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7/29/2019 Epilepsy 2nd Bsc
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EPILEPSY
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Dr Md MahbubulAlam
AssistantProfessor
Department of Neuro-Medicine
Dinajpur Medical College, Dinajpur.
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Epilepsy is one of the commonest neurological disorder
50 million people have epilepsy at any time
5% people in the world may have at least 1 seizure in theirlife time
Of 50 million 80% are in under developed countries
It has profound social physical physiological and economicconsequence.
WHO05
Neuro Asia04
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Seizure
An abnormal clinical event cause by sudden,
abnormal, excessive, disorderly electrical
discharge from cerebral neurons.
Epilepsy-
Unprovoked recurrent seizure. i.e. seizure
occurring more than once in adult & twice in
children.
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WHO definition of epilepsy
WHO dictionary defines epilepsy as chronic brain disorder of variousaetiologies characterized by recurrent unprovoked seizure due toabnormal excessive discharge of cerebral neurons, associate with avariety of clinical and laboratory manifestation.
Recurrent
Stereotyped awareness to surrounding may be impaired/ behavioraltered
Motor, sensory, autonomic, psychic
Sudden onset, ceased spontaneously Post- ictal phase
Bradley05
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Epidemiology - Epilepsy
Magnitude of problem- Epilepsy / Seizure 3rd most common chronic neurological disorder after
headache
Epidemiological picture is difficult to obtain because Episodic nature
Diagnosis essentially clinical
Relaying on patients account / Eye witness description
Verities of other condition can be confused
Between seizure, both clinical examination and investigationmay be perfectly normal
Ref- Neuro Asia 04.
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INCIDENCE IT IS HIGHER IN UNDERDEVELOPED
COUNTRIES
INCEDENCE RATE IS HIGH DURING FIRST YEAR
OF LIFE, DECLINE THROUGH CHILDHOOD AND
ADOLESCENCE AND RISE SHARPLY AGAIN
AMONG ELDERLY
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ETIOLOGYFIRST 6 MONTHS OF LIFE
SEVER BIRTH INJURY
CONGENITAL DEFECTS
INBORN ERROR OF METABOLISM
BETWEEN 2 AND 20YRS
BIRTH INJURYINFECTIONS
TRAUMA AND GENETIC FACTORS
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CONTD..
BETWEEN 20 TO 30YRS
STRUCTURAL LESIONS SUCH AS TRAUMA,
BRAIN TUMORS OR VESCULAR DISEASE
AFTER 50YRS
CEREBROVASCULAR LESIONS
METASTATIC BRAIN TUMORS
IDIOPATHIC
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PHASES PRODROMAL PHASE
AURAL PHASE
ICTAL PHASE
POST ICTAL PHASE
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Scenario of epilepsy-Developed/underdeveloped Face to Face
5-10% of population:- At least one seizure during their life time 4-10-/10,000active epilepsy
Race:- Black > White, Rural > Urban Age Extremes of life
Sex : Male >Female (2-2.4 times)
Possible explanation of disparity Profound contrast in Socio-economic structure
Poor pre/ peri-natal care, Birth injury
Malnutrition, Poor sanitation
Increased CNS infection, parasitic disease
Trauma, drug/substance abuse, violence
Prostitution, HIV infection
Treatment influence by combination of local, social perception, govt. policies and AEDavailability.
Bradiey05
WHO05
Developed Countries Under developed countries
Incidence/ 1000000/ year
40-70
UK-50
USA-2 million
100-190
Latin America
144-190
India, liberia, Nigeria 10/1000
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Scenario of epilepsy in-INDIA
Prevalence: 10 / 1,000
Number of patients 1.3 million
Treatment modality Homeopath, Kobiraz, Ojah, Snake Charmer, Spiritual
Leaders --- 70%
Medical access Very poor
High dropout.
Ref- Neuro, sc,04(4)
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SEIZURE TYPES
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CLINICAL MANIFESTATIONS GENERALIZED SEIZURES
TONIC CLONIC
LOSS OF CONSCIOUNESS
FALLING TO THE GROUND
STIFFENING OF THE BODY FOR 10-20SEC
SUBSEQUENT JERKING OF THE EXTREMITIES
CYNOSIS
EXESSIVE SALIVATION
TONGUE BITE OR CHEEK BITE
INCONTINENCE MAY ACCOMPANY THE SEIZURE
3/22/2013
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CONTD..
