Epilepsy, status epilepticus - General Medicine - ATOT

Topic: Epilepsy
Faculty: Medicine
Course: BSc ATOT - 2nd year

- Epilepsy
- Status epilepticus
- Febrile seizure
- Infantile spasm syndrome(West syndrome)
- Lennox- Gastaut syndrome
- Juvenile myoclonic epilepsy

1. EPILEPSY Dr. Salman Ahmad Ansari Kanachur Institute of Medical Sciences

2. Contents Epilepsy Status epilepticus Febrile seizure Infantile spasms Lennox-Gastaut syndrome Juvenile myoclonic epilepsy

3. Introduction Seizure: transient disturbance of brain function due to abnormal paroxysmal(sudden) neuronal discharge in the brain Unprovoked seizure: any seizure which is not due to any reversible cause such as hypoglycemia and electrolyte imbalance Epilepsy : neurological condition in which recurrent unprovoked seizures occur without any identifiable cause

4. Causes of epilepsy It is multifactorial Some of the common causes are: Idiopathic(commonest cause of epilepsy) Birth trauma Developmental abnormalities(e.g: microcephaly) Metabolic abnormalities: hypoglycemia, hyponatremia, uremia Infections: meningitis, tuberculosis Toxins: lead, carbon monoxide poisoning Head injury Cerebrovascular disease

5. Pathogenesis of a seizure E pilepsy is due to abnormal hyperexcitable neurons Neurotransmitters can be excitatory. E.g: glutamate Inhibitory neurotransmitter. E.g: gamma-aminobutyric acid(GABA) Seizure occurs when there is a change in balance between excitatory and inhibitory neurotransmitters Failure of inhibitory process leads to status epilepticus During a seizure, large groups of neurons are activated repetitively, unrestrictedly and hypersynchronously

6. Generalised seizure : epileptic activity in all parts of the brain Focal seizure(or partial seizure) : epileptic activity occurs in one area of the brain Focal seizure with secondary generalisation : it is a focal seizure which spreads to involve all parts of the brain Prolonged seizures lead to death of neurons

7. Classification of seizures Seizures are classified as ‘simple’ if there is no impairment of consciousness or as ‘complex’ if an alteration in consciousness occurs. Based on type of onset : Generalised onset Focal onset Unknown onset Further subclassified into : Motor onset Non-motor onset

8. Clinical features of different seizure types Generalised onset seizures : Generalised t onic-clonic(or Grand mal seizures): Sudden loss of consciousness Tonic phase : stiffening of muscles of arms, legs, chest and back, loud cry, incontinence Clonic phase : after one minute, there is synchronous clonic muscle jerking Post-seizure: patient may unconscious or confused with headache, bodyache, weakness, with injuries of the tongue, dislocation

9. Clonic seizures : rhythmic jerking motor movements Tonic seizures : stiffening of the body without convulsive jerking, usually during sleep in children. Lasts about 10 to 15 seconds Atonic seizures : sudden loss of postural tone, with falling and loss of consciousness Myoclonic seizures : brief jerking movements lasting less than a second and occurring within a few minutes. Usually seen in limbs and facial muscles.

10. Absence seizures(or Petit mal seizures) : brief, sudden lapses of consciousness, without any aura or postictal confusion. More common in children. Vacant stare lasting for 10 to 15 seconds. Sudden stop in motion without falling, as if frozen Automatic movements such as lip smacking, eyelid flutters, finger rubbing No memory of incident can happen dozens of times daily Worsening of child’s performance in school

11. Focal aware seizure(or simple focal seizure) : No loss of consciousness Affects only a part of the brain Can be motor, sensory or associate with autonomic symptoms Jerking movements of one limb or half of face Paresthesia of hand or leg

12. Focal seizure with impaired awareness(or complex focal seizure) : A part of the brain is involved with impaired/lost consciousness Usually affects temporal lobe Motionless stare with altered consciousness followed by automatisms Psychic symptoms related to memory such as deja vu and jamais vu Deja vu : feeling of familiarity in an unfamiliar situation Jamais vu : feeling of strangeness in a familiar situation Todd’s paralysis : reversible neurological deficit which lasts less than 48 hours, following a focal seizure

13. Focal onset with secondary generalisation : Seizure starts in a focal area of the brain and then spreads to involve the whole brain to become a generalised seizure Jacksonian march : progression of focal seizure due to spread of seizure in the brain - seizure proceeds from thumb to fingers to face to leg Patient is conscious initially but loses consciousness when seizure becomes generalised

14. Investigations Neuroimaging : CT or MRI scan to look for structural lesion in the brain Electroencephalography(EEG) : Helps to confirm the diagnosis and also to differentiate between partial and generalised seizures Video-EEG monitoring Serum prolactin levels : rise after an epileptic attack LP : to exclude CNS infections like meningitis. Done only after excluding space occupying brain lesion by neuroimaging

