Seizure disorders

Introduction
 Epilepsy has been recognized since antiquity.

 Word is drive from Greek word meaning “to seize” or “take hold of” .

 Epilepsy is not a single entity but collection of different and often

distinct disorders that have common occurrence of seizures

 Seizures are often describe as convulsive or non convulsive depending

on the prominence of motor features

 Seizures with an immediate cause are term
symptomatic or provoked
 Seizures without known cause is term idiopathic or
cryptogenic,
 Idiopathic are presumed to be of genetic basis
 Cryptogenic are presumed of symptomatic cause that
can not be diagnosed with currently available medical
technology
Definition

 A seizure is defined as an abnormal paroxysmal

discharge of cerebral neurons sufficient to cause

clinically detectable event that is apparent to the

subject, an observer or both.

Epilepsy
 Epilepsy is defined as the occurrence of two or more
unprovoked seizures.
 Group of disorders characterized by chronic, recurrent,
paroxysmal changes in the neurologic function caused
by abnormality in the electrical activities of the brain .
 Occasional seizures occurring during febrile episodes
or acute illness are not consider as epilepsy.
Epidemiology
 Epilepsy is a relatively a common neurological condition
with higher prevalence in developing countries.
 In most developed countries incidence rate range from
40-70/100,000
 In developing countries the incidence is about 100-
190/100,000
 Prevalence is about 0.5-5% of the population
 The prevalence is slightly higher in males (1-2.4 times) than women

 Higher in older people and in those of lower socio economic group.

 Also rural areas have higher prevalence than urban dwellers

(37/1000 Vs 5/1000)
Etiology

 Vary world wide and with age

 Multifactorial

 Cause is unknown in 2/3 of patients.

 Common causes include
 Cerebrovascular diseases
 Cerebral tumors
 Alcohol -related + illicit drugs
 Post –traumatic
 CNS infections ( e.g in Developing countries)
 Genetic < 1 %
 Developmental disorders
 Degenerative disorders
Pathophysiology
 Complete process of epileptogenesis is not known .
◦ Reciprocal corticothalamic interaction is probably important in generalized

seizures.

◦ Local excitation – inhibition imbalance is the likely basis of partial seizures.

◦ There are disorders of membrane channels in epilepsy.

◦ However complex changes at receptors, membranes, cyto-arthechectural

system levels are probably involved in most cases.

ILAE Classification of epileptic seizures

 Generalized Seizures ( convulsive and nonconvulsive)

a) Absence seizures
i) Typical Absence
ii) Atypical absence
b) Myoclonic seizures
c) Tonic seizures
d) Clonic seizures
e) Toni-clonic seizures
f) Atonic seizures
Cont
 Partial Seizures (focal, local) seizures
a) Simple partial seizures
b) Complex partial seizures
c) With impairment of consciousness
d) Partial seizures evolving to secondary generalized seizure
Unclassified epileptic Seizures
This includes some neonatal seizures eg rhythmic eye movement, chewing,
and swimming movements
Classification of epileptic syndromes

1. Generalized epilepsies and syndromes

a) Idiopathic generalized epilepsies with age related onset
a) Benign neonatal familial convulsions
b) Benign neonatal convulsions
c) Benign myoclonic epilepsy in infancy
d) Childhood absence epilepsy (pyknolepsy, petit mal)
e) Juvenile absence epilepsy
f) Juvenile myoclonic epilepsy
g) Epilepsy with grand mal seizures on awakening
b) Cryptogenic or symptomatic generalized epilepsies
i) West syndrome
ii) Lennox- Gastaut syndrome
iii) Epilepsy with myoclonic-astatic seizures
iv) ) Epilepsy with myoclonic absence seizures

c) Symptomatic generalized epilepsies.

