Epilepsy CME

1. Eldoret CME 12.03.15
Dr. Dilraj Singh Sokhi BMedSci(Hons) MBChB(Hons) MRCP(UK)(Neurology)
Honorary Teacher in Adult Clinical Neurology - University of Sheffield (UK)
Visiting Trainee Neurologist / ILAE Epilepsy Teacher - Aga Khan Uni. Hospital (Nairobi)
Graduate Research Fellow in Epilepsy - ILRI Research Institute (Kenya)
TLOC – A Quiz

2. Eldoret CME 12.03.15

3. Outline
 Introduction
 Causes and risk factors
 Classification of seizures
 Diagnosis and investigation
 Management
 Social aspect
 Conclude

4. Q1. TLOC (“Blackouts”)
Blackouts

5. A1. TLOC (“Blackouts”)
Blackouts
Problem with blood circulation
(Syncope)
Primary disturbance
of brain function
Epilepsy Non-epileptic
attacks
Idiopathic generalised
epilepsy
Focal epilepsyUnclassifiable
epilepsy
Non-cardiacCardiac

6. Q2. Syncope
 Definition
 Causes
 Investigations

7. A2. Syncope
 Definition: short loss of consciousness and muscle
strength - fast onset, short duration, and
spontaneous recovery - due to decreased blood
flow to brain
 Causes:
 Investigations
ECGECG
Lying/standing BPLying/standing BP

8. 3a. ECG 1 – usually in older people

9. 3b. ECG 2 – genetic or drug related

10. 3c. ECG – can be after MI

11. 3d. ECG – must NOT be missed!

12. 3e. ECG – bonus points! (rare)

13. ECG and TLOC – Important!Important!

14. Q4. Syncope vs. Seizures

15. A4. Syncope vs. Seizures
- P osture- P osture
- P rovoking factor- P rovoking factor
- P rodrome- P rodrome
- P rompt recovery- P rompt recovery

16. Q5. Epilepsy – Burden

17.  Africa: 2x incidence + prevalence, 3-5x  mortality
 Kenya: Similar figures. Approx 400,000 (1% ofApprox 400,000 (1% of
popn)popn)
A5. Epilepsy – Burden

18.  Seizure:
 Epilepsy:
 Active Epilepsy:
Q6. Epilepsy - definitions

19.  Seizure: transient signs and/or symptoms due to abnormal excessive synchronous neuronal activity in
the brain.
 Epilepsy: enduring predisposition to repeated and unprovoked seizures occurring more than twice in a
year.
 Active Epilepsy: ≥ 2 unprovoked seizures >24 hours apart in one year
National Epilepsy Guidelines www.epilepsykenya.orgwww.epilepsykenya.org
A6. Epilepsy - definitions

20. Q7. Causes of Epilepsy

21. A7. Causes of Epilepsy
 Infections
 Metabolic (acquired and genetic)
 Head trauma
 Perinatal injury
 Toxic
 SOL
 Vascular
 Congenital
 Degenerative

22. • Ti
Ba-Diop et al, 2014
Causes of Epilepsy in Africa

23. Q8. Seizure Classification

24. A8. Seizure Classification

25. Focal Epilepsy

26. Q9. Classification of Epilepsies

27. A9. Classification of Epilepsies

28. Q10. Diagnostic Workup

29. A10. Diagnostic Work-up
It’s all in the HISTORY!It’s all in the HISTORY!
Always always always get a collateral history (?video)
Onset
 age of first seizure
 Association with a particular event, accident, illness, fever?
 Is there always fever with the seizures?
Pre-ictal phase
 Any precipitating factors?
 Are there any prodromal symptoms?

30. History (cont…)
 lctal phase – semiology (description of seizure itself)
 Is there an aura? What does it consist of?
 Does the patient scream?
 Where in the body? How does the event start (e.g. turning face)
 Does the patient jerk? If so, both arms and legs, or one side?
 Are they unconscious? Does the patient fall down?
 Does the patient have incontinence of urine or stool?
 Does the patient bite the tongue?
 Does the patient make irrational or abnormal movements?
 Breathing: stertorous/snoring, shallow/deep, hyperventilating?
 How long is the ictal phase?

31. History (cont…)
 Post-ictal
 How long does the convulsion last? (incl. post-ictal phase)
 How is the patient's behaviour after the seizure?
 Is there any focal sign?
 How long is the recovery phase?
 Other important details
 Time: At what time of the day or night do the seizures occur
(daytime, when sleeping or awakening)?
 Frequency: when was the first / last / worst seizure?
How frequent have the seizures been?
Has there been a change in the frequency?
What is the interval between seizures?

