EPILEPSY (SEIZURE DISORDER)EPILEPSY (SEIZURE DISORDER)

•Epilepsy is a disorder of brain in which a fit occurs because of abnormal electrical discharge between certain brain cells.•a sudden loss of consciousness which is often accompanied by repeated jerky movements called convulsions.•These attacks are sometimes called fits or seizures.•Epilepsy is due to disturbance in the electrical activity of the brain.

Contd….Contd….

Is caused by a transient, excessive and abnormal discharge of nerve cells.

The abnormal discharge may involve a small part of brain only ( partial or focal seizure) or much more extensive area in both hemispheres (generalized seizures).

It can start at any age.In majority of the cases, it starts

in childhood and adolescence.

1. Primary( idiopathic) epilepsy:- Unknown genetic or

biochemical predisposition2. Secondary epilepsy:-a. Intracranial Tumor Cerebro -vascular disease Arteriovenous malformation Trauma ( birth injury,

depressed fracture, penetrating wound)

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Infection ( meningitis, encephalitis)

Congenital and hereditary disease (tuberous sclerosis)

b. Extra cranialMetabolicElectrolyteBiochemicalInborn errors of metabolismanoxia

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HypoglycemiaDrugsDrug withdrawalAlcohol withdrawal

DIFFERENT CAUSES OF EPILEPSY ARE COMMON IN CERTAIN AGE GROUPS:

NEONATAL PERIOD AND EARLY INFACY: HYPOXIC ISCHEMIC ENCEPHALOPATHY, CNS INFECTIONS, TRAUMA, CONGENITAL CNS ABNORMALITIES, METABOLIC DISORDES.

LATE INFANCY AND EARLY CHILDHOOD: CNS INFECTIONS AND TRAUMA

CHILDHOOD: WELL DEFINED EPILEPSY SYNDROME.

• ADOLESCENCE AND ADULTHOOD: SECONDARY TO ANY CNS LESIONS, IDIOPATHIC EPILEPSY, STRESS, TRAUMA, CNS, INFECTIONS, BRAIN TUMORS, ILLICITS DRUGS.

•OLDER ADULT: CEREBROVASCULAR DISEASES, TUMORS, HEAD TRAUMAS, OTHER DEGENERATIVE DISEASES SUCH AS DEMENTA.

EPILEPSY ARE CLASSIFIED IN FIVE WAYS:

BY THEIR FIRST CAUSE

BY THE OBSERVABLE MANIFESTITIONS OF SEIZURES, KNOWN AS SEMIOLOGY.

BY THE LOCATION IN THE BRAIN WHERE SEIZURES ORIGINATES.

• AS A PART OF DISCRETE, INIDENTIFIABLE MEDICAL SYNDROME.

•BY THE EVENT THAT TRIGGERS THE SEIZURES, SUCH AS READING OR MUSIC.

ANOTHER CLASSIFICATIONSANOTHER CLASSIFICATIONS

1. Generalized seizures Major epilepsy( Grand mal

seizure/epilepsy) Minor epilepsy(Petit mal,

absence seizure) Myoclonic seizures2. Partial seizures ( Focal/

Jacksonian seizure)3. Status epilepticus

GENERALIZED SEIZUREGENERALIZED SEIZURE

Involves the entire brainConsciousness is lost and the seizure may last from several seconds to several minutes

Types include;1.Major epilepsy2.Minor epilepsy3.Myoclonic epilepsy

Major (Grand mal) EpilepsyMajor (Grand mal) EpilepsyThe attack or fit occurs suddenly at any place or time.

The patient falls down and loses awareness of his surroundings

Convulsion proceeds as follows:Aura :Is a warning signal prior to onset of seizures e.g sensation of peculiar test or smell, spots before eyes, dizziness and feeling of weakness.

contd….contd….

Epileptic cry:Patient loses consciousness with an

epileptic cry, it is caused by spasm of thoracic and abdominal muscles expelling air through the glottis.

