A short presentation on treatment of focal epilepsy

2. Approach to a child with
Epilepsy
0 Is it an Epileptic seizure ?
0 Classify the Seizure : Epilepsy , Epilepsy Syndrome
0 Order the appropriate investigations
0 Treatment Modalities

3. Treatment of Seizures
Goals:
0 Block repetitive neuronal firing.
0 Block synchronization of neuronal discharges.
0 Block propagation of seizure.
Strategies
0 Modification of ion conductances.
0 Increase inhibitory (GABAergic) transmission.
0 Decrease excitatory (glutamatergic) activity.

4. Classification of Anticonvulsants
Classical
0 Phenytoin
0 Phenobarbital
0 Primidone
0 Carbamazepine
0 Ethosuximide
0 Valproic Acid
0 Trimethadione
Newer
0 Lamotrigine
0 Felbamate
0 Topiramate
0 Gabapentin
0 Tiagabine
0 Vigabatrin
0 Oxycarbazepine
0 Levetiracetam
0 Fosphenytoin
0 Others

5. Classification of Anti-Convulsants
Action on Ion
Channels
Enhance GABA
Transmission
Inhibit EAA
Transmission
Na+:
Phenytoin,
Carbamazepine,
Lamotrigine
Topiramate
Valproic acid
Ca++:
Ethosuximide
Valproic acid
Benzodiazepines
(diazepam, clonazepam)
Barbiturates
(phenobarbital)
Valproic acid
Gabapentin
Vigabatrin
Topiramate
Felbamate
Felbamate
Topiramate
Na+:
For general tonic-clonic
and partial seizures
Ca++:
For Absence seizures
Most effective in
myoclonic but also in
tonic-clonic and partial
Clonazepam: for Absence

10. Choice of anti-convulsants
0 Seizure type
0 Epilepsy syndrome
0 Pharmacokinetic profile
0 Interactions/other
medical conditions
0 Efficacy
0 Expected adverse effects
0 Cost
0 ALL FEMALES: Folate
1-4 mg/day
supplementation

11. AEDs by Seizure type
Partial Generalized
Tonic-clonic
PHT, CBZ, PB,
GBP, TGB, LVT,
OCBZ
ACTH
TPM?
TGB?
VGB?
Tonic Myoclonic Atonic
Infantile
Spasms
Absence
ESX
PHT, PB, VPA, LTG, TPM,
(FBM), ZNS
Simple
Complex
Secondary
generalized

12. 1st Generation AEDs
0 Incomplete Efficacy
0 Unfavorable Kinetics (M-M, protein binding)
0 Narrow Therapeutic Range
0 Adverse CNS Effects
0 Adverse Non-CNS Effects
0 Drug-Interactions

13. Adverse Effects
Hematologic damage
0 Marrow aplasia, agranulocytosis
0 Early symptoms: abnormal bleeding, acute onset of fever, symptoms
of anemia
0 Felbamate : aplastic anemia approx. 1:5,000 treated patients
0 Patient education

14. Long term adverse effects
0 Endocrine/Metabolic Effects
 Osteomalacia, osteoporosis : Carbamazepine, Phenobarbital, Phenytoin,
Oxcarbazepine, Valproate
 Folate (anemia, teratogenesis) : Phenobarbital, Phenytoin, Carbamazepine,
Valproate
 Altered connective tissue metabolism or growth (facial coarsening, hirsutism,
gingival hyperplasia or contractures) : Phenytoin, Phenobarbital
0 Neurologic
 Neuropathy ⦁ Cerebellar syndrome – phenytoin
0 Sexual Dysfunction - 30-60%
 Phenytoin Carbamazepine
 Phenobarbital Primidone

15. Focal Epilepsy
0 With secondary generalization
0 First-line drugs :carbamazepine and phenytoin (equally
effective)
0 Valproate, phenobarbital, and primidone
0 Without generalization
0 Phenytoin and carbamazepine
0 Phenytoin and carbamazepine can be used together

16. Focal Epilepsy – Newer Drugs
0 Adjunctive (add-on) therapy - felbamate, gabapentin,
lamotrigine, levetiracetam, oxcarbazepine, tiagabine,
topiramate, and zonisamide
0 Lamotrigine, oxcarbazepine, felbamate - monotherapy where
phenytoin and carbamazepine have failed.
0 Topiramate - refractory partial seizures.

17. Non - Conventional AED treatment
0Non-AED medical treatment
Steroids (ACTH, prednisolone)
IvIG
Vitamins (B6, biotin, folinic acid)
Melatonin
0Dietary manipulation
Ketogenic diet Classical ketogenic diet
MCT diet Atkins diet
Oligoantigenic diet

18. Epilepsy Surgery Techniques
0 Lesional surgery
0 Specific surgical techniques (Eg. Sub-pial transection for
Landau-Kleffner syndrome)
0 Palliative surgery

19. Indications for Surgery
0Medically intractable epilepsy (> 3 AEDs)
0Structural lesion
0Intolerable adverse effects of AEDs
0Psychosocial dysfunction
0Recurrent injury

20. Evaluation for Surgery
0MRI
0PET
0Ictal/interictal SPECT
0MR Spectroscopy