Epilepsy

5.Year

Prof.Dr.S.Naz Yeni

Objectives and method

• To learn general concepts about epilepsy and seizures

• Learn how to diagnose and classify epilepsy• Brief rules regarding laboratory investigations• Brief rules regarding treatment

There will be a presentation of videos of different type of epileptic seizures

Definitions:

• Epileptic seizure is a transitory clinical manifestation as a result of an abnormal excessive hypersynchronous discharges arising from a group of neurons. Manifestations consist of transitory motor sensory pyschic phenomena and/or loss of consiousness.

• Epilepsy: epilepsy is a chronic condition. Seizures are spontaneous and recurrent.

Definitions

• Acute symptomatic seizures: these seizures are provoked as a result of a metabolic/infectious/traumatic events. Acute symptomatic seizures are not as a result of primarily nervous system lesions.

Examples: febrile seizures seizures during acute head injury

Epilepsy clasificationetiology

• Structural/metabolic (formerly symptomatic)

• Genetic (formerly idiopathic)

• Unknown (formerly cryptogenic)

Epidemiology

• Incidence: 20-120/100000 depending on the developing underdeveloped developed countries

• There is a bimodal distribution. The first peak in the first 2 decades and the second peak is after the age 65.

• Prevalence: 6-18/1000

Etiology • ChidhoodPerinatal hypoxiaPerinatal insultsCNS infectionsCongenital malformations• AdulthoodNeoplasmsVascular malformationsHead injury• ElderlyCerebrovascular diseasesHead injuryNeoplasmsDegenerative diseases (Alzheimer disease)

ILAE (International League against Epilepsy)Classifications

• Proposal 1981

• Proposal 1989

• Proposal 2001

• Proposal 2010

ILAE 2010

• Focal

Originating at some point within networks limited to one hemisphere

• Generalised

Originating at some point within and rapidly engaging bilaterally distrubuted networks.

• Unclassified

Focal seizures

• Focal seizure with motor manifestations (with or without

jacksonien march)somatosensory manifestations special sensory manifestations adversive features

dysphasic manifestationspostural manifestationsdyscognitive features hyperkinetic manifestations

Subtypes

• Characterizes accoeding to one or more features

AuraMotorAutonomicAwareness/responsiveness: Altered (dyscogntive) or

retained

May evolve into Bilateral convulsive seizure

Generalised seizures

• Tonic-clonic

• Absence

• Tonic

• Atonic

• Myoclonic

Diagnosis

• Detailed description of seizures from the patient and/or observers

The role of

• EEG

• CT /MR

Differential diagnosis

• Depends on the seizure type

Frequenty misdiagnosed conditions

Seizures

Syncopes

Nonepileptic pyschogenic attacks

Epilepsy Nonepileptic physogenic

Injury Yes No

Sphinctary disturbance

Yes No

Eyes Open Closed

Color Cyanosis Pallor?

Tongue bite Yes Rare (front)

During sleep Yes No

Duration Short Variable

EEG

• Does not diagnose epilepsy• It is helpful in:

diagnosis

classification seizure type

classification electroclinical syndromes

decision of starting and discontinuing treatment

for epilepsy surgery

Radiology

• Emergency room: CT scan (helps to reveal acute lesions such as intracranial hematoma fractures of the skull etc.

Each patient with a diagnosis of epilepsy has a right to have at least one cranial MR scan to understand the underlying etiology.

Treatment

• Rules and steps Start with monotheraphyIncrease the dose in case of recurrence of seizuresIncrease the dose until the patient can not tolerate to side

effects.If there is no response switch the drug (monotherapy)If no response increase the doseIf no response combine two (later three) effective drugs If no response take a look at the diagnosis/classification of

the seizures/syndromeThink about epilepsy surgery

Treatment

• If there is a good response to treatment:

The drug may be withdrawn after a seizure-free period of 2-5 years. In some cases treatment is lifelong.

Patients with a high risk of recurrence:

Mental retardation

Neurologic deficit

Lesions on MR

Difficult to stop the seizures at the beginning

Drugs

Acting on focal seizures

• Carbamazepine• Oxcarbazepine• Diphenyl hidantoin• Phenobarbital

Acting on generalised

seizures• Valproic acide• Lamotrigine• Levetiracetam• Topiramate