EPILEPSY SLIDES.pptxG7EW8H8JD87H6GD6GGDEW

EPILEPSY

1. EPILEPSY ANEI PETER SUPERVISOR; DR. MUYINDA ASAAD 1

2. DEFINITION EPIDEMIOLOGY PATHOPHYSIOLOGY/ETIOLOGY TYPES SIGNS AND SYMPTOMS INVESTIGATIONS MANAGEMENT PROGNOSIS 2 COURSE OUTLINE

3. Seizure: the clinical manifestation of an abnormal, excessive excitation and synchronization of a population of cortical neurons Epilepsy: recurrent seizures (two or more) which are not provoked by systemic or acute neurologic insults 3 Definition

4. Seizures Incidence: 80/100,000 per year Lifetime incidence: 9% (1/3 febrile convulsions) Epilepsy Incidence: 45/100,000 per year Point prevalence: 0.5-1% 4 Epidemiology of Seizures and Epilepsy

5. In Uganda the prevalence is 1 – 5% in the general population In Mental health clinics, 60-70% Overall approx. 10% of children with mental handicap or cerebral palsy will develop epilepsy 5 PREVALENCE

6. To function normally, the brain must maintain a continual balance between excitation and inhibition, remaining responsive to the environment while avoiding continued unrestrained spontaneous activity. The inhibitory transmitter GAB A is particularly important, acting on ion channels to enhance chloride in fl ow and reducing the chances of action potential formation. 8/24/2023 6 Pathophysiology

7. Excitatory amino acids (glutamate and aspartate) allow influx of sodium and calcium, producing the opposite effect. It is likely that many seizures result from an imbalance between this excitation and inhibition. 8/24/2023 7 Pathophysiology

8. partial seizures (focal) : in which there is paroxysmal neuronal activity that is limited to one part of the cortex, generalised seizure : occurs when the electrophysiological abnormality involves both hemispheres simultaneously and synchronously 8 Pathophysiology  … Ctd

9.  Infancy and childhood Prenatal or birth injury Inborn error of metabolism Congenital malformation  Childhood and adolescence Idiopathic/genetic syndrome CNS infection Trauma 9 Etiology

10.  Adolescence and young adult Head trauma Drug intoxication and withdrawal  Older adult Stroke Brain tumor Acute metabolic disturbances Neurodegenerative 10 Etiology.. ctd

11.  Metabolic and Electrolyte Imbalance  Stimulant/other proconvulsant intoxication  Sedative or ethanol withdrawal  Sleep deprivation  Antiepileptic m edication reduction or inadequate AED treatment  Hormonal variations  Stress  Fever or systemic infection  Concussion and/or closed head injury 11 Seizure Precipitants

12. Metabolic and Electrolyte Imbalance Low blood glucose (or high glucose, esp. w/ hyperosmolar state) Low sodium Low calcium Low magnesium 12 Seizure Precipitants (cont.)

13. 13 Classification of Seizures Seizures Partial Generalized Simple Partial Complex Partial Secondarily Generalized Absence Myoclonic Atonic Tonic Tonic- Clonic ILAE* – International League Against Epilepsy

14. 14 ILAE Classification of Seizures Seizures Partial Generalized Simple Partial Complex Partial Secondarily Generalized

15. Consciousness is preserved The person is alert, can respond to questions or commands and can remember what occurred during the seizure. 8/24/2023 15 Simple Partial seizures

16.  Impaired consciousness  Clinical manifestations vary with site of origin and degree of spread Presence and nature of aura Automatisms Other motor activity  Duration typically < 2 minutes 16 Complex Partial Seizures Seizures Partial Generalized Complex Partial

17.  Begins focally, with or without focal neurological symptoms  Variable symmetry, intensity, and duration of tonic (stiffening) and clonic (jerking) phases  Typical duration 1-3 minutes  Postictal confusion, somnolence, with or without transient focal deficit 17 Secondarily Generalized Seizures Seizures Partial Generalized Secondarily Generalized

18. 18 ILAE Classification of Seizures Seizures Partial Generalized Absence Myoclonic Atonic Tonic Tonic-Clonic

19.  Brief staring spells (“petit mal”) with impairment of awareness 3-20 seconds ,Sudden onset and sudden resolution Often provoked by hyperventilation Onset typically between 4 and 14 years of age Often resolve by 18 years of age  N ormal development and intelligence  EEG: Generalized 3 Hz spike-wave discharges 19 Typical Absence Seizures Seizures Partial Generalized Absence

20.  Brief staring spells with variably reduced responsiveness 5-30 seconds Gradual (seconds) onset and resolution Generally not provoked by hyperventilation Onset typically after 6 years of age  Often in children with global cognitive impairment  EEG: Generalized slow spike-wave complexes (<2.5 Hz)  Patients often also have Atonic and Tonic seizures 20 Atypical Absence Seizures

21. Epileptic Myoclonus  Brief, shock-like jerk of a muscle or group of muscles  Differentiate from b enign, nonepileptic myoclonus (e.g., while falling asleep)  EEG: Generalized 4-6 Hz polyspike -wave discharges 21 Myoclonic Seizures Seizures Partial Generalized Myoclonic

22. T onic seizures Symmetric, tonic muscle contraction of extremities with tonic flexion of waist and neck Duration - 2-20 seconds. EEG – Sudden attenuation with generalized, low-voltage fast activity (most common) or generalized polyspike -wave. polyspike -wave 22 Tonic and Atonic Seizures Seizures Partial Generalized Tonic Atonic

