Epilepsy

&
Epilepticus Status
Sebastian M.P.S 201706010165
Cindy Maharani 201706010193
 Epilepsy Definition

• Conceptual definition (PERDOSSI

2016) :
• Epilepsy is a disorder of the brain
characterized by an enduring
predisposition to generate epileptic
seizures, and by the neurobiologic,
cognitive, psychological, and social
consequences of this condition. The
definition of epilepsy requires the
occurrence of at least one epileptic
seizure.
 Epilepsy Definition

• Practical definition (ILAE) :

• Epilepsy is a disease of the brain defined by
any of the following conditions :
1. At least two unprovoked (or reflex)
seizures occurring >24 hour apart
2. One unprovoked (or reflex) seizure and a
probability of further seizures similar to
the general recurrence risk (at least 60%)
after two unprovoked seizures, occurring
over the next 10 years
3. Diagnosis of an epilepsy syndrome
 Status Epilepticus

• Epileptic seizure lasting more than five

minutes
• The person remain unconscious
between two or more seizures
 Categories of SE

• Convulsive status epilepticus

presents with a regular pattern of
contraction and extension of the arms
and legs
• Nonconvulsive status epilepticus is a
relatively long duration change in a
person's level of consciousness without
large scale bending and extension of the
limbs due to seizure activity
 Classification of Status
Epilepticus
By Clinical Manifestation :
• Focal
• General
By Duration :
• Early SE (5-30 minutes)
• Established SE (>30 minutes)
• Refractory SE (the seizures persist despite
two or more adequate anticonvulsant is
given)
 Epilepsy in Female

• There are unique interaction between

endocrine hormone and epilepsy.
1. Pubertal Epilepsy
• Some types of seizures happen for the
first time around puberty, while some
types of epilepsy subsides.
• Different seizure types may be
exacerbated by different hormonal
patterns.
2. Menstrual (Catamenial) Epilepsy
• Definition : increased number of
seizures 2 or more times in
perimenstrual phase than ordinary days.
• Therapy : (not specific)
• Add fast acting AED (e.g Clobazam 20-30
mg/day, for 10 days in menstruation period)
• Hormonal therapy : progesterone,
progesterone metabolite, and estrogen
antagonist.
3. Epilepsy in pregnancy
• Increased hormone (progesterone and
estrogen) and altered hormone and AED
metabolism, affecting seizures frequency.
Seizures in pregnancy will resulting
complication (hypoxia, hypertension,
preterm delivery, fetal death, etc)
• Therapy :
• Must consider the teratogenicity of AED
• AED before, during, and after pregnancy
4. Epilepsy and Breastfeeding
• AED can be found in breastmilk, dose
adjustment may be required.
5. Epilepsy and Contraception Use
• Female with epilepsy is advised to use non
hormonal contraception
6. Epilepsy and Menopause
• Increased seizures can be happened in
perimenopause phase, maybe induced by high
estradiol to estrogen ratio.
 Resolved Epilepsy

• Epilepsy considered to be resolved if:

1. Individuals who had an age-dependent
epilepsy syndrome but are now past
the applicable age
2. Seizure-free for the last 10 years
without seizure, the last 5 years
without AED/seizure medicine
 INTERNATIONAL
CLASSIFICATION OF SEIZURES
1981
Partial Seizures (start in one place) Generalized Seizures
Simple (no loss of consciousness of memory)
(apparent start over wide areas of brain)
Sensory Absence (petit mal)
Motor
Tonic-clonic (grand mal)
Sensory-Motor
Atonic (drop seizures)
Psychic (abnormal thoughts or perceptions)
Autonomic (heat, nausea, flushing, etc.) Myoclonic

Complex (consciousness or memory impaired) Other

With or without aura (warning) Unclassifiable seizures
With or without automatisms
Secondarily generalized
Types of Seizure
 Etiology

• Idiopathic : No structural lesion or

neurological deficit.
• Cryptogenic : Considered symptomatic
but the cause still unknown
• Simptomatic : Epileptic seizure caused
by brain lesion
 Anamnesis
• Before seizure : physical and psychological
condition that indicating the seizure.
• During seizure :
• Is there any aura?
• Characteristic of seizure
• Are there more than one seizures?
• Change in seizures pattern
• Activity when seizures occur
• After Seizure : confused, awake, sleep, etc
• Triggering factor : lack of sleep, tired,
psychological stress, alcohol, etc
• Onset, duration, frequency,
consciousness between seizures
• Medical dan family history
 Physical Examination

• Signs of trauma, infection, congenital

abnormality, alcohol/drug abuse,
malignancy
• Diffuse or focal neurological deficits that
linked with the epilepsy.
 Diagnostic Test

