Epilepsy is a chronic neurological disorder characterized by recurrent unprovoked seizures due to abnormal neuronal activity, affecting approximately 50 million people globally. Seizure types vary and can be classified based on their symptoms, origin within the brain, and consciousness impact, with treatments including anticonvulsants and surgery. While management can lead up to 70% of individuals living normal lives, the prognosis depends on several factors including the underlying cause and timely treatment.

1. Epilepsy
 Epilepsy (from the Ancient Greek (epilēpsia):
seizure) is a group of chronic neurological disorders
characterized by seizures, which are the result of
abnormal, excessive or hyper synchronous neuronal
activity in the brain.

3.  Epilepsy (sometimes referred to as a seizure disorder)
is a common chronic neurological condition that is
characterized by recurrent unprovoked epileptic
seizures.
 It affects approximately 50 million people worldwide.
 It is usually controlled, but not cured.

4.  A chronic disorder characterized by paroxysmal brain
dysfunction due to excessive neuronal discharge, and
usually associated with some alteration of
consciousness.
 The clinical manifestations of the attack may vary
from complex abnormalities of behavior including
generalized or focal convulsions to momentary spells
of impaired consciousness.

5.  It affects between 2% and 3% of the population, ¾
before adolescence.
 It can be caused by genetic, structural, metabolic or
unknown factors.
 Among the structural factors, the most common
causes in developing countries are infectious and
parasitic diseases, perinatal brain damage, vascular
disease, and head trauma.
 The prognosis of epilepsy depends on the etiology of
the illness as well as on early and sustained treatment.
 It is estimated that up to 70% of people with epilepsy
can live normal lives if they receive proper care.

6.  The cause of an individual's epilepsy can be divided
into two categories: symptomatic and idiopathic.
 Symptomatic epilepsies originate due to some
structural or metabolic abnormality in the brain.
 The term idiopathic means "a disorder unto itself",
and not "cause unknown".
 No other condition has been implicated as the cause
of the epilepsy.
 Idiopathic epilepsies are often but not exclusively
genetic and generalized – for example Juvenile
Absence Epilepsy.

7.  Certain circumstances can lead to an increased
likelihood of seizures in someone with epilepsy or in
certain syndromes.
 For example:
During sleep
The transition between sleep and awake
Tiredness
Illness
Constipation
Menstruation
Stress

8.  They are variously based on:
1. The clinical manifestations of the seizure (motor,
sensory, reflex or psychic)
2. The pathological substrate (hereditary, inflammatory,
degenerative, neoplastic or traumatic)
3. The location of the epileptogenic lesion (rolandic,
temporal, diencephalic regions),
4. The time of life at which the attacks occur (nocturnal,
diurnal, menstrual, etc.)

9.  Seizure types are organized firstly according to
whether the source of the seizure within the brain is
localized (partial or focal onset seizures) or
distributed (generalized seizures).
 Partial seizures are further divided on the extent to
which consciousness is affected.
 If it is unaffected, then it is a simple partial seizure;
otherwise it is a complex partial seizure.

10.  Status epilepticus (SE)
Continuous convulsion lasting longer than 30
minutes OR occurrence of serial convulsions
between which there is no return of consciousness
 Idiopathic SE
Seizure develops in the absence of an underlying
CNS lesion/insult
 Symptomatic SE
Seizure occurs as a result of an underlying
neurological disorder or a metabolic abnormality

11. Seizures
Partial
– Electrical discharges in a
relatively small group of
dysfunctional neurones in
one cerebral hemisphere
– Aura may reflect site of
origin
– + / - LOC
Generalized
– Diffuse abnormal
electrical discharges
from both
hemispheres
– Symmetrically
involved
– No warning
– Always LOC

12. Simple Complex
Partial Seizures
1. w/ motor
signs
2. w/ somato-
sensory
symptoms
3. w/ autonomic
symptoms
4. w/ psychic
symptoms
1. simple
partial --> loss
of
consciousnes
s
2. w/ loss of
consciousnes
s at onset
Secondary
generalized
1. simple partial
--> generalized
2. complex partial
--> generalized
3. simple partial
--> complex partial
--> generalized

