1. CME on Epilepsy
Presented By-
Dr. Syed Shahreor Razzaque,
Resident (Phase-B, Year-2)
BSMMU
Date: 10.01.2021
2. Introduction
• Epilepsy is one of the most common
neurological disorders worldwide and its
pathophysiology yet not very well understood
by physicians and the general public alike. The
word epilepsy comes from the Greek verb
‘epilamvenien’, which means “to be seized”, “to
be taken hold of”, or “to be attacked”.
• Worldwide, an estimated 50 million people have
epilepsy and around 85% of people with
epilepsy live in developing countries. There are
two million new cases occurring in the world
every year.
3. Epidemiology
• Epilepsy presents most commonly in childhood and
adolescence or in those over 65, but may occur for the
first time at any age. 5% of the population suffer a
single seizure at some time.
• 0.5% of the population have recurrent seizures. Among
them 70% have well controlled with drugs with few
seizures and prolonged remissions, but 30% have
epilepsy at least partially resistant to drug treatment.
4. Epidemiology
• The overall incidence of epilepsy
is generally taken to be around 50
per 100,000 population per year
(range 40–70 per 100,000
population per year).
• In Bangladesh, no national
statistics, but hospital based
studies show similar scenario.
Therefore, with population of 160
million, prevalence of epilepsy is
around 7.5 lacs.
5. Definition
• In 2005, the International League Against Epilepsy (ILAE) proposed a
conceptual definition for clinicians diagnosing epilepsy: ‘a disorder
characterized by an enduring predisposition to generate epileptic
seizures and by neurobiologic, cognitive, psychological and social
consequences of this condition.
• Epilepsy is defined in practice as ‘two or more unprovoked seizures
occurring at least 24 hours apart’.
• Epileptic seizure may be defined as an abnormal paroxysmal cerebral
neuronal discharge that results in alteration of sensation, motor
function, behavior, or consciousness.
6. Definition
• The prodrome refers to mood or
behavioral changes which may
precede the attack by some hours.
• The aura refers to the symptom
immediately before a seizure and will
localise the attack to its point of origin
within the nervous system.
• The postictal period refers to the time
immediately after the ictus during
which the patient may be confused,
disorientated and demonstrate
automatic behaviours.
7. Epileptogenesis
• There is alteration in the balance between excitatory
and inhibitory mechanisms. Epileptogenesis may either
be due to increased excitation or reduced inhibition or a
combination of both.
• The three main elements in the expression of
epileptogenesis are:
1. The capability of membranes of pacemaker cells to
develop intrinsic burst discharges;
2. Reduction of gamma aminobutyric acid (GABA)
inhibition and
3. Enhancement of synaptic excitation.
8. Epileptogenesis
• Any factor that affects the balance of
depolarisation or repolarisation can
affect cellular excitability. Therefore,
agents that block potassium channels
(tetraethyl ammonium and barium)
prolong the action potential and
therefore are proepileptogenic.
• Blockers of Na+ and Ca2+ (e.g.
phenytoin, valproic acid, ethosuximide
and lamotrigine) inhibit action
potentials and are used in the
pharmacotherapy of epilepsy.
9. Epileptogenesis
• Glutamate is an excitatory neurotransmitter and mediates synaptic
excitation.
• The inhibitory system is mainly based on the neurotransmitter Gama
amino butyric acid (GABA).
• Other receptors that have been implicated in epileptogenesis are
acetylcholine receptors and adenosine receptors.
• The glial network is protective in nature and glial cells take up
glutamate. Failure of these mechanisms can result in secondary
generalisation of a focal seizure.
