Epilepsy Guideline in Adults

Clinical Epilepsy
American Epilepsy Society
CSlide 1
American Epilepsy Society 2008
Definitions
 Seizure: the clinical manifestation of

an abnormal, excessive excitation
and synchronization of a population
of cortical neurons
 Epilepsy: two or more recurrent

seizures unprovoked by systemic or
acute neurologic insults
CSlide 2
Epidemiology of
Seizures and Epilepsy
 Seizures
• Incidence: 80/100,000 per year
• Lifetime incidence: 9%
(1/3 febrile convulsions)
 Epilepsy
• Incidence: 45/100,000 per year
• Point prevalence: 0.5-1%
• Cumulative lifetime incidence: 3%
CSlide 3
ILAE Classification of Seizures
Seizures
Partial Generalized
Simple Partial Absence
Complex Partial Myoclonic
Secondarily
Atonic
Generalized
Tonic
Tonic-Clonic
CSlide 4
Seizures
Partial Generalized
Simple Partial
Complex Partial
Secondarily Generalized
CSlide 5
Seizures
Partial Generalized
Simple Partial
With somatosensoryy
or special sensory symptoms
With motor signs
With autonomic
symptoms or signs
With psychic or
experiential symptoms
CSlide 6
Complex Partial Seizures
 Impaired
consciousness Seizures
 Clinical manifestations
vary with site of origin
and degree of spread
• Presence and nature Partial Generalized
of aura
• Automatisms
• Other motor activity
 Duration typically < 2 Complex Partial
minutes
CSlide 7
Secondarily Generalized Seizures
 Begins focally, with or
without focal neurological
symptoms Seizures
 Variable symmetry,
intensity, and duration of
tonic (stiffening) and clonic
(jerking) phases Partial Generalized
 Typical duration 1-3

minutes
 Postictal confusion, Secondarily
somnolence, with or
without transient focal Generalized
deficit
CSlide 8
EEG: Partial Seizure
Right temporal
seizure with
maximal phase
reversal in the
right sphenoidal
electrode
CSlide 9
EEG: Partial Seizure
Continuation of
same seizure
Right temporal
seizure with
maximal phase
reversal in the right
sphenoidal
electrode
CSlide 10
Seizures
Partial Generalized
Absence
Myoclonic
Atonic
Tonic
Tonic-Clonic
CSlide 11
Typical Absence Seizures
 Brief staring spells (“petit mal”)
with impairment of awareness
 3-20 seconds Seizures
 Sudden onset and sudden
resolution
 Often provoked by
hyperventilation
Partial Generalized
 Onset typically between 4
and 14 years of age
 Often resolve by 18 years of
age
Absence
 Normal development and
intelligence
 EEG: Generalized 3 Hz spike-
wave discharges
CSlide 12
EEG: Typical Absence Seizure
CSlide 13
Atypical Absence Seizures
 Brief staring spells with variably reduced responsiveness
 5-30 seconds
 Gradual (seconds) onset and resolution
 Generally not provoked by hyperventilation
 Onset typically after 6 years of age
 Often in children with global cognitive impairment

 EEG: Generalized slow spike-wave complexes (<2.5 Hz)
 Patients often also have Atonic and Tonic seizures
CSlide 14
Atypical Absence Seizures
CSlide 15
Myoclonic Seizures
 Brief, shock-like jerk of a
muscle or group of muscles Seizures
 Epileptic myoclonus
 Typically bilaterally
synchronous
 Impairment of
consciousness difficult to
Partial Generalized
assess (seizures <1 second)
 Clonic seizure – repeated
myoclonic seizures (may
have impaired awareness)
Myoclonic
 Differentiate from benign,
nonepileptic myoclonus (e.g.,
while falling asleep)
 EEG: Generalized 4-6 Hz
polyspike-wave discharges
CSlide 16
Myoclonic Seizures
CSlide 17
Tonic and Atonic Seizures
Tonic seizures
 Symmetric, tonic muscle contraction of
extremities with tonic flexion of waist and neck
 Duration - 2-20 seconds.
 EEG – Sudden attenuation with generalized, low-
voltage fast activity (most common) or Seizures
generalized polyspike-wave.
Atonic seizures
Partial Generalized
 Sudden loss of postural tone
 When severe often results in falls
 When milder produces head nods or jaw drops. Tonic
 Consciousness usually impaired

 Duration - usually seconds, rarely more than 1 Atonic
minute
 EEG – sudden diffuse attenuation or generalized
polyspike-wave
CSlide 18
Tonic and Atonic Seizures
CSlide 19
Generalized Tonic-Clonic Seizures
 Associated with loss of
consciousness and post-ictal
confusion/lethargy Seizures
 Duration 30-120 seconds
 Tonic phase
 Stiffening and fall
 Often associated with ictal cry
Partial Generalized
 Clonic Phase
 Rhythmic extremity jerking
 EEG – generalized polyspikes Tonic-
Clonic
CSlide 20
Epilepsy Syndromes
Epilepsy Syndrome
Grouping of patients that share similar:
• Seizure type(s)
• Age of onset
• Natural history/Prognosis
• EEG patterns
• Genetics
• Response to treatment
CSlide 21
Epilepsy Syndromes
Epilepsy
Partial Generalized
Idiopathic Symptomatic Idiopathic Symptomatic
CSlide 22
Etiology of Seizures
and Epilepsy
 Infancy and childhood

• Prenatal or birth injury
• Inborn error of metabolism
• Congenital malformation
 Childhood and adolescence

• Idiopathic/genetic syndrome
• CNS infection
• Trauma
CSlide 23
Etiology of Seizures
and Epilepsy
 Adolescence and young adult

• Head trauma
• Drug intoxication and withdrawal*
 Older adult
• Stroke
• Brain tumor
• Acute metabolic disturbances*
• Neurodegenerative
*causes of acute symptomatic seizures, not epilepsy

CSlide 24
Questions Raised by a
First Seizure
 Seizure or not?
 Focal onset?
 Evidence of interictal CNS dysfunction?
 Metabolic precipitant?
 Seizure type? Syndrome type?
 Studies?
 Start AED?
CSlide 25
Evaluation of a First Seizure
 History, physical
 Blood tests: CBC, electrolytes, glucose,
calcium, magnesium, phosphate, hepatic and
renal function
 Lumbar puncture
(only if meningitis or encephalitis suspected and potential
for brain herniation is excluded)
 Blood or urine screen for drugs
 Electroencephalogram
 CT or MR brain scan
CSlide 26
Seizure Precipitants
 Metabolic and Electrolyte Imbalance
 Stimulant/other proconvulsant intoxication
 Sedative or ethanol withdrawal
 Sleep deprivation
 Antiepileptic medication reduction or inadequate
AED treatment
 Hormonal variations
 Stress
 Fever or systemic infection
 Concussion and/or closed head injury
CSlide 27
Seizure Precipitants (cont.)
Metabolic and Electrolyte Imbalance

