapy (anticonvulsants). In
intractable cases surgery may be necessary. The treatment target is
seizure-freedom and improvement in quality of life.
 The commonest drugs used in clinical practice are: Carbamazepine,
Sodium valproate, Lamotrigine (first line drugs) Levetiracetam,
Topiramate, Pregabaline (second line drugs) Zonisamide,
Eslicarbazepine, Retigabine (new AEDs).

21. Treatment
 Basic rules for drug treatment: Drug treatment should be
simple, preferably using one anticonvulsant (monotherapy).
“Start low, increase slow”. Add-on therapy is necessary in
some patients.
 If patient is seizure-free for three years, withdrawal of
pharmacotherapy should be considered. Withdrawal should be
carried out only if patient is satisfied that a further attack would
not ruin employment etc. It should be performed very carefully
and slowly. 20% of pateints will suffer a further seizure within 2
yrs.

22. Treatment
 The risk of teratogenicity is well known (~5%), especially with
valproates, but withdrawing drug therapy in pregnancy is
more risky than continuation.
 Epileptic females must be aware of this problem and thorough
family planning should be recommended.
 Over 90% of pregnant women with epilepsy will deliver a
normal child.

23. FDA approved monotherapy
PARTIAL SEIZURES
 Carbamazapine
 Sodium Valproate
 Phenytoin
 Lamotrigine
 Oxcarbazepine
GENERALISED SEIZURES
 Ethosuximide
 Sodium Valproate
 Phenobarbitone/Primidone
 Clonazepam
 Phenytoin

24. Choice of AED’s
 Carbamazepine, sodium valproate, lamotrigine and
oxcarbazepine can all be regarded as first-line treatments for
partial and secondary generalised seizures.
 Sodium valproate and lamotrigine are drugs of choice for
primary generalised seizures and should also be prescribed if
there is any doubt about the seizure types and/or syndrome
classification.

25. Choice of AED’s
 Combination therapy should be considered when treatment
with two first line AEDs has failed or when the first well-
tolerated drug substantially improves seizure control but fails to
produce seizure-freedom at maximal dosage.
 The choice of drugs in combination should be matched to the
patient(s) seizure type(s) and should be limited to two or at
most three AEDs.

26. Choice of AED’s

27. Choice of AED’s

28. Non-pharmacological therapy
 A proportion of the patients with intractable epilepsy will benefit
from surgery.
 Epilepsy surgery procedures:
Curative (removal of epileptic focus) and palliative (seizure-
related risk decrease i.e. by Vagus nerve stimulation (VNS) and
improvement of the QOL).

29. Status Epilepticus
 Common medical emergency
 A condition when consciousness does not return between seizures for
more than 30 min. This state may be life-threatening with the
development of pyrexia, deepening coma and circullatory collapse.
Death occurs in 5-10%.

30. Status Epilepticus
 Status epilepticus may occur with frontal lobe lesions following
head injury, on reducing drug therapy, drug intoxication,
metabolic disturbances or pregnancy.
 Treatment:
AEDs intravenously ASAP, general anesthesia with propofol or
thipentone should be commenced immediately.

31. Thank you