10. Classification of Epilepsy
• Idiopathic (No identifiable risk factor)
• Cryptogenic (Associated with CNS pathology)
• Symptomatic (Known structural abnormality)
11. Classification of
Seizure
I. Partial (Focal) seizures
A. Simple partial seizures
B. Complex Partial seizures
C. Partial Seizures evolving to
secondary generalized seizures
(tonic-clonic, tonic or clonic)
II. Generalized seizures
(Convulsive and non-convulsive)
A. Absence seizures
i) Typical ii) Atypical
B. Myoclonic seizures
C. Clonic seizures
D. Tonic seizures
E. Tonic-Clonic seizures
F. Atonic seizures
(Combinations may occur: myoclonic
and atonic or myoclonic and tonic)
III. Unclassified epileptic
seizures
12. Classification
• Primary generalized seizures: bilaterally
symmetrical and synchronous, involving both
cerebral hemispheres at the onset, no local
onset, consciousness lost from the start.
Represents ≈ 40% of all seizures.
• Clonic seizures: Fairly symmetric, bilateral
synchronous semi rhythmic jerking of the
UE & LE, usually with elbow flexion and
knee extension.
13. Classification
• Primary generalized seizures:
• Tonic seizures: Sudden sustained increased
tone with a characteristic guttural cry or grunt
as air is forced through adducted vocal cords.
• Generalized tonic-clonic (GTC) (AKA: grand-
mal seizure): sudden onset with immediate
loss of consciousness. There is a brief tonic
phase (10-30 seconds) with whole body tonic
contraction, associated with a loud scream
and vegetative symptoms such as tachycardia,
mydriasis, increased blood pressure, and
apnea followed by clonic jerks.
15. Classification
• Primary generalized seizures:
• Myoclonic seizure:
Myoclonic seizures are
manifested as brief
symmetrical muscular jerks
of variable intensity. Proximal
muscles such as girdle
muscles are mostly involved.
16. Classification
• Primary generalized seizures:
• Absence (AKA: petit-mal
seizure): Typical absence
seizures are brief (5-12
seconds). They appear mostly
in children and are clinically
characterized by sudden
interruption of ongoing
activity and staring straight
ahead or drifting upwards.
There is complete loss of
awareness during the seizure.
17. Classification
• Primary generalized seizures:
• Atonic seizure: Atonic seizures
are characterized by decrease
or complete inhibition of
postural tone. They manifest as
head nodding, dropping of the
jaw or of a limb, or falls. The
patient can then lie motionless
on the ground or promptly
resume the posture.
18. Classification
• Partial seizures (AKA focal
seizures): implies one
hemisphere involved at onset.
About 57% of all seizures. A new
onset of partial seizure
represents a structural lesion
until proven otherwise.
• Simple partial seizure: no
impairment of consciousness.
19. Classification
• Partial seizures (AKA
focal seizures):
• Complex partial
seizure: Associated
with any alteration
of consciousness,
usually LOC or
automatisms
(including lip
smacking, chewing,
or picking with the
fingers) with
autonomic aura.
20. Lobar Epilepsy
• Partial seizures are classified according to
both their:
• Severity – simple; complex partial;
evolving to tonic/clonic convulsion
• Semiology – what happens during the
seizure, which reflects the site of
origin, in order of frequency:
temporal, frontal, parietal and
occipital lobes.
21. Temporal Lobe Epilepsy
• Onset is most often during childhood or early adulthood.
• Seizures are simple or complex partial and are of relatively long
duration (1–2 min).
• Mesial temporal lobe epilepsy:
• Visceral disturbance: Gustatory (taste) and olfactory (smell)
hallucinations, lip smacking, epigastric fullness, choking sensation,
nausea, pallor, pupillary changes (dilatation), tachycardia.
• Memory disturbance: Déjà vu (‘something has happened before’),
jamais vu (‘feeling of unfamiliarity’), depersonalisation, derealisation,
flashbacks, formed visual or auditory hallucinations.
• Motor disturbance: Fumbling movement, rubbing, chewing, semi-
purposeful limb movements.
23. Parietal Lobe Epilepsy
• The patient describes paraesthesia or
tingling in an extremity or on the face
sometimes associated with a sensation of
distortion of body image (autoscopia).
• Visual illusions (macropsia, micropsia,
metamorphopsia): posterior parietal
cortex or the parietal-occipital junction.