 Low blood glucose
(or high glucose, esp. w/ hyperosmolar state)
 Low sodium
 Low calcium
 Low magnesium
CSlide 28
Seizure Precipitants (cont.)
Stimulants/Other Pro-convulsant Intoxication

 IV drug use
 Cocaine
 Ephedrine
 Other herbal remedies
 Medication reduction
CSlide 29
EEG Abnormalities
 Background abnormalities: significant
asymmetries and/or degree of slowing
inappropriate for clinical state or age
 Interictal abnormalities associated with seizures
and epilepsy
• Spikes
• Sharp waves
• Spike-wave complexes
 May be focal, lateralized, generalized
CSlide 30
Medical Treatment of
First Seizure
Whether to treat first seizure is controversial
 16-62% will recur within 5 years
 Relapse rate might be reduced by antiepileptic
drug treatment
 Abnormal imaging, abnormal neurological exam,
abnormal EEG or family history increase relapse
risk
 Quality of life issues are important (ie driving)
Reference: First Seizure Trial Group. Randomized Clinical Trial on the efficacy of antiepileptic drugs in reducing
the
risk of relapse after a first unprovoked tonic-clonic seizure. Neurology 1993; 43 (3, part1): 478-483.
Reference: Camfield P, Camfield C, Dooley J, Smith E, Garner B. A randomized study of carbamazepine versus
no medication after a first unprovoked seizure in childhood. Neurology 1989; 39: 851-852.
CSlide 31
Choosing Antiepileptic Drugs
 Seizure type
 Epilepsy syndrome
 Pharmacokinetic profile
 Interactions/other medical conditions
 Efficacy
 Expected adverse effects
 Cost
CSlide 32
 Limited placebo-controlled trials available, particularly of
newer AEDs
 In practice, several drugs are commonly used for
indications other than those for which they are officially
approved/recommended
 Choice of AED for partial epilepsy depends largely on drug
side-effect profile and patient’s preference/concerns
 Choice of AED for primary generalized epilepsy depends
on predominant seizure type(s) as well as drug side-effect
profile and patient’s preference/concerns
 ILAE and AAN recommendations indications listed in the
appendix
CSlide 33
Broad-Spectrum Agents Narrow-Spectrum Agents
Valproate Partial onset seizures

Felbamate Phenytoin
Lamotrigine Carbamazepine
Topiramate Oxcarbazepine
Zonisamide Gabapentin
Levetiracetam Pregabalin
Rufinamide* Tiagabine
Lacosamide*
Absence
Ethosuximide
* New AEDs (approved 2008) categorization may change CSlide 34
Choosing Antiepileptic
Drugs (cont.)
Drugs (cont.)
Monotherapy for Partial Seizures
Best evidence and FDA indication:
Carbamazepine, Oxcarbazepine, Phenytoin, Topiramate
Similar efficacy, likely better tolerated:
Lamotrigine, Gabapentin, Levetiracetam
Also shown to be effective:
Valproate, Phenobarbital, Felbamate, Lacosamide
Limited data but commonly used:
Zonisamide, Pregabalin
Azar and AbouKhalil, Seminars in Neurology, 2008 28:305316
CSlide 35
Drugs (cont.)
Monotherapy for Generalized-Onset

Tonic-Clonic Seizures
Best evidence and FDA Indication:
Valproate, Topiramate
Zonisamide, Levetiracetam
Phenytoin, Carbamazepine (may exacerbate absence and myoclonic sz )
Lamotrigine (may exacerbate myoclonic sz of symptomatic generalized epilepsies)
CSlide 36
Drugs (cont.)
Absence seizures
Best evidence:
Ethosuximide (limited spectrum, absence only)
Valproate

Lamotrigine
May be considered as second-line:

Zonisamide, Levetiracetam, Topiramate, Felbamate, Clonazepam
CSlide 37
Drugs (cont.)
Myoclonic Seizures
Best evidence:
Valproate
Levetiracetam (FDA indication as adjunctive tx)
Clonazepam (FDA indication)
Possibly effective:
Zonisamide, Topiramate
CSlide 38
Choosing Antiepileptic Drugs (cont.)
Lennox-Gastaut Syndrome
Best evidence/FDA indication*:
Topiramate, Felbamate, Clonazepam, Lamotrigine, Rufinamide
* FDA approval is for adjunctive treatment for all except clonazepam
Also effective:
Valproate
Some evidence of efficacy:
Zonisamide, Levetiracetam
CSlide 39
Antiepileptic Drug Monotherapy
 Simplifies treatment
 Reduces adverse effects
 Conversion to monotherapy from

polytherapy
• Eliminate sedative drugs first
• Withdraw antiepileptic drugs slowly over
several months
CSlide 40
Antiepileptic Drug Interactions
 Drugs that may induce metabolism of other drugs:
 carbamazepine, phenytoin, phenobarbital, primidone
 Drugs that inhibit metabolism of other drugs:
 valproate, felbamate
 Drugs that are highly protein bound:
 valproate, phenytoin, tiagabine
 carbamazepine, oxcarbazepine
 topiramate is moderately protein bound
 Other drugs may alter metabolism or protein binding of

antiepileptic drugs (especially antibiotics, chemotherapeutic
agents and antidepressants)
CSlide 41
Antiepileptic Drug Interactions
Drugs that may decrease the efficacy of hormonal contraception
• Phenytoin
• Carbamazepine
• Phenobarbital
• Topiramate*
• Oxcarbazepine*
• Felbamate*
*at high doses
“High-dose” birth control pills are recommended for patients taking
these medications.
Lamotrigine levels decreased by hormonal contraception
CSlide 42
AED Serum Concentrations
 AED serum concentrations are to be used as a
guide, not dictate clinical decision making.
 Serum concentrations are useful when optimizing
AED therapy, assessing compliance, monitoring
during pregnancy or oral contraceptive use, or
teasing out drug-drug interactions.
 Individual patients define their own “therapeutic”
and “toxic” ranges.
Patsalos PN, et al. Epilepsia.2008. 49(7): 12391276
CSlide 43
Adverse Effects of AEDs: Common
Often dose-related:
Dizziness
Fatigue
Ataxia
Diplopia
Irritability
 levetiracetam
Word-finding difficulty
 topiramate
Weight loss/anorexia
 topiramate, zonisamide, felbamate
Weight gain
 valproate (also associated with polycystic ovarian syndrome in young women)
 carbamazepine, gabapentin, pregabalin
CSlide 44
Adverse Effects of AEDs: Serious
Typically idiosyncratic:
Renal stones
 topiramate, zonisamide
Hyponatremia
 carbamazepine, oxcarbazepine
Aplastic anemia
 felbamate, zonisamide, valproate, carbamazepine
Agranulocytosis
 carabamazepine
Hepatic Failure
 valproate, felbamate, lamotrigine, phenobarbital
Anhydrosis, heat stroke
 topiramate
Acute closed-angle glaucoma
 topiramate
CSlide 45
Adverse Effects of AEDs: Rash
 15.9% patients ever experienced a rash
attributed to an AED
 Average rate of AED-related rash for a given

