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Meiti Frida

Department of Neurology
Andalas University
Padang
Abnormal and recurrent excessive
synchronized discharge of cerebral neuron
with clinical manifestation of epileptic
seizure which are an intermittent
stereotypical behavior, emotion, motor
function or sensation

Paroxysmal depolarization shift (PDS) of the
resting membrane potential, which triggers a
brief rapid burst of action potentials terminated
by a sustained after hyperpolarization
PDS : result of imbalance between excitatory
(glutamate and aspartate) and inhibitory
(GABA) neurotransmitters
Abnormalities of voltage controlled membrane
ion channels
Imbalance between endogenous
neuromodulators, acetylcholine favoring
depolarization and dopamine enhancing
neuronal membrane stability

Asynchronous burst firing in some
hypocampal and cortical neurons
Generalized epileptogenesis :
asynchronous burst firing in abnormal
thalamocortical interaction
Developed countries :
annual incidence 50-70 cases per 100.000
Developing countries : prevalence 1%
Incidence varies with age




Idiopathic
Cryptogenic
Symptomatic

Hypoxia
Hypoglycaemia
Hypocalcaemia
Febrile
Seizures
Intracranial
Infections
Birth trauma
Intracranial
haemorrhage
Congenital anomalies
Tuberous sclerosis
Storage diseases
1 5 10 0 20
Head Injuries
Drugs
and
alcohol
Genetic epilepsies
Cerebral tumours
60
Cerebrovascular
degenerations
Age (years)
Common Occasional
Sleep deprivation
Alcohol withdrawal
Television flicker
Epileptogenic drugs
Systemic infection
Head trauma
Recreational drugs
AED non-compliance
Menstruation
Barbiturate withdrawal
Dehydration
Benzodiazepine
withdrawal
Hyperventilation
Flashing lights
Diet and missed meals
Specific reflex triggers
Stress
Intense exercise
Partial seizures (beginning locally)
Simple partial seizures (without impaired
consciousness)
with motor symptoms
with somatosensory or special sensory symptoms
Complex partial seizures (with impaired
consciousness)
simple partial onset followed by impaired consciousness
impaired consciousness at onset
Partial seizures evolving into secondary
generalized seizures
Generalized seizures (convulsive or non-
convulsive)
Absence seizures
Typical
Atypical
Myoclonic seizures
Clonic seizures
Tonic seizures
Tonic clonic seizures
Atonic seizures
Unclassified seizures
Partial seizures
Simple preservation of awarness
Complex impairment of consciousnesss
Secondary generalized
Generalized seizures
Absence
Myoclonic
Tonic-clonic
Tonic
Atonic
Localization-related (focal, local or partial)
epilepsies and syndromes
Idiopathic epilepsy with age-related onset
- benign childhood epilepsy with
centrotemporal spikes
- chilhood epilepsy with occipital paroxysms
Symptomatic epilepsy
Generalized epilepsies and syndromes
Idiopathic epilepsy with age-related onset (listed
in order of age at onset)
- benign neonatal familial convulsions
- benign neonatal non-familial convulsions
- benign myoclonic epilepsy in infancy
- childhood absence epilepsy (formerly known as
pyknolepsy)
- juvenile absence epilepsy
- juvenile myoclonic epilepsy (formerly known as
impulsive petit mal)
- epilepsy with generalized tonic-clonic seizures
on awaking
Other idiopathic epilepsies
Idiopathic or symptomatic epilepsy (listed in order
of age at onset)
- West syndrome (infantile spasms)
- Lennox-Gastaut syndrome (childhood epileptic
encephalopathy)
- epilepsy with myoclonic-astatic seizures
- epilepsy with myoclonic absence seizures
Symptomatic epilepsy
Non-specific syndromes
- early myoclonic encephalopathy
- early infantile epileptic encephalopathy
Specific syndromes (epileptic seizures as a
complication of a disease, such as phenylketonuria,
juvenile Gauchers disease or Lundborgs
progressive myoclonic epilepsy)
Epilepsies and syndromes with both generalized
and focal seizures
Neonatal seizures
Severe myoclonic epilepsy in infancy
Epilepsy with continuous spike waves during
slow-wave sleep
Acquired epileptic aphasia (Landau-Kleffner
syndrome)
Epilepsies without unequivocal generalized or
focal features
Special syndromes
Situation-related seizures
- febrile convulsions
- seizures related to other identifiable situations,
such as stress, hormonal changes, drugs,
alcohol withdrawal or sleep deprivation
Isolated, apparently unprovoked epileptic
events
Epilepsies characterized by specific modes of
seizure precipitation
Chronic progressive epilepsia partialis continua
of childhood
Interviews with patients or witness
Circumstances surrounding the attacks
idiopathic and generalized
No seizure worning
No underlying brain lesions
Associated with a family history
Symptomatic and localization related
Aura
Specific site of onset
Identifiable cause
Recurrent episodes of seizures
Symptoms occured during and after seizures
Recording symptomatic events with videocamera and
continous ambulatory EEG monitoring



To confirm the clinical diagnosis
To support the classification of partial or
generalized seizures
Routine trace 50% normal
Diagnostic in non convulsion state epileptic
activities :
Hyperventilation
Photic stimulations
Sleep deprivation
Essential, particularly in partial onset
seizures
Computerized tomography (CT)
Magnetic resonance imaging (MRI)


Structural lesion
Scan should be repeated periodically :
Suspicion of a tumour
Worsening in neurological examination or
cognitive function
Deterioration in the frequency or severity of
the seizures




Single Photon Emission CT (SPECT)
Positron Emission Tomography (PET)
MRI spectroscopy
Functional MRI



Functional cerebral changes
Useful adjuncts in candidate epileptic
surgery
Migraine
Transient Ischaemic Attacks
Hyperventilation
Tics
Myoclonus
Hemifacial spasm
Syncope
Sleep disorders
Non Epileptic Attacks
Narcolepsy
Metabolic disorders
Transient global amnesia
Medical treatment :
Establish a correct diagnosis of epileptic
seizure type and epileptic syndrome
Decide treatment with epileptic drugs is
necessary
Decide which drug should be used
Patients and their families should receive
counselling regarding :
Aims of treatment
Prognosis and duration of the expected
treatment
Importance of compliance
Side effects
Proposed Indications for resective epileptic
surgery
Intractable seizures
Resectable structural abnormality as identified on
magnetic resonance imaging
Confirmation that seizures arise from a visible lesion
(using video telemetry)
Over 20% of seizures arising from the contralateral
temporal lobe in temporal lobe seizures
Intelligence quotient > 70 points
No significant psychiatry morbidity
No medical contraindications
Age < 45 years
Newly diagnosed epilepsy
First drug
Second drug
Refractory
Rational duotherapy
Surgical assessment
Seizure-free
Seizure-free
47%
13%
40%
Choose the correct drug for the seizure type or
epilepsy syndrome
Start at low dosage and increase incrementally
Titrate slowly to allow tolerance to central
nervous system side-effects
Keep the regiment simple with once- or twice-
daily dosing, if possible
Measure drug concentration when seizures are
controlled or if control is not readily obtained (if
possible)
Counsel the patient early regarding the
implications of the diagnosis and the
prophylactic nature of drug therapy
Try two reasonable monotherapy options
before adding a second drug
When seizures persist, combine the best
tolerated first-line drug with one of the
newer agents depending on seizure type
and mechanism of action
Simplify dose schedules and drug
regimens as much as possible in
patients receiving polypharmacy
Aim for the best seizure control
consistent with the optimal quality of life
in patients with refractory epilepsy


Seizure type First line Second line

Tonic clonic
Sodium valproate
Carbamazepine
Phenytoin
Lamotrigine*
Oxcarbamazepine*
Absence
Sodium valproate Ethosuximide
Lamotrigine*
Myoclonic
Sodium valproate Lamotrigine*

Partial
Carbamazepine
Phenytoin
Lamotrigine*
Oxcarbamazepine*
Sodium valproate
Unclassifiable
Sodium valproate Lamotrigine*
*Lamotrigine and oxcarbamazepine are regarded as first-line drugs in some countries
Seizure type First line Second line Third line
Tonic-clonic Sodium valproate
Carbamazepine
Lamotrigine*
Oxcarbazepine*
Phenytoin
Myoclonic Sodium valproate Lamotrigine* Clobazam
Phenobarbital
Tonic Sodium valproate Lamotrigine* Clobazam
Topiramate
Absence Sodium valproate Lamotrigine*
Ethosuximide
Clobazam


Partial
Carbamazepine
Phenytoin
Sodium valproate
Gabapentin
Oxcarbazepine*
Lamotrigine*
Vigabatrin
Clobazam
Topiramate
Infantile spasms Vigabatrin
Corticosteroids
Sodium valproate
Nitrazepam
Lamotrigine*

Lennox-Gastaut Sodium valproate Lamotrigine*
Topiramate
Clobazam
Felbamate
Life threatening medical defined as frequent
and / or prolonged epileptic seizure
Wrong diagnosis
Syncope, cardiac arrhythmia, etc.
Malingering, pseudoseizures
Underlying neoplasm
Wrong drug(s)
Inappropriate for seizure type
Kinetic / dynamic interactions
Wrong dose
Too low (ignore target range)
Side effects preventing dose increase
Wrong patient
Poor compliance with medication
Inappropriate lifestyle (e.g. alcohol or drug abuse)
After 2-3 years period of seizures free, must
be tappering off in six month
Dependent with underlying syndrome and /
or its cause
Patients compliance
Reciprocal illness or medications
60-70% controlled by first-line drug of
epilepsy
10% of the rest controlled by new drugs
The rest :
surgery
Institution

Behavioral problem :
-Label of epilepsy racial disadvantage
-Brain function, medication, type of seizure
-Attitudes of helpers and helped
Education :
-Discussion between doctors, families, schools
teachers and the patient, steps which might be
taken to promote normal education and
personal development
Employment :
-Personal and racial states as well as
financial reward
-Understanding of the employee of their illness in
the context of particular employment, safety for
their selves and environment
-People around in working hours need to know
what to do if the attack occurred
The law
Driving lisence
Free of seizure after 6 months controlled epilepsy


No permitting to drive if :
Have suffered of epileptic attack at the age before
adolescent
Medical condition caused driving a source of danger to
them selves and to the public
Leisure :
Swimming, water sport, cycling, horse riding in groups
with safety controlled
Boxing, climbing, sport with body contact are prohibited
Television and video games, avoid flickering of the
screen
Marriage and pregnancy
Health education
Impairment, disability and handicap