TYPICAL ABSENCE SEIZURESBRIEF STARING SPELL
BRIEF LOSS OF CONSCIOUSNESS
ATYPICAL ABSENCE SEIZURES
STARING SPELL ACCOMPANIED BY OTHER SIGNS
AND SYMPTOMS.
3/22/2013 ARUN PIRAVOM
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CONTD..
MYOCLONIC SEIZURESCHHRACTERIZED BY A SUDDEN, EXESSIVE
JERK OF THE BODY OR EXTREMITIES.
TONIC SEIZURES
SUDDEN ONSET OF MAINTAINED
INCREASED TONE IN THE EXTENSORMUSLES,PATIENTS OFTEN FALL.
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CONTD..
ATONIC SEIZURES
IT INVOLVE EITHER A TONIC EPISODES OR A
PAROXYSMAL LOSS OF MUSCLE TONE AND
BEGIN SUDDENLY WITH PERSON FALLING TO
THE GROUND
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CONTD..
CLONIC SEIZURES
BEGINS WITH LOSS OF CONSCIOUSNESS
SUDDEN LOSS OF MUSCLE TONE, FOLLOWED BYLIMB JERKING THAT MAY OR MAY NOT BE
SYMMETRIC
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CONTD..
PARTIAL SEIZURES
EX: IF THE DISCHRGING FOCUS IS LOCATED IN
MEDIAL ASPECT OF THE POST CENTRAL GYRUS,
PATIENT MAY EXPERIENCE PARASTHESIAS AND
TINGLING OR NUMBNESS IN THE LEG ON THE SIDE
OPPOSITE THE FOCUS.
3/22/2013 ARUN PIRAVOM
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Etiology
Seizures in general can be caused by any disorder that altersthe neuronal environment, so anyone can theoreticallyexperience a seizure
Onset of a seizure may indicate a previously existing, ongoingprimary neurological disease
Etiologic factors in seizures generally include
Cerebral lesions
Biochemical disorders
Cerebral trauma
Epilepsy In short, anything from illness to brain
damage to abnormal brain development
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Etiology, cont
Epilepsy can result from numerous conditions depending on the age
of the person experiencing the syndrome, including but not limited : metabolic defects
congenital malformations
genetic predisposition perinatal injury
postnatal trauma
mycological syndromes
Infection brain tumor
vascular disease
fever
drug or alcohol abuse
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Patho-physiology
Up regulation of excitatory system or
Down regulation of inhibitory system
Imbalance between excitatory system and
inhibitory system facilitates cellular influx ofNa+, K+ & Ca2+ and causes repetitive firing of
neuron & produce seizure.
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inhibitory neurons
stimulatory neurons
SYNAPTIC ARRANGEMENT
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inhibitory neurons less active
Stimulatory neurons overactive
EXCESSIVE ACTIVITY
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Aetiology
Gray matter lesions are mere likely to causeseizure/ epilepsy than pure white matter lesion
Etiology is often multiple combination of acquiredand genetic factors
Etiology is very much age related 60 to 70% of all
epilepsies are cryptogenic
Ref- Bradley 05
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Aetiology Contd
VascularCVDlate onset epilepsy
Infectionsviral, bacterial, protozoal, fungal
Traumatic acute, late post traumatic (PTE)
AutoimmuneSLE
MetabolicHypoxia, Hyponatrima, Hypoglycemia
(Drugs)Quinolones
NeoplasticPrimary/ Secondary
Degenerative MLD
DemylenatingM.S
DevelopmentalCortical dysphasia, congenital deformity.
