Presentation on epilepsy-1.ppt symptoms and classification

Presentation on epilepsy-1.ppt symptoms and classification

1. Presentation on epilepsy

2. definitions
•The word epilepsy comes from greek word-
means to be taken, seized or attacked
•Its characterized by repeated seizures due to a
disorder of the brain cells
•Life long tendency, may start at any time during
life and occur sporadically or frequently
•Average duration of epilepsy is approximately
13years, some suffer their life time.

3. Symptomatic epilepsy
•This is when epilepsy develops after a particular
identifiable event(e.g asphyxia, head injury,
meningitis

4. Idiopathic epilepsy
•No identifiable cause

5. seizure
•Its as a result of excessive nerve cell discharges
in the brain
•Manifests as:
•Sudden abnormal function of the body
•Loss of consciousness
•An excess of muscular activity, or sometimes a
loss of it, or
•Abnormal sensation

6. Partial focal) seizures
•This is when excessive cell discharges or
excitation remain in a small area of the brain( a
localized lesion or focus)

7. Generalized seizures
•This is when excessive nerve-cell discharges or
excitation start immediately in the whole brain
or spread from the small area focus) to the whole
brain and spinal cord

8. Causes of a seizure
•Metabolic:
•Hypoglycemia
•Hypocalcaemia
•Electrolyte imbalance
•Hypomagnesaemia
•Hyperbilirubinemia(kernicterus)
•Uremia
•Phenylketonuria
•Pyridoxine deficiency
•porphyria

9. cont
•Infections:
•Intracranial:
•Meningitis
•Encephalitis( AIDS included)
•Cerebral malaria
•Rabies
•Toxoplasmosis
•Cysticercosis
•Encephalopathy(SSPE)

10. CONT
▫Trauma:
▫Birth trauma
▫Head injury in later life
▫Cold injury in newborns
▫hypothermia

11. anoxia
•Birth asphyxia
•Conditions later in life

12. toxic
•Alcohol and withdrawal from alcohol
•Lead poisoning
•Carbon monoxide poisoning
•Organophosphate poisoning
•Drugs(high dose iv penicilli)

13. Space occupying lesion
•Hemorrhage
•Abscess
•Tumour
•Tuberculoma
•Cysticercosis
•toxoplasmosis

14. Circulatory disturbances
•Cerebro-vascular accident stroke)
•Vascular anomalies
•Sickle cell crisis

15. Cerebral edema
•Hypertensive encephalopathy
•eclampsia

16. congenital
•Malformations of the brain(hydrocephalus,
microcephaly, etc)
•Tuberose sclerosis(bourneville disease)
•Neurofibromatosis(von Recklinghausens
disease)

17. Degenerative diseases
•Tay-sach`s disease
•Niemann- pick disease

18. investigations
•Some causes of seizures are common , some
rare, very rare
•Most common causes are:meningitis
•Encephalitis
•Cerebral malaria
•Febrile convulsions
•Birth trauma
•Head injury in later life
•Tuberculoma
•Sickle cell crisis

19. cont
•Rare causes:
•Phenylketonuria
•Tuberose sclerosis
•Neurofibromatosis
•Degenerative diseases

20. investigations
•Electrolytes
•C-T SCAN
•X-ray
Csf analysis
Serology
Hgm, blood cultures, urinalysis

21. Causes of epilepsy
•Epilepsy is a condition characterized by
recurrent seizures
•If an acute disturbance, a metabolic like
hypocalcaemia or an infection such as
meningitis, or poisoning or any other causes are
recognized and treated adequately epilepsy will
not follow.

22. cont
•If the acute disorder was too severe, or not
treated correctly, convulsions might have
become prolonged and continuous, resulting in
anoxia of the brain with subsequate brain
damage followed by epilepsy
•In some infections, e.g
tuberculosis,toxoplasmosis, cysticercosis, the
disease may leave calcified areas in the brain

23. cont
•Some diseases—tuberose sclerosis, sturge-
weber`s syndrome—present with calcifications
in the brain
•A hemorhge, abscess or tumour has been
succesfully removed surgically, the conditions
will be much improved
•Any head injury , including birth trauma, may
result in permanent changes of brain tissuei.e.
scar tissue

24. cont
•Any area with abnormal brain
tissue( calcifications, scars, or vascular
abnormalities) may act as a focus from where
abnormal activity of the neurons take place
causing symptomatic epilepsy

25. cont
•NB:
•Only 30-40% of patients cause is found
•In rurals the percentage of symptomatic epilepsy is
higher than in urban areas
•This is because of more perinatal injuries, perinatal and
childhood infections, and less timely treatment( distance
from health facility)
•Prevalence of epilepsy among mentally handicapped is
higher( 20-35%)
•Concomitant mental handicap is present in about 10-
15% of people with epilepsy

26. cont
•In Tanzania matuja(1990) 48% of persons
epilepsy treated in muhimbili medical centre had
organic brain disease and psychological
disturbances
•In 60-70% of patients no cause is
found( idiopathic epilepsy.

