EPILEPSY

EPILEPSY
Dr ABDALLA NASSER
 DEFINITIONS
 •seizure: transient neurological dysfunction caused by excessive
activity of cortical neurons, resulting in paroxysmal alteration of
behavior and/or EEG changes
 • epilepsy: chronic condition characterized by two or more
unprovoked seizures
 An epileptic seizure can be defined as: a sudden synchronous
discharge of cerebral neurones causing symptoms or signs that
are apparent either to the patient or an observer.
 Epilepsy is a recurrent tendency to spontaneous, intermittent,
abnormal electrical activity in part of the brain, manifesting as
seizures.
 Using the definition of epilepsy as two or more
unprovoked seizures, the incidence of epilepsy is
∼0.3– 0.5% in different populations throughout the
world, and the prevalence of epilepsy has been
estimated at 5–10 persons per 1000.
 The incidence of epilepsy is age-dependent, being
highest at the extremes of life, most cases starting
before the age of 20 or after the age of 60. The
cumulative incidence (lifetime risk) of epilepsy is
over 3% and the lifetime risk of having a single
seizure is 5%.
 PARTIAL SEIZURES
simple (preserved LOC)
 Š motor: postural, phonotory, forceful turning of eyes and/or
head, focal muscle rigidity/jerking ± Jacksonian march
(spreading to adjacent muscle groups)
 Š sensory: unusual sensations affecting vision, hearing, smell,
taste, or touch
 Š autonomic: epigastric discomfort, pallor, sweating, flushing,
piloerection, pupillary dilatation
 Š psychiatric: symptoms rarely occur without impairment of
consciousness and are more commonly complex partial
 complex (altered LOC)
Š patient may appear to be awake but with
impairment of awareness
 Š classic complex seizure is characterized by
automatisms such as chewing, swallowing,
lipsmacking, scratching, fumbling, running,
disrobing, and other stereotypic movements
 Š other forms: dysphasic, dysmnesic (deja vu),
cognitive (disorientation of time sense),affective
(fear, anger), illusions, structured hallucinations
(music, scenes, taste, smells),epigastric fullness
GENERALIZED SEIZURES
(DECREASED LOC)
 absence (petit mal): usually only seen in
children, unresponsive for 5-10 s with arrest of
activity, staring, blinking or eye-rolling, no
post-ictal confusion; 3 Hz spike and slow
waveactivity on EEG
 ƒ clonic: repetitive rhythmic jerking movements
 ƒ tonic: muscle rigidity in flexion or extension
 ƒ tonic-clonic (grand mal, generalized tonic-clonic [GTC])
 Š prodrome of unease or irritability hours to days before the
episode
 Š tonic ictal phase: muscle rigidity

 Š clonic ictal phase: repetitive violent jerking of face and limbs,

tongue biting, cyanosis, frothing, incontinence
 Š post-ictal phase: flaccid limbs, extensor plantar reflexes,
headache, confusion, aching muscles, sore tongue, amnesia,
elevated serum CK lasting hours
 ƒ myoclonic: sporadic contractions localized to muscle groups of
one
 atonic: loss of muscle tone leading to drop attack
 CAUSES OF EPILEPSY
 Primary generalized epilepsy(idiopathic), e.g. JME
 Developmental, e.g. hamartomas, neuronal migration abnormalities

 Hippocampal sclerosis

 Brain trauma and surgery

 Intracranial mass lesions, e.g. tumour, neurocysticercosis

 Vascular, e.g. cerebral infarction, AVM

 Encephalitis and inflammatory conditions, e.g. herpes simplex, MS

 Metabolic abnormalities, e.g. hyponatraemia, hypocalcaemia

 Neurodegenerative disorders, e.g. Alzheimer’s

 Drugs, e.g. ciclosporin, lidocaine, quinolones, tricyclic

antidepressants, antipsychotics, lithium, stimulant drugs, e.g.
cocaine
 Alcohol withdrawal
 INVESTIGATIONS
 • CBC, electrolytes, fasting blood glucose, Ca2+, Mg2+, ESR, Cr,
liver enzymes, CK, prolactin
 • also consider toxicology screen, EtOH level, AED level (if
applicable)
 • CT/MRI (if new seizure without identified cause or known
seizure history with new neurologic signs/symptoms)
 • LP (if fever or meningismus)

 • EEG
 TREATMENT
 avoid precipitating factors
 indications for medical therapy (anticonvulsants): 2 or
more unprovoked seizures, known organic brain
disease, EEG with epileptiform activity, first episode of
status epilepticus, abnormal neurologic examination or
findings on neuroimaging
 psychosocial issues: stigma of seizures, education of
patient and family, status of driver’s license,pregnancy
issues
 safety issues: driving, operating heavy machinery,
bathing, swimming alone
 consider surgical treatment if focal and refractory
 Generalized seizure ;Phenytoin
/Carbamazepine
/NaValproate/Phenobarbital/Levetiracetam
 Partial complex seizure Carbamazepine
 Absence seizure ;Ethosuxomide
 Myoclonic seizure; Valproate
 Add-on therapy
Gabapentin/Lamotrigine/Topiramate/Levetiracet
am
STATUS EPILEPTICUS
 This means seizures lasting for >30min, or
repeated seizures without intervening
consciousness.or successive seizures without return
to abaseline state
 Mortality and the risk of permanent brain damage
increase with the length of attack.
 complications: anoxia, cerebral ischemia and
cerebral edema, rhabdomyolysis and renal failure,
aspiration pneumonia/pneumonitis, death (20%)
 Treatment

1 Lorazepam: 0.1mg/kg (usually 4mg) as a slow bolus into a large vein. If no response
within 10min give a second dose. Beware respiratory arrest during the lastBpart of the
injection. Have full resuscitation facilities to hand for all IV benzodiazepine use. The
rectal route is an alternative for diazepam if IV access is diffi cult.1 Buccal midazolam
is an easier to use oral alternative; dose for those 10yrs old and older 10mg; if 1–5yrs
5mg, if 5–10yrs 7 . 5mg; squirt half the volume between the lower gum and the
cheek on each side. While waiting for this to work, prepare other drugs. If fi ts
continue …
 2 Phenytoin infusion: 15–20mg/kg IVI (roughly 1g if 60kg, and 1 . 5g if 80kg; max
2g), at a rate of ≤50mg/min (don’t put diazepam in same line: they don’t mix). Beware
BP and do not use if bradycardic or heart block. Requires BP and ECG monitoring.
100mg/6–8h is a maintenance dose (check levels). If fi ts continue …
 3 Diazepam infusion: eg 100mg in 500mL of 5% dextrose; infuse at about 40mL/h

(max 3mg/kg/24h) until seizures respond. Close monitoring, especially respiratory

function, is vital. It is most unusual for seizures to remain unresponsive following
this. If they do, allow the idea to pass through your mind that they could be
pseudoseizures, particularly if there are odd features (pelvic thrusts; resisting
attempts to open lids and your attempts to do passive movements; arms and legs fl
ailing around).
 4 Dexamethasone: 10mg IV if vasculitis/cerebral oedema (tumour) possible.

 5 General anaesthesia: For refractory status: get anaesthetist/ICU involved early.