Jason R Ruslie 0906644865 Diagnosis of Epilepsy History Taking Upon doing the history taking of the attack in the

patient, it is important to separate the question into three groups which are the pre-ictal, ictal, and post-ictal condition of the patient. Pre-Ictal The condition prior to the attack must be taken either from the patient themselves or from a witness. Some of the things that have to be asked regarding pre-ictal are in which position before the patient gets the attack (sitting down, standing, sleeping, urinating), what activity was the patient doing before the attack, time of the day, an aura or symptoms that the patient had before the attack happened. usually this data is obtained from the last attack witnessed if the patient came after several episodes of seizure Ictal This is the condition in which the attack take place. It is crucial to gather the complete description of the attack and its duration. What should be observed are the pattern and the form of the attack; tonic or clonic movements, vocalization, automatisme, incontinensia, tounge biting, pale, sweaty, muscle weakness, loss of consciousness (when exactly did the patient lose their consciousness) or eyeball deviation. It is beneficial if the attack is recorded in a video, whether at the hospital or at home because sometimes, the witness may miss one or two description because so many things happens in a short period of time. Post-Ictal The condition right after the attack subsides should be gathered as well. Some of the things that should be observed are whether the patient is confused, fully awake and aware, develop a headace, asleep, anxious, or develop a Todd's paresis. . It is also important to see whether the patient develops another attack after the initial attack and the characteristics of the second attack, whether it is similar or different with the initial attack. After taking the history of attack in the patient, the physician must also ask about the medical history of the patient, whether the patient had a history of having a trauma especially to the head prior of the attack, another neurologic diseases, a psychiatric disorder, or another systemic diseases that may induce seizure. Determining the type of seizure is very important since it determines the pharmacological treatment for the patient.

Physical Examination General physical examination is done to see the condition that may induce the seizure such as head trauma, alcoholism, intra venous drug usage, infection, or any other neurologic deficit in the patient. A neurologic examination should be done in the patient. If a neurologic examination is done after several minutes of hours post-ictal, todds hemiparesis may be found and may indicate the focal deficit in the patient. But if the neurologic examination was done several days after the attack, the aim of the examination is to see whether the patient had a permanent nerve dysfunction due to the seizure. Laboratory Examination Hematologic examinations must be done to determine hemoglobin level, leucocytes, hematocrite, trombocyte, electrolite, liver function, etc. A hematologic examination is done on the initial treatment, a few months after the treatment, and done routinely in a yearly basis. It is also recommended to repeat the examination if there are arising clinical symptoms. Not only hematologic examinations, but also, anti-epileptic drug level must also be observed to see the target level after a steady state is achieved, when the seizure attack is controlled, and without any toxicity symptoms. This examination is repeated every year to monitor the patient's compliance. This test is also done when the attack relaps or if there are any toxicity symptoms in the patient, using a drug combination, any special medical condition such as pregnancy or kidney failure. CT-Scan and MRI Imaging modalities, such as CT-scan and MRI provide a useful image of the brain. It may detect a lesion in the brain that may induce the epileptic seizure in the patient, such as neoplasms and may give a good clinical reason on patients with no response toward antiepilepsy drugs.

Management of Epilepsy In managing patient with epilepsy, it is important to diagnosed accurately the type of seizure occurring in the patient as different types of seizure will have different type of pharmacological management. The main aim of therapy in patient with epilepsy is to achieve the optimum quality of life based on their disease progression and commonly their physical and mental disability which might be caused by the problem. It is usually simplified by living life with no seizures and have fewest adverse effects from treatment. To achieve the therapeutic goal, there must be collaboration between pharmacological and non-pharmacological management to prevent or minimalize the number of seizure with none or minimal medication side-effect, in order to reduce the number of morbidity and mortality. Anti-epileptic drug is given if: - The diagnosis of epilepsy is confirmed - Making sure the triggering factor can be avoided (alcohol, stress, sleep deprived) - There were at least 2 attacks in a year - Patient and their family have been educated with the diagnosis, and the treatment

Therapy begins with a monotherapy using a anti-epileptic drug of choice according to the type of seizure and epilepsy syndrome. In giving anti-epileptic drug, it is first initiated with monotherapy and dosage is increased periodically to reach its therapeutic effect. It is need to be noted that sometimes polypharmacy is needed in managing epilepsy. Polypharmacy is given if the medication given fails to suppress the number of seizures less than 2 in a year. If there is a need to change medication, then the second anti-epileptic drug is given first before tapering off the first epileptic drug.

Type of seizures and drug recommended

Seizure type Partial seizures Simple partial

Antiseizure Drugs

Optional drugs

Carbamazepine, phenytoin, valproate

Gabapentin, lamotrigine, levetiracetam, topiramate, zonisamide, oxcarbazepine Gabapentin, lamotrigine, levetiracetam, topiramate, zonisamide, oxcarbazepine Gabapentin, lamotrigine, levetiracetam, topiramate, zonisamide, oxcarbazepine

Complex partial

Carbamazepine, phenytoin, valproate

Partial with secondary generalized tonicclonic seizure

Carbamazepine, phenobarbital, phenytoin, valproate

Generalized seizures Absence seizure Ethosuximide, valproate Valproate Lamotrigine

Myoclonic seizure

Lamotrigine, topiramate Lamotrigine, topiramate

Tonic-clonic seizure

Carbamazepine, phenobarbital, phenytoin, valproate

Anti-epileptic drugs dose

Anti-epileptic drugs Carbamazepine

Loading dose (mg/day) 400-600

Maintanance dose (mg/day) 400-1600

Titration

100/200 mg/day, achieve in 1-4 weeks 100 mg/day, achieve in 3-7 days 500 mg/day, achieve after 7 days 30-50mg/day at night, achieve in 10-15 days if needed 300 mg/day, achieve in 1-3 weeks 500/1000 mg/day, increase after 2 weeks 25 mg/day, increase 2550 mg every 2 weeks 300-900 mg/day, achiee in 5-10 days 25mg/day for 2 weeks, increase by 50 every 2 weeks 100-200 mg/day, achieve in 1-2 weeks

Phenytoin

200-300

200-400

Valproate

500-1000

500-2000

Phenobarbital

50-100

50-200

Oxcarbazepine

600-900

600-3000

Levetiracetam

1000-2000

1000-3000

topiramate

100

100-400

Gabapentine Lamotrigine

900-1800 50-100

900-3600 50-200

zonisamid

100-200

100-400

Reference 1. Panaylotopoulos CP. The Epilepsies Seizure, Syndromes and Mangement Blandom Medical Publishing. UK;2005;1-26 2. Mosne Sl, Pedley TA : Overview Diagnostic Evaluation in Epilepsy, A Comprehensibe Textbook/ editors Jerome Engel JR, Timothy A. Pedley, 2nd edition, Vol 1, Lippincott Williams and Wilkins, 2008, page: 783-4 3. Panayiotopoulos CP. General Aspects on The Diagnosis of Epileptic Seizures and Epileptic Syndromes in Clinical Guide to Epileptic Syndrome and their Treatment. Based

on the New ILAE Diagnostic Cheme. Oxfordshire: Blandon Medical Publishing, 2010 Page: 172-199 4. Brodie MJ, Schacter SC, Kwan P. Fast Facts : Epilepsy 3rd ed. Health Press Limited. UK 2005: 37-94