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Epilepsy PowerPoint PPT Presentation

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Epilepsy. Prof. Magdy Dahab August 26 th , 2009. What Is Epilepsy?. A syndrome of recurring episodes of electrical activity of the central nervous system called seizures. Seizures may vary from mild and unnoticeable to full-scale convulsive seizures. Some Common Symptoms of Epilepsy.

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Prof. Magdy Dahab

August 26th, 2009

Prof. Magdy Dahab

What Is Epilepsy?

  • A syndrome of recurring episodes of electrical activity of the central nervous system called seizures.

  • Seizures may vary from mild and unnoticeable to full-scale convulsive seizures.

Prof. Magdy Dahab

Some Common Symptoms of Epilepsy

  • Uncontrollable movements of the body

  • Disorientation


  • Sudden fear

  • Loss of consciousness

Prof. Magdy Dahab

What Causes Epilepsy?

  • In over 70% of cases, no cause for epilepsy has been identified.

  • The other 30% can result from many other possibilities.

    • Head injuries

    • Lack of oxygen during birth

    • Genetic conditions

    • Lead poisoning

    • Severe Infections (Meningitis and Encephalitis)

    • Problems during development of the brain

Prof. Magdy Dahab


  • “Provoked”

    • Metabolic disorders

      • Hypoglycemia

      • Electolyte imbalance

    • Withdrawal from massive amounts of alcohol or sedatives

    • Massive sleep deprivation

    • High fever

    • Hypoxia

    • Substance abuse

    • Excessive use of stimulants

Prof. Magdy Dahab


  • “Unprovoked”

    • Birth trauma

    • Anoxia

    • Brain tumors

    • Infectious diseases in the mother

    • Parasitic infections

    • Genetic

    • Vascular diseases affecting the brain’s blood vessels

    • Neurotransmitter GABA (gamma-amino butyric acid) imbalance

Prof. Magdy Dahab


  • 1-2% of people with epilepsy will have a diagnosable genetic etiology for their seizure occurrence

  • The general incidence of epilepsy is between 1% and 4%

  • Two major type so seizures: Generalized and Partial

    • Generalized – uncontolled discharge of neurons on BOTH sides of brain. Seizure starts in one area and spreads across the brain.

    • Partial – abnormal electrical activity involving only a small part of the brain - although sometimes a partial seizure can spread to the whole brain

Prof. Magdy Dahab

Generalized Seizures

  • Tonic-clonic seizures

    • “grand mal” – massive discharge of neurons on both cerebral hemispheres. Body becomes rigid and jerks. “Tonic-clonic” means “stiffness-violent” “grand mal” means “great sickness”

  • Absence seizures

    • Non-convulsive. Person may be unaware of surroundings and stare off. Lasts only 5-30 seconds

  • Atonic seizures

    • Loss of muscle tone – causes person to fall down

  • Myoclonic seizures

    • Involves motor cortex and causes twitching or jerking of certain body parts.

  • Status epilepticus

    • Frequent, long-lasting electrical activity with no regaining of consciousness between attacks. Very dangerous and requires immediate medical attention.

Prof. Magdy Dahab

Partial seizures

  • Simple partial seizures

    • “Jacksonian” or “focal” seizures.

    • Short seizures with no loss of consciousness

    • People may see, hear or smell something odd & their body may jerk.

  • Complex partial seizures

    • “Psychomotor” seizures

    • A seizure with a change, but no loss, in consciousness.

    • People may hear or see things or have a memory resurface. Déjà vu may occur.

Prof. Magdy Dahab


  • Diagnosis requires a thorough evaluation of patients medical history describing seizure characteristics and frequency.

  • People suffering from epilepsy

    -brain waves have a characteristically abnormal rhythm.

  • Another way epilepsy is diagnosed is through an electroencephalograph (EEG).

Prof. Magdy Dahab

Overview of Epileptic Syndromes

Focal Seizures

  • 60% 0f Epilepsy

  • Focal Cortical Disturbance

  • Their origin usually determines the clinical picture

  • Focal Spikes on eeg

Primary Generalised Seizures

  • Origin unclear either sleep spindles or hypersynchrony

  • Commence bilaterally

  • Spike and wave

  • No aura

Prof. Magdy Dahab

Cerebral cortex regions

Functional Areas of the Brain

Prof. Magdy Dahab

Example of Primary Generalised Epilepsy

  • Childhood absence seizure

Complex partial seizures





Examples of Focal Seizures

Focal motor seizure that becomes secondarily generalised.

