Epilepsy

2. If you are on right path and you are not If you are on right path and you are not
facing difficulties… then think for a while: facing difficulties… then think for a while:
you may be on wrong path…because right you may be on wrong path…because right
path always contains difficulties.path always contains difficulties.
HAZRAT ALI R.AHAZRAT ALI R.A

3. DR. ARSHAD
RABBANI

4. CASE 1CASE 1
A young girl of age 10 is brough to A young girl of age 10 is brough to
medical OPD with c/o deteriorating medical OPD with c/o deteriorating
performance in her studies. According to performance in her studies. According to
her teacher, she stops doing her work & her teacher, she stops doing her work &
seems to have day-dreaming. This seems to have day-dreaming. This
happens at home too. No h/o loss of happens at home too. No h/o loss of
consciousness or any altered mental consciousness or any altered mental
status.status.
What may be the possible cause?What may be the possible cause?

5. CASE 2CASE 2
A 40 yrs old A 40 yrs old
gentleman is brought gentleman is brought
to ER with h/o to ER with h/o
GTCF.patient is GTCF.patient is
drowsy. there is h/o drowsy. there is h/o
low grade fever, low grade fever,
cough & anorexia for cough & anorexia for
last 1 month. CXR is last 1 month. CXR is
shown. Give your shown. Give your
diagnosis.diagnosis.

6. His CT brain is shownHis CT brain is shown

7. CASE 3CASE 3
 A 35 years old lady is brought to ER with A 35 years old lady is brought to ER with
c/o left sided weakness. Pt is slightly c/o left sided weakness. Pt is slightly
confused & shows features of left UMN confused & shows features of left UMN
lesion. There is history of epilepsy for lesion. There is history of epilepsy for
which she takes medicine which she takes medicine
continuously.her weakness recovered continuously.her weakness recovered
within 6 hrs. give your diagnosis.within 6 hrs. give your diagnosis.

8. Case 4Case 4
A 67 yrs old man is brought to ER with A 67 yrs old man is brought to ER with
H/O focal fits in right arm. There is h/o H/O focal fits in right arm. There is h/o
some neurosurgical procedure 14 yrs some neurosurgical procedure 14 yrs
back. Pt remained well since then. back. Pt remained well since then.
What may be the cause?What may be the cause?

9. CASE 5CASE 5
A 34 yrs old gentleman with history of A 34 yrs old gentleman with history of
epilepsy for last 15 yrs, on regular epilepsy for last 15 yrs, on regular
treatment presents with c/o multiple treatment presents with c/o multiple
swellings over his body. No h/o fever, swellings over his body. No h/o fever,
anorexia or weight loss. o/E there is anorexia or weight loss. o/E there is
generalised lymphadenopathy.generalised lymphadenopathy.
What rare possibility comes to your mind?What rare possibility comes to your mind?

10. CASE 6CASE 6
 A 34 yrs old lady comes to gynaecology A 34 yrs old lady comes to gynaecology
OPD with bad obstetric history. There is OPD with bad obstetric history. There is
h/o 2 abortions & 1 baby with cleft palate. h/o 2 abortions & 1 baby with cleft palate.
She is also an epileptic and takes She is also an epileptic and takes
medicine irregularly/medicine irregularly/
What advice should be given to her?What advice should be given to her?

11. CASE 7CASE 7
A 13 yrs old boy is brought to ER with c/o A 13 yrs old boy is brought to ER with c/o
GTCF at home about 30 min back. In ER GTCF at home about 30 min back. In ER
again he has an episode of GTCF. He is again he has an episode of GTCF. He is
given INJ DIAZEPAM 10mg IV. The boy is given INJ DIAZEPAM 10mg IV. The boy is
mentally retarded. Examination reveals mentally retarded. Examination reveals
small white oval lesions on skin. There is small white oval lesions on skin. There is
family history of epilepsy.family history of epilepsy.
What condition comes to your mind?What condition comes to your mind?

12. CASE 8CASE 8
A 65 yrs old gentleman is brought to OPD A 65 yrs old gentleman is brought to OPD
with c/o abnormal movements of right with c/o abnormal movements of right
hand. According to patient, this problem hand. According to patient, this problem
aggravates when he attempts to write or aggravates when he attempts to write or
perform some skilled work .his uncle also perform some skilled work .his uncle also
had similar problem. No other finding in had similar problem. No other finding in
history and examination. history and examination.
What may be the cause?What may be the cause?

13. CASE 9CASE 9
A 45 yr old diabetic is brought to OPD with A 45 yr old diabetic is brought to OPD with
2 days history of difficulty in walking and 2 days history of difficulty in walking and
inability to hold the objects. O /E: inability to hold the objects. O /E:
Pt is conscious orientedPt is conscious oriented
There are intention tremors on right side There are intention tremors on right side
Patient falls to right side when asked to Patient falls to right side when asked to
walk.walk.
What is your diagnosis?What is your diagnosis?

