WELCOME

the sacred disease

By
Basil

EPILEPSY

Introduction
The brain normally contain millions of neurons interacting through electrical discharges . If these interactions misfire it can cause series of problem in the brain. It can cause changes in the way person feels, think, and moves. Those changes are called seizure

History of epilepsy
References to epilepsy date back to ancient times and mystical explanation continued until 18th century. Hippocrates wrote the first book on epilepsy in 400 BC. He believed that epilepsy is a curse or sign from the GOD. In 1494 it was believed that seizure is a characteristics of witches. The prosecution that followed resulted in 2 lack deaths.

In 1890 one of the neurologist John Hughlings Jackson defined seizure as an occasional excessive and disorderly discharge of nerve tissue on the muscle tissue. In 1912 first seizure medication Phenobarbitone was created as a sedative but soon it was found useful for seizure and it is still using today. 1929 the German Psychiatrist Horns Burger invented the Electro Encephalo Gram (EEG) provided the first recording of epileptic discharge from brain.

 In 1930 Gibbs co-related the clinical evidence of epilepsy EEG findings. Even in 20th century some state has the low that Those With Epilepsy Shall Not Wed . But luckily this practice was ended. 1997 FDA approved a device The Vagus Nerve Stimulator to treat partial epilepsy in adults. Napoleon, Julius Caesar, and Jonty Rhodes are some prominent personalities who suffered due to epilepsy.

Seizure
Seizure the word came from a Latin word sacire means -to take possession of Seizure is a paroxysmal uncontrolled electrical discharge of neurons in the brain that interrupts normal functioning, leading to a sudden, violent involuntary series of contractions of a group of muscle.

DEFINITION
Seizure is a clinical syndrome caused by an electrical event that is characterized by hyper excitability and hyper synchronization of large group of neurons in the brain. Seizure is a medical disorder in which too many brain cell become excited at the same time. This can cause unexpected changes in the behavior, motor activity, sensation, or consciousness.

 Seizure is like an electrical storm in the brain. The end of the seizure is the transition back to the individuals normal stage. Seizure may occur spontaneously without any cause. A seizure typically goes on for a few seconds to a few minutes.

In adults metabolic disturbances that cause seizure include Acidosis Electrolyte imbalance Hypoglycemia Hypoxia Alcohol and barbiturate withdrawal Dehydration.

Extracranial disorders that cause seizure are Heart, lung, liver, or kidney diseases Systemic lupus erythematosus. Diabetes mellitus Hypertension Septicemia

[Epilepsia- (Greek)- seizure] Epilepsy is a chronic disorder of abnormal, recurrent, excessive, and self terminating electrical discharge from neurons. Spontaneously recurrent seizure more than one time is called as epilepsy. The periods between seizures can vary widely and can be measured in minutes, hours, days, weeks, months, or even years.

What is Epilepsy?

 However there is repetitive seizure activity at some time in the future regardless of the interval. Clinically epilepsy is recurring seizure in which there is disturbance in some type of behavior ( motor, sensory, autonomic, or consciousness.) To count it as epilepsy seizure should have to appear spontaneously without an immediate precipitating factor. Seizure resulting from systemic or metabolic disturbance are not considered as epilepsy.

Epidemiology
About 1% of the world population has epilepsy. Around 60 million people in the world are affected by epilepsy. Every individual have 1% life time risk to develop epilepsy. Incidence of epilepsy is 1 in 100 people in India.

 Every year one lack more cases get added. 30% of the epilepsy cases are of uncontrollable or persistent. The greatest number of people with newly diagnosed epilepsy will be among children under the age of two years and the elderly over the age of 60 years. The children who have Parents with epilepsy are having 5- 20% chance to develop epilepsy.

more common in

Etiology and risk factors

Seizure is a symptom of numerous disorders, but in 70% of sufferers the cause remains unclear (idiopathic) despite careful history taking,clinical examination and investigation!

Common causes
The risk factors for developing seizure can be broadly classified under three headings. 1- Metabolic or Chemical Imbalance. 2- Structural defects 3- Infections or Inflammatory reactions.

