Epilepsy

Epilepsy
Seizure

1. Epilepsy By Rima Jani (PT) (M.P.T. Pediatric Science)

2. Definitions Epileptic seizure- a transient occurrence of signs and/or symptoms due to abnormal excessive pattern of excitability and synchrony among neurons in select brain areas. Epilepsy - persistent epileptogenic abnormality of the brain that is able to spontaneously generate paroxysmal activity Recurrent seizures (two or more)which are not provoked by systemic or acute neurologic insults Epilepsy syndrome- complex of signs and symptoms that define a unique epileptic condition

3. Epilepsy is a disease of the brain defined by any of the following conditions 1. A least two unprovoked (or reflex) seizures occurring >24 h apart 2. One unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years 3. Diagnosis of an epilepsy syndrome

4. A seizure is the event Epilepsy is the disease associated with spontaneously recurring seizures Seizure versus Epilepsy

5. Epilepsy Facts 1 in 26 people will develop epilepsy during their lifetime More common then autism, cerebral palsy, MS and Parkinson’s disease combined

6. Risk of Epilepsy Highest at extremes of life ( 1st year of life and in elderly) Risk of having at least 1 seizure in lifetime is 10%, and 1/3 will develop epilepsy

7. Incidence and Prevalence in Pediatric Population 5 per 1000 in school-aged children 1.5 per 1000 in preschool-aged children Affects more then 300,000 children under age 15

8. Cellular Mechanisms of Seizure Generation Excitation (too much) Ionic --- inward Na+, Ca++ currents Neurotransmitter --- Glutamate, Aspartate Inhibition (too little) Ionic --- inward Cl-, outward K+ currents Neurotransmitter --- GABA

9. Seizure Classification International League Against Epilepsy (ILAE) 2010 revised classification Based on known causes of epilepsy: Genetic Structural/metabolic Unknown cause

10. Generalized: Seizures produced by widespread abnormal electrical impulses present throughout the entire brain. Partial (sometimes referred to as focal or localized): Seizures produced by electrical impulses that generate from a relatively small or “localized” part of the brain (referred to as the focus). Seizure types

11. Seizures take on many different forms and have a beginning (prodrome and aura), middle (ictal) and end (post-ictal) stage. Phases of Seizure

12. Generalized tonic- clonic (Grand Mal).  Symptoms:  The patient loses consciousness and usually collapses. The loss of consciousness is followed by generalized body stiffening (called the "tonic" phase of the seizure), then by violent jerking (called the " clonic " phase of the seizure), after which the patient goes into a deep sleep (called the "postictal" or “after-seizure” phase). During grand-mal seizures, injuries and accidents may occur, such as tongue biting and urinary incontinence. Generalized epilepsy classifications

13. Generalized epilepsy classifications Absence.  Symptoms:  Brief loss of consciousness (just a few seconds) with few or no symptoms. The patient typically interrupts an activity and stares blankly. These seizures begin and end abruptly and might occur several times a day. Patients are usually not aware that they are having a seizure, but may have a feeling of "losing time.”

14. Generalized epilepsy classifications Myoclonic.  Symptoms:  Sporadic and brief jerking movements, usually on both sides of the body. Patients sometimes describe the jerks as brief electrical shocks. When violent, these seizures might result in dropping or involuntarily throwing objects.

15. Generalized epilepsy classifications Clonic.  Symptoms:  Repetitive, rhythmic jerking movements that involve both sides of the body at the same time. Tonic.  Symptoms:  Muscle stiffness and rigidity. Atonic.  Symptoms:  Consist of a sudden and general loss of muscle tone, particularly in the arms and legs, which often results in a fall.

16. Partial epilepsy classifications Simple partial (awareness maintained).   Symptoms:  Simple partial seizures are further divided into four groups according to the nature of their symptoms: Motor. Motor symptoms include movements such as jerking, stiffening, muscle rigidity, spasms, and head-turning.

17. Partial epilepsy classifications Simple partial (awareness maintained).   Symptoms:  Simple partial seizures are further divided into four groups according to the nature of their symptoms: 2. Sensory. Sensory symptoms involve unusual sensations affecting any of the five senses (vision, hearing, smell, taste, or touch). The term “aura” is used to describe sensory symptoms that are present only (and not motor symptoms).

18. Partial epilepsy classifications Simple partial (awareness maintained).   Autonomic. Autonomic symptoms most often involve an unusual sensation in the stomach termed “gastric uprising”.

