EPILEPSY

DEFINITION
Abnormal and recurrent excessive
synchronized discharge of cerebral
neuron with clinical manifestation of
eiletic seizure which are an intermittent
stereotyical behavior! emotion! motor
function or sensation
"AT#O"#$%IO&O'$
(
"aroxysmal deolarization shift )"D%* of the
resting membrane otential! which triggers a
brief raid burst of action otentials terminated
by a sustained after hyerolarization
(
"D% + result of imbalance between excitatory
)glutamate and asartate* and inhibitory
)'A,A* neurotransmitters
(
Abnormalities of voltage controlled membrane
ion channels
(
Imbalance between endogenous
neuromodulators! acetylcholine favoring
deolarization and doamine enhancing
neuronal membrane stability
FO-A& E"I&E"TO'ENE%I%
FO-A& E"I&E"TO'ENE%I%
Asynchronous burst firing in some
Asynchronous burst firing in some
hyocamal and cortical neurons
hyocamal and cortical neurons
'eneralized eiletogenesis +
'eneralized eiletogenesis +


asynchronous burst firing in abnormal
asynchronous burst firing in abnormal


thalamocortical interaction
thalamocortical interaction
E"IDE.IO&O'$
(
Develoed countries +
annual incidence /0120 cases er
3004000
(
Develoing countries + revalence 35
Incidence varies with age

Incidence of eilesy in relation to age
ETIO&O'$
(
Idioathic
(
-rytogenic
(
%ymtomatic
-auses of Eilesy+
-ategory "ersentage -omment
-rytogenic6 73 895 age 01:y
Idioathic 985 age ;70
%ymtomatic
vascular 3/ <:5 age ;70
alcohol 7 =25 9019:
crb tumour 7 35 age >90
3:5 /01/:
335 age;70
Trauma 9
Infection =
Other 2
Aetiology of eilesy
Inherited genetic
Eilesy alone
Eilesy and other neurological manifestation
Ac?uired
Trauma
Neurosurgery
Infection
@ascular diseases
#iocamal sclerosis
Tumours
Neurodegenerative disorders
.etabolic disorders!toxic disorders!.iscellaneus!Demyelinating
diseases
-ongenital )inherited or ac?uired*
-ortical dyslasia6dysgenesis
-erebral tumours
@ascular malformations
"renatal inAury
Eilesy alone+
,enign familial neonatal convulsion
,enign familial infantile convulsion
Buvenile myoclonic eilesy
Familial frontal lobe eilesy
Idioathic generalize eilesy
Eilesy with other
manifestation
-hromosomal abnormality
Cith myoclonic eilesy and cerebral
degeneration4
Cith extrayramidal feature4
Cith muscular dystrohy and and mental
subnormality
Cith mental subnormality
Neurocutaneus syndrome
Cith intermittent disturbances+orhyria
Other inherited conditions with neurological and
systemic manifestations4
Hypoxia
Hypoglycaemia
Hypocalcaemia
Febrile
Seizures
Intracranial
Infections
Birth trauma
Intracranial
haemorrhage
Congenital anomalies
Tuberous sclerosis
Storage diseases
1 5 1 !
Head In"uries
#rugs
and
alcohol
$enetic epilepsies
Cerebral tumours
%
Cerebro&ascular
degenerations
Age (years)
Factors lowering seizure threshold
Common 'ccasional
(Sleep depri&ation
((lcohol )ithdra)al
(Tele&ision flic*er
(+pileptogenic drugs
(Systemic infection
(Head trauma
(,ecreational drugs
((+# non-compliance
(.enstruation
(Barbiturate )ithdra)al
(#ehydration
(Benzodiazepine
)ithdra)al
(Hyper&entilation
(Flashing lights
(#iet and missed meals
(Specific /reflex0 triggers
(Stress
(Intense exercise
International Classification of +pileptic Seizures
1artial seizures 2beginning locally3
(
Simple partial seizures 2)ithout impaired
consciousness3
D
)ith motor symptoms
D )ith somatosensory or special sensory symptoms
(
Complex partial seizures 2)ith impaired
consciousness3
D
simple partial onset follo)ed by impaired consciousness
D
impaired consciousness at onset
(
1artial seizures e&ol&ing into secondary generalized
seizures
$eneralized seizures 2con&ulsi&e or non-
con&ulsi&e3
(
Absence seizures
D
Tyical
D
Atyical
(
.yoclonic seizures
(
-lonic seizures
(
Tonic seizures
(
Tonic clonic seizures
(
Atonic seizures
(
Enclassified seizures
%imlified -lassification of Eiletic %eizures
1artial seizures