Metabolic or Chemical Imbalance

Hypoglycemia. Hyperglycemia Hypocalcaemia Hyponatremia Hypoxia Uremia Toxins Drugs intoxication or withdrawal. Alcohol consumptions Hyperthermia

Structural defects
Gliotic scars Post traumatic Post infraction Post infections Congenital malformation Vascular malformations Brain tumors ( primary or metastatic)

Infections or Inflammatory reactions. Meningitis Encephalitis Brain abscess Syphilis Systemic lupus erythematosus . Neurocysticercosis ( parasitic infection of the CNS)

OTHER CAUSES
Genetic factors(hereditary)/mutations Other diseases like Alzheimer's disease Dementia Kidney Failure Liver Failure Heart Failure

The risk factors classified according to age group

In young adultsTrauma Alcohol withdrawal Illicit drug use Brain tumor

Above 35 yr and olderCerebrovascular disease Alzheimers disease Neurodegenerative disease Metabolic disorder Brain tumor Alcohol withdrawal

Common triggers
Stress Sleep deprivation Boredom Alcohol Missing tablets Menstruation Photosensitivity (TV/flicker) Missed meals/hypoglycaemia Sudden loud noise Street drugs Particular odour

PATHOPHYSIOLOGY
Ropper and Brown explains that there is three sets of disturbances present before a seizure activity. 1-A population of pathologically excitable neurons. 2- A reduction in the activity of normal inhibitory gamma- aminobutyaric acid(GABA). 3-An increase in excitatory glutaminergic activity through recurrent connections to spread the discharge(hyper synchronization of neurons).

PATOPHYSIOLOGY
Due to etiological factors Alteration in normal chemical and structural environment of brain neurons Scarring of brain tissue (gliosis) A group of abnormal neurons forms in the brain (seizure focus)

The neurons present in the seizure focus are hypersensitive neurons and their cytoplasmic membrane are highly permeable(hyper excitable). This increased permeability renders them susceptible to activation by triggering factors Any stimulus that causes depolarization of the cell membrane of these neurons induce spontaneous firing of electrical impulse

Once the intensity of seizure discharge exceeds a certain point or seizure threshold, it spreads by physiologic pathways to involve adjacent or distant areas of the brain It spreads to the adjacent, cortical, and thalamic brain stem nuclei. This activity spread to involve the whole brain then a generalized seizure occurs causing muscle contraction and loss of consciousness.

There are some inhibitory centers in the brain which act as counter regulatory mechanism These inhibitory neurons of the cortex, anterior thalamus, and basal ganglion nuclei becomes active and slows the neuronal electrical discharge (diencephalo cortical inhibition)

This interrupting the seizure and produce intermittent contraction and relaxation phase (clonic phase)

As epileptogenic neurons are exhausted and the inhibitory process builds up the seizure stops and paralysis of neurons of epileptogenic focus occurs. This leads to Todds post epileptic paralysis. Todds paralysis is a temporary focal weakness or paralysis following a partial or generalized seizure that can last for up to 24 hours.

 Several ligand-gated ion channels have been linked to some types of frontal and generalized epilepsies. Epilepsy is linked to mutations of the genes which code for sodium channel proteins; these defective sodium channels stay open for too long thus making the neuron hyperexcitable.

 Glutamate, an excitatory neurotransmitter, may thereby be released from these neurons in large amounts which by binding with nearby glutaminergic neurons triggers excessive calcium (Ca2+) release in these post-synaptic cells. Such excessive calcium release can be neurotoxic to the affected cell

 The hippocampus, which contains a large volume of just such glutaminergic neurons is especially vulnerable to epileptic seizure, subsequent spread of excitation, and possible neuronal death. Another possible mechanism involves mutations leading to ineffective GABA (the brain's most common inhibitory neurotransmitter) action.

During seizure there is drastic increase in cellular respiration and glycolysis. This markedly increased demand for ATP, (the major direct source energy in the brain) the brain depends mainly on the metabolism of glucose for the production of phosphate bonds necessary for ATP. Cerebral blood flow to the brain also increased to meet the increased oxygen demand.

