The document provides information on epilepsy classification, diagnosis, and treatment. It discusses: 1. The 2017 ILAE classification system for seizures, which categorizes seizures as focal or generalized based on onset and includes motor and non-motor seizure types. 2. Factors that can help diagnose epilepsy including EEG, MRI/CT scans, and seizure description/videos. An EEG is most valuable within 24 hours of a seizure. 3. Treatment considerations like using broad-spectrum anti-epileptic drugs (AEDs) like levetiracetam as first-line due to few drug interactions and cognitive side effects. AED treatment should begin after the first seizure in adults.

1. By
DR.Hussein Abdeldayem, MD
Professor of Pediatric Neurology Unit , Alex
University
Member of : AAN, ICNA, ACNA

2. WHAT IS WRONG?

3. 3

4. Never restrain the child or place anything in the mouth

6. LOOK FOR THE STAR
6

7. 7
1. Epilepsy with brain dysfunction
(2ry) MOSTLY RESISTANT
as GDD, CP, postmeningitis ,etc
Prevalence up to 30-50%
Often intractable
Often mixed
Frequency and severity are proportion of
degree of the disorder
CT/MRI
Treatment is challenging
BROAD SPECTRUM AED
POLYTHERAPY
NEUROPROTECTIVE
ANTIEPILEPTOGENIC

8. 8
70%
RelapseFull response
AED Therapy Response
Classification
Partial intractable

9. 9
2. NOT ALL ABN EEG IS
EPILEPSY OR FOR AED

10. 10
 5- 10% of normal persons have
abnormal EEG
 10% of non epileptic persons have
abnormal EEG
 Migraine
 Anxiety
 Depression
 FC
 BHS
 Tension child
 ADHD

11. 11
Up to 30% of epileptic patients with
normal EEG
 30-60 minutes
 Sleep deprivation,
 HV,
 IPS
 Generalized slowing
activity

12. 12
 One normal EEG does not exclude epilepsy
 A second EEG performed during sleep in
sleep deprived patients reveals epileptiform
abnormalities in half of patients whose first
EEG was normal

13. 13
3. When EEG is of valuable?
 Same day
 After 2 weeks from the attack
 After 4 weeks from the attack

14. 14
 EEG is most valuable within 24 h of the
seizure
Arch Neurol. 2010 Jul 12.
Optimizing Electroencephalographic Studies for
Epilepsy Diagnosis in Children With New-Onset Seizures.

15. 15
Describe EEG. ? Possible diagnosis
Drug of Choice?

16. 16
Describe EEG ?possible diagnosis
Drug of choice ?

17. Some Seizure Onsets can be Focal or Generalized
Focal Onset Generalized Onset
atonic
clonic
epileptic spasms
myoclonic
tonic
tonic-clonic
atonic
clonic
epileptic spasms
myoclonic
tonic
tonic-clonic

18. Classification according to EEG
findings. ILAE 1981
Generalized Focal
Both Cerebral
Hemispheres
Only a part of a
hemisphere
Loss of Consciousness No loss of
consciousness
Treated by Valproate Treated by
Carbamazipine
MRI
Focal with
2ry G

19. Motor
Tonic-clonic
Other motor
Non-Motor (Absence)
Unknown Onset
Motor
Non-Motor
focal to bilateral tonic-clonic
Generalized OnsetFocal Onset
Motor
Tonic-clonic
Other motor
Non-Motor
ILAE 2017 Classification of Seizure Types Basic Version 1
Unclassified 2
1 Definitions, other seizure types and descriptors are listed in the accompanying paper & glossary of terms
2 Due to inadequate information or inability to place in other categories
Aware
Impaired
Awareness
From Fisher et al. Instruction manual for the ILAE 2017
operational classification of seizure types. Epilepsia doi:
10.1111/epi.13671

20. Motor
tonic-clonic
clonic
tonic
myoclonic
myoclonic-tonic-clonic
myoclonic-atonic
atonic
epileptic spasms2
Non-Motor (absence)
typical
atypical
myoclonic
eyelid myoclonia
Unknown Onset
Motor Onset
automatisms
atonic2
clonic
epileptic spasms2
hyperkinetic
myoclonic
tonic
Non-Motor Onset
autonomic
behavior arrest
cognitive
emotional
sensory
focal to bilateral tonic-clonic
Generalized OnsetFocal Onset
Aware
Impaired
Awareness
Motor
tonic-clonic
epileptic spasms
Non-Motor
behavior arrest
ILAE 2017 Classification of Seizure Types Expanded Version1
Unclassified3
1 Definitions, other seizure types and descriptors are listed in the
accompanying paper and glossary of terms.
2 These could be focal or generalized, with or without alteration of awareness
3 Due to inadequate information or inability to place in other categories
From Fisher et al. Instruction manual for the ILAE 2017
operational classification of seizure types. Epilepsia doi:

21. GENERALIZED FITS
Focal Fits
Focal with 2ry generalization FITS
Absence – Myoclonic - ES

22. 22
4. Do you ask for Brain CT or MRI?
When?