AED 2.8%, 2.1% causing AED discontinuation.
 Predictors significant in multivariate analysis:

 occurrence of another AED-rash
Arif H et al. Neurology 2007 CSlide 46
Stevens-Johnson Syndrome (SJS) and

Toxic Epidermal Necrolysis (TENS)
 severe life threatening allergic reaction
 blisters and erosions of the skin, particularly
palms/soles and mucous membranes
 fever and malaise
 rare: severe risk roughly 1-10/10,000 for many AEDs
 rapid titration of lamotrigine especially in
combination with valproate increases risk
CSlide 47
Drugs rarely associated with rash

 Valproate
 Gabapentin
 Pregabalin
 Levetiracetam
 Topiramate
CSlide 48
AED-related rash in adult patients with epilepsy
▲▲= rash rate significantly greater than average of all other AEDs (p<0.003)
▼▼= rash rate significantly lower than average of all other AEDs (p<0.003)
▲= trend towards significantly higher than average rash rate of all other AEDs
(0.003<p<0.05)
▼= trend towards significantly lower than average rash rate of all other AEDs
(0.003<p<0.05) CSlide 49
AED-related rash in Asian
patients with epilepsy
FDA alert 12/2007
Risk of “dangerous or even fatal skin reactions” (SJS and TEN) are
more common in those with HLA-B*1502
This allele is almost exclusively found in Asians

• In 10-15% of population in China, Thailand, Malaysia,
Indonesia, the Phillipines, and Taiwan
• 2-4% in India
• <1% in Japan and Korea
59/60 Asian patients w/ SJS/TEN had this allele vs 4% of cbz

tolerant patients
Estimated absolute risk for those with the allele: 5%
Asians “should be screened for the HLA-B*1502 allele before
starting treatment with carbamazepine”
These patients may also be at risk with other AEDs
• Use drugs not typically associated with rash CSlide 50
www.fda.gov
Epilepsy Comorbidities and AEDs
Osteoporosis
• Mostly worsened by the enzyme inducers: phenytoin,
phenobarbital, primidone. Carbamazepine data equivocal.
• Equivocal data with valproate, unavailable for other non- inducers.
• Take calcium 1000-1500/d; Vit D 400-4000/d
Depression
• Can be exacerbated by levetiracetam (and less so zonisamide)
• Can be helped by lamotrigine and possibly gabapentin, pregabalin
(and vagus nerve stimulator)
Migraine
• Consider topiramate, valproate
Obesity
• Weight loss with topiramate and zonisamide
• Weight gain with valproate > gabapentin/pregabalin,
carbamazepine
CSlide 51
Possible suicide risk with AEDs
Recent FDA alert (1/2008):
• Meta-analysis of 199 placebo-controlled add-on tx trials
(44,000 patients)
• Suicidality with adjunct AEDs than adjunct placebo:
– 0.43% vs 0.22%
• Extra 2.1 patients per 1000 more patients will have suicidality
• 4 suicides with AEDs vs 0 with placebo
• “generally consistent across the 11 AEDs”
Data analysis is controversial and overall difference is very small
Further investigation is needed
Clinicians should be aware of potential risk and screen for

depression/suicidality
www.fda.gov CSlide 52
Dose Initiation and Monitoring
 Discuss likely and unlikely but important
adverse effects
 Discuss likelihood of success
 Discuss recording/reporting seizures,

adverse effects, potential precipitants
CSlide 53
Discontinuing AEDs
 Seizure freedom for ≥ 2 years
implies overall >60% chance of successful
withdrawal in some epilepsy syndromes
 Favorable factors
• Control achieved easily on one drug at low dose
• No previous unsuccessful attempts at withdrawal
• Normal neurologic exam and EEG
• Primary generalized seizures except JME
• “Benign” syndrome
 Consider relative risks/benefits (e.g., driving,
pregnancy)
CSlide 54
Evaluation After Seizure
Recurrence
 Progressive pathology?
 Avoidable precipitant?
 If on AED
• Problem with compliance?
• Pharmacokinetic factor?
• Increase dose?
• Change medication?
 If not on AED
• Start therapy?
CSlide 55
Non-Drug Treatment/
Lifestyle Modifications
 Adequate sleep
 Avoidance of alcohol, stimulants, etc.
 Avoidance of known precipitants
 Stress reduction — specific techniques
CSlide 56
Ketogenic Diet
 Main experience with children, especially with
multiple seizure types
 Likely anti-seizure effect of ketosis (beta
hydroxybutyrate), but other mechanisms also
may be responsible for beneficial effects
 Low carbohydrate, adequate protein, high fat
 50% with a >50% seizure reduction
 30% with >90% reduction
 Side effects include kidney stones, weight loss,
acidosis, dyslipidemia
CSlide 57
Alternative Diets
 Modified Atkins diet

• 10 g/day carbohydrates to start, fats encouraged
• No protein, calorie, fluid restriction
• 3 reports to date from Johns Hopkins, 1 from South
Korea
– 47% all children with >50% seizure reduction
– Studies underway for adults
 Low-glycemic index treatment

• 40-60 g/day low-glycemic carbohydrates
• Portions generally controlled
• Single report from Massachusetts General
CSlide 58
Patient Selection for Surgery:
Criteria
 Epilepsy syndrome not responsive to medical
management
• Unacceptable seizure control despite maximum
tolerated doses of 2-3 appropriate drugs as
monotherapy
 Epilepsy syndrome amenable to surgical

treatment
CSlide 59
Evaluation for Surgery
History and Exam: consistency, localization of seizure
onset and progression
MRI: 1.5 mm coronal cuts with sequences sensitive to gray-
white differentiation and to gliosis
Other neuroimaging options: PET, ictal SPECT
EEG: ictal and interictal, special electrodes
Magnetoencephalography (MEG): interictal, mapping
Neuropsychological battery
Psychosocial evaluation
Intracarotid amobarbital test (Wada)
CSlide 60
Surgical Treatment
 Potentially curative
• Resection of epileptogenic region (“focus”)
avoiding significant new neurologic deficit
 Palliative
• Partial resection of epileptogenic region
• Disconnection procedure to prevent seizure
spread
– Callosotomy
– Multiple subpial transections
CSlide 61
Epilepsy Surgery Outcomes
Anterior Neocortical
Temporal Resection
Resection
Seizure Free 66% 49%
(except auras) (possibly higher if MTS) (63% if lesional)
Improved 21% 30%
Not improved 14% 21%
Reference: Engel, J. et al. Neurology 2003

CSlide 62
Epilepsy Surgery
Corpus Callosotomy
 Palliative surgery for intractable epilepsies with drop attacks (ie Lennox-
Gastaut)
 Up to 75% have > 75% reduction in atonic seizures
 Risk of disconnection syndromes
Hemispherectomy
 Indicated for catastrophic hemispheric epilepsies, usually presenting in
children (ie Rasmussen’s encephalitis, hemimegalencephaly)
 43-79% seizure free (varies by etiology)
 “Functional hemispherectomy” (disconnection without removal) now more
commonly performed
Multiple Subpial Transections