• Clear rotatory vertigo: inferior parietal
region or the temporo-parietal junction.
24. Occipital Lobe Epilepsy
• Elementary visual hallucinations
(coloured blobs, flashes of light)
associated to peri-ictal peripheral
visual field deficit (hemianopia).
• Eye movements are frequent in the
course of the seizure. They can be
phasic (oculo-clonic movement or
‘epileptic nystagmus’) or tonic (slow
version of the eyes contralateral to
the epileptic discharge).
25. Syndrome types in different age groups
• Early Childhood (1-5y):
• Lennox-Gastaut
Syndrome
• Febrile Seizures
• Late Childhood (5-10y):
• Childhood Absence
Epilepsy
• Landau-Kleffner
Syndrome
• Benign Rolandic
Epilepsy
• Adolescence:
• Juvenile Myoclonic
Epilepsy
• Juvenile Absence
Epilepsy
• Infancy:
• West Syndrome
• Ohtahara Syndrome
• Dravet Syndrome
26. Common Causes of Seizure
V =
Infections (Meningitis, Brain Abscess)
I =
Vascular (Stroke, AVM)
T = Trauma (RTA, Penetrating injury)
Autoimmune (CNS vasculitis, SLE)
A =
M = Metabolic (Hypoglycemia, Hypocalcaemia)
I = Idiopathic
N = Neoplasms (CNS tumors)
D = Drugs (Alcohol, Cocaine)
27. Differential Diagnoses of Seizure
Seizure
Syncope/
Vasovagal
attacks
Cardiac
arrythmias
Hypoglycaemia
Episodic
confusion
Movement
disorder eg.
Tic, Narcolepsy
with Cataplexy,
Parasomnia
Panic attacks
TIA
Dissociative/
Psychogenic
seizure
28. Diagnosis of Epilepsy
• Prodromal symptoms
• Aura
• Precipitating factors
• Time & environment of seizure
• Mode & duration of progression
• Ictal & post-ictal events
• Frequency & stereotypy of
menifestations
• Acquaintance with epileptic
individuals
Semiology
• Psychiatric illness
• Neurological
disorders
• Cardiac pathology
Associated
Illness • Past medical history
• Drugs, toxin,
alcohol intake
history
Others
• History:
36. Pharmacotherapy of Epilepsy
Epilepsy type First Line Second Line
Focal onset/ Secondary
GTCS
Lamotrigine Carbamazepine
Levetiracetam
Valproic Acid
Topiramate
GTCS Valproic Acid
Levetiracetam
Lamotrigine
Topiramate
Zonisamide
Absence Ethosuximide Valproic Acid
Myoclonic Valproic Acid Levetiracetam
Clonazepam
Diagnosis & management of epilepsy in adults (May,
2015) by Scottish Intercollegiate Guidelines Network
37. Surgery of Epilepsy
• Candidates for Surgery:
• Medically refractory
epilepsy
• Lesional epilepsy
• Surgical options:
• Resective (removing portions)
• Surgery like lesionectomy
• Multiple subpial transection
• Temporal lobectomy
• Corpus callosotomy
• Hemispherectomy
• Vagal nerve stimulation
• Deep brain stimulation
• Gamma Knife surgery
38. Epilepsy is not a curse!
Look at these people….
Aristotle Socrates
Julius Caesar
Fyodor Dostoyevsky
Lord Byron
Vincent Van Gogh
Alfred Nobel Vladimir Lenin
Naepoleon Bonaparte
Tony Greig
39. Epilepsy is one of the problems which is
hampering one’s quality of life.
The aim of modern neurosurgery is not only to
save lives but also to improve the function,
thereby improving patients’ quality of life.
But surgery alone may not be curative one,
sometimes AEDs may be needed to continue
lifelong.
One of the AEDs to be chosen most frequently
now-a-days is Levetiracetam (Iracet).
Editor's Notes
Jacksonian march
After a motor seizure the affected limb(s) may remain weak for some hours before return of function occurs – Todd’s paralysis.
