EPILEPSY ANS

SEIZURES
PRESENTER : DR. SHREYA
MODERATOR : DR. RAKESH JADAV

INTRODUCTION

CONVULSION : referring as it does to an intense

paroxysm of involuntary repetitive muscular
contractions

SEIZURE : is a paroxysmal event due to abnormal

excessive or synchronous neuronal activity in the
brain
Incidence: 5-10 % in general population

EPILEPSY : two or more unprovoked seizures

incidence of epilepsy is 0.30.5%
prevalence of epilepsy is 510 persons per 1000

CLASSIFICATION

Focal seizures
(Can be further described as having motor, sensory,
autonomic, cognitive, or other features)
Generalized seizures

Absence
Typical
Atypical
Tonic clonic
Clonic
Tonic
Atonic
Myoclonic

May be focal, generalized, or unclear

Epileptic spasms

EPILEPSY SYNDROMES

Autosomal dominant nocturnal frontal lobe

epilepsy (ADNFLE)
Benign familial neonatalconvulsions (BFNC)
Generalized epilepsy with febrile seizures plus
(GEFS+)
Autosomal dominant partial epilepsy with
auditory features (ADPEAF)
Progressive myoclonus epilepsy
Juvenile myoclonic epilepsy
Lennox gastaut syndrome
Mesial temporal lobe epilepsy syndrome

FOCAL :
Localized to one hemisphere
Types:
1. Focal seizures without dyscognitive
features:

Typically clonic at a frequency of 23 Hz

Jacksonian march
Todds paralysis
Epilepsia partialis continua
Parasthesias
Autonomic features
Illusion
Deja vu

2. Focal seizures with dyscognitive features

localized seizures with transient impairment
of the patient's ability to maintain normal
contact with the environment

Aura
Ictal phase with Automatisms
Post ictal confusion , Anterograde amnesia
Post ictal aphasia

GENERALIZED TONIC CLONIC SEIZURES

10% of seizures
Tonic contraction of muscles throughout the
body
"ictal cry."
Respirations are impaired, secretions pool in the
oropharynx, and cyanosis develops.
Contraction of the jaw muscles
A marked enhancement of sympathetic tone
After 1020 seconds, the tonic phase of the
seizure.
postictal phase :unresponsiveness, muscular
flaccidity, excessive salivation, bowel and
bladder incontinence

ABSENSE SEIZURES:
TYPICAL : sudden, brief lapses of consciousness
without loss of postural control.
4-8 years and adolesence
major seizure type
15-20% children with epilepsy
EEG : generalized, symmetric, 3-Hz spike-and-wave
discharge

ATYPICAL : the lapse of consciousness is usually of

longer duration and less abrupt in onset and
cessation
EEG : generalized, slow spike-and-wave pattern with a
frequency of 2.5 per second,

ATONIC SEIZURES :
Characterized by sudden loss of postural
muscle tone lasting 12 seconds.
Consiousness impaired
No post ictal confusion

MYOCLONIC SEIZURES:
Myoclonus is a sudden and brief muscle
contraction that may involve one part of the
body or the entire body

ETIOLOGY

NEONATES(<1 MONTH)
Perinatal hypoxia and ischemia
Intracranial hemorrhage and trauma
Acute CNS infection
Metabolic disturbances
Drug withdrawal
Developmental disorders
Genetic disorders

INFANTS AND CHILDREN (>1 MONTH AND <12 YEARS)

Febrile seizures
Genetic disorders (metabolic, degenerative, primary
epilepsy syndromes)
CNS infection
Developmental disorders
Trauma
Idiopathic
ADOLESCENTS (1218 YEARS)
Trauma
Genetic disorders
Infection
Brain tumor
Illicit drug use
Idiopathic

YOUNG ADULTS (1835 YEARS)

Trauma
Alcohol withdrawal
Illicit drug use
Brain tumor
Idiopathic

OLDER ADULTS (>35 YEARS)