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myoclonic seizures
atonic seizures
generalized tonic-clonic seizurescomplex partial seizures
clonic seizurestonic seizures
partial progressing to generalized seizures
absence seizuressimple partial seizures
Generalized EpilepsyPartial (Focal) Epilepsy
ILAE CLASSIFICATION
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MANIFESTATIONS
C A M P S
A
autonomic system disturbed
C
Consciousness altered
M
motor manifestations
Ssensory manifestations
P
psychic manifestations
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PARTIAL EPILEPSY
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S - tingling, numbness, electric shock-like
feeling, burning, pain, heat, altered smell,
taste
last for few seconds
A - changes in skin color, BP, HR, pupil size,
pilo-erection
P - dysphasic, dysamnesic, cognitive,
affective, illusions, hallucinations
M - muscle spasms (march) or jerking
C - no loss of consciousness
MAIN FEATURES
SIMPLE PARTIAL SEIZURES
xx
x
Frontal lobeParietal lobe
Occipital lobe
Temporal lobe
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GENERALIZED EPILEPSY
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GENERALIZED EPILEPSY
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further progression to generalized
seizures
begins like partial seizures
MAIN FEATURES
SECONDARY GENERALIZED SEIZURES
M li d f il
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Malignant syndromes of epilepsy
Strong evidence of cognitiveimpairment, learning disorderand progressive in course.
Combination of multiple seizuretype
Poor out come
Very difficult to control by AEDs
They includes Infantile spasms\ west syndrome
Lennox Gastaut syndrome
Tuberous sclerosis
Sturge- weber syndrome
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DIAGNOSIS
History
EEG
CT scans or MRI to rule out brain
lesion
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History
Birth history
About Febrile seizure
Injury & infection
Drug addiction
Past history
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PHYSICAL EXAMINATIONS
General examinations- pulse, BP, signs of trauma,
tongue bite, neuro-cutaneous manifestations etc
Examination of nervous system
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Investigations
EEGA sensitive tools but must be used with clinical data. Mainly done to find out the clinical type of seizure Single interictal EEG is 30-50% sensitive
3-4 interictal standard recording (>30mins) with provocationis 60-70% sensitiveAdvanced procedure: EEG with special electrodespheroidal
or foramen ovale & telemetric EEG with video monitoring ofpatient 90% sensitive.
So 10% epilepsy is EEG negative
23% normal person may have abnormal EEG.
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Indications of brain imaging in epilepsy
Late in onset after 20 years of age
Partial 20 generalized in type
Refractory to drug Rx. Or deteriorates
Focal neuro-deficit
Status Epilepticus
Suspected ICSOL
EEG shows a focal seizure source
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Treatment
Principles of treatment
Diagnosis of epilepsy including types of seizure
To find out possible aetiology.
Indication of treatment. Selection of drug. It depends on-
Types of epilepsy
Price of drug
Toxicity of drug
Drug interaction
Drug availability
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Immediate care of seizures
Must be given to every epileptic patientsirrespective of country or place First aid by relatives & witness Dos
Loosen tight clothes, if any (Knot of tie, buttons etc)
Move sharp objects away from the person. Move the person away from danger. (fire, water, machinery, furniture, road
etc).
After convulsion stopsturn into semiprone position.
Ensure airway is clear.
Note the duration of attack.
If seizure continues >5mins or recur or the person is injured take medicalhelp.
Person may be drowsy and confused for 3060mins. So, should not be leftalone until fully recovered.
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Tx
A. Medications used to treat patients with epilepsy arecalled anticonvulsants.
1. These drugs each have a differentmechanism of action, but all serve toreduce the frequency of epilepticseizures.
2. Monotherapy, treatment with a singleagent, is the goal.
3. Many seizures will stop withoutpharmacological intervention.
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Treatment
Donts Dont panic, most seizures are self-limiting and not life threatening.
Dont restrict the persons movements.
Dont allow crowd near the person.
Dont forcfully insert anything in the persons mouth.
Dont offer anything to eat or drink till the person is fully conscious.
Immediate Medical care
Ensure air- way is clear
Give O2 to combat cerebral hypoxia.
Give I/V or P/ R diazepam if convulsion continues >10 mins or repeated, and
then send to nearby hospital. Take blood for anticonvulsant levels (if known epileptic and taking antiepileptic
drugs)
Investigate for cause
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Treatment
Anticonvulsant therapy (Medical treatment)-
Indications :-
Single seizure with definite structural lesion.
Single seizure with abnormal EEG.
More than one unprovoked seizure for adult.
More than two unprovoked seizure for children.
One seizure with strong +ve family history of epilepsy
Single seizure with high risk job
Single seizure with mental disorder.
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Treatment
Guide line for AEDs Therapy
Start with 1st line drug( 80% controlled). Try to select appropriate drug with 1/3or th of optimum dose.