Likely focus in right frontal lobe

Cellular Electrophysiology

Membrane Potential

The Na+ / K+ Pump


Cellular Electrophysiology

  • Selectively Permeable Membrane - Channels

  • Depolarising Shift

  • Epileptic Focus

Principles of Epidemiology

  • Incidence Rate= new cases per year [n per 100,000 per year]

    • For epilepsy is around 50 per 100,000

  • Point Prevalence = All cases with active epilepsy at a point in time [n per 1000].

    • For epilepsy is 4-6 per 1000

  • Active Epilepsy = to have had a seizure or treatment in the last 5 yrs

  • Prof. Magdy Dahab

    Conditions that may look like a seizure

    • Syncope

    • “Psychogenic” seizures

    • Breath-holding spells

    • Paroxysmal REM sleep behavior

    • Panic attacks

    Prof. Magdy Dahab

    International classification of epilepsies

    • Originally established in 1989 – currently under revision

      • Current system comprises two major categories:

        • Localization-related syndromes

          • Idiopathic

          • Symptomatic

        • Generalized-onset syndromes

          • Idiopathic with age-related onset

          • Idiopathic &/or symptomatic

          • Symptomatic

          • Nonspecific etiology

          • Specific syndromes

    Prof. Magdy Dahab

    Complex partial seizures

    • stare into space/engage in automatisms, such as grimacing, gesturing, chewing, lip smacking

    • last 3 minutes or less

    • post-ictal: somnolence, confusion, headache for up to several hours

    Prof. Magdy Dahab

    Generalized tonic-clonic seizure

    • No aura

    • tonic phase x 10-20 seconds:

    • sudden LOC, loss of posture, arms flex, eyes deviate upward

    • extension of back, neck, arms, legs

    • involuntary crying out

    • ends with tremors which merge c clonic phase

    Prof. Magdy Dahab

    Generalized tonic-clonic seizure

    • Clonic phase x 90 seconds:

    • brief, violent, generalized flexor contractions alternating with progressively longer muscle relaxation

    • cyanosis

    • cheek or tongue biting, salivation

    • loss of bowel, bladder control

    Prof. Magdy Dahab

    Generalized tonic-clonic seizure

    • Post ictal phase x minutes to hours

    • headache

    • mild confusion

    • sore muscles

    • may sleep and feel refreshed

    Prof. Magdy Dahab

    Evaluation of single seizure

    • History of event

    • Medical History

    • Family History

    • Social History

    • Physical Examination

    • Neurological Examination

    • Laboratory Evaluation

      • EEG

      • MRI

      • Routine lab work

    Prof. Magdy Dahab

    Treatment and Prognosis

    • Antiepileptic (anticonvulsant) medications

      • Carbamazepine (Tegretol)

      • Clobazam (Frisium)

      • Clonazepam (Rivotril)

      • Diazepam (Valium)

      • Divalproex sodium (Depakote)

      • Ethosuximide (Zarontin)

      • Phenobarbital (many different names)

      • Phenytoin (Dilantin)

      • Valproic Acid (Depakene)

    Prof. Magdy Dahab

    Special topics in the Management of Epilepsy

    1. Woman and Epilepsy

    Pregnancy and epilepsy.

    • Pre-conceptual Care-

      • ensure pregnancies are planned [high dose oestrogen pills if necessary, 4 packs of COC consecutively with 4 day pill free interval, Depo-provera every 10 weeks not 12.]

      • Discuss modification of AED to reduce number and total dose

      • Advise oral folic acid 5mg daily when intending pregnancy

        Belfast Register ….www.epilepsyandpregnancy.com

    Prof. Magdy Dahab

    Special Topics in the Management of Epilepsy

    Ante-Natal Care

    • Continue 5mg Folic acid until at least 12 weeks

    • Adjust AED if necessary on medical grounds

    • Monitoring of plasma levels is not usually necessary [SIGN guidelines]

    • Offer serum screening at 16weeks and anomaly scan at 18-22 weeks

    • Prescribe oral vit K 20mg a day from 36weeks in on enzyme inducing AED

    • Prolonged seizures can be controlled by IV Diazepam [ rectally is OK if IV access not possible]

      Belfast Register ….www.epilepsyandpregnancy.com

    Prof. Magdy Dahab

    Special Topics in the Management of Epilepsy

    Intra-Partum Care

    • Continue usual AED regime during labour

    • Control seizures with i.v. diazepam

    • Early decision for LSCS if seizures uncontrolled

    • Offer same range of analgesics as available to other mothers

    • Give infant vitamin K 1mg IM at birth

    Prof. Magdy Dahab

    Special Topics in the Management of Epilepsy

    Post Partum Care

    • Encourage breast feeding

    • Offer advice for safe settings for feeding, bathing etc.