(
%imle D reservation of awarness
(
-omlex D imairment of consciousnesss
(
%econdary generalized
$eneralized seizures
(
Absence
(
.yoclonic
(
Tonic1clonic
(
Tonic
(
Atonic
International -lassification of Eilesies and
Eiletic %yndrome
&ocalization1related )focal! local or artial*
eilesies and syndromes
(
Idioathic eilesy with age1related onset
1 benign childhood eilesy with
centrotemoral siFes
1 chilhood eilesy with occiital aroxysms
(
%ymtomatic eilesy
$eneralized epilepsies and syndromes
(
Idiopathic epilepsy )ith age-related onset 2listed
in order of age at onset3
1 benign neonatal familial convulsions
1 benign neonatal non1familial convulsions
1 benign myoclonic eilesy in infancy
1 childhood absence eilesy )formerly Fnown as
yFnolesy*
1 Auvenile absence eilesy
1 Auvenile myoclonic eilesy )formerly Fnown as
imulsive etit mal*
1 eilesy with generalized tonic1clonic seizures
on awaFing
(
'ther idiopathic epilepsies
(
Idiopathic or symptomatic epilepsy 2listed in
order of age at onset3
1 Cest syndrome )infantile sasms*
1 &ennox1'astaut syndrome )childhood eiletic
encehaloathy*
1 eilesy with myoclonic1astatic seizures
1 eilesy with myoclonic absence seizures
(
Symptomatic epilepsy
(
4on-specific syndromes
1 early myoclonic encehaloathy
1 early infantile eiletic encehaloathy
(
Specific syndromes 2epileptic seizures as a
complication of a disease5 such as
phenyl*etonuria5 "u&enile $aucher6s disease or
7undborg6s progressi&e myoclonic epilepsy3
Eilesies and syndromes with both
generalized and focal seizures
(
Neonatal seizures
(
%evere myoclonic eilesy in infancy
(
Eilesy with continuous siFe waves
during slow1wave slee
(
Ac?uired eiletic ahasia )&andau1
Gleffner syndrome*
+pilepsies )ithout une8ui&ocal generalized or
focal features
Special syndromes
(
Situation-related seizures
1 febrile convulsions
1 seizures related to other identifiable situations!
such as stress! hormonal changes! drugs!
alcohol withdrawal or slee derivation
(
Isolated5 apparently unpro&o*ed epileptic
e&ents
(
+pilepsies characterized by specific modes of
seizure precipitation
(
Chronic progressi&e epilepsia partialis
continua of childhood
Diagnosis
(
Interviews with atients or witness
D -ircumstances surrounding the attacFs
idioathic and generalized
No seizure warning
No underlying brain lesions
Associated with a family history
H
D %ymtomatic and localization related
Aura
%ecific site of onset
Identifiable cause
D Iecurrent eisodes of seizures
D %ymtoms occured during and after seizures
(
Iecording symtomatic events with video camera
and continuos ambulatory EE' monitoring

E E '
(
To confirm the clinical diagnosis
(
To suort the classification of artial or
generalized seizures
(
Ioutine trace /05 normal
(
Diagnostic in non convulsion state
eiletic activities +
#yerventilation
"hotic stimulations
%lee derivation
EE'
EE'
,IAIN I.A'IN'
(
Essential! articularly in artial onset
seizures
-omuterized tomograhy )-T*
.agnetic resonance imaging ).II*
%tructural lesion
.II
.II
.II
-T %can
CT Scan should be repeated
periodically 9
(
%usicion of a tumor
(
Corsening in neurological examination
or cognitive function
(
Deterioration in the fre?uency or
severity of the seizures
Single 1hoton +mission CT 2S1+CT3
1ositron +mission Tomography 21+T3
.,I spectroscopy
Functional .,I
Functional cerebral changes
:seful ad"uncts in candidate epileptic
surgery
DIFFEIENTIA& DIA'NO%I%
(
.igraine
(
Transient Ischemic AttacFs
(
#yerventilation
(
Tics
(
.yo1clonic
(
#emi1facial sasm
(
%yncoe
(
%lee disorders
(
Non Eiletic AttacFs
(
Narcolesy
(
.etabolic disorders
(
Transient global amnesia
.anagement
.edical treatment 9
(
Establish a correct diagnosis of eilesy
seizure tye and eilesy syndrome
(
Decide treatment with eiletic drugs is
necessary
(
Decide which drug should be used
(
"atients and their family should receive