i) Non specific
ii) Specific syndrome
2. Localization related epilepsies

a) Idiopathic with age related onset

i) Benign childhood epilepsy with centrotemporal spike

ii) Childhood epilepsy with occipital paroxysms

b) Localization related epilepsies – symptomatic

 3. Epilepsies and syndrome undetermined as to whether
they are focal or generalized
A) With both generalized and focal seizures
i) Neonatal seizures
ii) Severe myoclonic epilepsy in infancy
iii) Epilepsy with continuous spikes and waves during slow wave sleep
iv) Acquired epilepsy aphasia ( landau- Kleffner syndrome)

B) Without unequivocal generalized or focal seizures

 IV Special syndromes
 A) Situation-related seizures
 i) Febrile convulsion
 ii) Seizures related to other identifiable situation; stress, alcohol, drugs,
hormones, and sleep deprivation
B) Isolated, apparently unprovoked epileptic events
C) Epilepsies characterized by the specific mode of seizure precipitant
D) Chronic progressive epilepsia partialis continua of childhood
Diagnosis
 Diagnosis is clinical; Eye witness account is almost essential.
 History Inquire about

 Circumstances of the episodes

 Pattern of occurrence

 Preceding symptoms

 Timing, pattern and tempo of evolution

 Reported behavior before, during and after the events

Differential diagnosis

 Syncope

 Cardiac disorder

 Metabolic or endocrine

 Psychological or psychiatric
Investigations

 Full Blood Count

 Electrolytes (including Calcium), glucose, liver function tests,

 ECG
 Electroencephalogram

 CT Scan

 MRI .

◦ Reveals causes of epilepsy in 30% of GE and in 70% in LE

 Clinical Features
Generalized tonic -clonic seizure

 May follow partial or start spontaneously.

 Start with cry
 Loss of consciousness
 Falling to the ground
 Cyanosis
 Tonic and clonic phase
 Biting of the tongue
 Incontinence – Urine and stools
 Confusion – headache – desire to sleep and recovery
Partial seizures
◦ Occurs in wide variety of forms
◦ Conscious is not impaired
 Features
 Temporal lobe abnormal taste or smell, rising
epigastric sensation, autonomic changes and psychic
phenomena such as fear, déjà vu, and jamis vu
 Frontal lobe bizarre and brief events eg aversion of
the eyes or head unilateral and bilateral limb
movement or posturing
 Parietal positive sensory or paraesthesia or pain
 Occipital positive colored vision phenomena or loss
of consciousness
Clinical features
 Usually a sudden flexion
movement of the arms .
Epileptic myoclonic jerk
 Is a generalized seizures
 Brief cessation or slowing of
activity
 Typical absences seizure EEG
pattern 3Hz spike and wave
 Atypical absences show slower
or poorly formed spike-wave
EEG.
Absences
Clinical features
Begins focally in the
cortex . It may • Involve much of the cortex
became generalized
involving the whole bilaterally from outset, and
cortex
usually cause loss of

conscious ness.

2. Generalized seizures,
1.Partial seizures
Tonic clonic seizures

 Cardinal feature

 Disordered muscular contraction - first tonic then clonic

phase
Management

 Consider seizure type

 Using combination of clinical history and EEG
 First line drugs
 Carbamazepine
 Sodium Valpraote (Epilium)
 Phenytion
 Lamotrgine
 Vigabatrin
 Gabapentin
 Primidone
 Ethosuximide, Clobazam, clonazepam, nitrazepam, diazepam,
 Corticosteriods (West syndrome)
Status Epilepticus

 Seizures may follow each other without remission.

 If tonic clonic seizures , patient is at risk from death cardiorespiratory

failure.

 Immediate control of the seizures is necessary

 Diazepam 10mg in2ml given over 2 to 5 minutes or lorazepam 4mg iv

 Phenytion 18mg/Kg at a rate of more than 50mg/min

Other treatment

 Ketogenic diet

 Surgery usually for temporal lobe seizures

Prognosis

 The risk of seizure recurrence after the first seizures

ranges from 27-80%
 Excellent prognosis
 20-30% genetic conditions
 Good prognosis
◦ 30-40% seizures easily controlled by AED
 Uncertain prognosis
◦ 10-20% AED is suppressive rather than curative
 Bad prognosis
◦ Medical + surgery reduce seizures partially