    • Review AED and contraceptive regimens

    • Encourage pre-conceptive care for future pregnancies

    Prof. Magdy Dahab

    Special topics in the Management of Epilepsy

    Catamenial seizures- “the clustering of epileptic seizures in relation to the menstrual cycle”

    • Seizure control is worse in anovulatory cycles

    • Oestrogen- inhibits GABA, potentiates glutaminergic transmission, increases neuronal metabolism and discharge rates and promotes kindling.

    • Progesterone- its metabolites are barbiturate like ligands at GABA receptor, reduces neuronal transmission and discharge rate, suppresses kindling and inhibits epileptic discharges

    • Seizures likely when oestrogen/progesterone ratio is highest

    Prof. Magdy Dahab

    Sexual dysfunction in epilepsy

    Hypo sexuality –

    • surveys suggest 22-67% reduction in sexual interest

      Erectile Dysfunction –

    • occurs in 57%[ Toone et al 1989], up to 83% in TLE

      Sexual Functioning in Males [1989]

    • Previous SI 56% [compared to 98% controls]

    • S.I. in the previous month 43% [compared to 91% in controls]

    • Previous erectile dysfunction 57% [compared to 18% controls]

    Prof. Magdy Dahab

    Social Aspects of Epilepsy

    • Occupational – Unemployment, poor job-seeking skills, Non competitive, unskilled manual employment as a result of disadvantaged education, pressure of keeping current job

    • Social – Social isolation as a result of no driving licence, unable to drink alcohol, stigma

    • Tiredness

    • Over protective parents

    Prof. Magdy Dahab


    Disability Discrimination Act 1995 & 1996Disability is defined as; “a physical or mental impairment which has a substantial and long term adverse effect upon one’s ability to carry out normal day to day activities.”

    Substantial is more than minor and long term is longer than 12 months

    Exclusions; Hay fever, tendency to set fires or steal, physical or sexual abuses of others

    Disability Discrimination Help Line Tel: 0345 622644

    Prof. Magdy Dahab


    Collapse at the wheel-

    • CVA 8%

    • Heart 9%

    • Diabetes 17%

    • Blackout 22%

    • Epilepsy 38%

    • Others 7%

      Group1 Driving Licence- Must be 1 yr seizure free with a medical review before restarting or only nocturnal seizures for 3 yrs

      Group 2- Withdrawn for 10 yrs and can be re-issued if 10yrs seizure freedom and has not taken AD during the time or does not have a continuing liability to epileptic seizures

    Prof. Magdy Dahab


    AED Withdrawal

    Risk of developing seizure increases by 40% so advise patients not to drive during withdrawal and for 6 months afterwards


    • If patients continues to drive inform patient not to

    • If continues to drive advise if continues will inform DVLA [copy of warning letter to patient and GP]

    • If still continues advise will inform DVLA and do so [occurs very exceptionally]

    Prof. Magdy Dahab

    Overview of established Anti Epileptic Drugs


    • Partial Epilepsy – Not for Absence or Myoclonic Jerks

    • Start at 100-200mg a day increase slowly

    • S/E- diplopia, nausea, headache, dizziness

    • Idiosyncratic reactions possible [up to 10%]

    • Monitoring needed- increase ‘Chrono’ dose

    • Beware of interactions

    Prof. Magdy Dahab

    Overview of established Anti Epileptic Drugs


    • Used intermittently

    • Extra cover for catamenial seizures, stressfull events , clusters of attacks

    • Dose- 10mg [SLS] once or twice a day for 3 days

    Prof. Magdy Dahab

    Overview of established Anti Epileptic Drugs


    • Limited role due to tolerance, sedation and withdrawal seizures

    • Usually reserved for refractory seizures especially Myoclonic jerks

    Prof. Magdy Dahab

    Overview of established Anti Epileptic Drugs


    • Indication – Absence seizures [hence paediatric field usually]

    • Introduce slowly 500mg daily increasing to 1-2 g a day

    • Side Effects – GI and CNS

    Prof. Magdy Dahab

    Overview of established Anti Epileptic Drugs


    • Add on therapy for partial seizures only

    • Dose starts at 300mg a day and increases to 1800-2400 mg a day with t.d.s dosing

    • No interactions[ not metabolised]

    • Side effects – well tolerated occas. drowsiness, dizziness, diploplia, ataxia and headaches

    • ? Efficacy

    Prof. Magdy Dahab

    Overview of established Anti Epileptic Drugs


    • Broad spectrum and first line [ less teratogenic than VPA]

    • Dosing – slow to minimise side effects usually 25mg a day increasing every 2 weeks, b.d. dosing. Max dose around 400mg a day.

