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Epilepsy

Epilepsy. Dr. Shreedhar Paudel May, 2009. Epilepsy…. Recurrent, paroxysmal, involuntary clinical events associated with abnormal electrical activity from the neurons Abnormal motor, sensory and psychomotor phenomenon. Epilepsy…. Causes of Epilepsy in Childhood

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Epilepsy

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  1. Epilepsy Dr. ShreedharPaudel May, 2009

  2. Epilepsy… • Recurrent, paroxysmal, involuntary clinical events associated with abnormal electrical activity from the neurons • Abnormal motor, sensory and psychomotor phenomenon

  3. Epilepsy… • Causes of Epilepsy in Childhood • The etiologies vary in an age-dependent fashion • Neonates, infants, and toddlers → • perinatal brain injury • congenital central nervous system malformations • metabolic derangements Poor myelination and incomplete dendritic arborization in neonates lead to clinical seizure characteristics different from that of older children

  4. Epilepsy… • Causes of Epilepsy in Childhood • Central nervous system infection, genetic epilepsies, and neurodegenerative disorders are more likely to present with seizures beginning in later childhood • These causes stand in contrast to the adult population, where traumatic brain injury, cerebrovascular disease, and neoplasms represent the most frequent causes of seizures

  5. Epilepsy… • Types:- • Generalised • Tonic- clonic (grand mal) • Tonic • Clonic • Absence (petit- mal) • Atonic • Epileptic myoclonus • Localised • Simple • complex

  6. Epilepsy…. • TONIC – CLONIC SEIZURES • Phases: • 1. Aura • 2.Tonic • 3. Clonic • 4. Postictal phase

  7. Epilepsy… • ABSENCE SEIZURES • Age 6-8 yrs • Absence moments • < 30 seconds • Inattentive pupils • Hyperventillation – precipitates • Pyknolepsy • EEG: 3 Hz spike and slow wave pattern

  8. Epilepsy… • MYOCLONIC SEIZURES West syndrome- triad of - Infantile spasm -Mental retardation -Hypsarrhythmic EEG ( diffuse high voltage slow spike and chaotic activity) • Infants – 3-8 months • Poor prognosis

  9. Epilepsy… • Management:- Under supervision of a physician for prolonged period extending over 1 to 4 years • Medical aspects • Emotional and psychosocial aspects (as chronic illness) • Identification of etiology • Side-effects of drugs

  10. Epilepsy…

  11. Epilepsy…. • Surgical treatment:- • Severely disabled cases • Resistant to medical treatment • Focal resection of parts of cerebral cortex (involved as epileptogenic foci)

  12. Epilepsy • Prognosis:- • 10- 15% recurrence even after adequate course of anticonvulsants • Recurrence less if child is seizure free within 2 yrs of start of treatment • Relapse low in • Generalised tonic- clonic • Absence fits • Juvenile myoclonic • Lifelong treatment

  13. Epilepsy… • Duration of therapy • Continued till 1-2 yrs in absence attacks and • 2 yrs seizure free period in tonic clonic seizures • Drug withdrawal should be attempted slowly over three months

  14. Status epilepticus • Single seizure or multiple episodes of seizures lasting more than 30 minutes without regaining consciousness in between • In around 50% of cases SE is the first episode of seizure

  15. Status epilepticus… • Pathophysiology:- • Failure of mechanism that aborts the seizure • Evaluation in ED:- • Good description of the event, surrounding circumstances, preliminary symptoms, progression of the clinical symptoms, duration of the event and postictal phase

  16. Status epilepticus… • Evaluation in ED:- • Presence of incontinence or tongue biting • hypoglycemia, CNS infections, CNS vascular events, drug toxicity, psychiatric disorders should be ruled out

  17. Status epilepticus… • Investigations:- • Serum glucose • Evaluation for underlying disorder if present • serum anticonvulsant level – patient with known seizure taking medications • CT, EEG

  18. Status epilepticus… • Management goals:- • Ensure adequate systemic and cerebral oxygen delivery • Terminate seizure activity • Prevent seizure recurrence • Diagnose and treat underlying cause if present

  19. Status epilepticus… • Management:- • Secure airway • Maintain oxygenation • Maintain blood pressure • Obtain IV access • Protect the patient from injury • If hypoglycemia suspected 25% dextrose given (2ml/kg) emperically

  20. Status epilepticus… • Management:- • Specific treatment Prehospital management of status epilepticus -A single dose of rectal diazepam by the caretakers -Usual rectal dose is 0.2-1.0mg/kg

  21. Management of SE… • Hospital treatment Diazepam IV or Lorazepam IV ↓ Repeat diazepam if seizure continues after 10 min ↓ IV Phenoitoin ↓ IV Phenobarbotal ↓ IM/PR Paraldehyde ↓ Midazolam infusion

  22. Management of SE.. • The benzodiazepine of choice is lorazepam for initial treatment • due to its long (2–8 hour) duration of action • rapid onset of action • thought to be due to its high affinity for GABA receptors and to its low lipidsolubility which causes it to remain in the vascular compartment. • If lorazepam is not available, then diazepam should be given.[10] • the failure of lorazepam alone is considered to be enough to classify a case of SE as refractory.

  23. Refractory SE • The seizure that lasts for more than 60 min after initiation of treatment • Seizure that continues even after 2 doses of Lorazepam Treatment is intubation and infusion of Midazolam or other forms of anaesthesia

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