• Metabolic screening : serum electrolyte,

blood sugar, BUN, creatinine, liver
function, toxicology.
• Imaging : head CT-Scan or MRI
• Electroencephalogram (EEG) :
• Diagnosing epilepsy
• Evaluating prognosis
• Evaluating teraphy
 Anti Epileptic Drug
Therapy
Tonic
Secondar
Focal y Cloni Absen Myoclo
Seizu Generaliz c ce nic
re ed Seizu Seizur Seizure
Seizure re e

Level of Confidence :
A : effective as monoteraphy, B : possibly effective as
monoterapny, C : maybe effective as monoteraphy, D :
potentially effective as monoteraphy
 Stopping Anti Epileptic
Drug
• Requirement :
• After minimum 3 years seizure-free and
normal EEG
• Approved by the patient or family
• Gradually reducing the dosage, 25% of the
initial dose, every 3-6 months
• If more than 1 AED given, reduce not the
main AED first
 SE non convulsive
Algorithm
• Benzodiazepine IV (e.g diazepam 0,2-0,3
mg/kg or clonazepam 1 mg or
lorazepam 0,07 mg/kg), repeat if
needed.
• If not effective, give fenitoin IV (loading
dose 15-18 mg/kg and maintenance dose
every 12 hour, start 6 hour after loading
dose(<70 kg : 150 mg iv, 70-80 kg : 175
mg iv, >90 kg : 200 mg iv).
Case 1
IDENTITY
 Present Illness (April, 25th 2018)

A 26 y.o male, had simple partial clonic

seizure on his left hand 3 hours before
admission (duration unknown). He was
sleeping when the seizure happened and
he was awake during the seizure. After
seizure, he felt weakness and numb on his
left hand and neck. During seizure his left
hand and fingers move like it’s jerking, his
eyelid and lips was twitching (duration <2
min).
 Present Illness (April, 25th 2018)

•Chief complaint
•Seizures (03.30)
•Additional complaints
•Productive cough
•Dyspnea
•Abdominal pain
•Chest pain
 PAST MEDICAL
HISTORY
•No trauma history
•No allergy history
•No hypertension history
•No diabetic mellitus history
th
•April,
14 Seizures (Atma Jaya Hospital à admitted for
6 days because of seizures)
•HIV on ARV
•Anemia
 •
MEDICATION
ARV
HISTORY
•Toxoplasma therapy

PERSONAL LIFESTYLE
Smoke cigarettes: 12 sticks/day (stop : 1 years
•
before hospital admission)
•Free sex (+) 2012-2014
•Alcohol (+)
•Tattoo (+)
•Narcotics use (-)
 PHYSICAL
EXAMINATION
th
(April, 25 2018)
•General condition : moderately ill
•Consciousness : E4M6V5, compos mentis
•Cooperation : cooperative
•Body type : athletics
•Congenital Disorder : none
Vital sign:
•Blood pressure : 120/70 mmHg / 110/70 mmHg
•Pulse rate : 100 times/ min. (regular, adequate
,full).
•Respiration rate : 20 times/ min.
0 0
•temperature : 37,9 C (Normal = 36,5 C –

37,50C)
Thorax
1. Lung

•Inspection : symmetrical movement

•Palpation : symmetrical tactile fremitus
•Auscultation : vesicular +/+, Wheezing -/-.
2. Jantung
•Inspection : ictus cordis not visible
•Palpation : ictus cordis not palpable

st nd
•Auscultation : regular 1 and 2 heart sound , murmur (-),
gallop (-).
•Left chest pain without spreading
 CRANIAL NERVE
EXAMINATION
N. I (right/left) : normosomia
N. II (right/left) :
Acies visus : OD 20/20 OS20/20
Color blindness : none
Campus visus : normal
Funduscopy : normal
 N.III-IV-VI (kanan/kiri)
N.III-IV-VI (right/left) :
Eyeball position : central, symetrical
•Ptosis : -/-
•Exo/endoftalmus: -/-
•Diplopia : -/-
•Eye movements : normal
Pupil : round, diameter 3mm/3mm, isochoric
Light relfex :
-Direct : +/ +
-Indirect : +/+
-Acomodation: normal
N. V (right/left)
Motor
•Open mouth : normal (symmetric)
•Jaw movement: normal (symmetric)
•Chewing : normal (symmetric)
Sensoric
qOpthalmic : normal
qMaxilar : normal
qMandibula : normal
•Corneal reflex : +/+
•Maseter reflex : negative
N.VII (right/left)
•Facial expression : symmetrical
•Frowning : normal
•Closing eye : normal
•Inflate cheek : normal
•Showing teeth : normal
•Pouting lips : normal
•Taste of 2/3 tongue: normal
N. VIII (right/left)
N. Vestibular
•Nystagmus : -/-
•Vertigo : negative
•Balance : can’t examined
•N. Cochlear
•Tinitus : -/-
•Finger movement: +/+
•Schwabach test: normal
•Rinne test : +/+
•Weber test : no lateralization
N. IX-X (right/left)
•Sound (aphony/dysphony/normal): normal
•Swallow : normal
•Cough : normal
•Pharyngeal reflex: positive
•Archof pharyng
•Rest: symmetric, center uvula
•Phonation : symmetric, center uvula
N. XI (right/left)
•Turning head
(M. Sternokleidomastoideus): normal