23. Atonic seizures Sudden loss of postural tone When severe often results in falls When milder produces head nods or jaw drops. Consciousness usually impaired Duration - usually seconds, rarely more than 1 minute EEG – sudden diffuse attenuation or generalized 23 Seizures Partial Generalized Tonic Atonic

24. Associated with loss of consciousness and post- ictal confusion/lethargy Duration 30-120 seconds Tonic phase Stiffening and fall Often associated with ictal cry Clonic Phase Rhythmic extremity jerking EEG – generalized polyspikes 24 Generalized Tonic- Clonic Seizures Seizures Partial Generalized Tonic- Clonic

25. DEFN: It is an epileptic seizure of greater than five minutes or more than one seizure within a five-minute period without the person returning to normal between them This is a medical Emergency Mortality is up to 20% Signs /symptoms: pyrexia, sweating, increased blood pressure, disturbed breathing, deepening coma, circulatory failure. 25 Status Epilepticus .

26. Seizure or not? Provoked? ( ie metabolic precipitant?) Seizure type? (focal vs. generalized) Evidence of interictal CNS dysfunction? Which studies should be obtained? Should treatment be started? Which drug should be used? 26 Questions Raised by a First Seizure

27. Detailed history and a thorough general and neurologic examination. Blood Studies (next slide) Lumbar Puncture for CSF analysis Electroencephalogram Neuroimaging(CT ,MRI) 27 Investigations and management

28. CBC , RBS Blood culture LFTS/RFTS Serum electrolytes ABG Toxicology studies(blood and urine) 28 Blood studies

29. If seizure is on-going Clear the airway, prevent aspiration of oral contents Place in prone/lateral position Suctioning Supply oxygen Rectal diazepam 0.5mg/kg (0.3-0.7mg/kg) IV diazepam 0.3mg/kg Check blood glucose 29 Acute Management

30. If seizure has stopped, Admit to hospital if: - No recovery of consciousness yet - Seizures lasted more than 30 min - Increasingly more seizures - Clinical suspicion of a more serious underlying condition e.g. meningitis, CM, ICH, raised ICP 30 Acute Management

31. Provoked Seizures Treatment directed to the provoking factor Unprovoked Seizures First Seizure Usually no treatment Treatment can be initiated if risk of recurrence is high or if a second seizure could be devastating Second Seizure Diagnosis of epilepsy is established and risk of a third Seizure is high Most physician treat at this stage In children, some may wait for a third seizure 31 Long term treatment of Seizures

32. 32 Use of anticonvulsants Cabamazepine Phenytoin Valproic acid Tonic-clonic and partial Ethosuximide Valproic acid Clonazepam Absence seizures Valproic acid Clonazepam Myoclonic seizures Diazepam Lorazepam Short term control Phenytoin Phenobarbital Prolonged therapy Status Epilepticus Corticotropin Corticosteroid s Infantile Spasms Drugs used in seizure disorders

33. Broad-Spectrum Agents Valproate Felbamate Lamotrigine Topiramate Zonisamide Levetiracetam Rufinamide * Vigabatrin Narrow-Spectrum Agents Partial onset seizures Phenytoin Carbamazepine Oxcarbazepine Gabapentin Pregabalin Tiagabine Lacosamide * Absence Ethosuximide 33 Choosing Antiepileptic Drugs

34. Drugs that may decrease the efficacy of oral contraceptive pills : Phenytoin Carbamazepine Phenobarbital Topiramate * *at high doses Oxcarbazepine * Felbamate * “High-dose” birth control pills are recommended for patients taking these medications . 34 Antiepileptic Drug Interactions

35. Lamotrigine and hormonal contraception: Oral contraceptive pills can decrease lamotrigine levels by 50% Lamotrigine can decrease progesterone levels. Patients using Depo-provera may need shorter intervals between injections. 35 Antiepileptic Drug Interactions

36. Typically Idiosyncratic: >Renal stones topiramate , zonisamide > Anhydrosis , heat stroke topiramate >Acute closed-angle glaucoma topiramate > Hyponatremia carbamazepine, oxcarbazepine 36 Adverse Effects of AEDs: Serious

37. Typically dose-related: >Dizziness , Fatigue , Ataxia, Diplopia all AEDs >Irritability levetiracetam >Word-finding difficulty topiramate >Weight loss/anorexia topiramate , zonisamide , felbamate >Weight gain valproate (also associated with polycystic ovarian syndrome ) carbamazepine, gabapentin, pregabalin 37 Adverse Effects of AEDs: Common

38. Never suddenly stop taking an AED because doing so could cause a seizure If no seizure for more than two years, it may be possible to stop taking AEDs This should be discussed with the client (and family) The drugs have to be tapered off 38 Discontinuation of AEDs

39. Hypoglycaemia Syncope Meningitis Hypocalcaemia Conversion disorders, hyperventilation, panic attacks 39 Differential diagnosis

40. Mental retardation Burns and their complications Children stop school • Stigma • Low self esteem • Isolation of the child • suicide • Family break down 40 Complications

41. Epilepsy cannot usually be cured, but medication can control seizures effectively in about 70% of cases. Of those with generalized seizures, more than 80% can be well controlled with medications while this is true in only 50% of people with partial seizures 41 PROGNOSIS

42. number of seizures that occur in the first six months little response to the initial treatment, generalized seizures, a family history of epilepsy, psychiatric problems, and waves on the EEG representing generalized epileptiform activity 42 predictors of long-term outcome

43. American Epilepsy Association, 2010 Davidsons Essentials of Medicine, 24 th Edition 43 REFERENCES