EPILEPSY & SEIZURE DISORDERS

ETIOLOGY

Adams and Victor’s Principle of Neurology 9th Ed

EPIDEMIOLOGY

Adams and Victor’s Principle of Neurology 9th Ed

PATHOPHYSIOLOGY
OF
EPILEPSY
 CLASSIFICATION
OF
SEIZURES

Adams and Victor’s Principle of Neurology 9th Ed

 GENERALIZED SEIZURES
• Generalized Tonic-Clonic Seizures (Grand Mal)
– Prodrome : apathetic, depressed, irritable,
abdominal pain/cramps, throbbing headache,
constipation, diarrhea, etc
– Flexion of trunk, mouth & eyelids opening,
upward deviation of eye, erms elevated and
abducted, elbows semifelxed, hands pronated
– Tonic phase(10-20s): stiff body, piercing cry, pupils
dilated, unresponsive to light, bladder empty

Adams and Victor’s Principle of Neurology 9th Ed

 GENERALIZED SEIZURES
– Clonic Phase : tremors, violent flexor spasm in
rhytmic salvos agitate the entire body
– Terminal phase : all movements ended, deep
coma, pupils contract to light, breathing quiet or
stertorous.
– Wake up  confused and bewildered, don’t
remember anything, pulsatile headache, sleepy

Adams and Victor’s Principle of Neurology 9th Ed

 GENERALIZED SEIZURES
• Absence, Petit Mal Seizures
– Coming without warning
– Sudden interruption of conciousness
– 10%  motionless. Minor automatism : lip-
smacking, chewing, fumbling movement of fingers
– May continue complex acts (walking, riding bike)
– After 2-10s  reestablish full contact, resume
preseizure activity
– Hyperventilation  provoke seizure

Adams and Victor’s Principle of Neurology 9th Ed

 GENERALIZED SEIZURES
• Absence Variants
– Less complete loss of conciousness, prominent
myoclonus
– Lennox-Gastaut Syndrome : atonic, astatic
seizures, succeded by motor, tonic-clonic, partial
seizure

Adams and Victor’s Principle of Neurology 9th Ed

 GENERALIZED SEIZURES
• Myoclonic Seizures
– Brusque, brief, muscular contraction
– May affect part muscle, or entire muscle
– Benign, respond well to medication
– Dissemniated myoclonus  suspicion of some
other diseases
– Juvenile Myoclonic Epilepsy : most common form
of generalized epilepsy in older children and
young adults

Adams and Victor’s Principle of Neurology 9th Ed

 PARTIAL OR FOCAL SEIZURES
• Simplex Partial Seizures
– Seizures begin in a focal area and do not impair
awareness
• Complex Partial Seizures
– Seizures with focal onset and impair awareness

Adams and Victor’s Principle of Neurology 9th Ed

EPILEPSY SYNDROMES

Blueprints Neurology 3rd Ed

 DIAGNOSIS
• History
– Most important, diagnosis can be made by history
alone
– Patient or witness describes the condition
• Physical Examination
– Rarely benefits in diagnosis
– Used to diagnose meningitis, or other underlying
etiology of seizures

Blueprints Neurology 3rd Ed

 DIAGNOSIS
• Laboratory Test
– Reveal underlying metabolic etiology
– Hyponatremia, hypocalcemia, lactic acidosis
• Radiographic Imaging
– MRI and CT to find structural abnormalities
• Electroencephalography (EEG)

Blueprints Neurology 3rd Ed

 EEG

Blueprints Neurology 3rd Ed

 TREATMENT
• Drugs
• Vagus nerve stimulation
• Surgery
• Ketogenic diet
 Drugs
• The mainstay of epilepsy treatment: medical
therapy ( AEDs).
• AED treatment is usually begun after 2
seizures that are not symptomatic or
provoked.
• Goal: monotherapy – control of seizures using
a single drug.
• Increase the dosage of a single drug until
either sizure control is achieved or adverse
effects become intolerable.
• If the latter occurs, the dose is lowered and a
second drug added if necessary.
• If seizure control is achieved  taper the 1st
drug  leaving the 2nd as monotherapy.
 TREATMENT
• Antiepileptic drugs for adults

Adams and Victor’s Principle of Neurology 9th Ed

 TREATMENT
• Antiepileptic drugs for children

Adams and Victor’s Principle of Neurology 9th Ed

 TREATMENT
• Drugs combination

Adams and Victor’s Principle of Neurology 9th Ed

 Vagus nerve stimulation
• Effective in the treatment of partial seizures.
• The device is implanted subcutaneosuly in the
chest and stimulates the left vagus nerve
through programmed electrical impulses
delivered through leads places in the neck.
 Surgery
• Patients refractory to medical management
may be treated with epilepsy surgery.
• The most common surgical procedure is
resection of the epileptogenic area.
• For seizure of medical temporal lobe origin,
the rate of seizure freedom following resective
surgery may be as high as 90%.
 Ketogenic diet
• The diet is used mainly in children between
the ages of 1 and 10 years.
• The regimen is initiated during hospitalization
by starvation for a day or two in order to
induce ketosis, followed by a diet in which 80
to 90 % of the calories are derived from fat.
– Traditional approach ketosis diet
• Fat : carbohydrate and protein = 4 : 1
– MCT based ketosis diet
 STATUS EPILEPTICUS
• Recurrent generalized convulsions at a
frequency that precludes regaining of
consciousness in the interval between seizures
• Prolonged convulsive status >30 minutes
• Emergencies : Rising temperature, acidosis,
hypotension, renal failure, epileptic
encephalopathy, neurogenic pulmonary
edema  hypertensive encephalopathy

Adams and Victor’s Principle of Neurology 9th Ed

 STATUS EPILEPTICUS
• Etiologies : all fundamentals of seizure
• Mostly associated with viral or paraneopastic
encephalitis, old traumatic injury, epilepsy
with idiopathic mental retardation

Adams and Victor’s Principle of Neurology 9th Ed

APPROACH TO TREATMENT
OF STATUS EPILEPTICUS

Adams and Victor’s Principle of Neurology 9th Ed

APPROACH TO TREATMENT
OF STATUS EPILEPTICUS

Adams and Victor’s Principle of Neurology 9th Ed

 REFERENCES
• Ropper AH, Brown RH. Adams and Victor’s
Principles of Neurology, 9th ed. New York :
McGraw-Hill, 2009
• Drislane FW et al. Neurology Blueprints.
Philadelphia : Lippincot Williams & Wilkins,
2006