The document provides an overview of epilepsy, defining it as the occurrence of two or more seizures and discussing various seizure types and classifications. It outlines the evaluation, management, treatment options, and when to consider starting antiepileptic drugs (AEDs) based on individual risk factors and seizure history. Additionally, it addresses considerations for treatment during pregnancy, specific health conditions, and the need for potential surgical interventions in refractory cases.

1. EVALUATION & MANAGEMENT
OF EPILEPSY
DR SUDHIR KUMAR
MD (MEDICINE), DM (NEUROLOGY)
SENIOR CONSULTANT NEUROLOGIST
APOLLO HEALTH CITY, HYDERABAD

2. What is epilepsy?
• Occurrence of 2 or more seizures, at least 24
hours apart, is called epilepsy (=seizure
disorder or fits)
• Convulsions: tonic and/or clonic movements,
as part of seizures
• Seizure: an episode of epileptic attack
• Seizures occur due to abnormal electrical
discharges in the brain.

3. DEFINITIONS
• Idiopathic epilepsy- presumed to be of genetic
origin
• Cryptogenic epilepsy- epilepsy of unknown
cause
• Acute symptomatic seizure- occurs due to a
known acute cause, such as metabolic/toxic
insult, CNS infection, stroke, head injury, drug
toxicity, alcohol or medication withdrawal
• Remote symptomatic seizure- > 1 week after
the occurrence of underlying disorder

4. SEIZURE MIMICS
• Syncope
• Transient ischemic attack (TIA)
• Non-epileptic attack disorder (=psychogenic
seizures)

5. SYNCOPE vs SEIZURE
• Syncope occurs in specific circumstances such as
pain, extreme emotions, cough, micturition, hot
environment, prolonged standing, exercise, etc
• Pre-syncopal symptoms such as dizziness,
lightheadedness and h/o cardiovascular disease also
favor syncope
• Factors favoring seizures include tongue biting, head
turning, posturing, urinary incontinence, cyanosis,
prodromal deja-vu, and postictal confusion.

6. PSYCHOGENIC SEIZURES (NEAD)
• Common in younger people, women>men
• Should be considered only in patients with
recurrent seizures, and not the first episode
• Patients may have tongue bites (on tip of
tongue as compared to sides in true seizures),
and urinary incontinence; but they avoid self-
injury during episodes.

7. FIRST EPISODE OF SEIZURE
• Work-up for underlying causes
• Metabolic profile (electrolytes, calcium, glucose, etc)
• Toxicity/drug overdosage screening (in suspected
cases)
• ABG- if hypoxia suspected
• Brain imaging
• EEG
• CSF analysis (in selected cases)

8. TREATMENT OF FIRST SEIZURE
• Treatment of the underlying cause
• Correction of metabolic derangements is
sufficient in cases of acute symptomatic
seizures and long-term AEDs are not required.
• Risk of seizure recurrence after a single
seizure is 51%
• Anti-epileptic drug therapy is required in cases
with higher risk of recurrence

9. RISK FACTORS FOR RECURRENT SEIZURES
• Age <16
• Seizures occurring between 12 MN and 9 AM
• Remote symptomatic seizures
• Family history of epilepsy
• Status epilepticus or multiple seizures in 24 hours
• Todd’s paresis
• Abnormal neurological examination
• Abnormalities on CT or MRI scan
• Epileptiform discharges on EEG

10. WHEN TO START AED THERAPY?
• Occurrence of 2 or more seizures,
After first episode if:
• Positive family history of epilepsy,
• Abnormal neurological exam,
• Abnormal CT/MRI findings
• Epileptiform discharges on EEG

11. TYPES OF EPILEPSY
• Partial (or focal)- simple or complex partial
• Generalized
• Partial onset with secondary generalization

12. Subtypes of Generalized epilepsy
• Absence (or petit mal)
• Grand mal (or GTCS)
• Atonic
• Myoclonic

13. ANTIEPILEPTIC DRUGS
• Conventional- Phenobarbitone (PB),
phenytoin (PHT), carbamazepine (CBZ),
valproate (VPT)
• Newer AEDs- oxcarbazepine (OXC),
lamotrigine (LTG), topiramate (TPM),
levetiracetam (LEV), clobazam, zonisamide,
lacosamide, etc.

14. WHICH DRUG TO CHOOSE?
Depends on:
1. Type of epilepsy,
2. Age & sex of patient,
3. Presence of co-morbid conditions,
4. Need for IV formulation,
5. Tolerability,
6. Affordability.

15. DRUGS OF CHOICE
• Partial epilepsy- CBZ, OXC; alternative: VPT,
LEV
• Generalized epilepsy- VPT; alternatives- PB,
PHT, LEV
• Absence- VPT
• Myoclonic- VPT; alternatives- clonazepam, LEV
• Mixed seizure types- VPT

16. HOW TO START AEDs?
• Choose monotherapy
• Start the lowest therapeutic dose (based on body
weight),
• Gradually increase the dose based on efficacy and
tolerability,
• Watch for any adverse events,
• 2nd
AED can be added if seizure occurs despite being
on the maximum tolerable dose of single drug
• Adding 3rd
or 4th
AED usually does not help.

17. HOW LONG TO CONTINUE AEDs?
• At least 3 seizure-free years.
• Attempt withdrawal at least once.
• There is a group of patients, where seizures recur
after or during withdrawal of AEDs.
• They need lifelong AEDs.
• Patients with structural brain lesions (such as
gliosis/scar/tumor/old infarcts/mesial temporal
sclerosis, etc) may need lifelong AEDs.

18. EEG in EPILEPSY
• Should be done for all cases,
• Helps in classifying epilepsy
• Helps in selecting the most appropriate AED,
• Can be diagnostic in some cases, such as
absence seizures, SSPE, etc
• Useful in diagnosing NEAD and non-convulsive
seizures.

19. BRAIN IMAGING in EPILEPSY
• Should be done for all cases
• Positive findings seen in about 30% of cases,
• Common findings include granulomas, old
infarcts, mesial temporal sclerosis.
• MRI is preferred,
• Contrast study should be performed if
suspecting infections/tumors.

20. SURGERY IN EPILEPSY
• Required for 10-15% of all cases,
• Offered to patients with medically-refractory
epilepsy,
• Also required for those with brain lesions
causing epilepsy (such as arachnoid cysts,
tumors, Rasmussen’s encephalitis, etc)

21. FEBRILE SEIZURES
• Occurs in children between age 6 months to 6 years,
• Associated with high fever,
• GTCS type,
• Single episode,
• No need of long-term AED
• Fever should be aggressively treated
• Intermittent clobazam may be used for prevention of
seizure.

22. EPILEPSY IN PREGNANCY
• Both epilepsy and AED can lead to adverse outcomes
in pregnancy.
• Single seizure during pregnancy is more harmful that
the intake of AEDs,
• AED should be withdrawn if woman is seizure-free
for 2 years,
• Use monotherapy if possible,
• Avoid VPT
• Use folic acid supplementation
• Risk of fetal malformations highest in 1st
trimester.

23. AEDs in specific situations
• Liver disease- avoid VPT
• Cardiac disease- avoid PHT
• Severe renal impairment- reduce LEV dose by
50%
• Porphyria- gabapentin and clobazam safe
• Children- avoid PB, as it leads to hyperactivity
and learning disability
• Hyponatremia- avoid CBZ, OXC

24. Any Questions?
Email: drsudhirkumar@yahoo.com
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