13. Simple partial
– In simple partial seizures, consciousness is not
impaired.
– Patients can present with motor, somatosensory,
special sensory, autonomic or psychic symptoms
Complex partial
– A complex partial seizure describes a seizure where
consciousness is impaired.
– A partial seizure may begin with a simple seizure,
conversely, its onset may coincide with the
impairment of consciousness.
– It may be presented with or without an aura.
2nd
ary generalized
– Partial sezure evolve to secondarily generalized
seizures . May be gen. Tonic-clonis, tonico or clonic

14. Simple partial seizures with autonomic symptoms
• Vomiting
• Pallor
• Flushing
• Sweating
• Pupil dilatation
• Piloerection
• Incontinence

15. Simple partial seizures with autonomic symptoms
• Stiffness in L cheek
• Difficulty in articulating
• R side of mouth is dry
• Salivating on the L side
• Progresses to tongue and back of throat

16. Simple partial seizures
with psychic symptoms
• Dysphasia
• Dysmnesic
• Cognitive
• Affective
• Illusions
• Structured hallucinations

17. Simple partial seizure with pyschic symptoms
• Dysmnesic symptoms
– “déjà-vu”
• Affective symptoms
– fear and panic
• Cognitive
• Structured hallucination
– living through a scene of her former life
again

18. Complex Partial Seizures
• Simple partial onset followed by impaired
consciousness
– with or without automatism
• With impairment of consciousness at onset
– with impairment of consciousness only
– with automatisms

19. Simple Partial Seizures followed by Complex Partial
Seizures
• Seizure starts from awake state
• Impairment of consciousness
• Automatisms
– lip-smacking
– right leg

20. Complex Partial Seizures with impairment of
consciousness at onset
• Suddenly sit up
• Roll about with vehement
movement

21. Partial Seizures evolving to Secondarily Generalized
Seizures
 Simple Partial Seizures to Generalized Seizures
 Complex Partial Seizures to Generalized Seizures
 Simple Partial Seizures to Complex Partial Seizures
to Generalized Seizures

22. Simple Partial Seizures to Generalized Seizures
• Turns to his R with upper body and
bends his L arm
• Stretches body
• Tonic-clonic seizure
• Relaxation phase
• Postictal sleep

23. Simple Partial Seizures to Complex Partial Seizures
to Generalized Seizures
• Initially unable to communicate but
understands
• Automatism
– Smacking
– Hand-rubbing
• Abolished communication
• Generalized tonic-clonic seizure

24. Generalized seizures
• Absence
• Myoclonic
• Clonic
• Tonic
• Tonic-clonic
• Atonic

25. Absence seizures
– Sudden onset
– Interruption of ongoing activities
– Blank stare
– Brief upward rotation of eyes
– Duration: a few seconds to 1/2 minute
– Evaporates as rapidly as it started

26. Absence seizures
• Stops hyperventilating
• Mild eyelid clonus
• Slight loss of neck muscle tone
• Oral automatisms

28. Myoclonic seizures
– Sudden, brief, shock-like
– Predominantly around the hours of going to or
awakening from sleep
– May be exacerbated by volitional movement
(action myoclonus)

29. Myoclonic seizures
• Symmetrical
myoclonic jerks

30. Clonic seizures
– Repetitive biphasic jerky movements
– Repetitive vocalisation synchronous with clonic
movements of the chest (mechanical)
– Passes urine

31. Tonic seizures
– Rigid violent muscle contraction
– Limbs are fixed in strained position
• patient stands in one place
• bends forward with abducted arms
• deep red face
• noises - pressing air through a closed mouth

32. Tonic seizures
• Elevates both hands
• Extreme forward bending posture
• Keeps walking without falling
• Passes urine

33. Tonic-clonic seizures
(grand mal)
Tonic Phase
– Sudden sharp tonic
contraction of respiratory
muscle: stridor / moan
– Falls
– Respiratory inhibition
cyanosis
– Tongue biting
– Urinary incontinence
Clonic Phase
– Small gusts of grunting
respiration
– Frothing of saliva
– Deep respiration
– Muscle relaxation
– Remains unconscious
– Goes into deep sleep
– Awakens feeling sore,
headaches

34. Tonic-clonic seizures
• Tonic stretching of arms and legs
• Twitches in his face and body
• Purses his lips and growls
• Clonic phase

36. Atonic seizures
– Sudden reduction in muscle tone
– Atonic head drop

38. Change in consciousness, so that you can't
remember some period of time
Change in emotion, like unexplainable
fear, panic, joy, or laughter
Change in sensation of the skin, usually spreading
over the arm, leg, or trunk.