counseling regarding +
Aims of treatment
"rognosis and duration of the exected
treatment
Imortance of comliance
%ide effects
%urgical treatment
"roosed Indications for resective eiletic
surgery
(
Intractable seizures
(
Iesectable structural abnormality as identified on
magnetic resonance imaging
(
-onfirmation that seizures arise from a visible lesion
)using video telemetry*
(
Over =05 of seizures arising from the contralateral
temoral lobe in temoral lobe seizures
(
Intelligence ?uotient ; 20 oints
(
No significant sychiatry morbidity
(
No medical contraindications
(
Age > </ years
%trategies for managing newly diagnosed eilesy
4e)ly diagnosed epilepsy
First drug
Second drug
,efractory
,ational duotherapy
Surgical assessment
Seizure-free
Seizure-free
47%
13%
40%
Ten commandments in the
pharmacological treatment of epilepsy
(
-hoose the correct drug for the seizure
tye or eilesy syndrome
(
%tart at low dosage and increase
incrementally
(
Titrate slowly to allow tolerance to central
nervous system side1effects
(
Gee the regiment simle with once1 or
twice1daily dosing! if ossible
(
.easure drug concentration when seizures
are controlled or if control is not readily
obtained )if ossible*
(
Counsel the patient early regarding the
implications of the diagnosis and the
prophylactic nature of drug therapy
(
Try t)o reasonable mono-therapy options
before adding a second drug
(
;hen seizures persist5 combine the best
tolerated first-line drug )ith one of the
ne)er agents depending on seizure type
and mechanism of action
(
Simplify dose schedules and drug
regimens as much as possible in patients
recei&ing poly-pharmacy
(
(im for the best seizure control
consistent )ith the optimal 8uality of life
in patients )ith refractory epilepsy
#rug choice in ne)ly diagnosed epilepsy in
adolescents and adults
Seizure type First line Second line
Tonic clonic
(Sodium &alproate
(Carbamazepine
(1henytoin
(7amotrigine<
('xcarbamazepine<
(bsence
(Sodium &alproate (+thosuximide
(7amotrigine<
.yoclonic
(Sodium &alproate (7amotrigine<
1artial
(Carbamazepine
(1henytoin
(7amotrigine<
('xcarbamazepine<
(Sodium &alproate
:nclassifiable
(Sodium &alproate (7amotrigine<
J&amotrigine and oxcarbamazeine are regarded as first1line drugs in some countries
Choice of antiepileptic drugs in children
Seizure type First line Second line Third line
Tonic-clonic %odium valroate
-arbamazeine
&amotrigineJ
OxcarbazeineJ
"henytoin
.yoclonic %odium valroate &amotrigineJ -lobazam
"henobarbital
Tonic %odium valroate &amotrigineJ -lobazam
Toiramate
(bsence %odium valroate &amotrigineJ
Ethosuximide
-lobazam
1artial
-arbamazeine
"henytoin
%odium valroate
'abaentin
OxcarbazeineJ
&amotrigineJ
@igabatrin
-lobazam
Toiramate
Infantile spasms @igabatrin
-orticosteroids
%odium valroate
Nitrazeam
&amotrigineJ
7ennox-$astaut %odium valroate &amotrigineJ
Toiramate
-lobazam
Felbamate
%ome Ieasons for Fail of .ono1theray
Crong diagnosis
(
%yncoe! cardiac arrhythmia! etc4
(
.alingering! seudo1seizures
(
Enderlying neolasm
Crong drug)s*
(
Inaroriate for seizure tye
(
Ginetic 6 dynamic interactions
Crong dose
(
Too low )ignore target range*
(
%ide effects reventing dose increase
Crong atient
(
"oor comliance with medication
(
Inaroriate lifestyle )e4g4 alcohol or drug abuse*
Chen to sto medication
(
After =19 years eriod of seizureKs free!
must be taering off in six month4
(
Normal EE'4
"rognosis
(
Deendent with underlying syndrome and 6 or its
cause
(
"atientKs comliance
(
Iecirocal illness or medications
(
701205 controlled by first1line drug of eilesy
(
305 of the rest controlled by new drugs
(
The rest +
surgery
Institution
%ecial "roblems of Eilesy
(
,ehavioral and cognitive roblem +
1&abel of eilesy racial disadvantage
1Deends on location! medication! tye of
seizure
1Attitudes of helers and heled
(
Education +
1Discussion between doctors! families!