Increased metabolic activity in contracting skeletal muscle often can result in hypoxemia and hypoglycemia particularly during status epilepticus. A rapid decrease in ATP and glucose with increased level of lactate following seizure. This produce energy deficit, hypoxia, cellular exhaustion, and selected cellular destruction.

Phases of seizure
1- The prodromal phase This refers to symptoms, such as a headache or feeling of depression, that precede a seizure by hours Some people have vague feeling one or two days prior to the seizure that something is going to happen.

2- The aural phase

Breeze (Greek word) It is a premonitory sensation or warning experienced at the beginning of a seizure, which the patient remembers. An aura may be gustatory, visual, auditory, or visceral experiences. unusual sounds unusual taste(metallic taste) disturbed vision(flashing lights) rising thoughts unusual smell(burning rubber)

 In complex partial seizure the person may feel dj vunew experiences appear familiar, jamais vufamiliar things appear foreign Forced thinking may occur in seizure involving temporal lobe. Some may feel rising of body Some person may feel fear and panic. There are some other strange feeling which is difficult to explain.

Physical symptoms of aura are dizziness headache lightheadedness numbness upset stomach tingling sensation Aura usually occur seconds to minutes before a seizure If a patient has an aura it usually the same experience each time.

 Ictus is a Latin word means seizure. It proceeds with full seizure activity. In this phase there is abnormal electrical discharge from the brain cause alteration in sensation, movement, behavior and consciousness.

3- The ictal phase

4- The postictal phase

It is the period immediately after a seizure has occurred The end of the seizure is the transaction back to the individual normal stage. This can last to seconds to hours. The person may have headache, muscle soreness, sore tongue or cheek. The person may be tired and sleep for long hours

EPILEPSY CLASSIFICATION PARTIAL SEIZURES (FOCAL

SEIZURES)

GENERALISED SEIZURES

 It begins with an electrical discharge in one limited area of the brain. Partial seizure begin in a specific region of the cortex as indicated by the EEG changes and by clinical manifestations. Partial seizure may be confined to one area of the brain and remain partial or focal in nature. The impact of partial seizure depends on where in the brain it originates and how it spread

PARTIAL SEIZURES (FOCAL SEIZURES)

Partial seizures are again divided in to, Simple partial seizures. Complex partial seizures. Partial seizures evolving to secondary generalized seizure.

Simple partial seizures.

The awareness is preserved The memory is preserved. The consciousness is preserved. If all these are preserved then we call the partial seizure as simple partial seizure. In simple partial seizures, only a finger or hand may shake or the mouth may jerk uncontrollably

 The person may talk unintelligibly, may be dizzy, and may experience unusual or unpleasant sights, sounds, odors, or tastes, but without loss of consciousness. They may involve motor, sensory, autonomic, or psychic phenomena or a combination of these.

Focal motor seizure

Symptoms depend on the motor region activated. May remain focal or may spared to other areas on the motor strip, a process called march, this type of seizure called jacksonian seizure.

 If a seizure spread along the motor strip the switching can watch along with the different parts of the body. It is called as jacksonian march. For example the seizure may begins in the fingers of one side and march to the hand, wrist, forearm, and arm of the same side of the body. Focal motor attack may cause head to turn to one side opposite epileptic foci.

 Todds paralysis may result and may lasts for minutes to hours. Continuous focal motor seizure is called Epilepsia Paralysis Continua FOCAL SENSORY SEIZURE Arise from cortical sensory strip Usually feel like numbness, tingling sensation, spatial disorientation etc. Auditory seizures with various sounds, gustatory sensation like metallic taste or primary tastes(salty, sweet, sour, or bitter).

 Occipital lobe contains brain cell responsible for vision . Seizure in the occipital lobe can produce flashing lights and visual hallucination. Some patients have the feelings of floating sensation or vertigo.