 Cuts horizontal cortical-cortical connections
 Generally reserved for epileptogenic regions in functional cortex
Spencer and Huh, Lancet 2008
CSlide 63
Vagus Nerve Stimulator
 Intermittent programmed electrical stimulation of left vagus
nerve
 Option of magnet activated stimulation
 Adverse effects local, related to stimulus (hoarseness,
throat discomfort, dyspnea)
 Mechanism unknown
 Clinical trials show that 35% of patients have a 50%
reduction in seizure frequency and 20% experience a 75%
reduction after 18 months of therapy.
 May improve mood and allow AED reduction
 FDA approved for refractory partial onset seizures and
refractory depression
CSlide 64
Status Epilepticus
 Definition
• More than 10 minutes of continuous seizure
activity
or
• Two or more sequential seizures without full

recovery between seizures
CSlide 65
Status Epilepticus
 A medical emergency
• Adverse consequences can include hypoxia,
hypotension, acidosis, hyperthermia,
rhabdomyolysis and neuronal injury
• Know the recommended sequential protocol
for treatment and distribute a written protocol
to emergency rooms, ICUs and housestaff.
• Goal: stop seizures as soon as possible
CSlide 66
SE Treatment Algorithm
Arif and Hirsch, Seminars in Neurology, 2008
One commonly used treatment algorithm is:

First 5 minutes:
• Check emergency ABC’s
• Give O2
• Obtain IV access
• Begin EKG monitoring
• Check fingerstick glucose
• Draw blood for Chem-7, Magnesium, Calcium,
Phosphate, CBC, LFTs, AED levels, ABG, troponin
• Toxicology screen (urine and blood).
CSlide 67
6-10 minutes
• Thiamine 100 mg IV; 50 ml of D50 IV unless
adequate glucose known.
• Lorazepam 4 mg IV over 2 mins; if still seizing,
repeat X 1 in 5 mins.
• If no rapid IV access give diazepam 20 mg PR or
midazolam 10 mg intranasally, buccally or IM.
CSlide 68
10-20 minutes:
• If seizures persist, begin fosphenytoin 20
mg/kg IV at 150 mg/min, with blood pressure
and EKG monitoring.
• Reasonable to bypass this step, or perform
subsequent step simultaneous with
fosphenytoin loading
CSlide 69
10-60 minutes: one (or more) of the following 4 options:

(intubation usually necessary except for valproate)
• CIV midazolam: Load: 0.2 mg/kg; repeat 0.2-0.4 mg/kg boluses

every 5 minutes until seizures stop, up to a maximum total loading
dose of 2 mg/kg. Initial cIV rate: 0.1 mg/kg/hr. cIV dose range: 0.05 –
2.9 mg/kg/hr.
OR
• CIV propofol: Load: 1 mg/kg; repeat 1-2 mg/kg boluses every 3-5
minutes until seizures stop, up to maximum total loading dose of 10
mg/kg. Initial cIV rate: 2 mg/kg/h. cIV dose range: 1-15 mg/kg/hr.
Avoid >48 hrs of >5 mg/kg/h (increased risk of propofol infusion
syndrome).
OR
• IV valproate: 40 mg/kg over ~10 minutes. If still seizing, additional 20
mg/kg over ~5 minutes.
OR
• IV phenobarbital: 20 mg/kg IV at 50-100 mg/min.
CSlide 70
60 minutes:
• CIV Pentobarbital. Load: 5 mg/kg at up to 50
mg/min; repeat 5 mg/kg boluses until seizures
stop. Initial cIV rate: 1 mg/kg/hr. cIV-dose
range: 0.5-10 mg/kg/hr; traditionally titrated to
suppression-burst on EEG.
Begin EEG monitoring ASAP if patient does not

rapidly awaken, or if any CIV treatment is used.
~20% of those successfully treated clinical
status will still be seizing on EEG.
Treiman et al, VA Coop Study, NEJM ‘98
CSlide 71
Differential Diagnosis of
Non-epileptic Events: Physiologic
 Syncope
 Cardiac (Arrhythmia)
 Non-Cardiac Syncope (Vasovagal, Dysautonomic)
 Metabolic (Hypoglycemia)
 Migraine
 Sleep Disorders (Narcolepsy)
 Movement Disorders (Paroxysmal Dyskinesia)
 Transient Ischemic Attacks
CSlide 72
Differential Diagnosis of
Non-epileptic Events: Psychogenic
 Psychogenic Seizures
 Malingering
 Panic Attacks
 Intermittent Explosive Disorder
 Breath-holding Spells
CSlide 73
Syncope
 Characteristic warning, usually gradual (except

with cardiac arrhythmia)
 Typical precipitants (except with cardiac
arrhythmia)
 Minimal to no postictal confusion/somnolence
 Convulsive syncope — tonic>clonic
manifestations, usually < 30 sec; usually from
disinhibited brainstem structures (only rarely from
cortical hypersynchronous activity)
CSlide 74
Syncope vs Sz: Before Spell
Syncope Seizure
Trigger
Common Rare
(position, emotion, Valsalva)
Sweating & nausea Common Rare
Aura (e.g., déjà vu, smell)
Rare Common
or unilateral symptoms
Hirsch et al, Merritt’s Textbook of Neurology, 2007
CSlide 75
Syncope vs Sz: During Spell
Syncope Seizure
Pallor Common Rare
Cyanosis Rare Common
Loss of consciousness <20 secs >60 secs

CSlide 76
Syncope Seizure
Common (in
Automatisms Occasional CPS & 2nd
GTC)
Tongue biting, lateral Rare Occasional
Frothing/hypersalivation Rare Common

CSlide 77
Syncope Seizure
Few clonic or Prolonged tonic
myoclonic jerks; phase, then
brief tonic prolonged
Movements
posturing (few rhythmic clonic
secs); duration <15 mvmts; dur’n >1
secs min
Frothing/hyper
Rare Common
salivation

CSlide 78
Syncope vs Sz: After spell
Syncope Seizure
Confusion/ Common;
disorientation Rare; <30 secs several mins or
longer
Rare, brief, usually Common,
Diffuse myalgias
shoulders/chest hoursdays
Common (esp.
CK elevation Rare after 1224
hours)
CSlide 79
Features That Are Not Helpful for
Differentiating Syncope from Seizure
 Incontinence  Injury other than

 Prolactin level lateral tongue biting
 Dizziness  Eye movements
 Fear (rolling back)
 Brief automatisms

CSlide 80
Migraine aura vs. occipital seizure
Migraine Occipital Seizure
Duration 5-20 min 0.5-5 min
Typical B&W; straight lines; Color, round, variable