•Elevate shoulder (M. Trapezius) : normal

N. XII (right/left)
•Dysarthria : none
•Tongue position
qInside mouth : center
qOut of mouth : center
•Tongue movement
qTo the right : normal
qTo the left : normal
•Fasiculation : negative
•Athrophy : negative
MOTORIC EXAMINATION
•Muscle strength (right/left) :
•No lateralization
Upper arms Hands:
•Ante flexion : 5/2 Flexion : 5/2
•Retro flexion : 5/2 Extension : 5/2
•Abduction : 5/2 Finger
•Adduction : 5/2
Flexion : 5/2
Lower arms Extension : 5/2
•Flexion : 5/2
Abduction: 5/2
•Extention : 5/2
Adduction: 5/2
Lower limbs Foot:
•Ante flexion : 5/4+ Flexion : 5/4+
•Retro flexion : 5/4+ Extension : 5/4+
•Abduction : 5/4+ Finger
•Adduction : 5/4+ Flexion : 5/4+
Lower limbs Extension : 5/4+
•Flexion : 5/4+ Abduction: 5/4+
•Extention : 5/4+ Adduction : 5/4+

•
 Physiologic Reflex Exam
•Biceps : ++/++
•Triceps : ++/++
•Knee : ++/++
•Ankle : ++/++
•Abdomen skin :
•Upper : +/+
•Middle : +/+
•Lower : +/+
•Muscle of abdomen: +/+
 Pathologic Reflex Exam
•Hoffman Trommer : -/-
•Babinski : -/-
•Chaddock : -/-
•Oppenheim : -/-
•Gordon : -/-
•Schaeffer : -/-
•Clonus
•Knee : -/-
•Heel : -/-

Trophic :
•Tonus: normotonus Arms: normotrophy
Arms: Legs: normotrophy
•At rest : normotonus/normotonus
•passive : spastic -/-, rigid -/-
Legs :
•At rest : normotonus/normotonus
•Passive : spastic -/-, rigid -/-
 Coordination and
Static:
cerebellar function
•Sit : normal
•Stand up : need asssistance (weakness after seizure)
•Intention tremor : -/-
•Disdiadokokinesia :-
•Rebound Phenomenon : +/-
Dynamic :
•Finger-finger : can’t examined
•Finger-nose : can’t examined
•Ankle-knee : normal
 Sensibility (Right/left)
Exteroceptive[tactile, temperature,
pain]:
•Arms : normal
•Legs : normal Autonomic system
• Body : normal Micturition : normal
Propioceptive: Defecation : +
•positional : normal Sweat : normal

•vibration : normal
•2 point discrimination : normal
•
Cognitive function
•Afasia motor : negative
•Afasia sensor : negative Regretion sign
•Memory function : normal Glabelar reflex : -
Snout reflex : -
•Apraksia : negative Grasp reflex : -/-
 RESUME (HR HO)
•male, 26 years, last education senior high school,
Moslem, live in jl. Teluk gong Raya, hospitalized 25th
april 2018.
•first, patient admitted complaining weakness in the left
hand after partial simplex seizures at 03.30. after
seizures, patients with fever and pain in the neck.
•After seizures he complained pain in te neck.
•15.00 à seizures (klonik seizures) <5 menit
•patients
have been admitted in rs atma jaya in April
th
16 with seizure, HIV and toxoplasma encephalitis.
 DIAGNOSIS

•Clinical : simple partial clonic seizure (left hand)

