Comprehensive Guide to Epilepsy: Diagnosis, Classification, and Treatment Recommendations

1. LAFAYETTE HOME HOSPITAL: EPILEPSY; 2004

2. Most important question: is ictus a seizure • CONCEPTS • Most unidentified spells are not seizures • If a diagnosis of a seizure is not definite, do not treat patient • Seizures most commonly dx. on history • Have family act out seizure • Video picture of event is extension of the history

3. HISTORY • Seizures; small spells, migraines big spells • Moment by moment • Sudden onset • Post ictal episode • Defined episode

4. Generally, episodes associated with event are not seizures • Paroxysmal choreoathetosis • Stretch syncope • Night terrors • Hyperventilation • Breath holding spells

5. Common episodes which are not seizures • Infant jerking during feeding • Nocturnal myoclonic jerks • Migraine headaches • Confusional • Post traumatic\ • Episodic vertigo • Periodic syndromes • Syncope • daydreaming

6. ILAE classification • Brain made up of very different cells “cerebrocyte” • Metabolism of different areas different • Generalized • Some TC seizures • Myoclonic seizures • Akinetic seizures • Absence episodes • Partial • Simple • Complex

7. Seizure syndromes museum

8. Infantile spasms • Many causes • 20% Tuberous sclerosis • If identifiable cause, treatment probably does not change course • West Syndrome • Onset 5-8 months • Whiff of ACTH helpful • Outcome • Pyridoxine

9. Doos syndrome • 2/3 boys • Onset 2-4 yr of age • Absence episodes • Myoclonic , astatic episodes • 50% with life long seizures and mental handicap • Other uncommon types with myoclonic sz

10. Childhood absence epilepsy • Peak onset 5-6 years • 2/3 are girls • ppt by hyperventilation • 90% remission before 12 yr of age • Rarely, uncommon GTCS as adult

11. BCECTS • Commonest pediatric epilepsy syndrome • Onset between 1-14 years • 1.5 male preponderance • Hemifacial sz • Nocturnal • May not need to treat • 2-3% normal children with CT spikes; • <10% with seizures

12. Juvenile Myoclonic epilepsy 90% misdiagnosed • Onset 5-16 yr of age • Irregular shock like myoclonic jerks in AM • Can be myoclonic status • 1/3 with absence attacks • gen t-c seizures • Sleep deprivation, alcohol ppt sz • Occipital Lobe epilepsy

13. Photosensitive epilepsy • Occurs with several seizure syndromes • Seizure occurs during the photic stimulation • Seizure occurs while exposed to flashing light • Pre TV stim • TV worst culprit • Preventing • Polarized sunglasses • Small screenCover one eye • Oblique viewing

14. TESTING: ROUTINE EEG • EEG best done to classify seizure • If partial sz, EEG often normal • Members of family with genetic epilepsy can have abnormal EEG without seizures

15. TESTING: 24 hr EEG • Best if ictus occurs during EEG • Video EEG • Ambulatory EEG

16. TESTING: Imaging Studies • CT scan • Good for trauma • In all other cases, MRI is best • Not a good screening tool • MRI • Developmental abnormalities • Assessment of hippocampus

17. EFFECTIVENESS OF AED • No real change in patients with uncontrolled seizures? • All agents with same effectiveness • Decision to use AED based on classification of seizure and side effects of AED

18. STARTING AED • If one seizure: 30% will have recurrance • If abnormal EEG: 60% will have seizure

19. SEIZURE CONTROL • 60% controlled on first anticonvulsant • 20% controlled on second anticonvulsant • 5% controlled on third anticonvulsant

20. AED and ring structure

21. AED;Monomechanism • Carbamazepine • Oxcarbazine • Zarontin

22. AED affecting thinking • Phenobarbitol • Valproate • Topomax • Keppra

23. AED with particular side effects • Lamotrigine; rash • Keppra; major thinking disorder • Topomax; word finding , acidosis

24. Use of meds • One drug first • Try for monotherapy • If sz correctly dx and 3 meds no help, consider • VNS • Surgery • KGD