    • Interactions – VPA , CBZ and PHT

    • Idiosyncratic reactions in up to 5%

    Prof. Magdy Dahab

    Overview of established Anti Epileptic Drugs


    • Need a wheelbarrow !

    • Indications – refractory myoclonus

    • Dose – 7.2g in t.d.s. dosage, increasing weekly to 12-24 g/day!!

    • No known interactions

    Prof. Magdy Dahab

    Overview of established Anti Epileptic Drugs


    • Was considered first line for partial seizures

    • Poor side effect profile- rash , liver toxicity. blood dyscrasias, cosmetic changes, neurotoxicity etc

    • Dosing difficulties – saturation kinetics

    • Many interactions

    Prof. Magdy Dahab

    Overview of established Anti Epileptic Drugs

    Phenobarbitone [and Mysoline]

    • World-wide best seller for partial seizures

    • Side –effects largely unacceptable- effects on cognition, mood and behaviour. Also arthritic changes, dupytrons contracture, frozen shoulder

    • Interactions- accelerates metabolism of many lipid soluble drugs

    Prof. Magdy Dahab

    Overview of established Anti Epileptic Drugs

    Sodium Valproate

    • Broad Spectrum and Powerful [ no-longer first line in women]

    • Dose – 300- 500mg a day, usually bd dosage

    • Side effects- tremor, wt. gain, POS, possible hepatotoxicity, blood dyscrasias and pancreatitus

    • Interactions- can inhibit liver enzymes

    Prof. Magdy Dahab

    Overview of established Anti Epileptic Drugs


    • Tertiary Care Initiation

    • Peripheral field loss [permanent in up to 40%]

    • Used for very resistant cases or in infantile spasms

    Prof. Magdy Dahab

    Overview of the Newer Anti Epileptic Drugs


    • Second line – Broad Spectrum [5 mechanisms of action]

    • Dose starts at 25mg a day -2 in 3 tolerate it slowly increased to 200-400mg a day

    • Side effects- Irritability, drowsiness, headaches, dizziness, cognitive slowing, speech impairment, weight loss and paraesthesia.

    • Beware of kidney stones [occurs in 4 %]

    Prof. Magdy Dahab

    Overview of the Newer Anti Epileptic Drugs

    Oxcarbazepine- analogue of CBZ

    • Indications – same as CBZ, may worsen absence and myoclonic epilepsy.

    • Dose – start at 300mg a day and increase to 900 – 2400mg a day as needed

    • Side effects – hyponatraemia, headaches, occas. rashes and teratogenicity

    Prof. Magdy Dahab

    Overview of the Newer Anti Epileptic Drugs

    Levetiracetam – Piracetam derivative

    • Licensed as second line for refractory partial epilepsy but is broad spectrum

    • Dose- start at 125mg [half a tab] a day and build up to max of 3,000mg if needed

    • Side effects – no known idiosyncratic reactions may cause somnolence, irritability [initially]

    • Interactions – Nil definite ?? CBZ and PHT

    Prof. Magdy Dahab

    Status epilepticus


    • Most epileptic seizures stop with minutes

      • Continuous seizures >10 mins

    • Does not recover between recurrent seizure

    Prof. Magdy Dahab


    • Generalized

      • Generalized tonic-clonic, absence, myoclonic ,tonic,atonic,akinetic,clonic

    • Partial onset

      • Simple

      • complex

    Prof. Magdy Dahab


    Prof. Magdy Dahab

    Treatment of protocol

    • 0 min: hx of recent seizures,impaired cons,observe 10 mins,start EEG as soon as possible

    • 5 mins:iv set normal saline or dextrose solution

    • 10 mins:lorazepam 0.1 mg/kg iv push (<2mg/min)

    • Epilepsy problem solving in clinical practice-Dieter Schmidt and Steven C Schachter

    Prof. Magdy Dahab

    Treatment protocol

    • 25 mins : phenytoin 20 mg/kg slow iv push (<50 mg/min) or fosphenytoin iv push fast 150 mg/min,monitor BP,ECG during infusion

    • If continuing: another 5 mg/kg phenytoin,can give twice,to a maximun dose of 30 mg/kg

    Prof. Magdy Dahab

    Treatment of protocol

    • 60 mins:phenobarbital 20 mg/kg iv push

    • Support respiration,on endo

    • Phenobarbital 5~15 mg/kg

    • Phenobarbital 0.5~5 mg/kg/hr for maintain

    • Continuous infusion of propofol or midazolam

    Prof. Magdy Dahab

    Thank You


    Prof. Magdy Dahab

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