27. Contributory factors
•Genetic factors:
•In many, if not all, epilepsies genetic factor
predominate
•Even in symptomatic epilepsy this factor play a
role
•As many people have had head injury but only
some develop epileptic seizures afterwards

28. cont
•If one of the parents has idiopathic epilepsy the
risk of them having a child with epilepsy is 4-6%
•If both parents have idiopathic epilepsy, the risk
rises to 12-20%
•In parents with symptomatic epilepsy, there is
still a slight increase in the risk ---upto 2% in
europe

29. Effects on brain maturation
•Resistance to seizures also depends on the
maturation of the brain
•The resistance in the first year of life (except
during the newborn period) is very high, and
therefore a severe injury such as severe brain
damage since birth, meningitis or tuberose
sclerosis, will produce seizurs.

30. cont
•Between 1-4years the resistance to seizures is
very low.
•A simple febrile disease may precipitate seizures
•After the age of 4 the resistance is again high,
and seizures are seen only in already brain-
damaged children

31. cont
•This resistance diminishes again from about the
seventh year when the idiopathic epilepsies tend
to appear
•Resistance is at its lowest around the time of the
prepubertal growth spurt.

32. Other precipitating factors
•These may be different for each individuals
patient
•Some patients learn which factors are important
for them , so as to modify their behavior or
activities to try avoid seizures

33. cont
•These are:
•Flashing lights
•Hyperventilation
•Lower alertness, sleep itself and lack of enough
sleep
•Emotions
•Physical stress
•Special smells, sounds or sensations of touch
•alcohol

34. cont
•Hormonal changes e.g during menses
•Acute illness( viral, malaria)
•overhydration

35. seizures
•Components of a seizure:
•Not all seizures will have all the stages
•The presence or absence and the nature of them
are important for diagnosing the seizure type.
•The components are:
•Prodromal
•Aura
•Seizure ictus)
•Post-ictal phase

36. Prodromal phase
•Begins a few hours or even days before the actual
seizure
•Not confuse with an aura
•The symptoms are:
•Headache
•Irritability
•Insomnia
•Bad temper
•Depression or increased activity

37. Aura
•It proceedes the seizure by seconds or a few
minutes
•It’s the beginning of the seizure
•This signals the focal onset of the seizure
•The symptoms depend on the location of this
focus
•The patient remembers the aura very well

38. Cont.
•The symptoms are:
•Strange epigastric sensation
•Dreamlike experiences
•Unpleasant smells
•The patient may not be able to recount it., he can
affirm the presence of it, as it happens before he
losses conciusness.

39. seizure
•In most seizures there is loss of conciousness
•Patient not able to give any information about
the actual ictus
•We are therefore dependent on witness who
have seen the seizure
•The patient has no memory of the seizure.

40. Cont.
•Characteristics of a seizure:
•The type of seizure
•The duration of seizure
•The frequency
•The time of day or night that the seizure occurs,
and its relation to sleep
•The presence of an aura
•The presence of a post-ictal phase
•The age of onset

41. Post-ictal phase
•This phase may be absent, brief or may last
several hours, and sometimes even days
•Usually a deep sleep and waking up with
headache, tiredness, irritability, vomiting,
confusion, muscular aches or ataxia
•Transient paralysis of a part of the body, known
as todds paresis may occur for a few hours or
days
•Altered speech or aphasia may occur when the
dominant hemisphere of the brain has been
onvolved

42. Cont.
•Altered behavior and emotional outbursts may
occur, if these are interfered with, violent
behavior is likely

43. Classification of epileptic seizures
•The classification is based on the clinical
expression of the seizure and the
electroencephalographic picture during and
between the seizures
•The main division in this classification is into
partial and generalized seizures

44. Cont.
•In the partial seizures:
•Electrical discharges in the localized area of the
brain
•s/s depends on the part of the brain affected
•Discharges may remain localized, or they may
spread to other parts of the brain---- become
generalized( secondarily generalized seizures)

45. Cont.
•Generalized seizures:
•Seizures are generalized from the onset(ie
primarily generalized seizures) starting in both
hemispheres of the brain simultaneously.