•Topic : Right brain cortex
•Etiology : infection
•Pathology : inflammation

Assessment : Simple partial clonic seizure (left hand) ec tuberculoma, post-

ichtal left hemiparesis, HIV on ARV
DIAGNOSTIC TEST
 Head CT-Scan with
th
contrast (April 14 )
•SOL in subcortical gyrus presentralis frontalis (right)
à malformasi vaskular (mass)
•Right mastoiditis
•Otitis media
•Chronic sinusitis right maxillary
• Mild Cerebry atrophy
 Head MRI with contrast
•Lession in right frontoparietal lobe
•Lession in right occipital
•Sinusiti ethmoidalis-maxsilla billateral
•Right mastoiditis
 th
EEG (April 16 )
•Epileptiform wave in left frontal
 RO Toraks
•Kardiomegali (-)
• Innactive Lung TB (+)
 Hematological Lab (April
th
25 )
•Hemoglobin : 8,8 (low)
•Hematokrit : 25 (low)
•Eritrosit : 2.75 (low)
•Trombosit : 90 (Low)
•Neut. Segment : 77 (high)
•Limfosit : 17 (low)
•MCV : 32,0 (high)
 Head MRI with Contrast
th
(April 26 )
•Lession in right frontoparietal lobe, 3,31 x 2,26 x
2,22 cm
•Lession in right occipital lobe, 0.58 cm
•Sinusiti ethmois-maksilla bilateral
•Right mastoiditis
Anti-toxoplasma IgG
(30-4-2018)
Result : -
Nod Date Time Duration

1 25-4-2018 3.30 <2 min simple partial clonic seizure (left hand), pre :
dizzy, post : left hand weakness

2 30-4-2018 17.00 <2 min simple partial clonic seizure (left hand)

3 01-4-2018 05.45 2 min simple partial clonic seizure (left hand)

4 02-4-2018 04.30 4 min simple partial clonic seizure (left hand)

5 02-4-2018 09.00 1 min simple partial clonic seizure (left hand)

6 03-4-2018 21.00 simple partial clonic seizure (left hand)

06.00
09.00

7 04-4-2018 04.30 12 min simple partial clonic seizure (left hand)

09.30
 Therapy

- Phenytoin 2x200 mg PO
- Folate acid 1x5 mg PO
- Diazepam (when seizure) 10 mg IV
- Fixed Dose Combination (for TB,
weight : 41 kg) : intensive phase 3 tabs
4FDC/day (2 months); maintenance
phase 3 tabs 2FDC/day (7 months)
 Case 2 (Status
Epilepticus)
A 57-year-old patient presented to emergency room
with persistent unconsciousness and repeated
convulsive seizures for 10 h. 10 h before
admission, his family noticed that he suddenly fell
into unconsciousness with no warning, followed by
repeated convulsive seizures. The convulsion
presented as gnashing of the teeth, eyes rolling
back, bulking-up of the arms, and extending of
the legs, with frothing at the mouth and
urinary incontinence. The convulsion lasted 35
min at the first time, followed by 2–3 min
similar attacks for more than 20 times. The
patient lost more than 20 kg body weight with
normal food intake within half a year before
He was diagnosed as gastroenteritis and treated with
antibiotic a month ago, but still had diarrhea 3–4 times per
day. 4 days before admission, he suffered from diaphoresis
and irritability, which improved after food intake. His
medical record was otherwise unremarkable.
On examination, he was unconscious and afebrile. The
blood pressure was 190/100 mmHg. Jaundice,
hepatomegaly and splenomegaly were determined by
inspection and palpation. Neurological examination
showed asymmetric pupils (right 5.5 mm, left 4.0 mm),
with poor light reflexes. Babinski sign was positive
bilaterally. His neck was supple and bilateral flexor plantar
responses were normal.
Emergent biochemical assessment revealed a markedly
reduced level of blood glucose (18 mg/dL) and blood urea
nitrogen (1.1 mmol/L), and a mildly reduced level of
potassium (K 3.33 mmol/L). Hypoglycemia was diagnosed
and intravenous glucose infusion was initiated
immediately. Electrolyte disorder was corrected
simultaneously. The blood glucose level returned to
Brain is most susceptible to hypoglycemic
damage. When the concentration of blood
glucose falls below a critical threshold,
hypoglycemic brain damage occurs and the
patients may present with unconsciousness or
epileptic seizures, or even status epilepticus.
Extended status epilepticus may in turn, aggravate
the hypoglycemia. Dealing with adults with a first-
time seizure requires prompt determination of serum
glucose and electrolyte. However, based on the
clinical manifestations, the diagnosis of convulsive
status epilepticus could be established. Convulsive
status epilepticus and unconsciousness induced by
hypoglycemia can be controlled by intravenous
glucose infusion.
Hepatic functions are usually compromised in
patients with late stage hepatic carcinoma, use
of anti-epileptic drugs such as diazepam may
result in severe consequences. In summary, we
described a case presenting to our department
with convulsive status epilepticus as initial
symptoms of hepatic carcinoma, and discussed
the pathology and treatment of convulsive
status epilepticus caused by hepatoma related
hypoglycemia. The blood glucose test should be
given priority in diagnosing unexplained status
epilepticus in the emergency room of neurology
department. Intravenous glucose infusion
rather than anti-epileptic drugs might be
safer and more effective in treating patient
with hypoglycemia induced status