This document provides an overview of epilepsy, including definitions, types of seizures, diagnosis, treatment and implications. It defines epilepsy as recurring unprovoked seizures and describes the different types of generalized and focal seizures. It outlines the diagnostic process including clinical evaluation, EEG and neuroimaging. It discusses treatment with antiepileptic drugs and risk of seizure recurrence. The document also covers refractory epilepsy, implications of an epilepsy diagnosis, and provides statistics on treatment effectiveness.

1. Epilepsy
Shan Ellawela

2. ‘Epileptic seizure’
“……Transient occurrence of signs and/or
symptoms due to abnormal , excessive or
synchronous neuronal activity in the brain…..”

4. VIDEO

5. VIDEO

6. Generalised tonic clonic seizures
• Pre ictal Phase
• Ictal Phase
Loss of consciousness
1) Stiffening (“tonic phase”)

7. 2)Jerking (“clonic phase”)
Sometimes (lateral)tongue-biting, incontinence
• Post ictal phase
Slow recovery, headache, sleepiness

8. ? Types
• Generalised
• Focal

11. Generalised seizures
Tonic-clonic (in any combination)
Absence
- Typical
- Atypical
- Absence with special features
Myoclonic absence
Eyelid myoclonia
Myoclonic
- Myoclonic
- Myoclonic atonic
- Myoclonic tonic
Clonic
Tonic
Atonic

14. Focal seizures
• Without impairment of consciousness or awareness
– Previous term: simple partial
– With observable motor or autonomic components
• eg. focal clonic, autonomic, hemiconvulsive
– With subjective sensory or psychic phenomena
• Aura - specific types
• Where alteration of cognition is major feature
– Previous term: complex partial
– Dyscognitive

16. Semiological classification (Luders et al.)
• 1. Auras
a. Somatosensory auras b. Visual auras c. Auditory auras d. Gustatory auras e. Olfactory auras f. Autonomic
auras g. Abdominal auras h. Psychic auras
• 2. Autonomic Seizures
• 3. Dialeptic Seizures
• 4. Motor Seizures
a. Simple Motor Seizures
i. Myoclonic seizures ii. Clonic Seizures iii. Tonic Seizures iv. Versive Seizures v. Tonic-Clonic Seizures vi.
Epiletic Spasms
b. Complex Motor Seizures
i. Automotor seizures ii. Hypermotor seizures iii. Gelastic Seizures
• 5. Special Seizures
a. Atonic seizures b. Akinetic seizures c. Astatic seizures d. Negative myoclonic seizures e.
Hypomotor seizures f. Aphasic seizures

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18. Syncope
• Precipitating factor apparent
• Warning/aura beforehand
• Multifocal arrhythmic jerks in up to 90%
• Head turns, oral automatisms in 70%
• Initial upward deviation of eyes common
• Consciousness may be partially preserved
• Short duration, rapid recovery

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21. Dissociative seizures
• Tend to wax and wane
• Nature/frequency/amplitude of the movements
• Longer duration and build up
• Often quick recovery
• ?Thrashing, ?flailing, pelvic-thrusting,
opisthotonus
• May be distracted
• May cause injury
• ‘absences’
• May or may not be obvious precipitants

22. Differential diagnosis
• Syncope
• Dissociative seizures
• Cardiac dysrhythmias
• Concussive syncope
• Panic attacks
• Breath-holding attacks
• Migraine
• Transient global amnesia
• Transient ischaemic attacks
• Hypoglycaemia

23. Diagnosis
• Clinical
• Clinical
• Clinical

24. • Detailed description:
• Precipitating factors
• Onset of seizure
• Frequency of attacks
• Duration of attacks
• State of consciousness
• Age at onset
• Previous febrile seizures
• Perinatal and developmental history
• History of CNS infections or head trauma
• Family history of epilepsy