Autonomic seizures
Autonomic seizures are common, evoking changes in autonomic activity (e.g., altered heart or breathing rate, sweating) or visceral sensations (e.g., in abdomen or chest).

Psychic seizures
Psychic seizures affect how we feel, think, and experience things. Patients may report a "dreamy state," transitional between waking and unconsciousness. Psychic seizures can alter language function, perception or memory.

 They can also evoke spontaneous emotions (e.g., fear, anxiety, or depression), altered perceptions of time (time slowing down or speeding up) Altered perceptions of familiarity;(dj vunew experiences appear familiar, jamais vufamiliar things appear foreign), depersonalization (feeling one is not oneself), derealisation (the world seems unreal, dream-like), or autoscopy (viewing one's body from outside).

Complex partial seizures

The consciousness The awareness The memory If any of the above factors are absent we call the partial seizure as complex partial seizure. These are often called as psychomotor seizures.

 The person either remains motionless or moves automatically but in appropriative for time and place. This will leads to a moment to moment world. During this time the person may repeat the same phrase or action over and over in an automatic way not recognizing the repetition. This automatic activity is called as automatisms.

 Automatic movements (automatisms) are common and involve the mouth (e.g., lip smacking, chewing, swallowing), upper extremities (e.g. fumbling, picking), vocalization/verbalization (e.g., grunts, repeating a phrase), or complex acts (e.g., shuffling cards). More dramatic automatisms occasionally occur (e.g., screaming, running, pelvic thrusting).

 Others just freeze and steer blankly without any movement. Some time the person may experience excessive emotions of anger, fear, elation, or irritability. Complex partial seizures usually last from 15 seconds to 3 minutes. After the seizure, postictal confusion is common, usually lasting less than 15 minutes, although other symptoms, such as fatigue, may persist for hours.

 Whatever the manifestation the person does not remember the episode when it is over and what they did. Later the memory start working again except for a gap during the seizure. The location of the discharging focus is usually in the temporal lobe, hence it is known as temporal lobe seizure.

 If the temporal lobe seizure spreads to both temporal region then the manifestation include Pause in activity Confusion

Temporary memory loss and Fragmentary automatic robot like activity

Partial seizures evolving to secondary generalized seizure

It begins as a Partial seizure may spread to involve the entire brain, culminating in a generalized tonicclonic seizure The abnormal electrical activity may spread to involve other areas of the brain, to cause a tonic clonic seizure. This may result in a transient residual neurologic deficit postictally. This is called as Todds paralysis (focal weakness)

GENERALIZED SEIZURES
It is characterized by hyper synchronized electrical activity of the neuron throughout the brain. Generalized seizure occur when the misfiring of the nerve cell occur over the entire brain at the same time. Because the entire brain is affected at the onset of the seizure there may be no warning or aura.

Generalized seizures is classified again in to Generalized tonic-clonic seizure Absence seizure Myoclonic seizure Tonic seizure Clonic seizure Atonic seizure

Tonic Clonic seizure (grand mal)

A prodromal period of irritability and tension may precede the seizure activity. Tonic-clonic seizures usually last 30120 seconds. The tonic clonic seizure begins with a sudden loss of consciousness . The tonic phase there is a major contraction (increased tones) of the voluntary muscle. The body stiffens with legs and arms extended. If the person is standing he will fall in to the ground. The jaw snaps shut and the tongue may be bitten.

 A shrill cry may be heard because of the forcible exhalation of the air through the closed vocal cord as the thoracic muscle initially contract. The pupil may dilate and unresponsive to light. During the tonic phase the person may apnic and may appear pale and dusty. This tonic phase may last for 10- 20 seconds.

 The clonic phase begins with gradual transition from the tonicity of the tonic phase. The clonic phase is characterized by violent rhythmic muscular contractions accompanied by strenuous hyperventilation. The eyes roll, and there is excessive salivation which frothing from the mouth. Profuse sweating and rapid pulse are common. The clonic jerking gradually subsides in frequency and amplitude over a period of about 30-40 seconds The bladder or bowel control may loose as the muscle relaxes.