schools teachers and the atient! stes
which might be taFen to romote normal
education and ersonal develoment
(
Emloyment +
1"ersonal and racial states as well as
financial reward
1Enderstanding of the emloyee of their illness in
the context of articular emloyment! safety for
their selves and environment
1"eole around in worFing hours need to Fnow
what to do if the attacF occurred
(
The law
D
Driving lisence
( Free of seizure after 7 months controlled eilesy
(
No ermitting to drive if +
D
#ave suffered of eiletic attacF at the age before
adolescent
D
.edical condition caused driving a source of danger to
them selves and to the ublic
(
&eisure +
D
%wimming! water sort! cycling! horse riding in grous
with safety controlled
D
,oxing! climbing! sort with body contact are rohibited
D Television and video games! avoid flicFering of the
screen
(
.arriage and regnancy
(
#ealth education
(
Imairment! disability and handica
%TATE% E"I&E"TI-E%
(
Definition+
D "rolonged seizures +Eiletic activity 90 min or more4
D Ieetitive attacFs without recovery in between4
(
-lassification of status eileticus+
D Deendent on age! seizures tye! underlying aethiology and
underlying athohysiology4
(
Etiology of status eileticus+
D Non eiletic atients+
D Eiletic etients
TONI- -&ONI- %TATE% E"I&E"TI-E%
(
"rolonged or recurrent tonic1clonic seizures ersist for 90
minutes or more4
(
Incidence+ 38 D =8 6300000 ersons4
D
Occurs most commonly in children! eole with learning
difficulties! structural cerebral athology
(
Aethiology+
D
Non eiletic +
(
Acut cerebral events+ infections! cerebral inAury! -@D!
cerebral tumour! acut toxic and metabolic
disturbances! febrile convulsions4
D
Eiletic+"resiitated by drug withdrawal! intercurrent
illness! metabolic disturbance! rogression of the
underlying diseases4
-erebral -hanges in %tatus Eileticus
%tatus Eileticus "hase I
%tatus Eileticus "hase II
%tatus Eileticus Treatment
%TA'E OF %TATE%
E"I&E"T$-E%
(
"remonitory stages+
D
Eiletic activity increases in fre?uency and
severity1warning of imending status4
Theray at this stages can revent %E4
(
%tatus eileticus+
D
Discrete tonic1 clonic seizures! the motor
activity continuous 4
D
%ometimes a rogressive changes in the
EE'4
"#$%IO&O'I- -#AN'E% IN
%TATE% E"I&E"TI-E%
(
"hase I+ "hase of comensation
D
-erebral metabolism marFedly increased4
(
.assive increased of cerebral blood flow4
(
%ystemic and cerebral lactate levels rise4
(
Endocrine changes result hyerglicaemia4
(
,lood ressure rises4
(
.assive autonomic activity4
(
Einehrine and noreinehrine release4
(
"hase II+ "hase of decomensation+
(
-omensatory hysiological mechanisms begin to
fail as seizures activity continues4
D -erebral autoregulation breaFsdown rogressively! seizures
related autonomic and cardioresiratory changes develo
hyotention!hyoxia and cardiac dysrithmia4
D Iise intracranial ressure and systemic hyotention result
cerebral oedema4
D .etabolic and endocrine disturbances
+acidocis4hyoglycaemia!hyonatremia and
hyoFalemia!acut tubular necrosis!renal failure! DI-!
D "ersistent convulsive movement can resiitate
rhabdomyolysis4
T#E .ANA'E.ENT OF TONI-1
-&ONI- %TATE% E"I&E"TI-E%
(
'eneral measures+
D
-ardiorasiratory function+
( Airway secure and resuscitation if necessary4
( Emergency investigation4
D ,lood test
D E-'
(
.onitoring
D
Emergency drug treatment4
( To sto the convulsion
( -orrection of the comlications4
(
Intensive care and seizures monitoring4
DIE' TIEAT.ENT
(
"remonitory stage+
D
Diazeam 30 mg i4v4or rectally!if status
continues!reeated after 3/ minutes or
&orazeam < mg bolus!If seizures continues;
(
%tages of early status+
D
&orazeam < mg I!v!bolus4If status continues
after 90 minutes
(
%tages of established status
(
%tages of established status+
D
"henitoin iv infusion of 3/ mg6Fg!rate /0 mg6min!if
status continues after 90 170 minutes
(
%tages of refractory status+
D
'eneral anaesthesia with either+
( "roofol = mg6Fg iv bolus!followed by continues infusion of /
D 30 mg6Fg6h innitially !reducing to3 D 9 mg6Fg6h!when
seizures have been controlled for 3=h!slowly taered over
3= h!or
( Thioental+300 D =/0 mg iv bolus over =0 s !with further /0
mg boluses every = D 9 minutes until seizure are
controlled!followed by a continues iv infusion 9 D / mg6Fg6h
to maintain a burst suression attern on the EE'4%hould
be slowly withdrawn 3= h after the last zeisure4
(
E"I&E"%$ "AITIA&I% -ONTINEA+
D
%ontaneous regular or irregular clonic muscle
AerF! confined to one art of the body and
continuing for hours! days or weeFs! there are
many otential causes4
(
-O."&EL "AITIA& % E +
D
"rolonged eiletic eisode! fluctuating or
fre?uently recurring result in a confusional state4
(
Absence status+
D
Tyical+ Non convulsive status! occuring in the
syndrome of idioathic generalized eilesy4
D
Atyical absence+ %tatus that occurs in secondary
generalized eilesy of the &ennox 'estaut tye4