39. • Changes in vision, including flashing lights, or
(rarely) hallucinations (seeing things that aren't
there)
• Loss of muscle control and falling, often very
suddenly Muscle movement such as twitching that
might spread up an armor leg
• Muscle movement such as twitching that might
spread up an arm or leg
• Muscle tension/tightening that causes twisting of
the body, head, arms or leg
• Tasting a bitter or metallic flavor

40. Diagnosis in epilepsy
• Aims:
– Differentiate between events mimicking
epileptic seizures
• E.g. syncope, vertigo, migraine, psychogenic non-
epileptic seizures (PNES)
– Confirm the diagnosis of seizure (or possibly
associated syndrome) and the underlying
etiology

41. Diagnosis in epilepsy
• Approach:
– History (from patient and witness)
– Physical examination
– Investigations

42. History
• Event
– Localization
– Temporal relationship
– Factors
– Nature
– Associated features
• Past medical history
• Developmental history
• Drug and immunization history
• Family history
• Social history

43. Physical Examination
• General
– esp. syndromal or non-syndromal dysmorphic
features, neurocutaneous features
• Neurological
• Other system as indicated
– E.g. Febrile convulsion, infantile spasm

44. Investigations
• I. Exclusion of differentials:
– Bedside: urinalysis
– Haematological: CBP
– Biochemical: U&Es, Calcium, glucose, ABGs
– Radiological: CXR, CT head
– Toxicological: screen
– Microbiological: LP
(Always used with justification)

45. Investigations
• II. Confirmation of epilepsy:
– Dynamic investigations : result changes with
attacks
• E.g. EEG
– Static investigations : result same between
and during attacks
• E.g. Brain scan

46. Electroencephalography (EEG)
• EEG indicated whenever epilepsy
suspected
• Uses of EEG in epilepsy
– Diagnostic: support diagnosis, classify
seizure, localize focus, quantify
– Prognostic: adjust anti-epileptic treatment

47. Electroencephalography (EEG)
• EEG interpretation in epilepsy
– Hemispheric or lobar asymmetries
– Periodic (regular, recurring)
– Background activity:
• Slow or fast
• Focal or generalized
– Paroxysmal activity:
• Epileptiform features – spikes, sharp waves
• Interictal or ictal
• Spontaneous or triggered

48. Electroencephalography (EEG)
• Certain epilepsy syndromes have characteristic or suggestive
features
• E.g.
Infantile spasms Hypsarrhythmia
Childhood absence epilepsy Generalized 3-Hz spike-wave
Juvenile myoclonic epilepsy Generalized/ multifocal 4-5 Hz spike-
wave and polyphasic-wave
Benign occipital epilepsy Unilateral/ bilateral occipital sharp/
sharp-slow activity that attenuates on
eye opening
Lennox-Gastaut syndrome Generalized/ bianterior spike-wave
activity at <2.5 Hz

49. Electroencephalography (EEG)
• E.g. Brief absence seizure in an 18-year-old patient with
primary generalized epilepsy

50. Electroencephalography (EEG)
• Note:
– Normal in 10-20% of epileptic patients
– Background slowed by:
• AED, diffuse cerebral process, postictal state
– Artifact from:
• Eye rolling, tremor, other movement, electrodes
• Interpreted in the light of proximity to
seizure

51. Neuroimaging
• Structural neuroimaging
• Functional neuroimaging

52. Structural Neuroimaging
• Who should have a structural
neuroimaging?
– Status epilepticus or acute, severe epilepsy
– Develop seizures when > 20 years old
– Focal epilepsy (unless typical of benign focal
epilepsy syndrome)
– Refractory epilepsy
– Evidence of neurocutaneous syndrome

53. Structural Neuroimaging
• Modalities available:
– Magnetic Resonance Imaging (MRI)
– Computerized Tomography (CT)
• What sort of structural scan?
– MRI better than CT
– CT usually adequate if to exclude large tumor
– MRI not involve ionizing radiation
• I.e. not affect fetus in pregnant women (but nevertheless
avoided if possible)

