epilepsy 2nd bsc

7/29/2019 Epilepsy 2nd Bsc

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EPILEPSY


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Dr Md MahbubulAlam

AssistantProfessor

Department of Neuro-Medicine

Dinajpur Medical College, Dinajpur.


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Epilepsy is one of the commonest neurological disorder

50 million people have epilepsy at any time

5% people in the world may have at least 1 seizure in theirlife time

Of 50 million 80% are in under developed countries

It has profound social physical physiological and economicconsequence.

WHO05

Neuro Asia04


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Seizure

An abnormal clinical event cause by sudden,

abnormal, excessive, disorderly electrical

discharge from cerebral neurons.

Epilepsy-

Unprovoked recurrent seizure. i.e. seizure

occurring more than once in adult & twice in

children.


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WHO definition of epilepsy

WHO dictionary defines epilepsy as chronic brain disorder of variousaetiologies characterized by recurrent unprovoked seizure due toabnormal excessive discharge of cerebral neurons, associate with avariety of clinical and laboratory manifestation.

Recurrent

Stereotyped awareness to surrounding may be impaired/ behavioraltered

Motor, sensory, autonomic, psychic

Sudden onset, ceased spontaneously Post- ictal phase

Bradley05


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Epidemiology - Epilepsy

Magnitude of problem- Epilepsy / Seizure 3rd most common chronic neurological disorder after

headache

Epidemiological picture is difficult to obtain because Episodic nature

Diagnosis essentially clinical

Relaying on patients account / Eye witness description

Verities of other condition can be confused

Between seizure, both clinical examination and investigationmay be perfectly normal

Ref- Neuro Asia 04.


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INCIDENCE IT IS HIGHER IN UNDERDEVELOPED

COUNTRIES

INCEDENCE RATE IS HIGH DURING FIRST YEAR

OF LIFE, DECLINE THROUGH CHILDHOOD AND

ADOLESCENCE AND RISE SHARPLY AGAIN

AMONG ELDERLY


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ETIOLOGYFIRST 6 MONTHS OF LIFE

SEVER BIRTH INJURY

CONGENITAL DEFECTS

INBORN ERROR OF METABOLISM

BETWEEN 2 AND 20YRS

BIRTH INJURYINFECTIONS

TRAUMA AND GENETIC FACTORS


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CONTD..

BETWEEN 20 TO 30YRS

STRUCTURAL LESIONS SUCH AS TRAUMA,

BRAIN TUMORS OR VESCULAR DISEASE

AFTER 50YRS

CEREBROVASCULAR LESIONS

METASTATIC BRAIN TUMORS

IDIOPATHIC


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PHASES PRODROMAL PHASE

AURAL PHASE

ICTAL PHASE

POST ICTAL PHASE


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Scenario of epilepsy-Developed/underdeveloped Face to Face

5-10% of population:- At least one seizure during their life time 4-10-/10,000active epilepsy

Race:- Black > White, Rural > Urban Age Extremes of life

Sex : Male >Female (2-2.4 times)

Possible explanation of disparity Profound contrast in Socio-economic structure

Poor pre/ peri-natal care, Birth injury

Malnutrition, Poor sanitation

Increased CNS infection, parasitic disease

Trauma, drug/substance abuse, violence

Prostitution, HIV infection

Treatment influence by combination of local, social perception, govt. policies and AEDavailability.

Bradiey05

WHO05

Developed Countries Under developed countries

Incidence/ 1000000/ year

40-70

UK-50

USA-2 million

100-190

Latin America

144-190

India, liberia, Nigeria 10/1000


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Scenario of epilepsy in-INDIA

Prevalence: 10 / 1,000

Number of patients 1.3 million

Treatment modality Homeopath, Kobiraz, Ojah, Snake Charmer, Spiritual

Leaders --- 70%

Medical access Very poor

High dropout.

Ref- Neuro, sc,04(4)


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SEIZURE TYPES


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CLINICAL MANIFESTATIONS GENERALIZED SEIZURES

TONIC CLONIC

LOSS OF CONSCIOUNESS

FALLING TO THE GROUND

STIFFENING OF THE BODY FOR 10-20SEC

SUBSEQUENT JERKING OF THE EXTREMITIES

CYNOSIS

EXESSIVE SALIVATION

TONGUE BITE OR CHEEK BITE

INCONTINENCE MAY ACCOMPANY THE SEIZURE

3/22/2013


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CONTD..