19. Partial epilepsy classifications Simple partial (awareness maintained).   4. Psychological. Psychological symptoms are characterized by various experiences involving memory (the sensation of déjà vu), emotions (such as fear or pleasure), or other complex psychological phenomena.

20. Partial epilepsy classifications Complex partial (awareness impaired).  Symptoms: Includes impairment of awareness. Patients seem to be "out of touch," "out of it," or "staring into space" during these seizures. Symptoms may also involve some complex symptoms called automatisms. Automatisms consist of involuntary but coordinated movements that tend to be purposeless and repetitive. Common automatisms include lip smacking, chewing, fidgeting, and walking around.

21. Partial epilepsy classifications Partial seizure with secondary generalization.  Symptoms:  A partial seizure that evolves into a generalized seizure (typically a generalized tonic- clonic seizure). Approximately 70% of patients with partial seizures can be controlled with medication. Partial seizures that cannot be controlled with medication can often be treated surgically.

22. Diagnosing Epilepsy Detailed history and physical examination EEG, video EEG Imaging ( CT, MRI, PET)

23. History Precipitating factors Aura Area of body first involved Progression of activity Specific activity observed (head or eye deviation, type of movement or posturing) Level of consciousness Incontinence Apnea or cyanosis Duration of seizure Postictal symptoms ( confusion, hemiplegia, aphasia)

24. Seizure Triggers Missed dose of medication Sleep deprivation Illness Stress, anxiety, overstimulation Hormonal changes Alcohol and drugs of abuse Hyperventilation Flashing lights Temperature extremes dehydration

25. Not everything that looks like a seizure is a seizure Migraine headache Syncope Behavioral outbursts Breath holding spells Tics Sleep disorders

26. Epilepsy Resolved Epilepsy is now considered to be resolved* for individuals who had an age-dependent epilepsy syndrome but are now past the applicable age or those who have remained seizure-free for the last 10 years, with no seizure medicines for the last 5 years. Fisher et al, Epilepsia 55 (4): 475-482, 2014 * “Resolved” has the connotation of “no longer present,” but it does not guarantee that epilepsy will never come back

27. Reflex Epilepsies Despite the fact that seizures are “provoked” in reflex epilepsies, these are considered epilepsy, because … If the seizure threshold were not altered, these precipitants would typically not cause seizures e.g., photosensitive epilepsy, eating epilepsy

28. Management Guideline Immediate antiepileptic drug (AED) therapy, as compared with delay of treatment pending a second seizure, is likely to reduce recurrence risk within the first 2 years (Level B) Clinicians’ recommendations whether to initiate immediate AED treatment after a first seizure should be based on individualized assessments that weigh the risk of recurrence against the adverse events of AED therapy. Courtesy of Jacqueline French

29. These are not Epilepsy because there is small risk of a seizure in the absence of a precipitating factor Febrile seizures in children age 0.5 – 6 years old Alcohol-withdrawal seizures Metabolic seizures (sodium, calcium, magnesium, glucose, oxygen) Toxic seizures (drug reactions or withdrawal, renal failure) Convulsive syncope Acute concussive convulsion Seizures within first week after brain trauma, infection or stroke

30. ILAE Definition of Acute Symptomatic Epilepsy Acute symptomatic seizures are events, occurring in close temporal relationship with an acute CNS insult, which may be metabolic, toxic, structural, infectious, or due to inflammation. The interval between the insult and seizure may vary due to the underlying clinical condition. Acute symptomatic seizures have also been called: Reactive seizures Provoked seizures Situation-related seizures Beghi et al. Epilepsia 2010;51:671-675 Courtesy of Dale Hesdorffer

31. Defining time in acute symptomatic seizures Events within 1 week of: Stroke TBI Anoxic encephalopathy Intracranial surgery First identification of subdural hematoma Presence of an active CNS infection During an active phase of multiple sclerosis or other autoimmune disease Beghi et al. Epilepsia 2010;51:671-675 Courtesy of Dale Hesdorffer

32. Status Epilepticus A seizure that lasts longer than 5 minutes, or having more than 1 seizure within a 5 minutes period, without returning to a normal level of consciousness between episodes is called status epilepticus. This is a medical emergency that may lead to permanent brain damage or death. In children, the main cause of status epilepticus is an infection with a fever. Children with severe, refractory seizure disorders can also have status epilepticus. In adults, the common causes are: Stroke.

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