32. History (cont…)
 Family history
 Pregnancy and perinatal history
 Developmental history (milestones)
 Past Medical History
 Medicines or alcohol used?
 Social History

33. Q11. Investigations?

34. A11. Investigations?
 IT’S ALL IN THE HISTORY!IT’S ALL IN THE HISTORY! (and the video!)
 ECG is mandatory
 Examination (BP, temp, neuro)
 Video EEG is gold standard
 EEG and brain imaging reasonable
 Not much room for other investigations except:
 FBC, U&E, Mg, Ca, glucose, inflammatory markers

35. Q12. Case Study 1 Video

36. Q13. Case Study 2 Video

37. Q14. Case Study 3 Video

38. Abversek et al, 2011
A14. PNES vs Epilepsy

39. ILAE PNES TF Global Survey
 We will collect Pan-African, including Kenyan, data this year
 Has been approved by local ethics board!
www.TinyURL.com/PNESKenya

40. Q15. Acute Seizures – First Aid
 Move patient away from fire, traffic or water
 Take away any objects that could harm the patient
 Loosen tight clothes, remove glasses
 Put wooden stick into the mouth to prevent injury
 Put something soft under the head
 Turn patient on his or her left side, so that saliva and
mucus can run out of the mouth
 Try to stop the jerking, or restrain the movements.
 Remain with patient until regains consciousness
 Give them something to drink during the seizure
 Put them in the recovery position at the end

41. A15. Treatment – First Aid
 Move patient away from fire, traffic or water
 Take away any objects that could harm the patient
 Loosen tight clothes, remove glasses
Put wooden stick into the mouth to prevent injury
 Put something soft under the head
 Turn patient on his or her left side, so that saliva and
mucus can run out of the mouth
Try to stop the jerking, or restrain the movements.
 Remain with patient until regains consciousness
Give them something to drink during the seizure
 Put them in the recovery position at the end

42. Q16. Case Study 4
A 24 year old male known to have epilepsy and is on
phenytoin is brought in by the wife as he has had 2
generalized tonic clonic seizures in the last 15 minutes
and is currently still drowsy, GCS 6. She did not know
how to give the rescue medication. Whilst you are
assessing him he has another GTCS in casualty.
How will you manage this man?

43. A16. Status Epilepticus
• ABC
• DEFG!
• Quick History
• Examine + vitals
• Treat underlying
condition
Diazepam 0.3mg/kg @1mg/min
(max 10mg adults, 5mg children)

44. Q17a. Case Study 5
A 3 year old is brought in by the mother as she has been
running a temperature for 2 days, and she has had two
GTCS – one yesterday evening and one today morning,
each lasting less than 10 minutes. She is currently
awake, alert but a bit irritable, not meningitic but has a
temperature of 39o
C.
How will you manage this girl?

45. Q17b. Febrile Seizures
Exclude CNS disease and electrolyte imbalance
Usually treat with anti-pyretics, ?diazepam of prolonged
Seizure recurrence based on if was:
Complex vs simple:
>15 minutes
≥ 2 seizures in 24 hours
Focal features (in seizure history or on examination)
Short duration (<1 hour) of fever
? Family history

46. Q18a. Case Study 6
A 34 year old boda boda rider travelling from Busia has
a side collision with a car. He is ejected from his seat at
approx. 50kph, and lands a few meters away. He is
found unconscious but recovers and is brought in to
your hospital for check up. Luckily he has not sustained
any significant injuries.
How do you gauge severity of head injury?

47. Q18b. Case Study 6 (cont.)
He was discharged home but returned 3 weeks later as
he had a witnessed single GTCS. He has no focal
neurological deficit.
How would you manage this man now?

48. Q19. Case Study 7
A 19 year old man with nocturnal episodes for 3 years,
which occur every few months but now more frequently.
He wakes up having wetted the bed and bit his tongue.
Recently he also had an attack when revising for exams,
witnessed by a friend and sounds like a generalised tonic
clonic seizure.
What will you do for this young man?

49. Q20. Why Control Chronic Epilepsy?

50.  Prevent injury
 Prevent death
 when in water, SUDEP
 Reduce interruption of daily life
 Driving regulations in UK
 Prolonged seizures (>30 mins) = brain damage
A20. Why Control Chronic
Epilepsy?

51. Chronic Treatment Considerations
 Confirmed diagnosis of active epilepsy:
 ≥ 2 unprovoked seizures > 24 hours apart in a year
 Rarely can start after single seizure. Evidence needed:
- relevant neurological deficit
- abnormal EEG: epileptiform activity or focal slowing
- patient, after adequate counselling, desires treatment
 Counsel patients – precipitating factors, adherence,
social impact, safety, side effects etc
 Also consider: - gender and age
- Other meds esp cART
- Other PMH

52. Q21. What Trigger Factors?

53. A21. What Trigger Factors?
 Non-adherence to treatment / stopping treatment
 Sleep deprivation / exhaustion
 Acute infections and fever
 Flickering lights e.g. televisions, computers, disco
 Alcohol intake/withdrawal
 Substance abuse/withdrawal
 Hormonal imbalances (catamenial-seizures)
 Dehydration
 Emotional Stress
 Hyperventilation

54. Treatment (1)
 Initiation of treatment
 Start with one drug and small doseStart with one drug and small dose
 Gradually adjust dosage at two weeks intervalsGradually adjust dosage at two weeks intervals
until: - complete seizure control
- maximum tolerated dose is reached
 If no seizure control, add second drug and consider gradually
reducing or maintaining the initial drug
 The aim of treatment is to achieve the lowest maintenance
dose which provides complete seizure control.
 Gradual introduction of AED can produce therapeutic effects
but with fewer side-effects.
 Severe "intoxication" side-effects at the beginning of the
treatment indicate too rapid or too large dose increases.

