1. A seizure is defined as an abnormal excessive discharge of neurons in the brain, while epilepsy is a disease characterized by recurrent unprovoked seizures. 2. The ILAE defines epilepsy as at least two unprovoked seizures more than 24 hours apart or one unprovoked seizure with a high risk of future seizures. 3. Seizures are classified as focal or generalized based on where they originate in the brain. Status epilepticus is defined as continuous seizure activity lasting more than five minutes.

1. A seizure (from the Latin sacire—to
take possession of) is the clinical
manifestation of an abnormal,
excessive, hypersynchronous
discharge of a population of cortical
neurons.

2. Seizure or Epilepsy
• Seizures and epilepsy are not the same.
• An epileptic seizure is a transient occurrence of signs
and/or symptoms due to abnormal excessive or
synchronous neuronal activity in the brain.
• Epilepsy is a disease characterized by an enduring
predisposition to generate epileptic seizures and by the
neurobiological, cognitive, psychological, and social
consequences of this condition.
• Translation: a seizure is an event and epilepsy is the
disease involving recurrent unprovoked seizures.

3. ILAE Operational (Practical) Clinical Definition of
Epilepsy :2014
1. At least two unprovoked (or reflex) seizures occuring more than 24
hours apart;
2. 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.
3. Diagnosis of epilepsy syndrome.
Epilepsy is considered to be resolved for individuals who had 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 for the last 5 years
No 2 : it allows a condition to be considered epilepsy after one seizure if there is a high
risk of having another seizure. Often, the risk will not precisely be known and so the old
definition will be employed, i.e., waiting for a second seizure before diagnosing epilepsy.

4. Epilepsy
• Nepal:Prevalence of 7.3 per 1000 population.*
– Age of seizure onset Age of onset of seizure (in Years)
Number of patients
• ≤10 27 (18%)
• 11-20 56 (37.3%)
• USA: 150,000 children and adolescent have single
unprovoked seizure.^
– 35 to 40% will develop epilepsy
– 1.0% prevalence in general population.
– 1 in 5 people will have single seizure in their life time.
*Krishna C. RAJBHANDARI. Epilepsy in Nepal. Neurol J Southeast Asia 2003; 8 : 1 – 4.
^ PCO webinar Dec. 7. 2016

5. System wise distribution of disease
TUTH (IOM)
Resp
CVS
CNS
GIT
Hemat
Immunity
Renal
Miscel
30.66%
21.33%

6. CNS DISEASE - 16
Diag/age 1-12 mth 1-5 yr 5-10 yr >10 yr
Pyogenic meningitis 1 4 1
Seizure disorder 2 1 2
T.B. meningitis with right cerebral
infarction
1
Guillaine Barre syndrome 1
T.B. meningitis with grade II
PEM
1
Simple partial seizure 2

7. International Classification of Epilepsies, Epileptic Syndromes, and Related Seizure Disorders
Localization-related (Focal, Local, Partial)
● Idiopathic (primary) —Benign childhood epilepsy with centrotemporal spikes —Childhood epilepsy
with occipital paroxysms —Primary reading epilepsy
● Symptomatic (secondary) —Temporal lobe epilepsies —Frontal lobe epilepsies —Parietal lobe
epilepsies —Occipital lobe epilepsies —Chronic progressive epilepsia partialis continua of childhood —
Syndromes characterized by seizures that have specific modes of precipitation
● Cryptogenic, defined by —Seizure type —Clinical features —Anatomic localization Generalized
● Idiopathic (primary) —Benign neonatal familial convulsions —Benign neonatal convulsions —Benign
myoclonic epilepsy in infancy —Childhood absence epilepsy (pyknolepsy) —Juvenile absence epilepsy —
Juvenile myoclonic epilepsy (Janz syndrome) —Epilepsies with grand mal seizures on awakening —Other
generalized idiopathic epilepsies —Epilepsies with seizures precipitated by specific modes of activation
● Cryptogenic or symptomatic —West syndrome (infantile spasms) —Lennox-Gastaut syndrome —
Epilepsy with myoclonic-astatic seizures —Epilepsy with myoclonic absences
● Symptomatic (secondary) —Nonspecific cause –Early myoclonic encephalopathy –Early infantile
epileptic encephalopathy with suppression burst –Other symptomatic generalized epilepsies —Specific
syndromes –Epileptic seizures may complicate many disease states Undetermined Epilepsies
● With both generalized and focal seizures —Neonatal seizures —Severe myoclonic epilepsy in infancy
(Dravet syndrome) —Epilepsy with continuous spike and waves during slow-wave sleep —Acquired
epileptic aphasia (Landau-Kleffner syndrome) —Other undetermined epilepsies
● Without unequivocal generalized and focal features Special Syndromes
● Situation-related seizures —Febrile convulsions —Isolated seizures or isolated status epilepticus —
Seizures occurring only with an acute or toxic event, due to factors such as alcohol, drugs, eclampsia,
and nonketotic hyperglycemia