14. CASE 10CASE 10
A young girl of age 17 is brought to A young girl of age 17 is brought to
hospital with c/o difficulty in walking and hospital with c/o difficulty in walking and
increasing clumsiness of hands for last 6 increasing clumsiness of hands for last 6
months. o/e a young girl with rapid months. o/e a young girl with rapid
involuntary movements of both hands. involuntary movements of both hands.
She has a broad-based gait. eye She has a broad-based gait. eye
examination reveals a characteristic examination reveals a characteristic
lesion. What is your impression? lesion. What is your impression?

16. DEFINITIONDEFINITION
Epilepsy is a tendency to have recurrent Epilepsy is a tendency to have recurrent
seizures. It is a symptom of brain disease seizures. It is a symptom of brain disease
rather than a disease itself.rather than a disease itself.
A seizure is any clinical event caused by A seizure is any clinical event caused by
abnormal electrical discharge in the brain.abnormal electrical discharge in the brain.

17. Seizures types

18. ETIOLOGYETIOLOGY

19. Incidence according to ageIncidence according to age

20. PRIMARY GENERALISED EPILEPSYPRIMARY GENERALISED EPILEPSY
SECONDARY GENERALISED EPILEPSYSECONDARY GENERALISED EPILEPSY
PARTIAL EPILEPSYPARTIAL EPILEPSY

22. It has four types:It has four types:
1)1)Childhood absence epilepsyChildhood absence epilepsy
2)2)Juvenile absence epilepsyJuvenile absence epilepsy
3)3)Juvenile myoclonic epilepsyJuvenile myoclonic epilepsy
4)4)GTCS on awakeningGTCS on awakening

23. PRIMARY GENERALISED EPILEPSYPRIMARY GENERALISED EPILEPSY
Onset mostly in childhood or adolescenceOnset mostly in childhood or adolescence
Mostly due to genetic predisposition Mostly due to genetic predisposition
without a structural causewithout a structural cause
It comprises upto 10% of all epilepsies It comprises upto 10% of all epilepsies
and upto 40% of tonic clonic seizures.and upto 40% of tonic clonic seizures.

24. It may be caused by:It may be caused by:
Spread of partial seizures due to structural Spread of partial seizures due to structural
disease ORdisease OR
May be secondary to drugs or metabolic May be secondary to drugs or metabolic
disorders.disorders.
Epilepsy presenting in adult life is almost Epilepsy presenting in adult life is almost
always secondarily generelised.always secondarily generelised.

25. CAUSES OF SECONDARY GENERALISED CAUSES OF SECONDARY GENERALISED
EPILEPSYEPILEPSY
secondary secondary
generalisation from generalisation from
partial seizurespartial seizures
GeneticGenetic
Cerebral birth injuryCerebral birth injury
AlcoholAlcohol
Toxins Toxins
Infective:Infective:
meningitismeningitis
Postinfectious Postinfectious
encephalopathyencephalopathy
Inflammatory:Inflammatory:
Multiple sclerosisMultiple sclerosis
SLESLE
Metabolic:Metabolic:
HypocalcemiaHypocalcemia
Hyponatremia Hyponatremia
HypoglycemiaHypoglycemia
Renal failureRenal failure
Liver failureLiver failure
DrugsDrugs
Degenerative Degenerative
diseasedisease

26. FOCAL LESIONS IN BRAIN FOCAL LESIONS IN BRAIN
CAUSING EPILEPSYCAUSING EPILEPSY

27. DRUGS CAUSING SEIZURESDRUGS CAUSING SEIZURES
Penicillin, isoniazid , metronidazolePenicillin, isoniazid , metronidazole
Chloroquine, mefloquineChloroquine, mefloquine
CiclosporinCiclosporin
Lidocaine, disopyramideLidocaine, disopyramide
Amphetamines (withdrawal)Amphetamines (withdrawal)
Psychotropic agents:Psychotropic agents:
phenothiazines, tricyclic antidepressantsphenothiazines, tricyclic antidepressants
lithiumlithium

28. 1: IDIOPATHIC1: IDIOPATHIC
2: FOCAL STRUCTURAL2: FOCAL STRUCTURAL
LESIONS:LESIONS:
Genetic:Genetic:
Tuberous sclerosisTuberous sclerosis
NeurofibromatosisNeurofibromatosis
CVACVA
TraumaTrauma
tumourstumours
Infective:Infective:
Cerebral abscessCerebral abscess
ToxoplasmosisToxoplasmosis
TuberculomaTuberculoma
Subdural empyemaSubdural empyema
EncephalitisEncephalitis
Inflammatory:Inflammatory:
SarcoidosisSarcoidosis
vasculitisvasculitis

