definition epilepsy: a group of recurrent disorders of cerebral function characterized by both...
TRANSCRIPT
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Definition
• Epilepsy: A group of recurrent disorders of cerebral function characterized by both seizures and convulsions.– Convulsion: Sudden attack of involuntary muscular
contractions and relaxations.– Seizure: Abnormal central nervous system electrical
activity.
• Sezures are generated by abnormal synchronous electrical brain activity
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Etiology
• Idiopathic – genetic conditions• Acquired:
– Trauma– Brain tumors– Stroke – Infections– Degenerative diseases
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Ion channels
• Proteins that are organised into small pores in the
cell membrane
• They allow selective passage of ions (Na, Ca, K,
Cl), with an important contribution in maintaining the
membrane potential and in forming the trans
membranare electric flow.
• Intercelular signals, transmembrane transport, pH
and cell volume
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Calcium channel
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Natrium channel
Na channel
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Potassium channel
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ClassificationPartial (focal)• Simple
– Motor– Sensitive– Vegetative– Psichical
• Complex• Secondary generalized
Generalized• Tonic• Atonic• Clonic• Tonic-clonic• Mioclonic• Absence
unclassifiable
International Classification of Seizures (ILAE, Epilepsia 1981)
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Copyright 2002 The Cleveland Clinic Foundation
Return to Epilepsy Article
Epilepsy Primary Generalized Epilepsy Focal or Partial
Seizure Features
Auras Not present Present
Prodrome Occasionally present Occasionally present
Starting with LOC Present Present
Starting with automatisms Not usually present Present
Prolonged postical confusion without generalization
Not usually present Present
Generalized tonic-clonic seizure Present Present
True versive head movements Not present Present
Focal motor clonic or tonic seizures
Not usually present Present
Risk Factors for Epilepsy
Family history of seizures May be present Not usually present
History of CNS infections, head truama, febrile seizures, CNS tumors, vascular malformation
Not usually present May be present
Examination Findings
Neurologic examination Usually normal May be abnormal
Neuroimaging Findings
Brain MRI Usually normal May be abnormal
EEG Findings
Generalized epileptiform activity Present Not present
Focal epileptiform activity Not present Present
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• Epileptogenesis
• The abnormal discharge originates usually in a definite area
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Investigatii• Electroencefalogrphy – spectral analysis• Cerebral Computed Tomography (CT)• MRI• Functional imagistics techniques:
– PET– fMRI– SPECT
• Magnetoencephalography• video – EEG monitoring
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Scalp EEG Data Acquisition
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10-second EEGs: Seizure EvolutionNormal Pre-Seizure
Seizure Post-Seizure
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EEG - normal
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-
Complexe virf-unda
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fMRI
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PET
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Magneto-encefalography
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TYPES OF SEIZURES
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Generalized Seizures
• Grand Mal• Absence• Tonic seizures• Atonic seizures• Mioclonic seizures
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Generalized Seizures
• Excessive electrical activity in both cerebral hemispheres.
• Usually originates in the thalamus or brainstem.
• Affects the whole body.
• Loss of consciousness is common.
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Generalized Seizures • Myoclonic: Brief shock-like muscle jerks generalized or
restricted to part of one extremity.
• Atonic: Sudden loss of muscle tone.
• Tonic Seizures: sudden stiffening of the body, arms, or legs
• Clonic Seizures: rhythmic jerking movements of the arms and legs without a tonic component
• Tonic-clonic (grand mal): – Tonic phase followed by clonic phase
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Generalized Seizures
• Absence (petit mal): Person appears to “blank out” - “Daydreaming”– Simple Absence (primarily effects consciousness only)– Complex Absence– Atypical Absence (Includes physical symptoms like eye blinking or
lip movements)
• Status Epilepticus: A seizure lasting longer than 30 min, or 3 seizures without a normal period in between– May be fatal
– Emergency intervention required
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Grand Mal epilepsy
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Absences
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Partial (focal) Seizures
• Excessive electrical activity in one cerebral hemisphere. -Affects only part of the body.
• Simple Partial: Person may experience a range of strange or unusual sensations.– Motor– Sensory– Autonomic– Key feature: preservation of consciousness.
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Partial (focal) Seizures
• Complex Partial:
– Loss of awareness at seizure onset. Person seems dazed or confused and exhibits meaningless behaviors.
– Typically originate in frontal or temporal lobes (e.g. Temporal lobe epilepsy)
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Motor partial seizures• Motor (Jacksonian) seizures• Oculo-cefalogiric seizures• Adversive seizures• Supplementary motor area seizures • Tonic seizures
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Sensory partial seizures
• Jacksonian sensory seizures• Visual • Auditive • Vestibulary • Olfactive & gustative• Vegetative
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Partial complex seizures
Association areas are involved:• Partial loss of awareness• Dream state,• Déjà vu,• Jamais vu• Anger, fear, joy crisis
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Partial motor & sensory seizures
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Complex partial seizures
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• Drugs
• Cetogenic diet
• Surgery
• Vagal stimulation
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Treatment principles
• Monotherapy
• Politherapy
• Titration
• Treatment cessation
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Absence seizures
• Etosuximide
• Oxazolidindione
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Drugs that work in seizures other than absence
• Phenobarbital
• Phenitoin
• Carbamazepine
• Primidone
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Drugs efficient in all types of seizures
• Sodium valproate
• Clonazepam
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Status epilepticus
• Prolonged seizure or seizures without remission periods between
• Parenteral treatment:–Clonazepam–Diazepam–Phenitoin
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Antiepileptics: efficacy rangeAntiepileptics: efficacy rangeLarge range
of efficacyNarrow range
* Based on preliminary evidence
• Sodium valproate• Levetiracetam• Phenobarbital• Benzodiazepines• Topiramate• Lamotrigine• Zonisamide*
• Phenytoin• Carbamazepine• Ethosuximide• Gabapentin• Oxcarbazepine• Tiagabine• Pregabalin
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Modern Antiepileptics
• Topiramate• Vigabatrin• Oxcarbazepine• Lamotrigine• Clobazam
• Gabapentin• Pregabalin• Tiagabine• Levetiracetam• Zonisamide
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Adverse efects
• Gingival hyperplasia• Hirsutism/ Transient hair loss • Vitamine/folate deficiency• Polycystic ovary syndrome and menstrual
disturbances • Bone loss
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Surgery
• Resection of epileptic abnormal discharge source
• Lobectomiy
• Hemispherectomy
• Calosotomy
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Vagal stimulation
• Electrodes are attached to the vagus nerve
• Intermittent stimulation
• Indication in treatment resistent epilepsy
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Special issues
• Driving
• Extreme/risky sports
• Special professions
• Pregnancy and breast feeding
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Lord Byron
“People with epilepsy have excelled in every area.”
Kardinal Richelieu
Wladimir Iljitsch Lenin
Margaux Hemingway
Vincent van Gogh
Gustave Flaubert
Jeanne d'Arc
Hermann von Helmholtz
Alfred Nobel
Sokrates
G. Julius Caesar
Napoleon Bonaparte
F.M. Dostojewskij