 The patient have no consciousness and will not remember what was happened. The person slowly awakes, confusion and disorientation are common. Headache, muscle ache, and fatigue are common. Sometime the person may sleep for long hours. Tonic-clonic seizure occur at anytime of the day or night, whether the patient is awake or asleep. The frequency of occurrence can vary from hours to weeks, months, or years

Emergency management of tonic-clonic seizure.

Ensure patent airway Assist ventilations if patient does not breathe spontaneously after seizure. Anticipate need for intubation if gag reflex absent. Suction as needed Establish IV access Anticipate administration of AEDs to control seizure.

 Monitor vital signs, level of consciousness, oxygen saturations, pupil reactivity and Glasgow coma scale. Never force an airway between a patients clenched teeth. Give IV dextrose for hypoglycemia.

Absence seizure (Petit mal )

It is characterized by 3-20 seconds of absence of consciousness during which the child may blink rapidly or roll the eyes or snaffle the lips . In absence seizure they disconnect from the world for a few seconds and came back exactly where they left out. But the child doesn't know what was happened during those 3-20 seconds. It can be mistaken for day dreaming. This can happen about 100 times per day and it may interfere with learning.

 Seizures begin and end suddenly. There is no warning before the seizure, and immediately afterward the person is alert and attentive. This lack of a postictal period is a key feature that allows one to distinguish between absence and partial complex seizures. Absence seizures are often provoked by hyperventilation The EEG signature of absence epilepsy is the generalized 3 Hz spike-wave discharge

 This is more common in children between the age group of 4 - 14 year of age, it may disappear during adolescent period. After the seizure the child may anxious about what was happened and the child may need reassurance. This condition usually not require any first aide.

Myoclonic seizure
Myoclonic seizures involve a brief, shock-like jerk of a muscle or group of muscles. These are usually so brief, last only for a second or two. Epileptic myoclonus usually causes bilateral, synchronous jerks most often affecting the neck, shoulders, upper arms, body, and upper legs. Brief loss of consciousness, may cause fall and often occur on waking.

Tonic seizure
A sudden onset of maintained increased tone or stiffness of the extensor muscle They often occur during sleep. They are characterized by flexion at the waist and neck, abduction and flexion or extension of the upper extremities, and flexion or extension of the lower extremities. Typical duration is 520 seconds. It involves bilateral musculature in a symmetric or nearly symmetric manner.

Clonic seizure
It is characterized by repetitive rhythmic clonic movements that are bilateral and symmetric. The EEG characteristics is symmetric spike wave complexes.

Atonic seizure (drop attack)

This type of seizure is also called as akinetic seizure or epileptic drop attack. Atonic seizures consist of a sudden loss of postural tone, often resulting in falls, or, when milder, head nods or jaw drops. Consciousness is usually impaired and significant injury may occur. Duration is usually several seconds, rarely more than 1 minute.

Diagnostic evaluation
History collection Birth and developmental history. Significant illness and injuries Family history Febrile seizures Seizure history. Precipitating factor Seizure description(including onset, duration, frequency, postictal stage)

 Physical Examination - Comprehensive neurological assessment Other diagnostic studies includes CBC Urinalysis Electrolytes S. creatinine Fasting blood glucose

Lumbar puncture CT scan MRI PET scan , (Positron emission tomography) EEG ( video-EEG monitoring)

First Aid For Seizure

During seizure
Stay calm Keep the surrounding safe Support the victims head by placing a pillow Keep the person lie on their side Record the time period of seizure Make the person as safe and comfortable as possible Loose tightened clothing

Do not shift the person unless the place is harmful to him. Do not put or give anything in their mouth Keep their head inclined, so that they dont choke Assess the course and nature of seizure activity, the body parts involved in the seizure activity and the presence of autonomic signs.

 After the seizure Do not restrain him after the seizure is over. Keep the person in a safe place. Be calm and reassuring. Ask the person some simple questions. Check for injuries. Be supportive and use a calm and reassuring voice. Check the vital signs, and assess the general condition

NEVER DO IT

REMEMBER!!
SEIZURE PATTERNS ARE INDIVIDUAL, THEREFORE RECOVERY PATTERNS WILL DIFFER FROM ONE PERSON TO ANOTHER.