TYPICAL ABSENCE SEIZURESBRIEF STARING SPELL

BRIEF LOSS OF CONSCIOUSNESS

ATYPICAL ABSENCE SEIZURES

STARING SPELL ACCOMPANIED BY OTHER SIGNS

AND SYMPTOMS.

3/22/2013 ARUN PIRAVOM


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CONTD..

MYOCLONIC SEIZURESCHHRACTERIZED BY A SUDDEN, EXESSIVE

JERK OF THE BODY OR EXTREMITIES.

TONIC SEIZURES

SUDDEN ONSET OF MAINTAINED

INCREASED TONE IN THE EXTENSORMUSLES,PATIENTS OFTEN FALL.



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CONTD..

ATONIC SEIZURES

IT INVOLVE EITHER A TONIC EPISODES OR A

PAROXYSMAL LOSS OF MUSCLE TONE AND

BEGIN SUDDENLY WITH PERSON FALLING TO

THE GROUND



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CONTD..

CLONIC SEIZURES

BEGINS WITH LOSS OF CONSCIOUSNESS

SUDDEN LOSS OF MUSCLE TONE, FOLLOWED BYLIMB JERKING THAT MAY OR MAY NOT BE

SYMMETRIC



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CONTD..

PARTIAL SEIZURES

EX: IF THE DISCHRGING FOCUS IS LOCATED IN

MEDIAL ASPECT OF THE POST CENTRAL GYRUS,

PATIENT MAY EXPERIENCE PARASTHESIAS AND

TINGLING OR NUMBNESS IN THE LEG ON THE SIDE

OPPOSITE THE FOCUS.



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Etiology

Seizures in general can be caused by any disorder that altersthe neuronal environment, so anyone can theoreticallyexperience a seizure

Onset of a seizure may indicate a previously existing, ongoingprimary neurological disease

Etiologic factors in seizures generally include

Cerebral lesions

Biochemical disorders

Cerebral trauma

Epilepsy In short, anything from illness to brain

damage to abnormal brain development
http://growabrain.typepad.com/photos/uncategorized/2008/03/04/brain_power.jpg


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Etiology, cont

Epilepsy can result from numerous conditions depending on the age

of the person experiencing the syndrome, including but not limited : metabolic defects

congenital malformations

genetic predisposition perinatal injury

postnatal trauma

mycological syndromes

Infection brain tumor

vascular disease

fever

drug or alcohol abuse
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Patho-physiology

Up regulation of excitatory system or

Down regulation of inhibitory system

Imbalance between excitatory system and

inhibitory system facilitates cellular influx ofNa+, K+ & Ca2+ and causes repetitive firing of

neuron & produce seizure.


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inhibitory neurons

stimulatory neurons

SYNAPTIC ARRANGEMENT


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inhibitory neurons less active

Stimulatory neurons overactive

EXCESSIVE ACTIVITY


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Aetiology

Gray matter lesions are mere likely to causeseizure/ epilepsy than pure white matter lesion

Etiology is often multiple combination of acquiredand genetic factors

Etiology is very much age related 60 to 70% of all

epilepsies are cryptogenic

Ref- Bradley 05


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Aetiology Contd

VascularCVDlate onset epilepsy

Infectionsviral, bacterial, protozoal, fungal

Traumatic acute, late post traumatic (PTE)

AutoimmuneSLE

MetabolicHypoxia, Hyponatrima, Hypoglycemia

(Drugs)Quinolones

NeoplasticPrimary/ Secondary

Degenerative MLD

DemylenatingM.S

DevelopmentalCortical dysphasia, congenital deformity.


