EPILEPSY Lecture Note
EPILEPSY Lecture Note
EPILEPSY Lecture Note
EPILEPSY
Dr ABDALLA NASSER
DEFINITIONS
•seizure: transient neurological dysfunction caused by excessive
activity of cortical neurons, resulting in paroxysmal alteration of
behavior and/or EEG changes
• epilepsy: chronic condition characterized by two or more
unprovoked seizures
An epileptic seizure can be defined as: a sudden synchronous
discharge of cerebral neurones causing symptoms or signs that
are apparent either to the patient or an observer.
Epilepsy is a recurrent tendency to spontaneous, intermittent,
abnormal electrical activity in part of the brain, manifesting as
seizures.
Using the definition of epilepsy as two or more
unprovoked seizures, the incidence of epilepsy is
∼0.3– 0.5% in different populations throughout the
world, and the prevalence of epilepsy has been
estimated at 5–10 persons per 1000.
The incidence of epilepsy is age-dependent, being
highest at the extremes of life, most cases starting
before the age of 20 or after the age of 60. The
cumulative incidence (lifetime risk) of epilepsy is
over 3% and the lifetime risk of having a single
seizure is 5%.
PARTIAL SEIZURES
simple (preserved LOC)
motor: postural, phonotory, forceful turning of eyes and/or
head, focal muscle rigidity/jerking ± Jacksonian march
(spreading to adjacent muscle groups)
sensory: unusual sensations affecting vision, hearing, smell,
taste, or touch
autonomic: epigastric discomfort, pallor, sweating, flushing,
piloerection, pupillary dilatation
psychiatric: symptoms rarely occur without impairment of
consciousness and are more commonly complex partial
complex (altered LOC)
patient may appear to be awake but with
impairment of awareness
classic complex seizure is characterized by
automatisms such as chewing, swallowing,
lipsmacking, scratching, fumbling, running,
disrobing, and other stereotypic movements
other forms: dysphasic, dysmnesic (deja vu),
cognitive (disorientation of time sense),affective
(fear, anger), illusions, structured hallucinations
(music, scenes, taste, smells),epigastric fullness
GENERALIZED SEIZURES
(DECREASED LOC)
absence (petit mal): usually only seen in
children, unresponsive for 5-10 s with arrest of
activity, staring, blinking or eye-rolling, no
post-ictal confusion; 3 Hz spike and slow
waveactivity on EEG
clonic: repetitive rhythmic jerking movements
tonic: muscle rigidity in flexion or extension
tonic-clonic (grand mal, generalized tonic-clonic [GTC])
prodrome of unease or irritability hours to days before the
episode
tonic ictal phase: muscle rigidity
Hippocampal sclerosis
• EEG
TREATMENT
avoid precipitating factors
indications for medical therapy (anticonvulsants): 2 or
more unprovoked seizures, known organic brain
disease, EEG with epileptiform activity, first episode of
status epilepticus, abnormal neurologic examination or
findings on neuroimaging
psychosocial issues: stigma of seizures, education of
patient and family, status of driver’s license,pregnancy
issues
safety issues: driving, operating heavy machinery,
bathing, swimming alone
consider surgical treatment if focal and refractory
Generalized seizure ;Phenytoin
/Carbamazepine
/NaValproate/Phenobarbital/Levetiracetam
Partial complex seizure Carbamazepine
Absence seizure ;Ethosuxomide
Myoclonic seizure; Valproate
Add-on therapy
Gabapentin/Lamotrigine/Topiramate/Levetiracet
am
STATUS EPILEPTICUS
This means seizures lasting for >30min, or
repeated seizures without intervening
consciousness.or successive seizures without return
to abaseline state
Mortality and the risk of permanent brain damage
increase with the length of attack.
complications: anoxia, cerebral ischemia and
cerebral edema, rhabdomyolysis and renal failure,
aspiration pneumonia/pneumonitis, death (20%)
Treatment
1 Lorazepam: 0.1mg/kg (usually 4mg) as a slow bolus into a large vein. If no response
within 10min give a second dose. Beware respiratory arrest during the lastBpart of the
injection. Have full resuscitation facilities to hand for all IV benzodiazepine use. The
rectal route is an alternative for diazepam if IV access is diffi cult.1 Buccal midazolam
is an easier to use oral alternative; dose for those 10yrs old and older 10mg; if 1–5yrs
5mg, if 5–10yrs 7 . 5mg; squirt half the volume between the lower gum and the
cheek on each side. While waiting for this to work, prepare other drugs. If fi ts
continue …
2 Phenytoin infusion: 15–20mg/kg IVI (roughly 1g if 60kg, and 1 . 5g if 80kg; max
2g), at a rate of ≤50mg/min (don’t put diazepam in same line: they don’t mix). Beware
BP and do not use if bradycardic or heart block. Requires BP and ECG monitoring.
100mg/6–8h is a maintenance dose (check levels). If fi ts continue …
3 Diazepam infusion: eg 100mg in 500mL of 5% dextrose; infuse at about 40mL/h