Epilepsy Overview

Norman Delanty
 Learning objectives:

Classification of seizures

Know the principles of diagnosis and

investigations of epilepsy

Management of epilepsy including lifestyle

and occupation
Why Treat Epilepsy?
Unpleasant

Unpredictable

Embarrassing

Restricting

Dangerous

SUDEP

Epilepsy may be a progressive disorder in many patients

 Definitions
Epilepsy
Seizure
Acute symptomatic seizure
Partial versus generalised epilepsy
Non-epileptic seizure
Status epilepticus
 Psychogenic
- e.g., non-epileptic seizures

Non-epileptic
Medical
- e.g. convulsive syncope

Seizure
- transient subjective or behavioural change

Epileptic
- abnormal hypersynchronous electrical brain activity

Unprovoked Provoked
-Epilepsy if recurrent - Acute symptomatic seizures
-Or if enduring predisposition
Epilepsy Classification
Generalised Partial

Primary (genetic) Genetic

Absence Benign rolandic
JME Benign occipital
Symptomatic Acquired
West syndrome Temporal
LGS Frontal
PME Occipital
Parietal
- Lesional
- Non-lesional
Classification of Seizures
Generalised
GTC convulsion
Absence
Myoclonic
Tonic
Atonic
Partial (focal)
Simple partial
Complex partial
Secondarily generalised
 Absence versus Complex Partial
Seizure

Absence Complex
Partial
Duration < 10 seconds Up to 2-3 mins
Automatisms Simple Complex
Post-event Normal Fatique
EEG Gen S+W Focal sz onset
Imaging Normal Normal / lesion
Treatment VPA/LTG/TPM AEDs/Surgery
 Partial Seizure Patterns
SP
CP
SP --- CP
SP --- CP ---
SecGen
SP --- SecGen
CP --- SecGen
SecGen
 Diagnosis
Epilepsy is primarily a clinical diagnosis
Importance of eye-witness account
Investigations may help to refine diagnosis,
establish aetiology, guide treatment, and
predict prognosis
Review / reconsider diagnosis in those with
uncontrolled seizures
High diagnostic error rate
Evaluation - General
Demographics

Handedness

Early Risks for partial epilepsy

Family history

Other medical problems

What is the psychosocial impact of the epilepsy?

Driving?
Evaluation - Seizures
Age of onset of first unprovoked seizure

Seizure type(s) + aura

Seizure frequency

Seizure precipitants

Nocturnal Vs daytime

Injuries

Any history of status epilepticus

Evaluation - Medication
History
Current medications

All prior AEDs (and reason for discontinuation)

Side effects

Other medications

Folic acid

Compliance issues
Additional Assessment
Multidisciplinary input

Epilepsy clinical nurse specialist

Education

Neuropsychology

Neuropsychiatry

Review imaging - ? need for repeat

 Optimal Use of Investigations
Know limitations and usefulness of various
types of EEG studies
MRI is generally imaging modality of choice
in those with partial (focal) epilepsy or
suspected partial epilepsy
Coronal cuts through temporal lobes
SPGR sequences
Auxillary tests, e.g., ECG, tilt-table testing
 What is Adequate Seizure
Control?
The doctor is not the one with the epilepsy
Patient / family usually the best judge of
adequacy of seizure control
Aim for no seizures and no side effects
Freedom from convulsions and / or drop
attacks may be a worthwhile goal in some
with severe epilepsy syndromes
 Aetiology of the Epilepsies
Unknown
Genetic, e.g. JME, PME - U-L disease
Acquired
Cortical dysplasia
Complicated febrile convulsions
Meningitis / encephalitis
Head trauma
Stroke / vascular anomaly / tumour
 What is Intractable Epilepsy?
Generally taken to mean continued seizures
despite treatment with two or more
appropriate AEDs at tolerated and adequate
doses

~ 10 % chance of seizure remission with

next AED in this situation

Consider epilepsy surgery if partial epilepsy

 Management Options
Lifestyle / education
Attention to other medical conditions
Anti-epileptic drugs
Treatment of co-morbidity, e.g., depression
Epilepsy surgery
Vagal nerve stimulation
Ketogenic diet
 Non-Epileptic Seizures
Common in neurological practice
Often difficult to diagnose - in both
directions!
No single feature is diagnostic
Beware frontal lobe seizures
Video EEG monitoring
A cry for help - needs intervention
 Dose Escalation Schedules

Important for initiation of new drugs and for

drug changeover
Safety issues
Tolerability issues
Half-life of medications
Epilepsy Surgery
For refractory partial epilepsy (most commonly temporal)

Consider early

Evaluation includes:
Video EEG monitoring

Epilepsy protocol MRI

Neuropsychology

Neuropsychiatry

Functional imaging
 Vagal Nerve Stimulation
Hypothesis formulated in the mid-1980s
First human implant in 1988
Two randomised active control studies in
patients with refractory epilepsy in early
1990s. FDA approval in 1997
30-40 % response; increases with time
AED burden may be reduced later
 The Single Seizure
Look for and define cause
Risk of recurrence is up to 50%
Driving issues
Decision to treat is individualised
Is there an underlying lesion on imaging?
Is there an epileptogenic pattern on EEG
What are the potential consequences of a
further seizure?
 Withdrawing Therapy
Individualise / discuss
What is the underlying epilepsy diagnosis?
Are there troublesome side effects of
therapy?
What are the consequences of seizure
recurrence?
Driving issues?
Try early in adolescence