Epilepsy

Epilepsy
Shi Xue Chuan
General Considerations
A seizure is a sudden, transient disturbance of brain function, manifested by involuntary motor, sensory, autonomic, or psychic phenomena, alone or in any combination, often accompanied by alteration or loss of consciousness. A seizure may occur after a metabolic, traumatic, anoxic, or infectious insult to the brain. Repeated seizures without evident cause justify the label of epilepsy.
Incidence is greatest in early and late life, with a prevalence of approximately 36 . Chance of having a second seizure after an initial unprovoked episode is 30%. Chance of remission from epilepsy in childhood is 80%.
Recurrence rate after the withdrawal of drugs is about 30%.

Idiopathic or genetic epilepsy most often appears between ages 4 and 16 yaers.
Factors adversely influencing recurrence include:
Difficulty in getting the seizures under control Neurologic dysfunction or mental retardation Age at onset under 2 years Abnormal EEG at the time of discontinuing medication Type of epilepsy
Etiology
Genetic factor
Brain damage and dysmetabolism

Inborn Acquired
Causative factor
Classification
Classified by etiology
Idiopathic (essential) epilepsy
Symptomatic (secondary) epilepsy

Cryptogenic epilepsy
Classification
Classified by epileptic seizures
Partial (foal, local) seizures

Simple

partial seizures, without impairment of consciousness

With motor signs With somatosensory or specialsensory symptoms With autonomic symptoms or signs With psychic symptoms
Classification
Complex partial seizures, with impairment of consciousness
Partial seizures evolving to secondarily generalized seizures
Classification
Generalized seizures
Absence seizures

Typical absence Atypical absence
Myoclonic seizures Clonic seizures Tonic seizures Tonic-clonic seizures Atonic seizures Infant spasm, tonic-spasm
Unclassified epileptic seizures
Classification
Classification of epilepsy and epilepsy syndromes

Benign children epilepsy with centroltemporal spike Lennox-Gastaut syndrome Infantile spaams Juvenile myoclonic
Clinical manifestation
Partial epilepsy
Focal epilepsy may arise from an intracerebral structural defect, causing motor or sensory symptoms localized to one body part, which may then spreads to contiguous regions of the cortex (e.g. jacksonian seizures). There are simple partial seizures without impairment of consciousness. Complex partial seizures associated with disturbance of consciousness usually arise in the temporal lobe.
Partial epilepsy
Seizures arising in the medial temporal lobe may produce disturbances of smell and taste, visual hallucinations. These may evolve to a tonic-clonic seizures ( secondary generalization). Weakness following the event may occur for minutes or hours (todds paresis).
Absence attacks usually consist of a brief interruption of activity, sometimes with complex motor activity (such as fumbling with clothes), but without collapse. EEG during this event shows a three-persecond spike-and-wave activity.
In a generalized tonic-clonic seizures, the tonic phase is a sudden tonic contraction of muscles usually with upward eye deviation. The clonic (with clonus-type activity) phase follows. Initial EEG changes are often bilateral. This condition usually has its onset in childhood.
Diagnosis of epilepsy
The integrate diagnosis should include seizure type, anatomy, etiology and concomitant mental disorders. For example:
Epilepsy--grand malsecondary (symptomatic) mental retardation Epilepsycentrotemporal spike wave-benign childhood epilepsy
Diagnosis of epilepsy
Clinical picture

Clinical history Description of Sz
EEG
Background activity
Symptomatology
Physical/Neurologic examination
Epileptiform activity

Interictal Ictal Postictal
Therapy
Laboratory tests Neuroimaging
Differenial diagnosis
Febrile Seizures
Ages 3 months to 5 years Fever Non-CNS infection Generalized seizures Last less than 5 minutes
Positive family history. Pulsatile headache Manifestations of autonomic nerve disorder Visual disorder Sensory disturbance
Migraine

Breath-holding spells

Age 6 months to 3 years, Cry, loss of consciousness Apnea and cyanosis Family historypositive in 30% Normal EEG.
Sleeping disturbance Sleepwalking , Nightmare
Night terrors
Masturbation
Consciousness not impaired Normal EEG