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myoclonic seizures

atonic seizures

generalized tonic-clonic seizurescomplex partial seizures

clonic seizurestonic seizures

partial progressing to generalized seizures

absence seizuressimple partial seizures

Generalized EpilepsyPartial (Focal) Epilepsy

ILAE CLASSIFICATION


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MANIFESTATIONS

C A M P S

A

autonomic system disturbed

C

Consciousness altered

M

motor manifestations

Ssensory manifestations

P

psychic manifestations


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PARTIAL EPILEPSY


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S - tingling, numbness, electric shock-like

feeling, burning, pain, heat, altered smell,

taste

last for few seconds

A - changes in skin color, BP, HR, pupil size,

pilo-erection

P - dysphasic, dysamnesic, cognitive,

affective, illusions, hallucinations

M - muscle spasms (march) or jerking

C - no loss of consciousness

MAIN FEATURES

SIMPLE PARTIAL SEIZURES

xx

x

Frontal lobeParietal lobe

Occipital lobe

Temporal lobe


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GENERALIZED EPILEPSY


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GENERALIZED EPILEPSY


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further progression to generalized

seizures

begins like partial seizures

MAIN FEATURES

SECONDARY GENERALIZED SEIZURES

M li d f il


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Malignant syndromes of epilepsy

Strong evidence of cognitiveimpairment, learning disorderand progressive in course.

Combination of multiple seizuretype

Poor out come

Very difficult to control by AEDs

They includes Infantile spasms\ west syndrome

Lennox Gastaut syndrome

Tuberous sclerosis

Sturge- weber syndrome


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DIAGNOSIS

History

EEG

CT scans or MRI to rule out brain

lesion


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History

Birth history

About Febrile seizure

Injury & infection

Drug addiction

Past history


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PHYSICAL EXAMINATIONS

General examinations- pulse, BP, signs of trauma,

tongue bite, neuro-cutaneous manifestations etc

Examination of nervous system


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Investigations

EEGA sensitive tools but must be used with clinical data. Mainly done to find out the clinical type of seizure Single interictal EEG is 30-50% sensitive

3-4 interictal standard recording (>30mins) with provocationis 60-70% sensitiveAdvanced procedure: EEG with special electrodespheroidal

or foramen ovale & telemetric EEG with video monitoring ofpatient 90% sensitive.

So 10% epilepsy is EEG negative

23% normal person may have abnormal EEG.


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Indications of brain imaging in epilepsy

Late in onset after 20 years of age

Partial 20 generalized in type

Refractory to drug Rx. Or deteriorates

Focal neuro-deficit

Status Epilepticus

Suspected ICSOL

EEG shows a focal seizure source


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Treatment

Principles of treatment

Diagnosis of epilepsy including types of seizure

To find out possible aetiology.

Indication of treatment. Selection of drug. It depends on-

Types of epilepsy

Price of drug

Toxicity of drug

Drug interaction

Drug availability


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Immediate care of seizures

Must be given to every epileptic patientsirrespective of country or place First aid by relatives & witness Dos

Loosen tight clothes, if any (Knot of tie, buttons etc)

Move sharp objects away from the person. Move the person away from danger. (fire, water, machinery, furniture, road

etc).

After convulsion stopsturn into semiprone position.

Ensure airway is clear.

Note the duration of attack.

If seizure continues >5mins or recur or the person is injured take medicalhelp.

Person may be drowsy and confused for 3060mins. So, should not be leftalone until fully recovered.


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Tx

A. Medications used to treat patients with epilepsy arecalled anticonvulsants.

1. These drugs each have a differentmechanism of action, but all serve toreduce the frequency of epilepticseizures.

2. Monotherapy, treatment with a singleagent, is the goal.

3. Many seizures will stop withoutpharmacological intervention.


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Treatment

Donts Dont panic, most seizures are self-limiting and not life threatening.

Dont restrict the persons movements.

Dont allow crowd near the person.

Dont forcfully insert anything in the persons mouth.

Dont offer anything to eat or drink till the person is fully conscious.

Immediate Medical care

Ensure airway is clear

Give O2 to combat cerebral hypoxia.

Give I/V or P/ R diazepam if convulsion continues >10 mins or repeated, and

then send to nearby hospital. Take blood for anticonvulsant levels (if known epileptic and taking antiepileptic

drugs)

Investigate for cause


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Treatment

Anticonvulsant therapy (Medical treatment)-

Indications :-

Single seizure with definite structural lesion.

Single seizure with abnormal EEG.

More than one unprovoked seizure for adult.

More than two unprovoked seizure for children.

One seizure with strong +ve family history of epilepsy

Single seizure with high risk job

Single seizure with mental disorder.


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Treatment

Guide line for AEDs Therapy

Start with 1st line drug( 80% controlled). Try to select appropriate drug with 1/3or th of optimum dose.