COLLABORATIVE CARE
Antiepileptic drugs(AEDs) Surgery Vagal nerve stimulation Psychosocial counseling

Antiepileptic drugs

Principles for AED therapy.

1- Do we need to treat the seizure with AED therapy ? 2- Choosing the best medication for the patient. The factors need to consider are Efficacy Side effects Risk of a serious reaction Convenience of administration Cost

3- Decide best AED regimen. The regimen of one drug is called as Monotherapy (Start low, increase slow). Advantage of Monotherapy: Fewer side effects, decreased drug-drug interactions, better compliance, and lower costs Addition of a second drug is likely to result in significant improvement in only approximately 10 % of patients.

4- Side effects need to be considered. 5- AED can be tapered. Withdrawal may be considered if the patient meet the below mentioned criteria Normal neurological examination Normal IQ Normal EEG prior to withdrawal Seizure- free for 2-5 yrs or longer The person not have had problems with prior attempts to stop medication.

PHENYTOIN (Dilantin)
Route -Well absorbed when given orally, however, it is also available as iv. (for emergency) Dose -300-400 mg/day Indication- Used for partial Seizures & generalized tonic-clonic seizures. But not effective for absence Seizures Mechanism of Action: Membrane stabilization by blocking Na & Ca influx into the neuronal axon or inhibits the release of excitatory amino acids via inhibition of Ca influx. .

Side effects
Gingival hyperplasia Hirsutism Megaloblastic anemia Hypersensitivity reactions (mainly skin rashes and lesions, mouth ulcer) Hepatitis rare Fetal malformations- especially cleft plate Bleeding disorders (infants) Osteomalacia due to abnormalities in vitamin D metabolism Hyperglycemia GI Disturbances

CARBAMAZEPINE(Tegretol)

Route-available as an oral form only Dose -200-800 mg/day (given BD as sustained release form) Indication -First line drug for partial seizures and tonic clonic seizures. Action decrease sodium and calcium ion influx in to neuronal membranes.

Side Effects of Carbamazepine:

G.I upset Drowsiness, ataxia and headache; diplopia Hepatotoxicity- rare Congenital malformation (craniofacial anomalies & neural tube defects). Hyponatremia & water intoxication. Late hypersensitivity reaction (erythematous skin rashes, mouth ulceration and lymphadenopathy).

 Route- oral and IV Dose- 50- 150 mg/day (1-3 mg/ kg/ day). Indication- status epilepticus, and in generalized seizures except absence and partial seizures. Mechanism of Action: Increases the inhibitory neurotransmitters (eg: GABA ) and decreasing the excitatory transmission(CNS depressant).

PHENOBARBITAL (PHENOBARBITONE)

Side effects: Somnolence Confusion Hypersensitivity reaction Renal impairment Sedation Drowsiness Fatigue Depression of cognitive functioning.

SODIUM VALPROATE or VALPROIC ACID

Route oral (available as capsule, Syrup), and I.V Dose-1000- 3000 mg/ day. Indication -Very effective against absence seizure. Also, effective in generalized tonic-clonic, tonic, atonic and Myoclonic seizures.

ACTION- Increase the concentration of inhibitory neurotransmitter GABA. Side effects Drowsiness Difficulty in thinking Psychotic reactions Nausea, vomiting and GIT disturbances Increased appetite & weight gain Transient hair loss. Hepatotoxicity Thrombocytopenia

TOPIRAMATE (topamax)
Route Oral Dose- 25-50 mg/ day(max-1600mg/day) at weekly interval. Indication- Recently, this drug become one of the safest antiepileptic which can be used alone for partial and generalized tonic-clonic, and absence seizures. Action- Blocks sodium channels (membrane stabilization) and also enhances the inhibitory effect of GABA.

