Neuro-Epilepsy I

NO

A seizure does not always equal epilepsy, yet epilepsy always equals seizures.

A single seizure or recurrent seizures due to correctable or avoidable circumstances dose not necessarily have epilepsy

A seizure is a single entity

Epilepsy: a condition which a person has recurrent seizures due to a chronic underlying process

Epilepsy is a clinical phenomenon

Paroxysmal event secondary to abnormal excessive or synchronous neuronal activity in the brain.

Depends on distribution of discharges (seizures manifests in various ways)

5 - 10%

• 1. Fever
• 2. CNS infection
• 3. Head trauma
• 4. Drugs

• Chronic disorder with recurrent unprovoked seizures
• -2 or more unprovoked seizures separated by 24 hrs

125,000 new cases diagnosed

1% of general population has epilepsy

• 1. First peak in newborns and young children
• 2. Second peak in patients >65 yrs old

Syndromes which epilepsy is predominant feature and there is sufficient evidence to suggest a common underlying mechanism

• Juvenile Myoclonic Epilepsy
• Lennox-Gastaut Syndrome
• Lesial Temporal Lobe Epilepsy Syndrome

• -result of shift in the normal balance of excitation and inhibition within the CNS
• -intricacy of the nervous system with numerous properties that control balance 
• -result from a dynamic interplay between endogenous factors, epileptogenic factors, and precipitating factors
• -Definitive mechanisms remains rudimentary

• Age
• Drugs
• Other disease states

Age:

• 1. Late infancy/early childhood- Febrile seizures
• -prevalence 3-5%
• -Occur 3 months and 5 years with peak incidence 18-24 months
• 2. Childhood: age at which many of the well-defined epilepsy syndromes present
• 3. Adolescence/early adulthood:Epilepsies secondary to acquired CNS lesions begin to predominate
• 4. Older adults: CVD

• Metabolic disturbances
• Hypo/Hyperglycemia
• Renal Failure
• Hepatic Failure

• 1. Beta-lactam antibiotics
• 2. Quinolones
• 3. Alkylating agents (busulfan, chlorambucil)
• 4. Antimalarials (chloroquine)
• 5. Meperidine
• 6. Tramadol
• 7. Psychotropics (antidepressants, antipsychotics, Lithium)
• 8. Theophylline
• 9. Amphetamine
• Cocaine
• Methylphinidate

Seizure type essential for diagnosing cause, therapy, and prognosis

• International League against Epilepsy:
• Based on clinical features associated with EEG, Seizures may be focal or generalized

• -originate within neuronal networks limited to one hemisphere
• -results in asymmetric motor manifestations
• -described as having motor, sensory, autonomic, cognitive features
• -focal seizures are classified with/without dyscognitive features

Yes

• may evolve into generalized seizures
• -progress to include both hemisphere of brain
• -may still be referred to as secondarily generalized

• 1. no loss of consciousness
• 2. altered motor fxn, sensory or somatosensory symptoms or automatism
• 3. Simple Partial Seizures

• -transient loss of awareness/consciousness
• -begin with an aura 
• autaomatisms, periods of memory loss, or aberrations in behavior (start of ictal phase often a sudden arrest of motionless state)
• -Postictal amnesia
• -Complex partial seizures

• Involve both cerebral hemisphere and result in bilateral motor manifestations
• -associated with loss of consciousness
• -Several types:
• Absence (petit mal): Typical and Atypical
• Tonic-Clonic (grand mal)
• Pure clonic
• Pure tonic
• Atonic
• Myoclonic

• -sudden, brief lapses of counsciousness w/o loss of postural control
• -lasts for seconds
• -No postictal confusion

• -longer lapses of counsciousness
• -less abrupt onset and cessation
• -more obvious motor signs

• -seizures with convulsive episodes
• -initial phase is tonic contraction
• -after 10-20 secs, seizure evolves into clonic phase (periods of muscle relaxation on tonic muscle contraction)
• -Ictal phase last no more than 1 min
• -Postictal phase- unresponsiveness (mins to hrs), and possible bladder/bowel incontinence
• -Postictal confusion: H/A, fatigue, muscle ache (hours)

• -repetitive clonic jerking with loss of consciousness
• -No initial tonic component

repetitive clonic jerking accompanied by a loss of consciousness, No initial tonic component

Continuous muscle contraction, no clonic phase, accompany respiratory arrest resulting in cyanosis

• -sudden loss of muscle tone
• -described as head drop, dropping of a limb or slumping to the ground
• -consciousness is usually impaired, but w/o postictal confusion
• -often need protective head gear

• -brief lightening-like jerking muscular contractions of one part or entire body
• -isolated or repetitive

A thorough Patient history and physical examination

Complete neurologic exam

• -Time of occurence
• -Presence of aura
• -Ictal activity
• -Postictal state

Risk Factors & Predisposing events

• RF: h/o of febrile seizures, FH of seizures, h/o of head trauma, stoke, tumor
• Precipitating factors: sleep deprivation, systemic diseases, electrolyte imbalances, acute infection, drugs that lower seizure threshold or illicit drug use

• -No diagnostic lab tests for epilepsy
• -Serum prolactin levels may be transiently elevated following generalized tonic-clonic seizures
• -Lab tests are done to help r/o treatable causes of seizures (hypoglycemia, infection, altered electrolyte concentrations)

Electroencephalogram (EEG)

• -confirms diagnosis of epilepsy
• -classify seizures
• -locate site of seizure
• -Selection of best antiepileptic drug (AED)

brain tumor and cerebral hemorrhage

• -treat underlying conditions
• -avoid precipitating factors (sleep deprivation, systemic diseases, electrolyte imbalances, acute infection, drugs that lower seizure threshold or illicit drug use)

No seizures, no side effects, and an optimal quality of life

Control or reduce frequency of seizures and ensure compliance (30-35% of patients are refractory to treatment)

Provide optimal quality of life and allow the patient to live as normal as possible (driving, social relationships, future plans, safety, social stigma)

Balance tolerability, efficacy, and side effects

Accurately diagnose seizure type and classification to determine appropriate AED

Suppression of recurrent seizures with AED or surgery

-AED for all patients with recurrent seizures of unknown or unremovable causes