epilepsy and its management

7/29/2019 Epilepsy and Its Management

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Epilepsy The origin of the term:The term epilepsy has come from an ancient Greek word (epilpsa) meaning seizure.


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History A quick overview

400 B.C. - The Greekphysician Hippocrateswrites the first bookon epilepsy. Refutingthe idea that epilepsyis a curse or aprophetic power,Hippocrates provesthe truth: It's a braindisorder. "It is thuswith regard to thedisease called Sacred:it appears to me to benowise more divinenor more sacred thanother diseases, buthas a natural cause

like other affections.


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1904: The term "epileptologist" was first used to describe a person who

specializes in epilepsy. William Spratling, the neurologist who coined theword, is now regarded as North America's first epileptologist.

History A quick overview70 A.D. - In the Gospel Accordingto Mark (9:14-29), Jesus Christcasts out a devil from a youngman with epilepsy.


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Any of various neurological disorders characterized by:

sudden recurring attacks of motor or sensory nervous system

psychic malfunction with or without loss of consciousness

convulsive seizures.

What Constitutes Epilepsy?


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Structural causes of epilepsy Trauma, which may not be recalledby the patient

Degenerative disease, particularlysenile dementia of the Alzheimerstype

Infectious causes, such asmeningitis or encephalitis.

Primary brain tumor or metastasis.

Etiology Excessive firing of neurons

in CNS

Decrease in level of GABA


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CausestiologyNon Structural causes of epilepsy

Idiopathic

Vascular

Others


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Partial seizure

Simple Partial Complex Partial Partial seizure with

secondary Generilazation

Primarily generalized seizures

Absence/Petit Mal Tonic clonic

Tonic Atonic Myoclonic

Unclassified


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A) Juvenile Myoclonic Epilepsy

B) Lennox-Gastaut Syndrome

C) Mesial temporal lobe epilepsy syndrome


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Incidence and prevalence

INDIA - Based on the total projected population of India in the year 2001,the estimated number of people with epilepsy would be 5.5 million. Basedon a single study on the incidence of epilepsy, the number of new cases of

epilepsy each year would be close to half a million. Because ruralpopulation constitutes 74% of the Indian population, the number of peoplewith epilepsy in rural areas will be approximately 4.1 million, three fourthsof whom will not be getting any specific treatment as per the presentstandard.


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Incidence and prevalence

5% of the population suffer asingle sz at some time

0.5-1% of the population haverecurrent seizure = EPILEPSY

70% = well controlled with drugs(prolonged remissions); 30%

epilepsy at least partially resistantto drug treatments =INTRACTABLE EPILEPSY.


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Challenges

Social Stigma Religious Belief Non-compliance


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Approach

Old /New case

Age ofonset

Family History

Other Relevant Data


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Syncope

Psychological Disorders

Metabolic Disorders

Migraine

TIA

Narcolepsy

TICS

Differential Diagnosis


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Diagnostic Aids The concern of the clinician is that epilepsy may be symptomatic of a

treatable cerebral lesion.

Routine investigation: Haematology, biochemistry (electrolytes, urea andcalcium), chest X-ray, electroencephalogram (EEG).

Neuroimaging (CT/MRI) should be performed in all persons aged 25 ormore presenting with first seizure and in those pts. with focal epilepsyirrespective of age.

Specialised neurophysiological investigations: Sleep deprived EEG,video-EEG monitoring.

Advanced investigations: Neuropsychology, Semiinvasive or invasive EEGrecordings, MR Spectroscopy, Positron emission tomography (PET) andictal Single photon emission computed tomography (SPECT)


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Non pharmacological Measureso Reassurance

o Prevention/Damage Control

o Early identification and treatment


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Pharmacological Measures The majority of pts respond to drug therapy (anticonvulsants). In

intractable cases surgery may be necessary. The treatment target isseizure-freedom and improvement in quality of life.

Basic rules for drug treatment: Drug treatment should be simple,preferably using one anticonvulsant (immunotherapy). Start low,increase slow. Polytherapy is to be avoided especially as druginteractions occur between major anticonvulsants.

The commonest drugs used in clinical practice are: Carbamazepine,

Sodium valproate, Phenytoin (first line drugs) Lamotrigine,Topiramate, Levetiracetam, Pregabaline (new AEDs).


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Pharmacological Measures (Contd.) If pt is seizure-free for three years, withdrawal of pharmacotherapy

should be considered. Withdrawal should be carried out only if pt issatisfied that a further attack would not ruin employment etc. (e.g.

driving license). It should be performed very carefully and slowly!20% of pts will suffer a further seizure within 2 yrs.

The risk of teratogenicity is well known (~5%), especially withvalproates, but withdrawing drug therapy in pregnancy is more riskythan continuation. Epileptic females must be aware of this problemand thorough family planning should be recommended. Over 90% ofpregnant women with epilepsy will deliver a normal child.


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Surgical Correction

Curative Palliative Anteromesial temporal

resection

Selectiveamygdalohippocampectomy

Extensive lesionectomyCortical resectionHemispherectomy

Corpus callosotomy andVagal nerve stimulation(VNS).


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A condition when consciousness does not return between seizures

for more than 30 min. This state may be life-threatening with the

development of pyrexia, deepening coma and circullatory collapse.

Death occurs in 5-10%.

Status epilepticus may occur with frontal lobe lesions (incl. strokes),

following head injury, on reducing drug therapy, with alcohol

withdrawal, drug intoxication, metabolic disturbances or pregnancy.

Treatment: AEDs intravenously ASAP, general anesthesia with

propofol or thipentone should be commenced on failure of AEDs.


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Purple Day is an international grassrootseffort dedicated to increasing awarenessabout epilepsy worldwide. On March

26th annually, people in countries

around the world are invited to wear

purple and host events in support of

epilepsy awareness. In 2012, people in

dozens of countries on all continents

INCLUDING Antarctica will be

participating in Purple Day!


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A history of the medical understanding of epilepsy: brain.oxfordjournals.org

A Greater Role for Surgical Treatment of Epilepsy:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC321163 Jerome Engel, Jr.,M.D., Ph.D.

Challenges in the Management of Epilepsy:www.medscape.com/viewarticle/705599 Kurupath Radhakrishnan

Prevalence and pattern of epilepsy in India: Sridharan R.

Principle of internal medicine: Harrison et al. 15thed.


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