8. International Classification of Epileptic Seizures
Partial (Focal, Localized) Seizures
● Simple partial seizures —With motor signs —With somatosensory or
special sensory systems —With autonomic symptoms and signs —With
psychic symptoms
● Complex partial seizures —Simple partial onset followed by impairment
of consciousness —With impairment of consciousness at onset
● Partial seizures evolving to secondarily generalized seizures —Simple
partial seizures evolving to generalized seizures —Complex partial seizures
evolving to complex partial seizures evolving to generalized seizures
Generalized Seizures (Convulsive or Nonconvulsive)
● Absence seizures
—Typical absences
—Atypical absences
● Myoclonic seizures
● Clonic seizures
● Tonic seizures
● Tonic-clonic seizures
● Atonic seizures Unclassified Epileptic Seizures

9. ILAE Seizure Classification 2016
basic scheme
Focal Generalized Unknown onset
Motor
Non-motor
Motor
Absence
Motor
Non-motor
Aware
impaired awareness
Unknown awareness
Aware
Impaired awareness
Unknown awareness
To bilateral tonic-clonic unclassified

10. PARTIAL
Seizure activity starts in one area of
the brain
Complex
Altered awareness and
behavior e.g. confusion,
repetitive movements
Simple
Patient remains alert e.g.
Jerking of limb , déjà vu,
nausea, strange taste or smell
GENERALIZED
Seizure involves whole brain,
consciousness is lost at the onset.
May become generalized (spreading from one area to the whole of brain
Tonic Clonic
‘grand mal’ or
convulsion with loss of
consciousness,
stiffening of body then
jerking of limbe
Absence
‘petit mal’ or
staring or
trance-like state
Tonic or atonic
‘drop attack or
abrupt fall, either
with stiffening (tonic)
or loss of muscle
tone (atonic or
astatic attacks)
Myoclonic
Sudden muscle
jerks.
Classifying the type of seizure by observation of seizures

11. HISTORY
CLINICAL
EXAMINATION/
OBSERVATION
INVESTIGATIONS
-FUNCTION
-STRUCTURE
TREATMENT
Diseases
diagnosis

12. Investigations
• EEG
• MRI/CT
• Single proton emission computed tomography (SPECT).
• Positron emission tomography (PET).
• USG (young infant)
• Other tests:
– appropriate blood tests (eg, glucose, electrolytes, calcium,
renal function, liver function and urine biochemistry,
metabolic panel, chromosomal studies) to identify
potential causes and/or to identify any significant
comorbidity should be considered.
– A 12-lead ECG

14. Seizure Type Commonly Prescribed Antiepileptic Medications
focal seizures carbamazepine, clobazam, lamotrigine, levetiracetam,
oxcarbazepine, phenytoin, sodium valproate, topiramate,
lacosamide, zonisamide
Generalised
tonic clonic
seizures
carbamazepine, clobazam, lamotrigine, levetiracetam,
oxcarbazepine, phenytoin, sodium valproate, topiramate,
lacosamide, zonisamide
Absence
seizures
ethosuximide, lamotrigine, sodium valproate
Myoclonic,
tonic and
atonic
seizures
clobazam, clonazepam, lamotrigine, levetiracetam,
sodium valproate, topiramate
Infantile
spasms
prednisolone, vigabatrin, ACTH, nitrazepam
Neonatal
seizures
phenobarbitone, phenytoin, clonazepam, levetiracetam,
topiramate

31. Status Epilepticus
• Conventional text book:
– Single seizure >30 minutes
– Series of seizures >30 minutes without full
recovery.
– Longer the SE persist
• Unlikely to have spontaneous cessation
• Harder to control
• Higher the risk of mortality and morbidity
• A seizure which requires prompt intervention

32. Revised definition
• Genarilized , convulsive status epilepticus in
older children (>5 yrs) refers to >5 minutes of
continuous seizure or >2 discrete seizures with
incomplete recovery of consciousness.
• Patients with generalized seizure activity at
arrival in the ER are treated promptly
regardless of prior duration.

33. Drugs which can seizure
• Anti biotics
– Penicillins, isoniazid, metronidazole
• Anaestheics, narcotics
– Halothane, fentanyl, cocaine
• Psychopharmaceuticals
– Antihistamines
– Antidepressents
– Antipsychotics
– Tricyclic antidepressents

34. Mortlity
• Adults: 15-22%
• Children: 3-30%

35. Temporary systemic changes life threatening systemic changes Death
Duration of seizure

36. Specific treatment
• Anticonvulsants
• Rapid acting
– loazepam 0.1mg/kg over 1-2 minutes IV
– Diazepam 0.2mg/kg over 1-2 minutes IV
– Midazolam may be given IM
– Rectal diazepam
– If SE persists, repeat every 5-10 minutes

37. Specific treatment contd
• Long acting
– Phenytoin: 20mg/kg over 20 minutes. IV
– Fosphenytoin: 20mg PE /kg over 5-7 minutes. IV
– Phenobarbital: 20mg/kg over 10-15 minutes IV.
If SE persists: PICU transfer
Infusion:
Propofol/midazolam/pentobarbitol