EPILEPSY PART I 2013

Sam lazuardi

EPILEPSY National Institute of

Neurol. Disorders and Stroke
Is a brain disorder that causes people
to have recurring seizures
The seizures happen when clusters of
nerve cells, or neurons, in the brain
send out the wrong signals
People may have strange sensations
and emotions or behave strangely
They may have violent muscle spasms
or lose consciousness

SEIZURES - EPILEPSY
TWO in 100 people has experienced an
unprovoked seizure at some point in life
A solitary seizure does not mean an epilepsy
High fever, severe head injury, lack of oxygen
can affect the brain enough to cause a single
seizure

EPILEPSY MENTAL ILLNESS

Epilepsy in not contagious
Epilepsy is not caused by mental illness or
mental retardation
Many people with epilepsy have normal &
above average intelligence (Socrates, Alfred
Nobel)

EPILEPSY SYMPTOMS

Seizure = abn activity of brain cellls ->

temporary confusion
A staring spell
Uncontrollable jerking movements of the arms
and legs
Loss of consiousness or awareness
Symptoms are similar each time
5

2 KIND OF SEIZURES
Kinds of seizures : 2 major categories : focal
& generalized seizures
Focal seizures partial seizures occur in one
part of the brain (60 % of epilepsy)
Simple focal: conscious but experience
unusual feelings (joy, anger, sadness, nausea
or hear, smell, taste, see or feel things that are
not real

SIMPLE FOCAL / PARTIAL S

The more restricted the brain region involved,
the more limited the symptoms & the less likely
consciousness will be impaired : aura = abn
sensations (smells, flashing lights, somatosensoric symptoms etc) or experimental phenomenon (hallucination, dj vu)
Seizure in motor cortex focal clonic S
Jacksonian march : progressive focal S

4/6/16

COMPLEX FOCAL SEIZURES

Focal Seizure spreads & becomes unconsious
= complex partial seizures
Change (dreamlike experience) or loss of
consciousness & showed repetitious
movements (automatism), staring, blinks,
twitches, washing dishes & nonpurposeful
movements (hand rubbing, chewing,
swallowing or walking in circles)
9

10

11

PRIMARY GENERALIZED S-1

Abnormal neuronal activity on both sides of
the brain, loss of consciousness, falls &
massive muscle spasms
1.Absence seizures (petit mal), familial
staring, jerking, twitching (< 30 seconds
unresponsiveness), may disturb concentration,
but not IQ, starts in childhood & stop during
puberty EEG 3 Hz spike & wave
12

PRIMARY GENERALIZED S-2

2. Tonic seizures : stiffening of muscles of
the body (back, legs, arms) & may cause fall
to the ground (EEG 10 Hz or faster)
3.Clonic seizures : repeated jerking
movements of muscles on both sides of the
body
4.Myoclonic seizures : sudden brief jerks
or twitches of upper body, arms or legs
(EEG : generalized spike polyspike & wave)
13

PRIMARY GENERALIZED S-3

5. Atonic seizures (drop attacks ): loss of
normal muscle tone, drop head involuntarily sudden collapse or fall down
6.Tonic clonic seizures (grandmal) : stiffening of the body & repeated jerks of arms
legs, loss of consciousness, loss of bladder
control or biting the tongue (EEG : generalized 10 Hz during tonic followed by slow
waves or sharp & slow waves during clonic)
14

COMPLEX PARTIAL S (CPS)

ABSENCE S (AS) DIFFERENCE
CPS preceded by aura
CPS last 90 seconds, AS only 10 15 sec
Following CPS confused, postictal
cognitive problem
AS no postictal state, return to baseline
cognitive state
Automatisms common on both

4/6/16

15

OTHER KINDS OF EPSY (1)

1.Temporal lobe epilepsy (TLE) :
most common, focal seizures with aura,
begins in childhood, frequent seizures cause
hippocampus shrinkage memory &
learning problems treat early !

16

OTHER KINDS OF EPSY (2)

2. Neocortical epilepsy : from brains cortex,
focal or generalized, strange sensations,
visual hallucinations, emotional changes,
muscle spasms, convulsions depending on
where it originate

17

OTHER KINDS OF EPSY (3)

3.Lennox-Gastaut sy (children): severe
epsy, different types of seizures incl. atonic
seizures (sudden falls / drop attacks), very
hard to treat
4.Rasmussens encephalitis : progressive
epsy, continual inflammation in half of
brain radical hemispherectomy

18

OTHER KINDS OF EPSY(4)

5. Benign epsy sy (benign myoclonic epsy &
benign neonatal convulsions) do not impair
cognitive functions, easily treated & stop
spontaneously
5.Infantile spasms, most common seizures,
started before 6 mo, infant bend & cry out
during attack, anticonvulsant dont work
ACTH or prednisone
19

