Epilepsy

dr.Sasmoyohati

SpS(K)

Definition

A chronic neurologic disorder manifesting by

repeated epileptic seizures (attacks or fits) which
result from paroxysmal uncontrolled discharges of
neurons within the central nervous system (grey
matter disease).
The clinical manifestations range from a major motor
convulsion to a brief period of lack of awareness. The
stereotyped and uncontrollable nature of the attacks is
characteristic of epilepsy.

Pathogenesis
The 19th century neurologist Hughlings
Jackson suggested a sudden excessive
disorderly discharge of cerebral neurons
as the causation of epileptic seizures.
Recent studies in animal models of focal
epilepsy suggest a central role for the
excitatory neurotransmiter glutamate
(increased in epi) and inhibitory gamma
amino butyric acid (GABA) (decreased)

Definition of epilepsy by
cause

Idiopathic no structural cause, probably

genetic

Symptomatic structural cause

e.g : drugs , BT , alcohol , CVA , infection

Cryptogenic no structural cause found

but one suspected

Epidemiology and course

Epilepsy usually presents in childhood or

adolescence but may occur for the first
time at any age.

Epidemiology and course

5% of the population suffer a single sz at
some time
0.5-1% of the population have recurrent
sz = EPILEPSY
70% = well controlled with drugs
(prolonged remissions); 30% epilepsy at
least partially resistant to drug treatments
= INTRACTABLE EPILEPSY.

Epilepsy
is a symptom of numerous disorders, but in the majority
of
sufferers the cause remains unclear despite careful
history
taking,examination and investigation!

Epilepsy - Classification
The modern classification of the epilepsies
is based upon the nature of the seizures
rather than the presence or absence of an
underlying cause.
Seizures which begin focally from a single
location within one hemisphere are thus
distinguished from those of a generalised
nature which probably commence in a
deeper structures (brainstem? thalami)
and project to both hemispheres
simultaneously.

Epilepsy - Classification

Focal seizures

account for
80% of adult epilepsies
Simple partial seizures
Complex partial seizures
Partial seizures secondarilly
generalised

Generalised seizures

Unclassified seizures

Focal (partial) seizures

Simple partial seizures

Motor, sensory, vegetative or psychic
symptomatology
Typically consciousness is preserved

Focal (partial) seizures

Simple partial seizures

Motor, sensory, vegetative or psychic
symptomatology
Typically consciousness is preserved

Focal (partial) seizures

Simple partial seizures

Motor, sensory, vegetative or psychic
symptomatology
Typically consciousness is preserved

Focal (partial) seizures

Complex partial seizures (= psychomotor seizures)

Initial subjective feeling (aura), loss of
consciousness, abnormal behavior (perioral and
hand automatisms)

Usually originates in TL

Focal (partial) seizures

Partial seizures evolving to tonic/clonic

convulsions secondary generalised tonic/clonic
seizures (sGTCS)

Generalized seizures
(convulsive or non-convulsive)

Absences
Myoclonic seizures
Clonic seizures
Tonic seizures
Atonic seizures

Generalized seizures

Absences
Myoclonic seizures
Clonic seizures
Tonic seizures
Atonic seizures

Revised ILAE (International

League Against Epilepsy)
Seizure Classification
I.

PARTIAL (FOCAL, LOCAL) SEIZURES

A. Simple partial seizures
B. Complex partial seizure
C. Partial seizures evolving to generalized
tonic-clonic convulsions (GTC)

II. GENERALIZED
SEIZURES

A. 1. Absence seizures
2. Atypical absence
B. Myoclonic seizures, Myoclonic jerks
(simple or multiple)
C. Clonic seizures
D. Tonic seizures
E. Tonic-clonic seizures
F. Atonic seizures (astatic)

III. UNCLASSIFIED EPILEPTIC

SEIZURES
Includes all seizures that cannot be classified
because of inadequate or incomplete data and
some that defy classification in hitherto
described categories. This includes some
neonatal seizures, e.g., rhythmic eye
movements, chewing, and swimming
movements.

Some Possible Triggers

Missed medication
Lack of sleep
Stress / boredom
Irregular eating
Over indulgence of alcohol
Hormones
Visual triggers (very rare)

Epilepsy Investigation

The concern of the clinician is that epilepsy may be

symptomatic of a treatable cerebral lesion.
Routine investigation: Haematology, biochemistry
(electrolytes, urea and calcium), chest X-ray,
electroencephalogram (EEG).
Neuroimaging (CT/MRI) should be performed in all persons
aged 25 or more presenting with first seizure and in those pts.
with focal epilepsy irrespective of age.
Specialised neurophysiological investigations: Sleep
deprived EEG, video-EEG monitoring.
Advanced investigations (in pts. with intractable focal
epilepsy where surgery is considered): Neuropsychology,
Semiinvasive or invasive EEG recordings, MR Spectroscopy,
Positron emission tomography (PET) and ictal Single photon
emission computed tomography (SPECT)

Epilepsy
Differential
Diagnosis
The following should be considered in the diff. dg. of epilepsy:

Syncope attacks (when pt. is standing; results from global

reduction of cerebral blood flow; prodromal pallor, nausea,
sweating; jerks!)
Cardiac arrythmias (e.g. Adams-Stokes attacks). Prolonged arrest
of cardiac rate will progressively lead to loss of consciousness
jerks!
Migraine (the slow evolution of focal hemisensory or hemimotor
symptomas in complicated migraine contrasts with more rapid
spread of such manifestation in SPS. Basilar migraine may lead
to loss of consciousness!
Hypoglycemia seizures or intermittent behavioral disturbances
may occur.
Narcolepsy inappropriate sudden sleep episodes
Panic attacks
PSEUDOSEIZURES psychosomatic and personality disorders

Epilepsy - Treatment

The majority of pts respond to drug therapy

(anticonvulsants). In intractable cases surgery may
be necessary. The treatment target is seizurefreedom and improvement in quality of life!
Basic rules for drug treatment: Drug treatment
should be simple, preferably using one
anticonvulsant (monotherapy). Start low, increase slow.
Polytherapy is to be avoided especially as drug
interactions occur between major anticonvulsants.
The commonest drugs used in clinical practice are:
Carbamazepine, Sodium valproate, Phenytoin (first line drugs)
Lamotrigine, Topiramate, Levetiracetam, Pregabaline (new AEDs)

Epilepsy Treatment
(cont.)

If pt is seizure-free for three years, withdrawal of

pharmacotherapy should be considered. Withdrawal
should be carried out only if pt is satisfied that a
further attack would not ruin employment etc. (e.g.
driving licence). It should be performed very carefully
and slowly! 20% of pts will suffer a further sz within 2
yrs.
The risk of teratogenicity is well known (~5%),
especially with valproates, but withdrawing drug
therapy in pregnancy is more risky than continuation.
Epileptic females must be aware of this problem and
thorough family planning should be recommended.
Over 90% of pregnant women with epilepsy will
deliver a normal child.

Treatment Goals
No seizures
No side effects
Monotherapy
Once daily dosing
No blood tests

What actually happens

70%

seizure free with one drug

With careful monitoring and adjustment

5% to 10% seizure free with two or more

drugs

20%

still have seizures

Principals of pharmacological
treatment 1
Use the right drug for the seizure type
Use one drug and increase the dose until a
therapeutic effect is gained or toxicity
appears (maximum tolerated dose)
Monitor treatment including blood levels
If required add a second drug.

If a response consider slowly removing the first

drug

Principals of pharmacological
treatment 2

If monotherapy fails use two drugs

Review and replace the combinations used

Add in a third drug if necessary

Be prepared to accept that a significant
reduction in seizure frequency maybe as
good as it gets

Modes of action
1 Suppress action potential
Sodium channel blocker or modulator
Potassium channel opener
2 Enhance GABA transmission
GABA uptake inhibitor
GABA mimetics
3 Suppression of excitatory transmission

Choice of antiepileptic 1
Seizure type

Drug of choice

Alternatives

Partial simple &

Partial complex

Carbamazepine
Phenytoin
Valproate

Lamotrigine
Gabapentin
Levetiracetam
Topiramate
Tiagabine
Oxcarbazepine
Phenobarbital

Choice of antiepileptic 2
Seizure type

Drug of choice

Alternatives

Generalised tonic Carbamazepine

clonic
Phenytoin
Valproate
Absence
Ethosuximide
Valproate

Lamotrigine
Topiramate
Phenobarbital
Lamotrigine
Clonazepam

Atypical absence Valproate

Atonic, myoclonic

Clonazepam

Drugs to be used with care

Aminophylline
Amphetamines
Analgesics
Antibiotics
Antidepressants
Antimuscarinics
Antipsychotics
Baclofen
Bupropion
Donepezil etc

Cyclosporin
Cocaine
Isoniazid
Lignocaine
Mefloquine
NSAIDs
Opioids
Oral contraceptives
Vincristine

Epilepsy Surgical
Treatment

A proportion of the pts with intractable epilepsy

will benefit from surgery.
Epilepsy surgery procedures: Curative (removal of
epileptic focus) and palliative (seizure-related risk
decrease and improvement of the QOL)
Curative (resective) procedures: Anteromesial
temporal resection, selective
amygdalohippocampectomy, extensive
lesionectomy, cortical resection, hemispherectomy.
Palliative procedures: Corpus callosotomy and
Vagal nerve stimulation (VNS).

Status Epilepticus

A condition when consciousness does not return

between seizures for more than 30 min. This
state may be life-threatening with the
development of pyrexia, deepening coma and
circullatory collapse. Death occurs in 5-10%.
Status epilepticus may occur with frontal lobe
lesions (incl. strokes), following head injury, on
reducing drug therapy, with alcohol withdrawal,
drug intoxication, metabolic disturbances or
pregnancy.
Treatment: AEDs intravenously ASAP, event.
general anesthesia with propofol or thipentone
should be commenced immediately.