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Epilepsy

Epilepsy. Meiti Frida Department of Neurology Andalas University Padang. DEFINITION.

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Epilepsy

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  1. Epilepsy MeitiFrida Department of Neurology Andalas University Padang

  2. DEFINITION Abnormal and recurrent excessive synchronized discharge of cerebral neuron with clinical manifestation of epileptic seizure which are an intermittent stereotypical behavior, emotion, motor function or sensation

  3. PATHOPHYSIOLOGY • Paroxysmal depolarization shift (PDS) of the resting membrane potential, which triggers a brief rapid burst of action potentials terminated by a sustained after hyperpolarization • PDS : result of imbalance between excitatory (glutamate and aspartate) and inhibitory (GABA) neurotransmitters • Abnormalities of voltage controlled membrane ion channels • Imbalance between endogenous neuromodulators, acetylcholine favoring depolarization and dopamine enhancing neuronal membrane stability

  4. FOCAL EPILEPTOGENESIS • Asynchronous burst firing in some hypocampal and cortical neurons

  5. Generalized epileptogenesis : asynchronous burst firing in abnormal thalamocortical interaction

  6. EPIDEMIOLOGY • Developed countries : annual incidence 50-70 cases per 100.000 • Developing countries : prevalence 1% Incidence varies with age

  7. Incidence of epilepsy in relation to age

  8. ETIOLOGY • Idiopathic • Cryptogenic • Symptomatic

  9. Congenital anomalies Tuberous sclerosis Storage diseases Cerebral tumours Birth trauma Intracranial haemorrhage Genetic epilepsies Intracranial Infections Head Injuries Febrile Seizures Drugs and alcohol Cerebrovascular degenerations Hypoxia Hypoglycaemia Hypocalcaemia 0 1 5 10 20 60 Age (years)

  10. Factors lowering seizure threshold

  11. International Classification of Epileptic Seizures Partial seizures (beginning locally) • Simple partial seizures (without impaired consciousness) • with motor symptoms • with somatosensory or special sensory symptoms • Complex partial seizures (with impaired consciousness) • simple partial onset followed by impaired consciousness • impaired consciousness at onset • Partial seizures evolving into secondary generalized seizures

  12. Generalized seizures (convulsive or non-convulsive) • Absence seizures • Typical • Atypical • Myoclonic seizures • Clonic seizures • Tonic seizures • Tonic clonic seizures • Atonic seizures • Unclassified seizures

  13. Simplified Classification of Epileptic Seizures Partial seizures • Simple – preservation of awarness • Complex – impairment of consciousnesss • Secondary generalized Generalized seizures • Absence • Myoclonic • Tonic-clonic • Tonic • Atonic

  14. Absence Seizure

  15. Atonic Seizure

  16. Focal Seizure

  17. Grandmal Seizure

  18. MioClonic seizure

  19. Tonic Atonic Seizure

  20. International Classification of Epilepsies and Epileptic Syndrome Localization-related (focal, local or partial) epilepsies and syndromes • Idiopathic epilepsy with age-related onset - benign childhood epilepsy with centrotemporal spikes - chilhood epilepsy with occipital paroxysms • Symptomatic epilepsy

  21. Generalized epilepsies and syndromes • Idiopathic epilepsy with age-related onset (listed in order of age at onset) - benign neonatal familial convulsions - benign neonatal non-familial convulsions - benign myoclonic epilepsy in infancy - childhood absence epilepsy (formerly known as pyknolepsy) - juvenile absence epilepsy - juvenile myoclonic epilepsy (formerly known as impulsive petit mal) - epilepsy with generalized tonic-clonic seizures on awaking • Other idiopathic epilepsies

  22. Idiopathic or symptomatic epilepsy (listed in order of age at onset) - West syndrome (infantile spasms) - Lennox-Gastaut syndrome (childhood epileptic encephalopathy) - epilepsy with myoclonic-astatic seizures - epilepsy with myoclonic absence seizures • Symptomatic epilepsy • Non-specific syndromes - early myoclonic encephalopathy - early infantile epileptic encephalopathy • Specific syndromes (epileptic seizures as a complication of a disease, such as phenylketonuria, juvenile Gaucher’s disease or Lundborg’s progressive myoclonic epilepsy)

  23. Epilepsies and syndromes with both generalized and focal seizures • Neonatal seizures • Severe myoclonic epilepsy in infancy • Epilepsy with continuous spike waves during slow-wave sleep • Acquired epileptic aphasia (Landau-Kleffner syndrome)

  24. Epilepsies without unequivocal generalized or focal features Special syndromes • Situation-related seizures - febrile convulsions - seizures related to other identifiable situations, such as stress, hormonal changes, drugs, alcohol withdrawal or sleep deprivation • Isolated, apparently unprovoked epileptic events • Epilepsies characterized by specific modes of seizure precipitation • Chronic progressive epilepsia partialis continua of childhood

  25. Diagnosis • Interviews with patients or witness • Circumstances surrounding the attacks idiopathic and generalized No seizure worning No underlying brain lesions Associated with a family history • Symptomatic and localization related Aura Specific site of onset Identifiable cause • Recurrent episodes of seizures • Symptoms occured during and after seizures • Recording symptomatic events with videocamera and continous ambulatory EEG monitoring