Content slow spread spread
Laterality Either side Always same side

(contralateral)
Associated Altered awareness, motor
Features fx, automatisms
CSlide 81
Psychogenic Nonepileptic
Seizures
 10-45% of patients referred for intractable spells
 Females > males
 Psychiatric mechanism — dissociation, conversion
 Common association with physical, emotional, or sexual abuse
 Spells with non-epileptic etiology
 No obvious ictal eeg correlation
(classically normal awake background during episode of impaired consciousness)
Caveats: Diagnosis can be complicated

 The majority of simple partial seizures have no EEG correlation
 Frontal lobe seizures may have unusual semiology and no discernable EEG
correlation
CSlide 82
Seizures (cont.)
FEATURES SUGGESTIVE OF NONEPILEPTIC PSYCHOGENIC
SEIZURES
 Eye Closure
 Pelvic thrusting
 Opisthotonus
 Side-to-side head shaking
 Prolonged duration (>4 minutes)
 Stopping and starting
 Suggestibility
CSlide 83
Seizures (cont.)
 Represents psychiatric disease

 Once recognized, approximately 50%
respond well to specific psychiatric
treatment
 Epileptic and nonepileptic seizures may
co-exist
 Video-EEG monitoring often required for
diagnosis
CSlide 84
Utility of epilepsy video/EEG monitoring units
Epilepsy Monitoring Unit (EMU):

 Inpatient unit with specialized personnel
 Continuous video and EEG recording
 Utility:
 Differentiate between epileptic and non-epileptic spells
 Identification of unrecognized seizures
 Recording seizures for presurgical evaluation
NAEC Guidelines for EMU evaluation:

 Treatment failure of 1 year
 Failure of 2-3 AEDs
CSlide 85
Utility of epilepsy video/EEG monitoring units:
Non-epileptic spells
Study of 213 EMU admissions

Smolowitz et al, Am J Med Qual 2007
• 21% had purely nonepileptic events

– Treated as if epilepsy for a mean of 9 yrs
– Half treated w/ >3 AEDs
• EMU yielded definitive diagnosis in 88%
CSlide 86
Utility of epilepsy video/EEG monitoring units (EMU):
Epilepsy
Early Identification of Refractory Epilepsy n=525

Kwan and Brodie, NEJM 200
• 192 (37%) patients were refractory.

• Only 11% of patients became seizure-free if the first
drug was ineffective.
• Suggests need for early pre-surgical evaluation
Patient awareness of seizures n=31

Blum et al. Neurology. 1996
• 30% patients deny all seizures

• Only 23% were aware of all seizures
CSlide 87
Sudden Unexplained Death in
Epilepsy: SUDEP
Definition:
“sudden, unexpected, witnessed or
unwitnessed, nontraumatic and non-
drowning death in a patient with epilepsy
where the postmortem examination does
not reveal a toxicologic or anatomic cause
of death, with or without evidence of a
seizure and excluding documented status
epilepticus.”
Nashef L, Brown S. Epilepsy and sudden deaths.

Lancet. 1996;348:1324-1325.
CSlide 88
Sudden Unexplained Death in
Epilepsy: SUDEP
Witnessed SUDEP Langan et al. (2000)

• 15/135 SUDEP cases were witnessed.
• 12/15 were associated with a convulsive seizure.
• One collapse occurred 5 minutes after a GTC seizure
and one after an aura.
• One patient died in a probable postictal state.
• 12/15 were noted to have experienced respiratory
difficulties.
• Suggests that respiratory dysfunction may be an important
contributing factor in SUDEP.
• Suggests that positioning or stimulation of respiration may be
important in the prevention of SUDEP.
CSlide 89
Epidemiology of SUDEP
SUDEP
• Represents about 2-18% of deaths among the
general population of patients with epilepsy.
• Risk of sudden death in epilepsy patients 24 X
that of general population.
• Mean SUDEP incidence: 3.7/1000 people per
year.
• Higher in patients referred for epilepsy
surgery (up to 1 per 100).
Walczak et al. Neurology 2001;56(4):519-525
Ryvlin P, Kahane P. Epilepsy Res. 2003;56(2-3):105-120
Dasheiff RM. J Clin Neurophys. 1991;8(2):216-222
Leestma et al. Ann Neurol 1989;26(2):195-203
CSlide 90
Epidemiology of SUDEP
SUDEP Risk Factors
• History of and number of GTCS

• Frequent seizures
• Subtherapeutic AED levels
• Young adults
• Long epilepsy duration; early epilepsy onset
• AED polytherapy
• Frequent AED changes
• IQ <70
Tomson, 2005; Tellez-Zenteno, 2005; Langan, 2005; So, 2006
CSlide 91
Recommendations for SUDEP
prevention
Optimize seizure control as promptly as possible
• Re-evaluate epilepsy diagnosis and treatment as soon as
2 AEDs have failed, or when GTC szs are frequent despite
initial AED treatment
• Consider epilepsy surgery at that point
• Maximize compliance with AEDs
Use the least number of AEDs needed to control seizures

• Add AED with the aim of replacing the current AED in a
timely fashion (But not at the expense of worsening of
seizure control)
Educate patients and families
CSlide 92
Pregnancy and Epilepsy:
Major Congenital Malformation and AEDs
 Most available data on risk of AEDs comes from
pregnancy registries.
 Main outcome variable of most registries are major
congenital malformations (MCM)
 MCM = malformation that affects physiologic function or
requires surgery
 Neural tube defects
 Cardiac defects
 Genitourinary defects
 Oral clefts
 MCMs are more common with AED exposure
 MCM risk in general population 1.6-2.1%
 MCM risk with AED monotherapy 4.5% (OR 2.6)
 MCM risk with Polytherapy 8.6% (OR 5.1)
Holmes eta l. NEJM 2001. 344 (15): 1132-8.

CSlide 93
Pregnancy and Epilepsy
 96% of pregnancies in mothers with epilepsy produce
normal children
 Spontaneous abortions and pre-term birth more
common in women with epilepsy
 Increased rate of fetal malformations associated with
antiepileptic drug exposure
 Seizures during pregnancy may be harmful
 Tonic-clonic seizures associated with intracranial hemorrhage,
fetal bradycardia and lower IQ in children
 Status associated with increased fetal and maternal mortality in
some studies
 Insufficient data on non-convulsive seizures
Morrow et al. J Neurol Neurosurg Psychiatry. 2006. 77(2):193-8

Holmes eta l. NEJM 2001. 344 (15): 1132-8.
Meador et al. Neurology. 2008; 71:1109-1117
Adab et. al. J Neurol Neurosurg Psychiatry. 2004: 75(11): 1575-1583
CSlide 94
Valproate consistently associated with poorer outcomes

 MCM rate with valproate monotherapy 6.2-13.2%
across 5 registries
 Most studies show dose- related increase in risk
with doses > 1000mg/day
 Polytherapy regimens including valproate also
substantially increased risk of MCM
 Valproate associated with lower IQs in exposed
children
Phenobarbital probably also poses higher risk of MCM

compared with other monotherapy regimens.
Meador etal. Neurology 2007; 68 (suppl 1): A337