29. Sleep deprivationSleep deprivation
Alcohol withdrawalAlcohol withdrawal
Physical & mental exhaustionPhysical & mental exhaustion
Recreational drug misuseRecreational drug misuse
Intercurrent infectionsIntercurrent infections
Metabolic disordersMetabolic disorders
Flickering lights including TV & computerFlickering lights including TV & computer
Loud noise, music, hot bath, reading Loud noise, music, hot bath, reading
(uncommon)(uncommon)

30. EEGEEG
CT scan brainCT scan brain
MRIMRI
TESTS FOR SECONDARY CAUSES:TESTS FOR SECONDARY CAUSES:
RFTs, LFTs , blood glucose, s electrolytesRFTs, LFTs , blood glucose, s electrolytes
CXRCXR
CP, ESR, CRP,CP, ESR, CRP,
CSF examinationCSF examination

32. IMMEDIATE CAREIMMEDIATE CARE
FIRST AID BY RELATIVESFIRST AID BY RELATIVES
IMMEDIATE MEDICAL ATTENTION:IMMEDIATE MEDICAL ATTENTION:
ENSURE PATENT AIRWAYENSURE PATENT AIRWAY
GIVE OXYGENGIVE OXYGEN
GIVE IV ANTICONVULSANTGIVE IV ANTICONVULSANT
TAKE BLOOD FOR DRUG LEVELSTAKE BLOOD FOR DRUG LEVELS
INVESTIGATE THE CAUSEINVESTIGATE THE CAUSE

34. ANTICONVULSANT DRUGSANTICONVULSANT DRUGS
CarbamazepineCarbamazepine
Sodium valproateSodium valproate
diazepamdiazepam
ClonazepamClonazepam
PhenytoinPhenytoin
phenobarbitonephenobarbitone
TopiramateTopiramate
GabapentinGabapentin
LamotrigineLamotrigine
ethosuximideethosuximide

35. Guidelines for anticonvulsant Guidelines for anticonvulsant
therapytherapy
Start with one first-line drug.Start with one first-line drug.
Start with low dose & increase to effective Start with low dose & increase to effective
dose.dose.
If first drug fails, start second drug while If first drug fails, start second drug while
gradually withdrawing first.gradually withdrawing first.
Try three agents singly before using Try three agents singly before using
combination.combination.
Don’t use more than 2 drugs at a time.Don’t use more than 2 drugs at a time.

36. Withdrawal of AEDsWithdrawal of AEDs
After complete control of seizures for 2-4 yrs, After complete control of seizures for 2-4 yrs,
consider AED withdrawal.consider AED withdrawal.
Childhood epilepsy carries the best prognosis for Childhood epilepsy carries the best prognosis for
successful drug withdrawal.successful drug withdrawal.
Seizures that begin in adult life particularly those Seizures that begin in adult life particularly those
with partial features are likely to recur esp if with partial features are likely to recur esp if
there is underlying structural cause.there is underlying structural cause.
Overall recurrence rate after withdrawal is 40%Overall recurrence rate after withdrawal is 40%
Withdrawal should be gradual over 6-12 months.Withdrawal should be gradual over 6-12 months.

38. Status epilepticus exists when a series of Status epilepticus exists when a series of
seizures occur without the patient seizures occur without the patient
regaining awareness between attacks regaining awareness between attacks
over a period of 30 minutes.over a period of 30 minutes.

39. MANAGEMENTMANAGEMENT
GENERAL CAREGENERAL CARE
IV lineIV line
Diazepam 10mg IV or rectally, can be repeated Diazepam 10mg IV or rectally, can be repeated
once OR lorazepam 4mg IVonce OR lorazepam 4mg IV
If seizures continue after 30 minutesIf seizures continue after 30 minutes: :
IV infusion phenytoin or phenobarbitalIV infusion phenytoin or phenobarbital
If seizures still continue after 30 -60 min:If seizures still continue after 30 -60 min:
Intubation & ventilationIntubation & ventilation
Once status controlled:Once status controlled:
Commence longterm anticonvulsant medicationCommence longterm anticonvulsant medication

41. EPILEPSY OUTCOME AFTER 20 YRSEPILEPSY OUTCOME AFTER 20 YRS
50% seizure free 50% seizure free
without drugs for last without drugs for last
5 years5 years
20% seizure-free for 20% seizure-free for
last 5 years but last 5 years but
continue to take continue to take
medicationmedication
30% seizures 30% seizures
continue inspite of continue inspite of
anti-epileptic therapyanti-epileptic therapy