23. 23
Brain CT/MRI
1. every patient with a newly diagnosed focal
epilepsy should undergo CT/MRI
2. RESISTANT EPILEPSY
3. SECONDARY EPILEPSY

24. 24
 Identify structural causes of epilepsy as
cortical malformation, traumatic brain injury,
brain cyst or tumour, and cerebrovascular
disease
 Repeat MRI in case of drug-resistant epilepsy
as a first step to explore surgical options

25. WHEN U START AED ?
 AFTER ONE SEIZURE
 AFTER TWO SEIZURES IN SAME DAY
 AFTER TWO SEIZURES WITH ONE DAY
APART
 AFTER THREE SEIZURES SAME DAY
 AFTER THREE SEIZURES A DAY APART
25

26. In adults , after one attack
Because of
• Driving
• Employability

27. 27
Practical points
Aim : to stop attacks
 Monotherapy avoid polytherapy
 Treat fits but not blood serum level
 Start with minimal dose and increase gradually
 Stop if side effects appeared
 Don’t ask for SGOT ..ONLY If suspect hepatic
dysfunction so ask for SGPT
 Don’t withdraw AED suddenly but gradually
Treatment

28. Compliance :
dose, cost, availability
28

29. 29
Principles of drug usage
 Monotherapy
 Least dosage
 First choice
 Compliance: cost, dosage division, formula
 Least S/E especially cognitive functions

30. 30
Impact of Dosing Frequency
on Compliance
Cramer JA, et al. JAMA. 1989;261:3273-3277.
20
40
60
80
100
Patients(%)
QD BID TID QID
87%
81%
77%
39%
EpilepsyIn epilepsy patients
 Higher compliance rates
are associated with once-
or twice daily dosing
 Noncompliance with AEDs
is a major factor in:
 Breakthrough seizures
 Recurrence of seizures
N=24 patients followed for 2 to 37 weeks.
increase till max ( or S/E) before changing to other AED

31. 31
5. WHEN TO Withdrawal of
AED?
 After 2 years of last attack REGARDELESS
EEG ?
 withdraw over 3 months
 Same period of AED if it will recur
 ?? 2ry epilepsy

32. 32
AEDs
 First-generation AEDs include: phenobarbital,
phenytoin, carbamazepine, valproic acid,
clonazepam, and primidone
 Since early 1990’s: lamotrigine, gabapentin,
oxcarbazepine, levetiracetam, divalproex
sodium, topiramate, zonisamide, vigabatrin,
tiagabine, and felbamate
 The latest AEDs to become available are
pregabalin, lacosimide, and rufinimide.

33. 6.WHICH ?
BROAD SPECTRUM IS THE EASIEST
33

34. 34
AE S/E
5+1
 CNS S/E
 GIT S/E
 Dermal S/E
 BM S/E
 Teratogenic
 Specific S/E

35. 35
CARBAMAZEPINE S/E
LMT esp with VPA
 Skin rash: UP TO ST J SYNDROME
ESPECIALLY WITH?

36. 36

37. Levetiracetam
 Dose
 Children: weight/10 ( ml) twice
,MAXIMUM x3
 {20 – 60 mg/kg/d}
 Therapeutic plasma concentration
 Not relevant
 Indicated for
NEARLY ALL
 Comments
 No drug interactions described

38.  Forms:
Oral: (100mg/1ml)
250, 500, 1000 mg tablets
AMPOULES
 Blood Follow up: NONE
 Onset of action 24-48HRS
 Monotherapy or Add on, no drug
interaction
(Levetiracetam)

39. January 26, 2012
FDA approval for levetiracetam
in infants and children from one
month of age with partial onset
seizures

40.  Quick onset of action
 No cognitive S/E
 Bind specific CNS areas only as hippocampus
 Not liver metabolism, not protein binding so not
interact with other AED
The starting dose of 20mg/kg/day was increased
at intervals of 1 week by 10mg/kg/day,
if necessary, up to a maximum dose of 60mg/kg/day.
Steady state: 8hX5

41.  Quick onset of action
 No cognitive S/E
 Not liver metabolism, not protein binding so not
interact with other AED
Steady state: 8hX5