55. Treatment (2)
 Maintenance
 Ideally, only one drug should be used.
 If the first drug has only produced a partial response, then a
second drug can be added gradually taking into
consideration drug interactions.
 The aim should be to have a maximum of two drugs.
 If the two drugs fail, then consult the next level.
Partnership between patient and provider is
important to ensure that the patient
understands the importance of adhering to
treatment.

56. Treatment (3)
 Follow up and monitoring
 Holistic approach with partnership of patient, family and
care providers enhances patient's insight and compliance.
 Drug monitoring should be done by measuring serum levels
in cases where there is difficulty in management.
 Compliance is the key to successful seizure control, and
counselling the patient is the most critical factor.

57. Treatment (4)
 When to withdraw drugs – done by specialistsdone by specialists
 If the patient has been seizure-free for 2-3 years (depends)
 Prior to drug withdrawal, consider:
- Focal seizures are often very difficult to control
especially hippocampus and other temporal
lobe areas. Relapse rate is high. ? Carry on
indefinitely
- IGE generalised seizures have best remission rates
- Perisistently abnormal EEG vs. seizures controlled
- Patient views: may opt to remain on medications
despite achieving prolonged remission.
5-10% chance getting another seizure anyway.
 Counselling is very important to alert them of the chance of

59. Treatment Choices
First Line
Phenobarbitone
Phenytoin
Carbamezapine
Sodium Valproate
Rescue medication
Second Line
Clonazepam, Clobazam, Lorazepam, Lamotrigine, Gabapentin, Pregabalin,
Ethosuximide, Methsuximide, Esclimezapine, Oxcarbazapine, Topiramate,
Levetiracetam, Peramapanel, Tiagabine, Vigabatrin, etc etc
REFER TO GUIDELINES
FOR RATIONALE OF
CHOICES, DOSES,
REGIMES ETC

60. Q22. Case Study 8
12 year old boy who had attacks of suddenly getting
fearful and anxious with no precipitating factor, and on
two occasions has run out of the house. The father
followed him to the sugarcane farm and found him on the
ground, with right leg twitching, unresponsive. This went
on for 5 minutes and then he woke up and kept asking “I
was in the home just now. Why are we here?” The
younger brother then said he has witnessed him falling a
few times and shaking when walking to school.
What will you do for this young boy?

61. A22. Case Study 8 – one option

62. Q23. Case Study 9
24 year old woman known to have seizures since she had
meningitis 8 years previously, who is currently on
phenytoin. She is well controlled on her treatment and has
not had a seizure for 2 years. She recently got married
and moved to Busia, and is on malaria prophylaxis
(Doxicycline). She works as a secretary in a local
business. Her and her husband want to have a baby and
she has come to you for advice.
What will you do for this young woman?

63. Q23. Case Study 9
24 year old womanwoman known to have seizures since she had
meningitis 8 years previously is currently on phenytoinphenytoin.
She is well controlled on her treatment and has not had a
seizure for 2 years2 years. She recently got married and moved
to Busia, and is on malaria prophylaxis (doxicyclinedoxicycline).
She works as a secretarysecretary in a local business. Her and her
husband want to start a familystart a family and she has come to you
for advice.
What will you do for this young woman?

64. A23. Case Study 9 - issues

65. About Stigma and Beliefs…
 Drugs have to be taken for many years, possibly a life-time.
 Combination with herbal treatment might be dangerous as
interaction between the drugs and the herbs unpredictable.
 Not contagious and anyone can touch the person while they are
having a seizure (e.g. to remove them from the danger of fire or
water) or in between the seizures.
 Child of normal intelligence should be placed in normal school.
 Over-protection not helpful in a child's upbringing, but
reasonable precautions should be taken
 Epilepsy should be talked about with family, school, work etc
 Epilepsy is NOT a reason for not marrying or have a family.

66. Summary
 3 main causes of TLOC; important to differentiate
 Clinical features of these 3 main types
Remember:Remember:
Fall + loss of consciousness + shaking + incontinenceFall + loss of consciousness + shaking + incontinence
IS NOT ALWAYS A SEIZURE!IS NOT ALWAYS A SEIZURE!
 Its all in the history! (and the video…)
 (some) Role of investigations: ECG always, EEG, CT/MRI
 Treatment options; status epilepticus
 Counselling patients and families/caretakers is key on all
aspects of their disease.

67. Acknowledgements
 Professor Markus Reuber
 Dr. Richard Grünewald
 Dr. Stephen Howell
 And of course Moi Teaching and Referral Hospital!