46. cont
•NB.
•A definite aura is an indication that the seizure is
of focal, partial onset.
•A patient does not necessarily have only one type
of seizure
•The type may change over the years, this
depends on the age and maturation of the brain
•One patient may have a combination of different
seizure types

47. Partial seizures
•Divided into two groups:
•Consciousness is maintained
•Impairment of the consciousness
•Both these groups may develop into generalized
seizures, then forming a third group

48. Simple partial seizures
•No loss of consciousness
•Thus able to narrate what has happened, but the
experience may be so strange that he may not be
able to express himself properly
•What happens is dependent on the location of
the affected area.

49. Motor seizures
•Focus in the primary motor cortex
•Present as: twitching---starting in the distal part
of the extremity, or in the face
•Twitching may remain localized or spread to the
whole extremity to be generalized
•The spreading is called jacksonian march.

50. Sensory seizures
•Focus in the post central gyrus( primary sensory
cortex)
•There may be feeling of tingling, pins and
needles, cold or heat, or numbness of a limb
•Sometimes strange feeling of visual signs, or
hearing or smelling sensations.

51. Autonomic seizures
•Associated with foci in the temporal lobe
•Sensation of rising from the epigastrium to the
throat, palpitation, sweating or flushing

52. psychic
•Changes in mood ,memory or thought( thinking)
•May be distorted perceptions( time, space, or
person) or problems with language
•NB:-- THESE SIMPLE PARTIAL SEIZURES
ARE USUALLY ONLY RECOGNIZED AS
EPILEPTIC SEIZURES WHEN THEY DEVELOP
INTO GENERALIZED SEIZURES.

53. Complex partial seizures
•Impaired consciousness
•No complete loss of consciousness, he is slightly aware of
what is going on but he can not respond to anything,
neither can he change his behavior during an attack
•There is an aura, strange feeling in the stomach, rising
up the throat and head , or sensation of light, smell,
sound or taste
•Seizure occur with changes in perception e.g. of
time( time seems to pass too slowly or too fast), of light
or sound or space
•The surroundings may suddenly seem completely
strange and different in scale( things seem larger or
smaller then usual)

54. cont
•Sometimes he seizures occur with hallucinations
or with psychomotor symptoms such as
automatisms, automatic movements e.g. pulling
at the clothes, chewing, lip smacking or repeated
aimless movements
•These automatisms may become complex,
patient able to perform difficult tasks or travel
somewhere, but later not able to remember
having done such a thing.

55. cont
•He suddenly comes to again and finds himself in
a completely different place
•During such an automatism the patient may
become aggressive and violent when restrained
•Slow recovery after a complex partial seizure,
with a period of confusion

56. cont
•After the attack there is complete amnesia of it
•These seizures were previously called
psychomotor seizures becoz the localization of
the abnormal discharges is often in the temporal
lobe, it was formerly called temporal lobe
epilepsy( the focus might occur in the frontal
lobe too)

57. Partial seizures secondarily
generalized
•Both the sps and cps may become generalised
TCS
•The beginning is as described above, they end as
GTCS

58. Generalized seizures
•These are characterized by:
•Complete loss of consciousness
•Absence of an aura
•Come suddenly and unexpectedly, patient may
injure himself
•These consist of six different seizure types, of
which the primary generalized TCS is the most
common, all seizures types can be seen in a
special epilepsy clinic.

59. Absence seizures
•Short periods of loss of consciousness, lasting only a few
seconds( not more than half a minute)
•Sudden onset
•With no or minimal motor manifestations.
•There is is a blank stare
•Brief upward rotation of the eyes, interuption of ongoing
activity
•Unresponsive when spoken to
•Then its suddenly over, he continues what he he was
doing before
•The child has no memory of these seizures

60. Cont.
•Generalized absences occur during childhood
•In school aged , occur many times a day
•During an episode child does not hear what the
teacher is saying, not follow the lesson well,
•Unless the teacher is aware of this condition ,he
will scold the child for daydreaming and
inattentiveness.

61. Cont.
•Most parents are unaware of these small
seizures, not think they are important, thus will
not mention them to the doctor
•Unless these children also suffer from GTCS , are
not brought to a clinic, especially not to an
epilepsy clinic, not aware that these absences are
epileptic seizures.