Meador et al. Neurology 2008; 71:1109-1117
CSlide 95
MCM rate similar among other studied AEDs in monotherapy,

but not enough data to show significant difference between
them
 Levetiracetam
 Early data promising (0% in monotherapy, 2.7% in polytx)
 Carbamazepine (2.2-3.9%)
 Substantial data available, relatively good track record
 Lamotrigine (1.4-4.4%)
 Increased risk (5.4%) with doses > 400/day
 Gabapentin (0-3.2%)
 Topiramate (0-4.8%)
 Phenytoin (3.2-6.7%)
 Zonisamide, Pregabalin
 No substantial data on monotherapy
Meador etal. Neurology 2007; 68 (suppl 1): A337
Meador et al. Neurology 2008; 71:1109-1117
CSlide 96
Guidelines for Management
All women of child-bearing potential should

receive education and carefully considered
management before and during pregnancy
to optimize the chances of a good outcome
for both mother and child.
Reference: Liporace J, D’Abreu. Epilepsy and Women’s Health: Family Planning, Bone Health,
Menopause, and Menstrual Related Seizures. Mayo Clinic Proceedings 2003; 78: 497-506.
CSlide 97
Pregnancy and Epilepsy: Major Congenital
Malformation Rates in Monotherapy
20%
15%
10%
5%
0%
LEV GBN CBZ LTG TPM PHT PHB VPA
UK Pregnancy Registry North American AED Pregnancy Registry
Australian Pregnancy Registry Finland National Birth Registry
Swedish Medical Birth Registry GSK International Lamotrigine Pregnancy Registry
CSlide 98
Education
• Most women with epilepsy have normal children
• Risk of fetal malformations is increased
• AED teratogenicity is related to exposure in the first
trimester of pregnancy
• Planning should begin well before pregnancy
• Seizures may be deleterious to the fetus
• Compliance with AED treatment is important
• Prenatal diagnosis of fetal malformations is possible
CSlide 99
Before pregnancy
• Attempt AED monotherapy with lowest
effective dose
• Consider switching AEDs prior to pregnancy,
particularly if on valproate
• Establish baseline therapeutic levels
• Folate supplementation
– At least 1mg/day for women of childbearing
age
– 4mg/day if planning pregnancy or at risk for
pregnancy
CSlide 100
During pregnancy
• Monitor AED dose requirements to maximize
seizure control
– Particularly with lamotrigine (levels fall > 50%
and sz increase)
– Also increased clearance of levetiracetam,
oxcarbazepine, phenobarbital and phenytoin
• Continue folate supplementation
• High-risk OB care, consider prenatal diagnosis of
malformations
• Vit K (10 mg/day orally) starting at 36 weeks
CSlide 101
Breast Feeding and Epilepsy
Breastfeeding should be encouraged unless clear risk posed
Probably safe:
• Carbamazepine
• Phenytoin
• Valproate
• Lamotrigine
“Use with caution” in lactating women:
• Primidone
• Phenobarbital
• Ethosuximide
Pennell et al. Epilepsy and Behavior. 2007. 11: 263-9

Newport et al. Pediatrics 2008. 122(1). E223-31
CSlide 102
Driving and Epilepsy
 Regulation varies state by state regarding:

• Reporting requirements
• Required seizure-free period
• Favorable/unfavorable modifiers
 Insurance issues
 Employment issues
Resource: www.efa.org
CSlide 103
First Aid
Tonic-Clonic Seizure
 After seizure ends, turn person on side

with face turned toward ground to keep
airway clear, protect from nearby hazards
 Transfer to hospital needed for:
• Multiple seizures or status epilepticus
• Person is pregnant, injured, diabetic
• New onset seizures
 DO NOT put any object in mouth or
restrain
CSlide 104
Neonatal Seizures
 Incidence: 1.6 – 3.5 per 1000 live births
 Major risk factors are prematurity, low-birth

weight, hypoxic-ischemic encephalopathy
 Associated with increased morbidity and mortality
 May be symptomatic of treatable, serious

condition (hypoglycemia, meningitis)
 Diagnosis: observation with vs. without EEG

References: Ronen, J Pediatr, 1999; Lanska, Neurology, 1995;
Saliba, Am J Epidemiol, 1999.
CSlide 105
Recognition of Neonatal Seizures
 Observation of abnormal, repetitive attacks of
movements, postures or behaviors
 Classification
• subtle
• tonic
• clonic
• myoclonic
• autonomic
 Evaluation for cause(s) of seizures
 Confirmation/support by EEG
CSlide 106
Examples of Acquired Conditions
That May Provoke Neonatal Seizures
 Hypoxia-ischemia
 Physical trauma
 Toxic-metabolic
 Inborn errors of metabolism
 Systemic or CNS infections
 Intracranial hemorrhage
CSlide 107
Acute Treatment of
Neonatal Seizures
 Phenobarbital
loading dose: 20 mg/kg
 Fosphenytoin
loading dose: 20 mg/kg PE@ 1
 Diazepam
first dose about 0.25 mg/kg
 Lorazepam
first dose about 0.05 to 0.1 mg/kg
CSlide 108
Selected Pediatric
Epilepsy Syndromes
 Epileptic Encephalopathies
• West Syndrome — infantile onset, hypsarrhythmic EEG;
infantile spasms; cryptogenic vs. symptomatic
• Lennox-Gastaut Syndrome — childhood onset, slow
spike-wave EEG, tonic, atypical absence, atonic and
other seizure types, and mental retardation
• Myoclonic epilepsies of infancy and early childhood —
heterogeneous
CSlide 109
Selected Pediatric Epilepsy
Syndromes (cont.)
Febrile convulsions — 6 mo.-5 yrs.
• Simple: Duration less than 15 minutes, generalized, and
do not recur within 24 hours
• Complex: Duration longer than 15 minutes, focal in
nature or recur within 24 hours
Febrile convulsions: Risk Factors for development of epilepsy:

• Complex febrile seizures
• Neurodevelopmental abnormalities
• Afebrile seizures in first-degree relatives
• Recurrent febrile seizures
• Febrile seizures following brief and low grade fever
• Febrile seizure onset in first year
CSlide 110
Syndromes (cont.)
 Benign epilepsy with centrotemporal

spikes — nocturnal oropharyngeal simple
partial seizures, with or without secondary
generalization
 Childhood epilepsy with occipital

paroxysms — visual or autonomic
phenomena, especially ictal vomiting, at
times with secondary generalization
CSlide 111
Syndromes (cont.)
 Idiopathic generalized epilepsies
• Childhood absence epilepsy —