15. Treatment of epilepsy Treatment during an attack Treatment of underlying condition Antiepileptic drug therapy General measures: avoiding triggers Surgical treatment for epilepsy Vagal nerve stimulation

16. Treatment During an attack: Put patient in a safe place away from fire and sharp objects Lateral position and insert a padded mouth gag Inj. lorazepam 4 mg slow iv Treatment of underlying condition : correction of hypoglycemia, removal of structural brain lesion If risk of further seizure, antiepileptic therapy is started

17. Antiepileptic drug therapy : Indicated in people with 2 or more episodes of seizure Introduced slowly to minimise side effects and dose increased gradually If seizure continues even after maximum dose of first drug, a second antiepileptic drug is to be added If patient is seizure-free for at least 2 years and has a normal EEG, antiepileptic drugs can be discontinued, gradually over a period of 2-3 months

18. E.g of antiepileptic drugs : For Generalised onset tonic clonic seizures: v alproate , t opiramate , lamotrigine For focal onset: carbamazepine, p henytoin , lamotrigine For absence seizures: ethosuximide, valproate, lamotrigine

19. General measures : Avoid precipitating factors such as sleep deprivation, stress, blinking lights, loud noise and alcohol intake Avoid swimming, heights, fire and moving machinery Risky occupations such as driving bus

20. Surgical treatment for epilepsy : In patients not responding to medical therapy Temporal lobectomy, hemispherectomy Vagus nerve stimulation : New treatment, involving electrical stimulation of left vagus nerve

21. Status epilepticus

22. Status epilepticus Generalised tonic-clonic seizure lasting for 5 minutes or more It is an emergency and must be treated immediately

23. Causes of status epilepticus Stopping antiepileptic medication or noncompliance Metabolic abnormalities like hypoglycemia, hyponatremia, hypocalcemia Drug intoxication or withdrawal CNS infections CNS lesions Head trauma

24. Pathophysiology Imbalance between excitatory and inhibitory neurotransmitters Glutamate is excitatory neurotransmitter Failure of inhibitory neurotransmitter(GABA) In prolonged seizures, repeated abnormal neuron discharges lead to death of neurons

25. Investigations Serum electrolytes, calcium, magnesium Blood sugar level CBC, LFT, RFT Toxicology screen Anticonvulsant level ABG EEG

26. Treatment ABC protocol: Airway, Breathing, Circulation Intubation of patient Anticonvulsant drugs: i.v benzodiazepines are drug of choice(e.g: lorazepam or diazepam) If not controlled -> phenytoin

27. Complications Rhabdomyolysis Lactic acidosis Aspiration pneumonia Cardiac injury Respiratory failure Neuronal death

28. Febrile seizure

29. Febrile seizure Generalised tonic-clonic seizure seen between 3 months and 5 years of age, in a fever greater than 100.4* F(38*C) Usually occurs during the rising phase of the temperature curve(first day of fever) Types: Simple febrile seizure : single, brief, isolated event. No risk of developing epilepsy Complex febrile seizure : repeated seizure attacks, lasting more than 15 minutes. 5% risk of developing epilepsy.

30. Treatment : No specific treatment Supportive care Most seizures resolve on their own and do not recur Antipyretics not useful in preventing recurrence If it lasts more than 5 minutes: i.v lorazepam or rectal diazepam

31. West syndrome

32. Infantile spasms syndrome(West syndrome) S yndrome in infancy characterized by infantile spasms, Salaam attacks, other findings of cerebral abnormalities, and abnormal EEG pattern showing Hypsarrhythmia West syndrome often evolves into Lennox-Gastaut syndrome

33. Salaam attack

34. Lennox-Gastaut syndrome

35. Lennox-Gastaut syndrome(LGS) Seen in children between ages of 1 to 8 years Cause : CNS dase due to developmental abnormalities, hypoxia, trauma, infection Triad of : Multiple seizure types EEG shows slow spike and wave discharge Impaired cognitive function Treatment : Difficult to treat Multiple types of antiepileptic drugs

36. Juvenile Myoclonic Epilepsy(JME)

37. Juvenile Myoclonic Epilepsy(JME) Generalised seizure disorder of unknown cause seen in early adolescence Bilateral myoclonic jerks Causes: Unknown cause Sleep deprivation

38. Clinical features : Most frequently in the morning after waking up and also provoked by sleep deprivation Consciousness is preserved Patients can also have GTCS and some have absence seizures Treatment : Lifelong treatment with sodium valproate

39. References: Manipal Prep Manual of Medicine Archith Boloor, Ramadas Nayak - Exam Preparatory Manual StatPearls Questions: [email protected] For PPT, scan: