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.
 General Considerations
 Incidence is greatest in early and late
life, with a prevalence of approximately
3 ～ 6 ‰.
 Chance of having a second seizure after
an initial unprovoked episode is 30%.
 Chance of remission from epilepsy in
childhood is 80%.
General Considerations
 Recurrence rate after the withdrawal of
drugs is about 30%.
 Idiopathic or genetic epilepsy most often
appears between ages 4 and 16 yaers.
General Considerations
 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
 Simplepartial seizures, without
impairment of consciousness
 With motor signs
 With somatosensory or special-
sensory symptoms
 With autonomic symptoms or signs
 With psychic symptoms
 Classification
 Classified by epileptic seizures
 Complex partial seizures, with

impairment of consciousness

 Partial seizures evolving to

secondarily generalized seizures

Classification
 Classified by epileptic seizures
 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 centrol-
temporal 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.
Clinical manifestation
 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 (todd’s paresis).
Clinical manifestation
 Generalized seizures
 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-per-
second spike-and-wave activity.
Clinical manifestation
 Generalized seizures
 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 mal—secondary
(symptomatic)— mental retardation
 Epilepsy—centrotemporal spike wave--
benign childhood epilepsy
 Diagnosis of epilepsy
 Clinical picture
 Clinical history  EEG
 Description of Sz  Background activity
 Epileptiform activity
 Symptomatology  Interictal
 Physical/Neurologic  Ictal
examination  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
 Migraine
 Positive family history.
 Pulsatile headache
 Manifestations of autonomic nerve disorder
 Visual disorder
 Sensory disturbance
Differenial diagnosis
 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
Differenial diagnosis
 Masturbation
 Consciousness not impaired
 Normal EEG
 Pseudoseizures
 Effectual Suggestive therapy
 Normal EEG
 Tourette sydrome
 Simple or complete stereotyped jerks or
movements
 Cough and grunt
 Normal EEG
 Positive Family history
An approach to Seizures
I s it a s e i z u r e ?

Yes No

I s it s y m p t o m a t i c o f a n a c u t e il ln e s s

No Yes

W h a t is t h e p r o b a b l e c a u s e ? D ia g n o s e a n d T r e a t

n a t u r a l h is t o r y
in v e s t ig a t io n
tre a tm e n t
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
Treatment of epilepsy
AEDs selection on types of epileptic seizure
types drugs

Tonic-clonic seizures VPA, PB, CBZ, PRM or PHT

Absence seizures VPA, ES, CNP

Myoclonic seizures VPA, CNP, PRM, Topamax

Partial seizures CBZ, VPA, PB, PHT, PRM, T

Infantile spasms CNP, ACTH, Prednison, VPA

 Antiepilepsy drugs,AEDs
drug Dosage Effective blood T1/2 Side effect
mg/kg level ug/ml
VPA 15-50 50-120 8h Ganstric discomfort, sthenic
apptite , hepatic dysfunction

CBZ 15-30 4-12 15h Drowsiness, Skin rash, WBC

decrease, hepatic dysfunction
PHT 4-8 10-20 22h Skin rash,ataxia, WBC decrease,
unsteady gait
PB 4-6 20-40 4d Hyperkinesia, inattention, Skin
rash
ESX 20 40-120 55h Gastrointestinal disorder,
headache , WBC decrease,
CZP 0.01-0.2 20-80 55h Drowsiness, Skin rash, unsteady
gait, ataxia, salivate
ACTH 25-40u Hyperfuction of the adrenal
cortex
 Update on newer AEDs
drug Dosage Effective blood T1/2 Side effect
mg/kg level ug/ml
TMP 3-10 20-30h Drowsiness, inattention, slow
infant reaction, lose appetite, weight
15h lose
LTG 5-15 (used 1.1-3.0 20-30h Drowsiness, Skin rash, ataxia,
with VPA headache, gastric discomfort
1-5)
GBP 20-50 2-3 5-7 Drowsiness, ataxia, nystagmus,
personality and behavioral
changes
Treatment of epilepsy 1 種抗癲癇藥物

30% 難 以 控 制 70% 控 制 良 好

2 種抗癲癇藥物

25% 難 以 控 制 5% 控 制 良 好

3 種抗癲癇藥物

20% 難 以 控 制 5% 控 制 良 好

10% 難 以 控 制 10% 手 術 治 療

試用新藥 3% 難 以 控 制 7% 控 制 良 好

10% 難 以 控 制 3% 控 制 良 好

VNS

7% 難 以 控 制 3% 控 制 良 好
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
Thank you