42. 42
Childhood Pharmako-dinamic
1- absorption : ↑ fast
2- distribution: ↓ protein binding*
3- metabolism: ↑
4- excretion: ↑ clearance
So higher dose > adults

43. 43
Levetiracetam LVT
 Bind specific CNS areas only as hypocampus
 Pathogenesis:
SV2A* binding site so prevent vesicles
release of its stimulant contents
 Not liver metabolism, not protein binding so
not interact with other AED

44. Advantages
 Broad spectrum
 Not interfere with other AEDs
 Same day effect
 Prophylaxis after brain operation
 Prophylaxis after HIE
 Anti-epileptogenic
 Neuroprotective
 No cognitive S/E
44

45. NEUROPROTECTIVE LVT
 IN HIE / NEWBORN /PREMATURE
 POST BRAIN SURGICAL TREATMENT
 POST I C HGE
 NON CLINICAL SEIZURES AS AUTISM
45

47. S/E
47

48. DIAGNOSE AND TT
48

49. 49
DIAGNOSE AND TT

50. Q
50
DIAGNOSE AND TT

51. 51
DIAGNOSE AND TT

52. 52
DIAGNOSE AND TT

53. 53
DIAGNOSE AND TT

54. 54
DIAGNOSE AND TT

55. 55
Q & A
 CBZ,
 oxcarbazepine
 Phenytoin
 Gabapentin
May not work or may even exacerbate absence
or myoclonic seizures

56. 56
DIAGNOSE AND TT

57. 57
DIAGNOSE AND TT

58. 58
DIAGNOSE AND TT

59. 59
DIAGNOSE AND TT

60. 60
Q & A
 LEV (levetiracetam)
Useful for both partial and generalized absence
or myoclonic seizures and unclassifiable
seizures
? LVT for absence

61. 61
DIAGNOSE AND TT

62. 62
DIAGNOSE AND TT

63. 63
DIAGNOSE AND TT

64. 64
DIAGNOSE AND TT

65. 65
DIAGNOSE AND TT

66. 66
ADD On / start with : LVT
except absence seizures
 GTC
 Absence
 Myoclonic
 ES
 ES withTS
 Focal
ETX,VPA
VPA
ACTH
VIGABATRIN
CZP
Never
CBZ,
SUMMARY

67. 67

68. 68

69. The End
“Words, words, words, I’m so sick of words!”
Eliza Doolittle, My Fair Lady

70. Partial Seizures (start in one place)
Simple (no loss of consciousness of memory)
Sensory
Motor
Sensory-Motor
Psychic (abnormal thoughts or perceptions)
Autonomic (heat, nausea, flushing, etc.)
Complex (consciousness or memory impaired)
With or without aura (warning)
With or without automatisms
Secondarily generalized
Generalized Seizures (apparent start over wide areas of brain)
Absence (petit mal)
Tonic-clonic (grand mal)
Atonic (drop seizures)
Myoclonic
Other
Unclassifiable seizures
Dreifuss et al. Proposal for revised clinical and
electroencephalographic classification of epileptic
seizures. From the Commission on Classification
and Terminology of the International League
Against Epilepsy. Epilepsia. 1981;22:489-501.
INTERNATIONAL CLASSIFICATION OF SEIZURES 1981

71. New generalized seizures
absence with eyelid myoclonia
epileptic spasms (infantile spasms)
myoclonic-atonic (e.g., Doose)
myoclonic-tonic-clonic (e.g., JME)
New combined seizures
(focal to bilateral tonic-clonic)
Non-Motor
behavior arrest
(autonomic)
(cognitive)
emotional
(sensory)
Motor
atonic
automatisms
clonic
epileptic spasms
hyperkinetic
myoclonic
tonic
New Focal Seizures
(parentheses) indicates prior existence, but renaming
The 2017 ILAE Classification of Seizures

72. O L D T E R M N E W T E R M
Unconscious (still used, not in name) Impaired awareness (surrogate)
Partial Focal
Simple partial Focal aware
Complex partial Focal impaired awareness
Dyscognitive (word discontinued) Focal impaired awareness
Psychic Cognitive
Secondarily generalized tonic-clonic Focal to bilateral tonic-clonic
Arrest, freeze, pause, interruption Behavior arrest
Wording Changes

73. Supportive Information
Seizures are usually classified by symptoms and signs
But supportive information may be helpful, when available:
• Videos brought in by family
• EEG patterns
• Lesions detected by neuroimaging
• Laboratory results such as detection of anti-neuronal ANTIBODIES,
Blood prolactin within 10-15 min
• Gene mutations
• Diagnosis of an epilepsy syndrome diagnosis