Kavneel Chand

20130101
Definition
• Epilepsy is the recurrent tendency to spontaneous,
intermittent, abnormal electrical activity in part of
the brain, manifesting as seizures.
• Convulsions are the motor signs of electrical
discharges.
Elements of a seizure
• A prodrome lasting hours or days may rarely
precede the seizure
• An aura is part of the seizure of which the patient is
aware, and may precede its other manifestations.
• Post- ictally there may be headache, confusion,
myalgia, and a sore tongue; or temporary weakness
after a focal seizure in motor cortex or dysphasia
following a focal seizure in the temporal lobe.
Causes
• 2/3 are idiopathic

• Structural :cortical scarring, developmental, space-

occupying lesion, hippocampal sclerosis, vascular
malformations.
• Non epileptic causes of seizures: trauma, stroke,
haemorrhage, increased ICP, alcohol or
benzodiazepine withdrawal, liver disease, infection,
and drugs.
• About 3 out of 10 children with autism spectrum
disorder may also have seizures.
• In people over 65, stroke is the most common cause
of new onset seizures.
RISK FACTORS
• About 1% of the general population develops
epilepsy.
• The risk is higher in people with certain medical
conditions.
• Mental retardation
• Cerebral palsy
• Alzheimer's disease
• Stroke
Seizure development
 Imbalance between excitatory and inhibitory
neuronal activity.
 Causes bursts of high frequency abnormal
discharge.
 Abnormal discharge may remain local (focal
seizure) or spread to adjacent areas
(generalized seizure)
•it is only when attacks are recurrent that a
diagnosis of epilepsy should be made.
•A person is typically diagnosed as having
epilepsy after experiencing two or more
seizures.
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Seizure Classification
• Partial seizures: focal onset, with features referable
to one part of the hemisphere.
• Simple partial: awareness is unimpaired, with focal
motor, sensory autonomic or psychic symptoms.
• Complex partial seizures: awareness is impaired.
Most commonly arise from the temporal lobe. Post
ictal confusion is common.
• Partial seizure with secondary generalization:
Electrical disturbance starting focally, then
spreading widely, causing a secondary generalized
seizure.
Primary generalised seizures
• Absences: Brief (<10s) pauses, eg suddenly stops
talking in midsentence, then carries on where left
off. Presents in childhood.
• Tonic-clonic. Sudden onset, loss of consciousness,
limbs stiffen (tonic) then jerk (clonic); may have one
without the other. Presence of post-ictal confusion
and drowsiness.
• Myoclonic seizures: sudden jerk of a limb, face or
trunk (eg thrown suddenly to ground, or a violently
disobedient limb.
• Atonic or Akinetic seizures: sudden loss of muscle
tone causing a fall, no LOC.
• Infantile spasms: commonly associated with
tuberous sclerosis.
Localising features of partial(focal)
seizures
• Temporal lobe
automatisms: complex motor phenomenon, but
with impaired awareness afterwards varying from
primitive oral or manual to complex actions.
Abdominal rising sensation or pain
Dysphasia
Memory phenomena( déjà vu and jamais vu)
Hippocampal involvement may cause emotional
disturbance
Uncal involvement may cause hallucinations
Delusional behaviour.
• Frontal lobe
• Motor features such as posturing , versive
movements of the head and eyes, or peddling
movements of the legs.
• Jacksonian march
• Motor rest
• Subtle behavioural disturbances
• Dysphasia or speech arrest
• Posy-ictal todds palsy
• Parietal lobe
• Sensory disturbances- tingling, numbness, pain
• Motor symptoms
• Occipital lobe
• Visual phenomena such as spots, lines or flashes.
DIAGNOSIS

Three key questions:

1. Are these real seizures?

2.What type of seizures is it, partial or

generalised?
3.Are there trigger factors? E.g.
alcohol, stress, etc.
Tests and examinations
• Neurological examination
• Blood tests
• Electroencephalogram (EEG).
• Computerized tomography (CT) scan
• Magnetic resonance imaging (MRI)
• Functional MRI (fMRI)
• Positron emission tomography (PET)
• Neuropsychological tests
Management
• Generalised tonic-clonic seizures: sodium valproate
or lamotrigine- 1st line then carbamazepine or
topiramate.
• Absence seizures: sodium valproate, lamotrigine,
ethosuximide.
• Tonic atonic and myoclinic seizures: same for
generalised but avoid carbamazepine.
• Partial seizure +/- secondary generalisation:
carbamazepine- 1st line then sodium valproate,
lamotrigine and others.
Drugs and dosages
• Carbamazepine:
• Start with 100mg/12h PO; maximum dose: 800-
1000mg/12h. A slow-release form is available,
which is useful if intermittent side-effects
experienced when dose peaks. Toxic effects: rash,
nausea, diplopia, dizziness, fluid retention,
hyponatraemia, blood dyscrasias.
Sodium valproate
• initially 300mg/ 12h, increase by 100mg/12hr every 3
days up to max 30mg/kg( 2.5) daily.
• Valproate side effects
• Vomiting
• Alopecia, increase in appetite.
• Liver toxicity
• Pancreatitis/ Pancytopenia
• Retention of fats (weight gain)
• Oedema (peripheral oedema)
• Anorexia, ataxia
• Tremor, teratogenicity, thrombocytopenia
• Enzyme inhibition, encephalopathy( due to
hyperammonaemia)
Phenytoin
• Used in status eplileticus
• Dose of 10-15 mg/kg
• Maintenance 100mg IV q6-8hr PRN.
• When administering IV administer it slowly; not to
exceed 50mg/min.
• Anti-convulsant
• 100mg PO TID
• Maintenance 300-400mg/day increase to 600
mg/day if necessary.
• Toxicity : nystagmus, diplopia, tremor, dysarthria,
ataxia
• Side effects: decrease intellectual, depression, coarse
facial features, acne, gum hypertrophy,
polyneuropathy, blood dyscrasias.
Diazepam
• Seizure disorder
• 2-10mg PO q6hr as adjunct, or
• 0.2mg/kg PR, repeat after 4-12 hrs PRN.
• Status epilepticus
• 5-10 mg IV/IM Q5-10 mins; not to exceed 3omg or
• 0.5 mg /kg PR (using parenteral solution), then 0.25
mg/kg in 10 mins PRN.
Others
• Ethosuximide
• Magnesium sulphate
• Midazolam
• Phenobarbitone
• Primidone
• Lamotrigine
• Levetiracetam
• vigabatrin
Women with epilepsy
• Teratogenicity of AEDs : women of child- bearing
age should take folic acid 5mg/day. Valproate in
particular should be avoided.
• Pre- conception counselling is vital
• Breastfeeding: most AEDs except carbamazepine
and valproate are present in breastmilk.
• The pill: non enzyme inducing AEDs have no effect
on the pill. With other AEDs ≥ 50 ūg of estrogen
may be needed.