Cerebrovascular disease
Brain tumor
Alcohol withdrawal
Metabolic disorders
Alzheimer's disease and other degenerative CNS diseases
Idiopathic

PATHOPHYSIOLOGY

Causes of Hyperexcitability:

excitatory post synaptic potentials (EPSPs)

inhibitory post synaptic potentials (IPSPs)
changes in voltage gated ion channels
alteration of local ion concentrations

MECHANISM OF SEIZURE
PRODUCTION
1. INITIATION PHASE
2. PROPAGATION PHASE

INITIATION PHASE
(1) high-frequency bursts of action
potentials
(2) hypersynchronization.

influx of extracellular calcium (Ca2+)

depolarization of the neuronal
membrane(BURSTING ACTIVITY)
opening of voltage-dependent sodium (Na +)
channels
generation of repetitive action
potentials(HYPERSYNCHRONIZATION)
hyperpolarizing afterpotential mediated by
GABA receptors or potassium (K+) channels

PROPAGATION PHASE
Recruitment of surrounding neurons via a number
of synaptic and nonsynaptic mechanisms,
including:
(1) an increase in extracellular K+
(2) accumulation of Ca2+ in presynaptic terminals
(3) depolarization-induced activation of the
N-methyl-D-aspartate
(4) changes in tissue osmolarity and cell swelling.
The recruitment of a sufficient number of neurons
leads to the propagation of seizure activity.

MECHANISM OF EPILEPTOGENESIS
Epileptogenesis refers to the transformation
of a normal neuronal network into one that
is chronically hyperexcitable
Initial injury : trauma, infection, hypoxia, stroke
Lowering of seizure threshold
Structural changes in neuronal network
reorganization or "sprouting" of surviving
neurons affecting its excitability of the
network

APPROACH TO
SEIZURES

CLINICALS
Identify whether it is a true seizure
h/o associated risk factors and predisposing
factors(sleep disturbances, systemic
diseases, electrolyte abnormalities
Past h/o head trauma, tumor, stroke ,infection
On examination look for neurocutaneous
markers, signs of liver cell failure
,organomegaly
Developmental milestones assessment in
children
Complete neurological examination

TREATMENT

Vital signs, respiratory and cardiovascular support.

GENERALIZED-ONSET TONIC-CLONIC
Valproic acid
Lamotrigine
Topiramate
FOCAL
Lamotrigine
Carbamazepine
Oxcarbazepine
Phenytoin
Levetiracetam
TYPICAL ABSCENSE
Valproic acid
Ethosuximide
ATYPICAL ABSENSE
Valproic acid
Lamotrigine
Topiramate

PHENYTOIN- 3-6 mg/dl

Gum hyperplasia
Lymphadenopathy
Hirsutism
Osteomalacia
Facial coarsening
Skin rash
CARBAMAZEPINE- 600-1800 mg/day
Aplastic anemia
Leukopenia
Gastrointestinal irritation
Hepatotoxicity
Hyponatremia

VALPROATE: 20-60 mg/kg

Hepatotoxicity
Thrombocytopenia
Gastrointestinal irritation
Weight gain
Transient alopecia
Hyperammonemia
LAMOTRIGINE : 150-500mg
Skin rash
Stevens-Johnson syndrome

ETHOSUXIMIDE : 20-40 mg/kg

Gastrointestinal irritation
Skin rash
Bone marrow suppression
TOPIRAMATE : 200-400mg/dl
Renal stones
Glaucoma
Weight loss
Hypohidrosis

STATUS EPILEPTICUS

Status epilepticus refers to continuous

seizures or repetitive, discrete seizures with
impaired consciousness in the interictal
period
> 2 episodes in 30 mins.

Initial assessment Ensure adequate

ventilation, oxygenation, blood pressure
Intubate if necessary, based on low oxygen
saturation and labored breathing
Insert intravenous line ,Administer glucose
and thiamine in appropriate cirumstances
,Send toxic screen
Assess quickly for cranial and cervical injury
if onset of seizures is unwitnessed

THANK YOU