25. Aids to diagnosis….
• EEG
• MRI
• Others..
ECG,Echo,24 Hr or longer monitoring
Tilt test….

26. EEG
• An EEG should be performed only to support a diagnosis of epilepsy in
adults in whom the clinical history suggests that the seizure is likely to be
epileptic in origin.
• An EEG should be performed only to support a diagnosis of epilepsy in
children and young people. If an EEG is considered necessary, it should be
performed after the second epileptic seizure but may, in certain
circumstances, as evaluated by the specialist, be considered after a first
epileptic seizure.
• An EEG should not be performed in the case of
probable syncope because of the possibility of a false-positive result.
• The EEG should not be used to exclude a diagnosis of epilepsy in a child,
young person or adult in whom the clinical presentation supports a
diagnosis of a non-epileptic event.
• The EEG should not be used in isolation to make a diagnosis of epilepsy.
• An EEG may be used to help determine seizure type and epilepsy
syndrome in children, young people and adults in whom epilepsy is
suspected. This enables them to be given the correct prognosis.
• In children, young people and adults presenting with a first unprovoked
seizure, unequivocal epileptiform activity shown on EEG can be used to
assess the risk of seizure recurrence.

27. Neuroimaging
• Neuroimaging should be used to identify structural abnormalities
that cause certain epilepsies.
• MRI should be the imaging investigation of choice in children,
young people and adults with epilepsy.
• MRI is particularly important in those:
who develop epilepsy before the age of 2 years or in
adulthood
who have any suggestion of a focal onset on history, examination or
EEG (unless clear evidence of benign focal epilepsy)
In whom seizures continue in spite of first-line medication.
• Children, young people and adults requiring MRI should have the
test performed soon.
• Neuroimaging should not be routinely requested when a diagnosis
of idiopathic generalised epilepsy has been made.

31. ? Epilepsy
‘Conceptual’ definition
“…Enduring predisposition to generate
epileptic seizures………….”

32. Practical clinical definitions
“ two unprovoked seizures occurring at least 24
hours apart…..”
‘Unprovoked’: Absence of a temporary or a
reversible factor lowering the seizure threshold
‘Provoked’: Transient factor acting on an otherwise
normal brain to temporarily lower the seizure
threshold

33. Current practical definition
• At least two unprovoked (or reflex) seizures
occurring greater than 24 hours apart.
• One unprovoked (or reflex) seizure and a
probability of further seizures similar to the
general recurrence risk (at least 60%) after two
unprovoked seizures, occurring over the next 10
years.
• Diagnosis of an epilepsy syndrome
Epilepsy is considered to be resolved for individuals who had an age-
dependent epilepsy syndrome but are now past the applicable age or those
who have remained seizure-free for the last 10 years, with no seizure
medicines for the last 5 years

34. • What is the chance it can happen again?
• How long does it take to know it won’t
happen again?
• How effective is treatment?
• If treatment is delayed does it change my
chances of getting seizure control?

35. Risk of recurrence after first seizure
In prospective series….
• Meta-analysis by Berg and Shinnar 1991
36% by 2 years (Treated and untreated)
• FIRST Trial (Italy) 1993
51% in 2 years in untreated
• MESS Trial (MRC UK) 2005
39% in 2 years in the deferred treatment group

38. Treatment
• Sure of diagnosis?
• Risk of recurrence
• Severity of seizures
• Patient’s wishes
• Driving/employment
• Other factors eg pregnancy

39. AED

43. • 47% of patients become seizure-free on 1st
antiepileptic drug
• 14% of patients become seizure-free on 2nd or
3rd antiepileptic drug
• Chance of becoming seizure-free after this
?4%
Kwan and Brodie(2000 NEJM)

44. Refractory Epilepsy
• Epilepsy surgery
• VNS
• Others…

45. Implications of diagnosis
• Legal restrictions eg driving
• Loss of independence
• Effect on work/loss of job
• Injuries
• Responsibilities eg childcare
• Anxiety/depression
• Underlying cause of seizures

46. …Lot more to talk about!
Thank you !