absence, occasionally with tonic-clonic
seizures
• Juvenile myoclonic epilepsy —

myoclonic, tonic-clonic, at times absence
CSlide 112
AEDs in Pediatrics
 Extrapolation of efficacy data from adult studies
 Importance of adverse effects relative to efficacy
 Susceptibility to specific adverse effects
(valproate hepatotoxicity, lamotrigine rash)
 Age-related pharmacokinetic factors
 Neonate: low protein binding, low metabolic rate,
possible decreased absorption if given with
milk/formula
 Children: faster metabolism
CSlide 113
Managing Pediatric Epilepsy
 Consider chewable/liquid formulations
 Weight-based dosing with frequent adjustments
to account for growth
 Minimize missed school
 Develop safety plan with family
 For intractable epilepsy consider
 Ketogenic diet
 Surgery
 Vagal nerve stimulation
CSlide 114
Appendix: References for Nurses
Reprinted with permission from the American Association of Neuroscience Nurses
CSlide 115
Journals
 Clinical Nursing Practice in Epilepsy
 Epilepsia (the Journal of the International League Against
Epilepsy).
 Epilepsy Currents (Bimonthly Journal for American Epilepsy
Society. Also on www.aesnet.org)
 Epilepsy USA Magazine, published by the Epilepsy Foundation.
Also available on www.epilepsyfoundation.org.
 The Journal of Neuroscience Nursing (the Journal of the American
Association of Neuroscience Nurses). There is a yearly index in
the December issue by author and by topic (epilepsy) for easy
reference.
 Seizure
CSlide 116
Books
 A Guide to Understanding and Living with Epilepsy, Devinsky, O, F.A.
Davis Company, 1994.
 Anticonvulsant Prescribing Guide, PDR second edition, 1998, Ortho-
McNeil.
 Clinical Epilepsy, Duncan, J.S., Shorvon, S.D., Fish, D.R., Churchill
Livingstone, 1995.
 Core Curriculum for Neuroscience Nursing, third ed., American
Association of Neuroscience Nursing.
 Epilepsy A to Z: A Glossary of Epilepsy Terminology, Kaplan PW,
Loiseau P, Fischer RS, Jallon P, Demos Vermande, 1995.
 Epilepsy in Clinical Practice: A Case Study Approach, Wilner, A., Demos,
2000.
 Managing Seizure Disorders: A Handbook for Health Care Professionals,
Santilli, N., Lippincott-Raven, 1996.
CSlide 117
Books, Cont.
• Seizures and Epilepsy in Childhood A guide for parents, third edition,
Freeman JM, Vining EPG, Pillas DJ, Johns Hopkins Press, 2002.
• The Ketogenic Diet: A Treatment for Children and Others with Epilepsy,
Freeman JM, Kossoff EH, Kelly MT, Freeman JB. Demos, 2006.
• Childhood Seizures, Shinnar, S., Amir N, Branski D, Karger, 1995.
• Students with Seizures A manual for school nurses, Santilli N, Dodson
WE, Walton AV. Health Scan Publications, 1991. (*there is a section in
this book that lists references for specific groups.)
• Treatment of Epilepsy: Principles and Practice, Wyllie E, Gupta A,
Lachhwani DK. 2005
Videos
 The Epilepsy Foundation Catalog contains many videos that can be used
for education for nurses, families and schools. The “First Aid” video is a
good one. (800) EFA-1000 or www.epilepsyfoundation.org. (Spanish
videos also available)
CSlide 118
Networking
 American Association of Neuroscience Nurses (AANN), 4700 W. Lake
Avenue, Glenview, IL 60025-1485, (847) 375-4733, http://www.aann.org.
The professional organization for nurses specializing in the neurosciences.
 American Epilepsy Society, 342 North Main Street, West Hartford, CT
06117-2507, (860) 586-7505, www.aesnet.org. A membership society of
professionals interested in epilepsy. Within the society are special interest
groups including a nurses group. Contact the Society for more
information.
 Association of Child Neurology Nurses (ACNN), 1000 West County Road
East, Suite 290, St. Paul, MN, 55126, (651) 486-9447. A membership
organization of nurses interested in child neurology.
 Epilepsy Foundation, eCommunities. Chat rooms for four different groups:
Women and Epilepsy; Parents Helping Parents; The Teen Chat Room;
and Living Well with Seizures. Located at www.epilepsyfoundation.org
CSlide 119
Web Sites
 American Association of Neuroscience Nurses http://www.aann.org
 American Child Neurology Nurses http://www.acnn.org
 American Epilepsy Society http://www.aesnet.org
 Epilepsy Foundation (National Office) http://www.epilepsyfoundation.org
or
http://www.efa.org/education.firstaid.html
 Epilepsy Therapy Development Project/Epilepsy.com
http://www.epilepsy.com
 First Aid for Epilepsy http://www.epinet.org.an/info/general.asp
 Nursing Care Implications
http://www.nurseweek.com/ce/191-sb1.html
 Nursing CEUs for Neurological Nursing http://www.nursecen.com/nur.htm
 Nursing Case Studies http:www.webclinics.org
(log in as AED and use password NURSE)
CSlide 120
Appendix:
References for Neurologists
Epidemiology and Classification

 Herman ST. Classification of Epileptic Seizures.
Continuum Neurol. 2007; 13(4): 13-47.
 Engel J et al. A Proposed Diagnostic Scheme for
People with Epileptic Seizures and with Epilepsy:
Report of the ILAE Task Force on Classification
and Terminology. Epilepsia 2001; 42(6): 796-803.
CSlide 121
Appendix:
Epidemiology and Management

 French, JA and Pedley, TA. Management of Epilepsy. N Engl J
Med 2008 359: 166-176
 Krumholz A, Wiebe S, Gronseth G, et al. Evaluating an apparent
unprovoked first seizure in adults (an evidence-based review):
report of the Quality Standards Subcommittee of the American
Academy of Neurology and the American Epilepsy Society.
Neurology 2007;69:1996-2007
 Blum, DE et al. Patient awareness of seizures. Neurology. 1996
Jul;47(1):260-4
 Arif, H and Hirsch, L. Treatment of status epilepticus. Semin
Neurol. 2008 Jul;28(3):342-54.
CSlide 122
Appendix:
Antiepileptic Drugs
 Azar NJ and BW Abou-Khalil. Considerations in the Choice of an
Antiepileptic Drug in the Treatment of Epilepsy. Seminars in Neurology.
28(3): 305-316.
 French JA, Kanner AM, Bautista J et al., Efficacy and tolerability of the
new antiepileptic drugs I: treatment of new onset epilepsy: report of the
Therapeutics and Technology Assessment Subcommittee and Quality
Standards Subcommittee of the American Academy of Neurology and the
American Epilepsy Society, Neurology 62 (2004), pp. 1252–1260.
 French JA. Treatment with Antiepileptic Drugs, New and Old. Continuum
Neuol 2007; 13(4): 71-90
 Glauser T, Ben-Menachem, Bourgeois B et al. ILAE treatment guidelines:
evidence-based analysis of antiepileptic drug efficacy and effectiveness as
initial monotherapy for epileptic seizures and syndromes. Epilepsia 2006;
47(7): 1094-1120.
 Patsalos PN, Berry DJ, Bourgeois BFD et al. Antiepileptic drugs—best
practice guidelines for therapeutic drug monitoring: A position paper by the
subcommission on therapeutic drug monitoring, ILAE Commission on
Therapeutic Strategies. Epilepsia. 49(7): 1239-1276
CSlide 123
Appendix:
Intractable Epilepsy and Epilepsy Surgery