NONEPSY SEIZURES (1)

1. First seizure : seizure occur in reaction to
anesthesia, strong drug (unless a family history of
epsy or brain damage) no 2nd attack.
2nd attack within 4 yrs (33 %)
Risk 3rd attack after 2nd attack 73 % (4 yrs)
After 2nd attack anticonvulsant therapy
Idiopathic epsy (children) seizure free after 20
yrs (68 92 %) not included severe epsy

20

NONEPSY SEIZURES (2)

2. Febrile seizures: high fever in child + seizure,
epilepsy
3. Psychogenic seizure dependence, attention
seeking, stressful conditions
4. Other nonepsy seizures : narcolepsy,
Tourette sy, cardiac arrhythmia
5. Eclampsy (pregnancy, hypertension,
seizures)

21

NONEPSY SEIZURES (3)

1.Physiologic nonepsy seizures : hypoglycemia, hyponatremia, cardiac arrhytmia,
syncope, migraine, TIA, eclampsia, benign
febrile convulsion
2. Psychogenic nonepsy seizures : stressful
psychological conflicts or major emotional
trauma

22

PSYCHOGENIC SEIZURES

Seizures are usually witnessed

No seizures-related injuries
Begin slowly & escalates in intensity
Cry in the middle or at the end
Movements affect left & right alternately
Unusual posturing & symptoms are not similar
Postictal state is brief & wake up immediately
D/ video / EEG monitoring
23

Epilepsy Pregnancy Mother-hood (1)

Normal baby 90 %, birth defects risk 4 6 %,
epilepsy risk 5 % (except hereditary form)
Diagnosis amniocentesis, high level maternal
serum alphafetoprotein test prenatally
Valproate, phenytoin, trimethidone risk for birth
defect (cleft palate, heart problems, finger toe
defect) change medications before pregnancy

4/6/16

24

Epilepsy Pregnancy Mother-hood (2)

Dont stop medication during
pregnancy
Seizure during pregnancy (25 40 %)
due to blood volume dilution effect,
stress & lack of sleep
Add folic acid (prevent birth defects) &
vit k (to reduce risk of neonatal
coagulopathy result from fetal exposure to
epsy drugs)
4/6/16

25

Epilepsy Pregnancy Mother-hood (3)

Anti epsy drug IV & monitor blood levels of
epsy drug during labor (drugs to be
decreased)
Breast feeding outweigh risks (minor
amounts of drugs secreted in breast milk)

4/6/16

26

ANTICONVULSANT & THE

DEVELOPING BRAIN
To prevent neural tube defects (anencephaly, spina bifida) women should take
a 400 microgram of folic acid supplement
every day, beginning about 1 month
before conception & continuing until at
least the end of the first trimester of
pregnancy (over the counter supplements
of 1000 micrograms = 1 mg per day is
safe during pregnancy)
4/6/16

27

EPILEPSY & AUTISM (HealthDay, 5

Dec 2011)
Fetal exposure in uterine to epilepsy drug
valproate might raise autism risk nearly
three times higher and almost five times more
likely to have early onset autism
Autistic teens with epilepsy are often light sensitive

CATAMENIAL EPILEPSY (HealthDay 3

Dec 2011)
Seizures among women of childbearing age
with epilepsy may worsen during menstruation
or ovulation : catamenial epilepsy
Two-third of them had a diagnosis of partial
epilepsy & the rest had primary generalized
epilepsy
About 75 % of them are medically refractory
seizures, resistant to treatment and a high
percentage of them reported having more
seizures during pregnancy

FEBRILE SEIZURES (FS)1

Convulsions by a fever in infants - small
children, lose consciousness, shakes, moving
limbs on both sides, lasting a minute or two,
rectal temp > 102 F (38.8 C), occur during
the first day of fever and not to be considered
to have epilepsy
One in every 25 children & more than 1/3 will
have additional FS & outgrow them
30

FEBRILE SEIZURES (FS)2

FS occur between 6 mo 5 yr
Rarely before 6 mo or after 3 yrs
Risk factors : frequent fevers & family
history
FS are short & harmless (normal school
achievement)
95 % FS do not develop epilepsy

31

FEBRILE SEIZURES (FS)3

FS management as Fist Aid for Seizure

FS lasting > 10 min -> hospital
Look for cause of fever
Treat fever with acetaminophen
Prolonged use of anticonvulsant not
recommended
Prone to FS : diazepam oral or rectally
32

WHEN TO SEE A DOCTOR

Seizure lasts more than 5 minutes
Breathing or consiousness does not return after
seizure stops
A second seizure follows immediately
A high fever, heat exhaustion, pregnant,
diabetes & injure yourself during seizure
After 1st seizure, seek medical advice