Start with low dose, gradually increase to minimum effective dose or till controlof seizures or side effects. If seizure is uncontrolled with highest dose, test for
serum drug level. Use minimum division of doses.
Check compliance
If first drug fails (seizure continues or side effects) start 2 drug from the 1st linewhilst gradually withdrawing the first.
Try three agents singly from 1st line before using combination. Dont use more than two drugs in combination at any one time.
If above fails, consider whether any structural or metabolic lesion present orreview diagnosis.
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About 80% of patients responds to mono-
therapy.
20% need polytherapy.
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Duration of therapy
3 5years after the last attack
Single drug can control 80% of epilepsy
Dose regimens should be kept as simple as
possible to ensure compliance.
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Prognosis
Primary generalized than partial or 20 generalized seizure.
In structural lesion complete control less likely.
out come after 20 yrs.
50-60% seizure free after withdrawal of drugs
20-30% seizure free with drugs
In 20-30 seizures present in spite of AEDs
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Withdrawal of AED therapy
At least 3-5 yrs after the last attack
Then withdraw gradually over 6 months
During and 6 months after withdrawal,
patients should follow the general safetyadvices.
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Rate of recurrence
Recurrence rate 40% within 6 months
9% in the next 6 months
8% in the following 12 months
Chance of recurrenceIn primary generalized seizure less
Dont withdraw
If focal deficit present Seizure focal or 20 generalized
Future attack may ruin is employment (e.g. driver) or endanger life.
If seizure recurs.
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Intractable Epilepsy
About 5% Epilepsy are intractable
At least 5 of the major anti-epileptics have failedin adequate doses
Second level intractability is defined as failure oftwo drugs
Third level intractability is defined as failure ofthree drugs and so on
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Factors underlying
Underlying structural lesion
Mental retardation
Concomitant metabolic disorders
Cerebral Palsy
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Surgical treatment
Indication
Intractable Epilepsy
Intra-cranial structural lesion
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Surgery
Surgical resection ofepileptogenic areas ofthe brain in patientswith partial seizures isconsidered when
seizure activity fails torespond to even themost aggressivemedical management.
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Epilepsy in special Situations
Epilepsy with pregnancy
Epilepsy in child bearing age
Status epilepsy
Epilepsy and driving
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Febrile convulsion
Age 6 months to 5 yrs common between 9-20 months
Recurrent in 50% cases
Seizure usually occurs when fever is raising
Treatment
Reduction of temperature and per-rectal diazepam
Prophylaxis is debatable, but should be given in complex febrile seizureand in EEG change
Out come Complicated (Focal, prolonged or repeated) - 30% in develops epilepsy
in later life
Simple 2.4% develops epilepsy in later life.
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Status epilepticus
Predisposing factors
Sudden withdrawal of AED.
Presence Of Structural Lesion
Acute metabolic disturbances
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TREATMENT
General- ABC Collection of blood sample for glucose, electrolytes
and for future analysis. Infusion of 25% glucose Inj. Thiamin 100 mg if patient is alcholic
Specific-
Diazepam 5mg iv stat, 2 mins after another 5mg
If not control within 15 mins- repeat 10 mg diazepamor Lorazepam and wait 15 mins, if not controlledshiftthe patient in icu
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Contu-- Persisting of seizure after 30 mins-
Loading dose phenytoin or fosphenytoin iv15mg\kg or phenobarbitone 10mg\kg
If seizure is still continues-
Treatment for refractory status withintubation and GA by Propofol or thiopental
Once status controlled Long acting AEDSshould be started.
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Restrictions of epilepsy patients
Work or recreation above ground level
Work with dangerous machinery, fire or water.
Should take shallow bath in presence of relatives No cycling till 6 months seizure free
Swimming, fishing , boating always be
accompanied by others who knows about his orher illness.
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Prevention
There is no way to prevent seizures
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Treatment is not always indicated after a singleseizure.
After a second and third seizure, the risk of
further seizure increases to about 75% andtreatment is indicated.
Seizure control is achieved in most individualwith the single medication.
Principles of poly pharmacy guides the choice ofdrugs with different mechanisms of action.
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Conclusion (contd.)
After discontinuation of therapy, two-third of patients remain seizure-free.
Routine checking of drug levels is seldomindicated, but planned-checking may beneeded.
In refractory cases, surgery may be theoption of management.
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