Side effects:
Ataxia Nystagmus Diplopia Weight loss Sedation Dizziness Fatigue Nausea Paresthesias (abnormal sensation ) Nervousness

Surgery

SURGICAL MANAGEMENT
A proportion of the patient's with intractable epilepsy will benefit from surgery. The aim of the surgery is to carefully remove the brain tissue that is sparkling the seizure while leaving intact areas that control other functions. Epilepsy surgery procedures: Curative (removal of epileptic focus) and palliative (seizure-related risk decrease and improvement of the QOL)

Curative (resective) procedures: Temporal lobectomy Lesionectomy, Cortical resection, Hemispherectomy. Palliative procedures: Corpus callosotomy Vagal nerve stimulation (VNS).

TEMPORAL LOBECTOMY
Seizure most commonly arising from the one or both temporal lobe. Temporal lobectomy is a resective surgery (resection= removal) in which the area of the temporal lobe which is responsible for seizure is surgically removed. In the deep front part of the temporal lobe are located the most seizure prone structures. These areas are hippocampus and the amygdala which is removed by cutting and suction. The CSF surrounding the brain fill the area

 Nausea and headache are common during post operative period. The clean surgical scar will not produce seizure most of the time. Temporal lobectomy is the most common and successful type resective surgery. Following temporal lobectomy memory and word finding may be affected. There is improvement in anxiety and depression after temporal lobectomy. Some patients may experience visual problems of right upper visual field

 There is 1-2% chance of stroke after surgery 0.1% chance of death After temporal lobectomy 55- 75% are free of seizure that impair consciousness. 10-30% have significant reduction of seizure after surgery. However 15% of patients have no improvement after surgery.

LESIONECTOMY
Is the removal of the scar tissue or brain lesion which is responsible for seizure. Lesionectomy have a stroke risk of 1-2% . Depending up on the position of seizure focus there is risk of causing impairment in language, movement , or sensation.

CORPUS CALLOSOTOMY
The cerebral hemispheres are connected internally by the corpus callosum. These are a broad band of white matter containing axons that extended between the hemispheres. After a partial corpus callosotomy the seizure reduction is around 60-80% for certain seizure types including tonic-clonic, Atonic, and tonic seizures. This surgery have a slightly higher risk of stroke or problems with attention and behavior.

HEMISPHERECTOMY
Removal of half of the brain In the patients some of the brain function is already impaired and the remaining will be lost after surgery. This procedure will provide complete seizure relief in 75% of patients.

Vagal nerve stimulation

Is effective in treatment of partial seizures in patients who are: Refractory to multiple drugs Sensitive to the adverse effects of antiepileptic Having difficulty to follow medication schedule In this method an electrode is surgically placed around the left Vagus nerve in the neck. It is connected to a battery placed beneath the skin in the upper chest and the battery is surgically replaced about every 5 years.

 The device is programmed to deliver intermittent electrical stimulation to the brain to reduce the frequency and intensity of seizures. Intermittent stimulation is delivered every 0.310 minutes for 730 seconds, but patients who experience a seizure warning can trigger the device manually. The stimulation may interrupt synchronization of epileptic brain wave activity. 30% of patients have 50% reduction of seizure by implanting this device.

The adverse effects are

Coughing Hoarseness Dyspnoea Tingling in the neck

 Lifestyle modifications, particularly avoidance of alcohol and sleep deprivation, can be very important in certain syndromes and individuals. Relaxation, biofeedback, and other behavioural techniques can help a subset of patients, especially those with a reliable aura preceding complex partial or secondarily generalized seizures.

Non Pharmacological Methods Of Treatments.

KETOGENIC DIET
The ketogenic diet has been used for more than 80 years in children with severe seizure disorders. It is based on the observation that ketosis and acidosis have anti-seizure effects. Strict protein, calorie, and especially carbohydrate restriction in the setting of a high fat diet is needed for ketosis, and may be difficult to maintain.

 In a minority of patients with intractable epilepsy, staying on this diet for months or years can result in a sustained improvement in seizure control, rarely even allowing withdrawal of AEDs.