Tonic stage:Patient falls to the ground with all

his muscle in an increased tone with rigidity.

The skin become pale and cyanotic, the respiration ceases.

Pupil dilated and fixed. It lasts for 10-30 sec.

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Clonic stage:Is characterized by rhythmic,

jerking movements that follow the tonic stage.

Usually start at one place and become generalized, including the muscle of the face.

There is frothing at the mouth and incontinence of urine and faeces.

Duration is approximately 1-5 min.

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Post ictal stage:It refers to the recovery period after a seizure

The patient may sleep deeply for 30 min to several hours.

Following this deep stage, client may complain of headache, confusion, fatigue.

Client may realize that they had a seizure but not remember the event itself.

b. Minor epilepsy (absence b. Minor epilepsy (absence seizure)seizure)Also referred as petit mal seizures.

Are more common in children and usually disappears after puberty

Such patient doesn’t fallThe patient demonstrates a brief change such as rolling of the eyes, blinking and slight mouth movement.

Contd…Contd…

They often describe their attack as “blackouts”

Because of the brief duration and relative lack of prominent movement, these seizures often go unnoticed.

People with absence seizure can have them many times a day.

Myoclonic seizureMyoclonic seizure

Are characterized by sudden, excessive jerking of the arms, legs or entire body.

In some instances, the muscle activity is so severe that the client falls to the ground

These seizures are brief.

2. Partial seizure( 2. Partial seizure( Focal/Jacksonian)Focal/Jacksonian)

It begins in a specific area of the cerebral cortex.

A partial seizure can progress to a generalized seizure.

It begins as a localized motor seizure, with convulsions starting in one part of the body eg. From the thumb and gradually involving hand and arms, face and other parts.

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Patient may or may not loose consciousness.

Feeling of nausea, sweating, skin flushing and dilation of pupil can also occur.

3.Status epilepticus 3.Status epilepticus

It is characterized by at least 30 min of repetitive seizure activity with out return to consciousness.

In other words, it is state in which a person has continuous seizures lasting at least 30 min.

This is medical emergency and requires prompt intervention to prevent irreversible neurological damage.

Contd..Contd..

Abrupt cessation of anticonvulsant therapy is the usual cause of status epilepticus.

MANAGEMENT OF EPILEPSY

APPROACH CONSIDERATIONS:

THE GOAL OF TREATMENT IN PATIENTS WITH EPILEPTIC SEIZURES IS TO ACHIEVE A SEIZURES FREE STATUS WITHOUT ADVERSE EFFECTS. THIS GOAL IS ACCOMPLISHED BY IN MORE THAN 60% OF PATIENTS WHO REQUIRE TREATMENT WITH ANTI-CONVULSANTS.

ANTICONVULSANT THERAPY:

THE MAINSTAY OF SEIZURE TREATMENT IS ANTICONVULSANT MEDICATION. THE DRUG OF CHOICE DEPENDS ON AN ACCURATE DIAGNOSIS OF THE EPILEPTIC SYNDROME, AS RESPONSE TO SPECIFIC ANTICONVULSANTS VARIES AMONG DIFFERENT SYNDROMES.

ANTI CONVULSANTS CAN BE DIVIDED INTO LARGE GROUP BASED ON THEIR MECHANISM, AS FOLLOWS:

• BLOKERS OF REPETITIVE ACTIVATION OF THE SODIUM CHANNEL:PHENYTOIN, CARBAMAZEPINE.

• ENHANCER OF SLOW INACTIVATION OF THE SODIUM CHANNEL:LACOSAMIDE, RUFINAMIDE.

• GABA-A RECEPTOR ENHANCERS: PHENOBARBITAL.

•N AND L- CALCIUM CHANNEL BLOCKERS: LAMOTRIGINE, VALPORATE

•H- CURRENT MODULATORS: GABAPENTIN, LAMOTRIGINE.