Effectual Suggestive therapy Normal EEG Simple or complete stereotyped jerks or movements Cough and grunt Normal EEG Positive Family history
Pseudoseizures

Tourette sydrome

An approach to Seizures
Is it a seizure? Yes Is it symptomatic of an acute illness No What is the probable cause? natural history investigation Yes Diagnose and Treat No
treatment
Treatment of epilepsy
Therapeutic principle of ntiepilepsy drugs (AEDs)

Early treatment Treatment as the types of epileptic seizure Treatment with one drug Individual therapy Long course of treatment Slow drug withdrawal Periodic re-examination
AEDs selection on types of epileptic seizure
types
Tonic-clonic seizures Absence seizures
drugs
VPA, PB, CBZ, PRM or PHT VPA, ES, CNP
Myoclonic seizures
Partial seizures Infantile spasms
VPA, CNP, PRM, Topamax

CBZ, VPA, PB, PHT, PRM, T CNP, ACTH, Prednison, VPA
Antiepilepsy drugs,AEDs
drug VPA Dosage mg/kg 15-50 Effective blood level ug/ml 50-120 T1/2 8h Side effect Ganstric discomfort, sthenic apptite , hepatic dysfunction Drowsiness, Skin rash, WBC decrease, hepatic dysfunction Skin rash,ataxia, WBC decrease, unsteady gait Hyperkinesia, inattention, Skin rash Gastrointestinal disorder, headache , WBC decrease, Drowsiness, Skin rash, unsteady gait, ataxia, salivate Hyperfuction of the adrenal cortex
CBZ PHT PB ESX CZP ACTH
15-30 4-8 4-6 20 0.01-0.2 25-40u
4-12 10-20 20-40 40-120 20-80
15h 22h 4d 55h 55h
Update on newer AEDs

drug TMP Dosage mg/kg 3-10 Effective blood level ug/ml T1/2 20-30h infant 15h 20-30h Side effect Drowsiness, inattention, slow reaction, lose appetite, weight lose Drowsiness, Skin rash, ataxia, headache, gastric discomfort Drowsiness, ataxia, nystagmus, personality and behavioral changes
LTG
5-15 (used with VPA 1-5) 20-50
1.1-3.0
GBP
2-3
5-7
1
30% 70%
2
25% 5%
3
20% 10% 5% 10% 3% 7%
10% 3%
VNS
7%
3%
Status epilepticus
Status epilepticus is a clinical or electrical seizure lasting at least 30 minutes, or a series of seizures without complete recovery over the same period of time. Emergency Treatment
ABC(airway, breathing, circulation) Diazepam 0.3-0.5mg/kg ;may repeat in 15-30 minutes Phenytoin 10-20mg/kg Phenobarbital 5-20mg/kg
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Epilepsy

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Epilepsy

Shi Xue Chuan

Recurrence rate after the withdrawal of drugs is about 30%.

Factors adversely influencing recurrence include:

Brain damage and dysmetabolism

Idiopathic (essential) epilepsy

Symptomatic (secondary) epilepsy

Classified by epileptic seizures

Partial (foal, local) seizures

partial seizures, without impairment of consciousness

Classified by epileptic seizures

Complex partial seizures, with impairment of consciousness

Partial seizures evolving to secondarily generalized seizures

Classified by epileptic seizures

Typical absence Atypical absence

Unclassified epileptic seizures

Classification of epilepsy and epilepsy syndromes

Clinical history Description of Sz

Interictal Ictal Postictal

Laboratory tests Neuroimaging

Sleeping disturbance Sleepwalking , Nightmare

Consciousness not impaired Normal EEG

Therapeutic principle of ntiepilepsy drugs (AEDs)

VPA, CNP, PRM, Topamax

CBZ PHT PB ESX CZP ACTH

15-30 4-8 4-6 20 0.01-0.2 25-40u

4-12 10-20 20-40 40-120 20-80

15h 22h 4d 55h 55h

Update on newer AEDs

5-15 (used with VPA 1-5) 20-50

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