Complication
1-STATUS EPILEPTICUS
Status epilepticus is defined as more than 30 minutes continues seizure activity or two or more sequential seizure without full recovery of consciousness between seizure . The most common cause is an abrupt discontinuation of antiepileptic drugs. Other causes are fever, withdrawal from alcohol, or sedative. Status epilepticus may occur with frontal lobe lesions (strokes), following head injury, drug intoxication, metabolic disturbances or pregnancy.

Clinically status epilepticus present with obvious tonic, clonic, or tonic-clonic movements with subtle twitching of the hand or face; or with absence of movement. It can occur in both convulsive and non convulsive seizure. Convulsive seizures can be easily observed clinically, but partial seizures are less obvious and very difficult to identify.

The most common type of status epilepticus is tonic-clonic status epilepticus. Higher rates among the very young and very old. Status epilepticus is a medical emergency associated with significant mortality or morbidity (20%), if not treated aggressively. It can cause cardiopulmonary dysfunction, hyperthermia, and metabolic imbalance can occur , leading to cerebral ischemia and neural death.

Management of status epilepticus

1- ABCs of life support. Position the patient to avoid aspiration or inadequate oxygenation. A soft plastic airway is inserted if it is possible to do so without forcing the teeth apart. The airway will need to be suctioned. Oxygen is administered 100% through nasal cannula.

 Monitor respiratory function with pulse oximetry. IV access should be secured and vital signs and neurological signs should be monitored frequently. Monitor arterial blood gases as the patient will have profound metabolic acidosis. Hypoglycemia should be treated by administering 50 ml of 50% glucose. Hyperthermia should be corrected by passive cooling.

 2-Administrating antiepileptic drugs.

Time line in minutes 0-3 4-23 Drug (progression along this algorithm if the pervious drug is not effective) 1-Lorazepam ;0.1 mg/kg IV at 2mg/minutes 2-Phenytoin 20 mg/kg in normal saline at rate of 50mg/minutes.

22-33
37-58 58-68

3- Phenytoin (additional) 5- 10 mg/kg

4- Phenobarbital 20mg/kg IV at a 50-75 mg/min 5- Phenobarbital additional 5-10mg/kg 6- anesthesia with midazolam or protocol

 3-Treating The Underlying Cause. Find out the underlying cause and treat the primary problem. 4- Preventing Or Treating Medical Complications. The patient must be moved to well equipped ICU . Hypoxia, hyperthermia, hypoglycemia, hypotension, cardiac arrhythmias, aspiration pneumonia and myocardial infraction can occur.

 Other complications of epilepsy include

2- Severe Injury Due To Accidents 3- Depression 4- Sudden Unexpected Death In Epilepsy.(SUDEIP)

This is the syndrome attached where a person with epilepsy dies suddenly and no other cause of death is revealed.

Patient education
Adhere to treatment regimen. Regular review and health check up Avoid alcohol Proper diet Proper rest and sleep Avoid stress by practicing yoga, meditation etc.. Never suddenly stop medication

Non-epileptic attack disorder

These are attacks which arise for reasons other than those which cause epilepsy. They suggest an underlying psychological or emotional problem. The incidence of NEAD is higher in women NEAD often begins in adolescence or early twenties

 A history of previous trauma or abuse is quite common Antiepileptic drugs are unhelpful Stress Attacks The person is unable to cope with certain situations. This may be specific life events, or more general changes such as adolescence.

 Distress Attacks Feeling of slipping in and out of consciousness. Inner distress. Attacks occur as a way of avoiding feelings. Often difficult and painful recovery. Treatment: support without fuss Psychotherapy

Nursing diagnosis
Ineffective breathing pattern related to neuromuscular impairment secondary to prolonged tonic phase as evidenced by abnormal respiratory rate and rhythm. Risk for injury related to seizure activity. .

 Ineffective coping related to perceived loss of control and denial of diagnosis as evidenced by verbalizations about not having epilepsy.

Ineffective therapeutic regimen management related to lack of knowledge about management of seizure disorder as evidenced by verbalization of misconception.

Questions?????????

Thank you