Start with low dose, gradually increase to minimum effective dose or till controlof seizures or side effects. If seizure is uncontrolled with highest dose, test for

serum drug level. Use minimum division of doses.

Check compliance

If first drug fails (seizure continues or side effects) start 2 drug from the 1st linewhilst gradually withdrawing the first.

Try three agents singly from 1st line before using combination. Dont use more than two drugs in combination at any one time.

If above fails, consider whether any structural or metabolic lesion present orreview diagnosis.


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About 80% of patients responds to mono-

therapy.

20% need polytherapy.


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Duration of therapy

3 5years after the last attack

Single drug can control 80% of epilepsy

Dose regimens should be kept as simple as

possible to ensure compliance.


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Prognosis

Primary generalized than partial or 20 generalized seizure.

In structural lesion complete control less likely.

out come after 20 yrs.

50-60% seizure free after withdrawal of drugs

20-30% seizure free with drugs

In 20-30 seizures present in spite of AEDs


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Withdrawal of AED therapy

At least 3-5 yrs after the last attack

Then withdraw gradually over 6 months

During and 6 months after withdrawal,

patients should follow the general safetyadvices.


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Rate of recurrence

Recurrence rate 40% within 6 months

9% in the next 6 months

8% in the following 12 months

Chance of recurrenceIn primary generalized seizure less

Dont withdraw

If focal deficit present Seizure focal or 20 generalized

Future attack may ruin is employment (e.g. driver) or endanger life.

If seizure recurs.


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Intractable Epilepsy

About 5% Epilepsy are intractable

At least 5 of the major anti-epileptics have failedin adequate doses

Second level intractability is defined as failure oftwo drugs

Third level intractability is defined as failure ofthree drugs and so on


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Factors underlying

Underlying structural lesion

Mental retardation

Concomitant metabolic disorders

Cerebral Palsy


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Surgical treatment

Indication

Intractable Epilepsy

Intra-cranial structural lesion


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Surgery

Surgical resection ofepileptogenic areas ofthe brain in patientswith partial seizures isconsidered when

seizure activity fails torespond to even themost aggressivemedical management.


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Epilepsy in special Situations

Epilepsy with pregnancy

Epilepsy in child bearing age

Status epilepsy

Epilepsy and driving


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Febrile convulsion

Age 6 months to 5 yrs common between 9-20 months

Recurrent in 50% cases

Seizure usually occurs when fever is raising

Treatment

Reduction of temperature and per-rectal diazepam

Prophylaxis is debatable, but should be given in complex febrile seizureand in EEG change

Out come Complicated (Focal, prolonged or repeated) - 30% in develops epilepsy

in later life

Simple 2.4% develops epilepsy in later life.


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Status epilepticus

Predisposing factors

Sudden withdrawal of AED.

Presence Of Structural Lesion

Acute metabolic disturbances


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TREATMENT

General- ABC Collection of blood sample for glucose, electrolytes

and for future analysis. Infusion of 25% glucose Inj. Thiamin 100 mg if patient is alcholic

Specific-

Diazepam 5mg iv stat, 2 mins after another 5mg

If not control within 15 mins- repeat 10 mg diazepamor Lorazepam and wait 15 mins, if not controlledshiftthe patient in icu


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Contu-- Persisting of seizure after 30 mins-

Loading dose phenytoin or fosphenytoin iv15mg\kg or phenobarbitone 10mg\kg

If seizure is still continues-

Treatment for refractory status withintubation and GA by Propofol or thiopental

Once status controlled Long acting AEDSshould be started.


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Restrictions of epilepsy patients

Work or recreation above ground level

Work with dangerous machinery, fire or water.

Should take shallow bath in presence of relatives No cycling till 6 months seizure free

Swimming, fishing , boating always be

accompanied by others who knows about his orher illness.


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Prevention

There is no way to prevent seizures


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Treatment is not always indicated after a singleseizure.

After a second and third seizure, the risk of

further seizure increases to about 75% andtreatment is indicated.

Seizure control is achieved in most individualwith the single medication.

Principles of poly pharmacy guides the choice ofdrugs with different mechanisms of action.


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Conclusion (contd.)

After discontinuation of therapy, two-third of patients remain seizure-free.

Routine checking of drug levels is seldomindicated, but planned-checking may beneeded.

In refractory cases, surgery may be theoption of management.


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epilepsy 2nd bsc

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