  26. E E G • To confirm the clinical diagnosis • To support the classification of partial or generalized seizures • Routine trace 50% normal • Diagnostic in non convulsion state epileptic activities : Hyperventilation Photic stimulations Sleep deprivation

  27. EEG

  28. BRAIN IMAGING • Essential, particularly in partial onset seizures Computerized tomography (CT) Magnetic resonance imaging (MRI) Structural lesion

  29. MRI

  30. MRI

  31. MRI

  32. Scan Scan should be repeated periodically : • Suspicion of a tumour • Worsening in neurological examination or cognitive function • Deterioration in the frequency or severity of the seizures

  33. Single Photon Emission CT (SPECT)Positron Emission Tomography (PET)MRI spectroscopyFunctional MRI Functional cerebral changes Useful adjuncts in candidate epileptic surgery

  34. DIFFERENTIAL DIAGNOSIS • Migraine • Transient Ischaemic Attacks • Hyperventilation • Tics • Myoclonus • Hemifacial spasm • Syncope • Sleep disorders • Non Epileptic Attacks • Narcolepsy • Metabolic disorders • Transient global amnesia

  35. Management Medical treatment : • Establish a correct diagnosis of epileptic seizure type and epileptic syndrome • Decide treatment with epileptic drugs is necessary • Decide which drug should be used • Patients and their families should receive counselling regarding : Aims of treatment Prognosis and duration of the expected treatment Importance of compliance Side effects

  36. Surgical treatment Proposed Indications for resective epileptic surgery • Intractable seizures • Resectable structural abnormality as identified on magnetic resonance imaging • Confirmation that seizures arise from a visible lesion (using video telemetry) • Over 20% of seizures arising from the contralateral temporal lobe in temporal lobe seizures • Intelligence quotient > 70 points • No significant psychiatry morbidity • No medical contraindications • Age < 45 years

  37. Strategies for managing newly diagnosed epilepsy Newly diagnosed epilepsy 47% First drug Seizure-free 13% Second drug Seizure-free 40% Refractory Surgical assessment Rational duotherapy

  38. Ten commandments in the pharmacological treatment of epilepsy • Choose the correct drug for the seizure type or epilepsy syndrome • Start at low dosage and increase incrementally • Titrate slowly to allow tolerance to central nervous system side-effects • Keep the regiment simple with once- or twice-daily dosing, if possible • Measure drug concentration when seizures are controlled or if control is not readily obtained (if possible)

  39. Counsel the patient early regarding the implications of the diagnosis and the prophylactic nature of drug therapy • Try two reasonable monotherapy options before adding a second drug • When seizures persist, combine the best tolerated first-line drug with one of the newer agents depending on seizure type and mechanism of action • Simplify dose schedules and drug regimens as much as possible in patients receiving polypharmacy • Aim for the best seizure control consistent with the optimal quality of life in patients with refractory epilepsy

  40. Drug choice in newly diagnosed epilepsy in adolescents and adults *Lamotrigine and oxcarbamazepine are regarded as first-line drugs in some countries

  41. Choice of antiepileptic drugs in children

  42. Status Epilepticus • Life threatening medical defined as frequent and / or prolonged epileptic seizure

  43. Some Reasons for Failure of Monotherapy Wrong diagnosis • Syncope, cardiac arrhythmia, etc. • Malingering, pseudoseizures • Underlying neoplasm Wrong drug(s) • Inappropriate for seizure type • Kinetic / dynamic interactions Wrong dose • Too low (ignore target range) • Side effects preventing dose increase Wrong patient • Poor compliance with medication • Inappropriate lifestyle (e.g. alcohol or drug abuse)

  44. When to stop medication • After 2-3 years period of seizure’s free, must be tappering off in six month

  45. Prognosis • Dependent with underlying syndrome and / or its cause • Patient’s compliance • Reciprocal illness or medications • 60-70% controlled by first-line drug of epilepsy • 10% of the rest controlled by new drugs • The rest : surgery Institution

  46. Special Problems of Epilepsy • Behavioral problem : -Label of epilepsy racial disadvantage -Brain function, medication, type of seizure -Attitudes of helpers and helped • Education : -Discussion between doctors, families, schools teachers and the patient, steps which might be taken to promote normal education and personal development

  47. Employment : -Personal and racial states as well as financial reward -Understanding of the employee of their illness in the context of particular employment, safety for their selves and environment -People around in working hours need to know what to do if the attack occurred • The law • Driving lisence • Free of seizure after 6 months controlled epilepsy

  48. No permitting to drive if : • Have suffered of epileptic attack at the age before adolescent • Medical condition caused driving a source of danger to them selves and to the public • Leisure : • Swimming, water sport, cycling, horse riding in groups with safety controlled • Boxing, climbing, sport with body contact are prohibited • Television and video games, avoid flickering of the screen • Marriage and pregnancy • Health education • Impairment, disability and handicap

  49. THANK YOU

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