EPILEPSY

Dr. FITRIYANI Sp.S

DEFINITION
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

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




ETIOLOGY
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)
Factors lowering seizure threshold
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
International Classification of Epileptic Seizures
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
Simplified Classification of Epileptic Seizures
Partial seizures
Simple preservation of awarness
Complex impairment of consciousnesss
Secondary generalized
Generalized seizures
Absence
Myoclonic
Tonic-clonic
Tonic
Atonic
Diagnosis
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



E E G
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
EEG

EEG
BRAIN IMAGING
Essential, particularly in partial onset
seizures
Computerized tomography (CT)
Magnetic resonance imaging (MRI)


Structural lesion
MRI
MRI
MRI
Scan
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
DIFFERENTIAL DIAGNOSIS
Migraine
Transient Ischaemic Attacks
Hyperventilation
Tics
Myoclonus
Hemifacial spasm
Syncope
Sleep disorders
Non Epileptic Attacks
Narcolepsy
Metabolic disorders
Transient global amnesia
Management
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
Surgical treatment
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
Strategies for managing newly diagnosed
epilepsy
Newly diagnosed epilepsy
First drug
Second drug
Refractory
Rational duotherapy
Surgical assessment
Seizure-free
Seizure-free
47%
13%
40%
Drug choice in newly diagnosed epilepsy in
adolescents and adults

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
Prognosis
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

Special Problems of Epilepsy
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