54. Functional Neuroimaging
• Principles in diagnosis of epilepsy:
– When a region of brain generates seizure, its
regional blood flow, metabolic rate and
glucose utilization increase
– After seizure, there is a decline to below the
level of other brain regions throughout the
interictal period

55. Functional Neuroimaging
• Modalities available:
– Positron Emission Tomography (PET)
– Single Photon Emission Computerized Tomography
(SPECT)
– Functional Magnetic Resonance Imaging (fMRI)
• Mostly used in:
– Planning epilepsy surgery
– Identifying epileptogenic region
– Localizing brain function

56. Venn Diagram

57. Seizure Therapy
Anticonvulsant Surgery
Specific Treatments
Reassurance and
Education
General Treatment
Seizure

58. Focal with/
without secondary
generalisation
Carbamazepine
Lamotrigine
Levetiracetam
Oxcarbazepine
Generalised
tonic-clonic
Carbamazepine
Lamotrigine
Oxcarbazepine
Sodium valproate
Tonic or atonic
Sodium valproate
Absence
Ethosuximide
Lamotrigine
Sodium valproate
Myoclonic
Levetiracetam
Sodium valproate
Epilepsy with generalised
tonic-clonic seizures only
Carbamazepine
Lamotrigine
Oxcarbazepine
Sodium valproate
Idiopathic generalised
epilepsy
Lamotrigine
Sodium valproate
Topiramate

59. Drug Starting
dose/day
Typical
maintenance
dose/day
Dosing
interval
Commonest
side effects
Carbamazepine 200 mg 400−1800 mg Bid Rash
Diplopia
Dizziness
Headache
Nausea
Hyponatraemia
Ethosuximide 250 mg 500-2000 mg Bid Nausea
Drowsiness
Headache
Lamotrigine 25 mg 100-400 mg Bid Nausea
Dizziness
Headache
Insomnia
rash
Levetiracetam 250 mg 1000−3000 mg Bid Lethargy
Irritability
Mood disturbance
Insomnia
Drowsiness
Unsteadiness
Sodium
valproate
300 mg 600-2500 mg bid Weight gain
Tremor
Hair loss
Teratogenesis

60. Education & Support
• Information leaflets and information
about support group
• Avoidance of hazardous physical
activities
• Management of prolonged fits
– Recovery position
– Rectal diazepam
• Side effects of anticonvulsants

61. Anticonvulsants
• Suppress repetitive action potentials in
epileptic foci in the brain
– Sodium channel blockade
– GABA-related targets
– Calcium channel blockade
– Others: neuronal membrane
hyperpolarisation

62. Anticonvulsants
Cabamazepine
Phenytoin
Valproic acid
Tonic-clonic and partial
Ethosuximide
Valproic acid
Clonazepam
Absence seizures
Valproic acid
Clonazepam
Myoclonic seizures
Diazepam
Lorazepam
Short term
control
Phenytoin
Phenobarbital
Prolonged
therapy
Status Epilepticus
Corticotropin
Corticosteroids
Infantile Spasms
Drugs used in seizure disorders

63. Adverse Effects
• Teratogenicity
– Neural tube defects
– Fetal hydantoin syndrome
• Overdosage toxicity
• Life-threatening toxicity
– Hepatotoxicity
– Stevens-Johnson syndrome
• Abrupt withdrawal

64. Medical Intractability
• No known universal definition
• Risk factors
– High seizure frequency
– Early seizure onset
– Organic brain damage
• Established after adequate drug trials
• Operability

65. Surgery
• Curative
– Catastrophic unilateral or secondary
generalised epilepsies of infants and young
children
• Sturge-Weber syndrome
• Large unilateral developmental abnormalities
• Palliative
– Vagal nerve stimulation

66. Surgical Outcome
• Medical Intractability
• A well-localised epileptogenic zone
– EEG, MRI
• Low risk of new post-operative deficits

67. References
1. Stedman’s Medical Dictionary.
2. MDConsult: Nelson’s textbook.
3. Illustrated Textbook of Pediatrics.
4. Video atlas of epileptic seizures – Classical
examples, International League against epilepsy.
5. Guberman AH, Bruni J, 1999, Essentials of
Clinical Epilepsy, 2nd
edn. Butterworth
Heinemann.
6. Manford M, 2003, Practical Guide to Epilepsy,
Butterworth Heinemann.