62. Cont.
•Absences are easily provoked by over
breathing( hyperventilation)
•They have a typical EEG pattern and therefore
are easily recognized on an EEG
•A child with absence seizures may , in addition
have other types of seizures such as primarily
GTCS, or myoclonic seizures
•Previously these seizures were called petit mal
seizures or pyknolepsy.

63. Myoclonic seizures
•Consist of sudden, brief, shock like muscle
contractions, occurring either in one limb or
more widespread and bilateral
•They may be single jerks, or jerks repeated over
longer periods
•Often seen in combination with other seizures
types occurring in special epileptic syndromes

64. Clonic seizures
•They are generalized seizures
•The tonic component is not present, only
repetitive clonic jerks
•When the frequency diminishes the amplitude of
the jerks do not.

65. Tonic seizures
•Sudden sustained muscle contractions, fixing the
limbs in some strained position
•Immediate loss of consciousness
•Often with deviation of the eyes and head
towards one side
•Sometimes with rotation of the whole body
•They are seen mainly in pediatric practice.

66. Tonic-clonic seizures
•Patient loses consciousness
•Falls down, sometimes with a scream
•Develops a generalized stiffness( tonic phase)
•Breathing stops, as all the muscles of the trunk
are in spasms, the patient becomes cyanotic
•The head retracted, the arms flexed and the legs
extended

67. cont
•After a while tonic phase is followed by the clonic phase,
when the muscles alternately contract and relax, this
results in clonic movements
•With this jerking the patient may bite his tongue, pass
urine, or sometimes stool.
•The clonic phase may last several minutes
•When all the jerking stops and the patient regains
consciousness, he may feel very tired, with a headache
and confusion
•Has no memory of what happened, and may find himself
on the floor in a strange position
•Often falls in a deep sleep

68. cont
•Not as frequent as absences
•Varies from one a day to one a month or once a
year, or even once every few years.
•Its not found in the new born period or infancy
•In these generalized seizures there is no aura(=
no focal onset) and they are therefore they are
primarily GTCS
•Should be differentiated from sec. GTCS

69. Atonic seizures(astatic seizures)
•Sudden loss of muscle tone causing the head or
limb to drop
•Patient falls suddenly on the floor
•Also called drop attacks
•There is loss of consciousness, sudden onset and
no post ictal phase
•The patient stands up and continues with what
he was doing
•The seizure is very short, only seconds, but may
occur several times a day

70. cont
•The patient present with :
•Scars or fresh wounds on chin cheek or
forehead, or back of the head
•Thus a protective helmet is recommended for
these patients
•May have in addition absence or myoclonic
seizures

71. UNCLASSIFIED EPILEPTIC SEIZURES
•Include all seizures which can not be classified
because of the inadequate or incomplete data

72. WHICH SEIZURES DO WE SEE IN DAILY
PRACTISE?
•The majority of our patients(70-80%) present
with generalized TCS for short.
•Used to be referred as grand mal epilepsy
•But GTCS is a combination of two seizure types:
•The secondarily GTCS and the primarily GTCS—
tonic clonic seizures

73. cont
•Both of these seizures types are seen equally
commonly:35-40%--will have primarily GTCS
AND THE SAME PERCENTAGE secondarily
GTCS
•The differentiation is important, as the DOC is
different in each group
•Most of the patients have to be treated without
the help of EEG recording
•We rely on the medical history for this
differentiation

74. cont
•The four main AEDS can be used for all GTCS
•The DOC for the secondarily GTCS is phenytoin
or carbamazepine, and for the primarily GTCS
pb or valproate
•Minority of patients present with the other
seizure types
•Most of the patients who do not present with
GTCS present with cps

75. cont
•Approximately 15% of all patients present with
CPS
•These are a strange mixture of feelings and
signs, were previously called psychomotor
seizures or temporal lobe epilepsy--- origin in
the temporal lobe.
•These CPS should not be called complex
absences, but should be differentiated from
generalized absences
•The DOC for CPS is carbanazepine or phenytoin

76. cont
•From 1-4% of our patients will present with
generalized absences
•When they have only generalized absences, they
can be treated with ethosuximide, but when they
have other types as well , then valproate is the
DOC
•SPS might occur in a small % of our pts, and the
DOC phenytoin or carbamazepine
•The rest of our pts might have myoclonic or
astatic seizures for which the DOC-- valproate

77. Bottom line
•Definite figures of the occurrence of these
seizures can not be given as the diagnosis is
made on a clinical impression, and not verified
by an EEG