•BLOCKERS OF UNIQUE BINDING SITES: GABAPENTIN

•NEURONAL POTASSIUM CHANNEL OPENER: EZOGABINE.

THE TWO METHODS ARE:

A KETOGENIC OR MODIFIED ATKINS DIET( LOW CARBOHYDATE DIET)

VAGAL NERVE STIMULATION (VNS)

THE KETOGENIC DIET, WHICH RELIES HEAVILY ON THE USE OF FAT, SUCH AS HYDROGENATED VEGETABLE OIL SHORTENING, HAS A ROLE IN THE TREATMENT OF CHILDREN WUTH SEVERE EPILEPSY.

ALTHOUGH THIS DIET IS UNQUESTIONABLY EFFECTIVE IN SOME REFRECTORY CASES OF SEIZURE, A KETOGENIC DIET IS DIFFICULT TO MAINTAIN; LESS THAN 10% OF PATIENTS CONTINUE THE DIET AFTER YEAR.

FURTHERMORE, ANY SMALL CARBOHYDRATES IN TAKE RESETS KETONE METABOLISM FOR 2 WEEKS, THEREBY ELIMINATING ANTISEIZURE EFFICACY.

VAGAL NERVE STIMULATION:

VNS IS A PALLIATIVE TECHNIQUE THAT INVOLVES SURGICAL IMPLANTATION OF A STIMULATING DEVICE. IT IS CURRENTLY INDICATED FOR PATIENT OLDER THAN 12 YEARS WITH MEDICALLY PARTIAL SEIZURE THAT ARE NOT TREATED SURGICALLY.

• VNS MAY HAVE IMPROVED EFFICACY OVER TIME.

•CHILDREN SHOULD BE CAREFULLY MONITORED FOR THE SITE OF INFECTION AFTER VNS IMPLANTATION.

LOBECTOMY

LESIONECTOMY

THE MAJOR PROBLEM FOR PATIENTS WITH SEIZURES IN THE UNPREDICTABILITY OF THE NEXT SEIZURE. CLINICIANS SHOULD DISCUSS THE FOLOWING TYPES OF SEIZURES PRECAUTIONS WITH PATIENTS WHO HAVW EPILEPTIC SEIZURES:

• DRIVING

•ASCENDING HEIGHTS

•WORKING WITH FIRE OR COOKING

•USING POWER TOOLS OR •DANGEROUS ITEMS

•TAKING UNSUPERVISED BATHS

•SWIMMING

THESE LIFESTYLES PRECAUTIONS ARE CLEARLY MORE APPLICABLE TO SOME PATIENTS THAN TO OTHERS.

ASSESSMENT:

• HISTORY, INCLUDING PRENATAL, BIRTH, AND DEVELOPMENTALHISTORY, FAMILY HISTORY, AGE AT SEIZURE ONSET, HISTORY OF ALL ILLNESS AND TRAUMAS.

•DETERMINE WHETHER THE PATIENT HAS AN AURA BEFORE AN EPILEPTIC SEIZURE, WHICH MAY INDICATE THE ORIGIN OF SEIZURE.

•OBSERVE AND ASSESS NEUROLOGICAL CONDITION.

•ASSESS VITALS AND EUROLOGICAL SIGNS CONTINUOUSLY.

•ASSESS EFFECT OF EPILEPSY ON LIFESTYLE.

•RISK FOR INJURY RELATED TO SEIZURE ACTIVITY.

•FEAR RELATED TO POSSIBILITY OF HAVING SEIZURES.

•INFEECTIVE COPING RELATED TO STRESS IMPOSED BY EPILEPSY.

•DEFICIT KNOWLEDGE ABOUT EPILEPSY AND ITS CONTROL.

PREVENTION OF INJURY.

CONTROL OF SEIZURES.

ACHIEVEMENT OF PSYCHOSOCIAL ADJUSTEMENT.

ACQUISITION OF KNOWLEDGE.

ABSENCE OF COMPLICATIONS.