 Kwan P and MJ Brodie. Early Identification of Intractable
Epilepsy. N Engl J Med. 2000 Feb 3;342(5):314-9.
 Wiebe S et al. A randomized, controlled trial of surgery for
temporal-lobe epilepsy, N Engl J Med 345 (2001), 311–318
 Engel J et al. Practice parameter: temporal lobe and
localized neocortical resections for epilepsy: report of the
Quality Standards Subcommittee of the American Academy
of Neurology, in association with the American Epilepsy
Society and the American Association of Neurological
Surgeons, Neurology 60 (2003), 538–547.
 Spencer SS and L Huh, The evaluation of surgical outcome
in epilepsy, Lancet Neurol 7 (2008), 525–537.
CSlide 124
ILAE Summary Guidelines
Seizure type or Class I Class II Class III Level of efficacy and effectiveness evidence
epilepsy syndrome Studies Studies Studies (in alphabetic order)
Adults with partial-onset 2 1 30 Level A: CBZ, PHT
seizures Level B: VPA
Level C: GBP, LTG, OXC, PB, TPM, VGB
Children with partial-onset 1 0 17 Level A: OXC

Seizures Level B: None
Level C: CBZ, PB, PHT, TPM, VPA
Elderly adults with partial- 1 1 2 Level A: GBP, LTG

onset seizures Level B: None
Level C: CBZ
Adults with generalized 0 0 23 Level A: None

onset tonic–clonic seizures Level B: None
Level C: CBZ, LTG, OXC, PB, PHT, TPM, VPA
Children with generalized 0 0 14 Level A: None

onset tonic–clonic seizures Level B: None
Level C: CBZ, PB, PHT, TPM, VPA
Children with absence 0 0 6 Level A: None

Seizures Level B: None
Level C: ESM, LTG, VPA
BECTS 0 0 2 Level A: None

Level B: None
Level C: CBZ, VPA
JME 0 0 0 Levels A, B, C: None
Reference: Epilepsia 2006:47; 10941120.
CSlide 125
AAN’s Recommendation Levels
Level A Established as useful/predictive or not useful/predictive for the given condition in
= the specified population.
Level B Probably useful/predictive or not useful/predictive for the given condition in the
= specified population.
Level C Possibly useful/predictive or not useful/predictive for the given condition in the
= specified population.
Level U Data inadequate or conflicting. Given current knowledge, test, predictor is

= unproven.
References:
Neurology 2004, 62:12521260.
Neurology 2004, 62:12611273.
CSlide 126
Summary of AAN evidence-based guidelines
level A or B recommendations
Newly Diagnosed
Monotherapy Newly Diagnosed
AED
Absence
Partial/mixed
Gabapentin Yes* No
Lamotrigine Yes* Yes*
Topiramate Yes No
Tiagabine No No
*Not FDA approved for this indication
Reference: Neurology 2004, 62:12521260.
CSlide 127
Summary of AAN evidence-based
guidelines level A or B recommendations
Newly Diagnosed
Monotherapy Newly Diagnosed
AED
Absence
Partial/mixed
Oxcarbazepine Yes No
Levetiracetam No No
No
Zonisamide No
*Not FDA approved for this indication
Reference: Neurology 2004, 62:12521260.
CSlide 128
guidelines level A or B recommendation
Partial
Partial Primary Symptomatic Pediatric
AED adjunctive
Monotherapy generalized generalized partial
adult
Gabapentin Yes No No No Yes
Yes*(only
Lamotrigine
Yes Yes absence) Yes Yes
Levetiracetam Yes No No No No
* Not FDA approved for this indication
References:
Neurology 2004, 62:12521260. | Neurology 2004, 62:12611273.
CSlide 129
guidelines level A or B recommendation
Partial
Partial Primary Symptomatic Pediatric
AED adjunctive
Monotherapy generalized generalized partial
adult
Oxcarbazepine Yes Yes No No Yes
Tiagabine Yes No No No No
Topiramate Yes Yes* Yes Yes Yes
Zonisamide Yes No No No No
* Not FDA approved for this indication

References:
Neurology 2004, 62:12521260. | Neurology 2004, 62:12611273.
CSlide 130
Summary of ILAE guidelines on
therapeutic drug levels
CSlide 131

Epilepsy Guideline in Adults

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Epilepsy Guideline in Adults

Uploaded by

Copyright:

Available Formats

Clinical Epilepsy

American Epilepsy Society

 Seizure: the clinical manifestation of

 Epilepsy: two or more recurrent

Simple Partial Absence

Complex Partial Myoclonic

or special sensory symptoms

With motor signs

 Duration typically < 2 Complex Partial

 Typical duration 1-3

 Often in children with global cognitive impairment

 Consciousness usually impaired

Idiopathic Symptomatic Idiopathic Symptomatic

 Infancy and childhood

 Childhood and adolescence

 Adolescence and young adult

• Drug intoxication and withdrawal*

*causes of acute symptomatic seizures, not epilepsy

Metabolic and Electrolyte Imbalance

Stimulants/Other Pro-convulsant Intoxication

Valproate Partial onset seizures

Monotherapy for Generalized-Onset

Also shown to be effective:

May be considered as second-line:

 Reduces adverse effects

 Conversion to monotherapy from

 Other drugs may alter metabolism or protein binding of

Lamotrigine levels decreased by hormonal contraception

 Average rate of AED-related rash for a given

 Predictors significant in multivariate analysis:

Stevens-Johnson Syndrome (SJS) and

Drugs rarely associated with rash

This allele is almost exclusively found in Asians

59/60 Asian patients w/ SJS/TEN had this allele vs 4% of cbz

Data analysis is controversial and overall difference is very small

Further investigation is needed

Clinicians should be aware of potential risk and screen for

 Discuss likelihood of success

 Discuss recording/reporting seizures,

 Avoidance of alcohol, stimulants, etc.

 Avoidance of known precipitants

 Stress reduction — specific techniques

 Modified Atkins diet

 Low-glycemic index treatment

 Epilepsy syndrome amenable to surgical

Improved 21% 30%

Not improved 14% 21%

Reference: Engel, J. et al. Neurology 2003

Multiple Subpial Transections

• Two or more sequential seizures without full

One commonly used treatment algorithm is:

10-60 minutes: one (or more) of the following 4 options:

• CIV midazolam: Load: 0.2 mg/kg; repeat 0.2-0.4 mg/kg boluses

Begin EEG monitoring ASAP if patient does not

 Characteristic warning, usually gradual (except

Sweating & nausea Common Rare

Hirsch et al, Merritt’s Textbook of Neurology, 2007

Pallor Common Rare

Cyanosis Rare Common

Loss of consciousness <20 secs >60 secs

Hirsch et al, Merritt’s Textbook of Neurology, 2007

Tongue biting, lateral Rare Occasional

Frothing/hyper­salivation Rare Common

Frothing/hypersalivation Rare Common