33

EPILEPSY CAUSES - 1
Has no identifiable cause in about half of those
who have epilepsy
The other half may be traced to various factors
:
1. Genetic influence (run in families) about
500 genes making a person more susceptible
to environmental conditions that trigger
seizures
34

EPILEPSY CAUSES - 2
2. Head trauma (car accident & other traumatic
injury)
3. Medical disorders (stroke & heart attacks
that causing brain damage, stroke is responsible for up to one-half cases over age 35)
4. Dementia (leading cause among older
adults)

35

EPILEPSY CAUSES - 3
5. Diseases ( meningitis, AIDS, viral
encephalitis)
6. Prenatal injury (before birth they are susceptible to brain damage caused by infection
in the mother, poor nutrition or O2 deficiency,
which can lead to CP 20 % of seizures in
children associated with CP or other
neurological abnormalities)
36

EPILEPSY CAUSES - 4
7. Developmental disorders, such as autism
and Down syndrome
8. Imbalance in neurotransmitter (abnormal
high excitatory neurotransmitter or abnor-mal
low inhibitory neurotransmitter GABA)
9.Brain tumors, especially metastatic tu
10. Systemic metabolic derangements

37

METABOLIC CAUSES OF SEIZURES

Hypocalcemia, hyponatremia,
hypoglycemia
Liver failure, renal failure
Anoxia
Nonketotic hyperglycemic states
Inherited metabolic diseases
(aminoaciduria, urea cycle disorder)

4/6/16

38

DRUGS CAUSING SEIZURES

Cocaine & amphetamine
Toxic levels of penicillin, lidocaine,
aminophylline, isoniazid
Phenothiazine, tricyclic antidepressant
lower seizure treshold
Drug withdrawal : alcohol, barbiturat,
benzodiazepine

4/6/16

39

RISK FACTORS -1
1.Age : onset of epilepsy is most common
during early childhood and after age 65, but
the condition can occur at any age
2.Sex : men are slightly more at risk
3. Family history : if you have a family history of epilepsy
4. Head injury, reduce by wearing seat belt and
helmet
40

RISK FACTORS -2
5. Stroke and other vascular diseases
6. Brain infections (meningitis)
7. Prolonged sezures in childhood (high fevers
in childhood can sometimes associated with
prolonged seizures)

41

HEAD TRAUMA CAUSING EPILEPSY

Open head trauma (ht) associated with
50 % chance of developing epilepsy
Closed ht carries a lower risk 5 %
Factors predisposing epilepsy following ht
seizure within 2 wks of injury included
depressed skull fracture, cerebral
contusion, subarachnoid bleeding

4/6/16

42

TRIGGER FACTORS
Seizures are often triggered by lack of sleep,
stress, hormonal changes associated with
menstrual cycle , excessive alcohol
consumption , smoking and recreational
drug usage

43

EPILEPSY DIAGNOSIS (1)

1.EEG monitoring : 24 hrs awake & sleeping record &
video monitoring
2.Brain scan : CT-scan or MRI brain structure (tumor,
cyst, bleeding etc)
3.Medical history : detailed history (seizures, past
illnesses, other symptoms) caregiver information is
very important

4.
44

EPILEPSY DIAGNOSIS (2)

4.Blood tests in children for metabolic or
genetic disorders associated with seizures and to
look for underlying cause (infections, lead
poisoning, diabetes, anemia)
5.Neurological & behavioral tests (how seizures
are affecting your behavior & intellectual
capacity
6. At least 2 unprovoked seizures are
required for epilepsy diagnosis
45

sence epsy - Anteriorly dominant, ty

Hz spike & wave discharges
46

Polyspike and wave discharges seen in

juvenile myoclonic epilepsy

47

EPILEPSY COMPLICATIONS-1
1. Falling : you can injure your head or break a bone

2. Drowning : 13 times more likely to drown (swimming

or bathing), because of having a seizure in water
3. Car accidents : drivers licensing restrictions
4. Pregnancy complications : seizures during pregnancy
pose dangers to mo & baby; certain anti-epileptic drugs
increase birth defects, important to work with your
doctor to plan your pregnancy
5. Emotional health issues : prone to depression, anxiety
and suicide
49

EPILEPSY COMPLICATIONS-2
6.Status epilepticus : continous seizure activity lasting
more than 5 minutes or frequent seizures without regaining full consciousness in between them -> increased
risk of permanent brain damage and death.
7. Sudden unexplained death in epilepsy (SUDEP).
Risk of SUDEP is particularly elevated when generalized
tonic-clonic seizures are frequent & the risk in one year
period could be 1 in a 100 (usually 1 in 1000).
50