EPILEPSI

Dr. Hadia Angriani M, Sp.A (Maret 2004)

1. DEFINITION
Epilepsy may be diagnosed after has had two or more unprovoked Seizure

Hughlings Jacksons : An occasional excessive

and disordered discharge of nerve tissue (Menkes)

Recurrent convulsive or non convulsive

Seizure caused by partial or generalized epileptogenic discharges in the Cerebrum (Menkes) More recent estimates of the prevalence of single and recurrent non febrile Seizures in children younger than 10 years of age range from : 5,2 to 8,1 per 1000 (Menkes)

2. CLINIC MANIFESTATION
2.1 PARTIAL SEIZURES
2.1.1 Simple P.S : Motor activity is the most common symptoms Asynchronous clonic or tonic movements face, neck & extremities

Automatisme (-), Aura (+)

The average Seizure : 10-20 sec

EEG : spike or sharp wave unilateral / bilateral/

a. multifocal spike

2.1.2 Complex. P.S : S.P.S with / without aura followed impaired consciousness

Automatism (+) 50-75% cases, aura (+) a focal

onset of seisure. Spreading of epileptiform discharge secondary generalized with a.tonic-clonic convulsion Average duration of C.P.S : 1 2 min EEG : anterior temporal lobe sharp waves / focal spikes, multifocal spike frequent

2.1.3 Benign partial epilepsy with centro temporal spike (BPEC) : Common type of partial epilepsy excellent prognosis

Age : 12-14 years, peak age : 9-10 year

History of epilepsy in family (+)

Usually partial & motor sign & somatosensary

symptoms are often confired to the face Unilateral tonic-clonic contractures of lower face Consiousness may be intact or impared EEG : Rolondi foci

2.2 GENERALIZED SEIZURE :

2.2.1 Absence S : A sudden cessation of motor activity or speech with a blank facial expression & flickering of eyelids

Uncommon < 5 years, more prevalent in girls

Rarely > 30 sec. Do not lose body tore, but their head fray fall forward slightly Automatism (+) Hyperventilation for 3 4 min EEG : spike & generalized wave discharge

2.2.2 Generalized tonic clonic seizure :

Follow a partial seizure with a focal onset (second generalized) or occur de novo

Aura (+)
Suddenly lose consciousness Eyes roll back, body musculature tonic contractions, rapidly became cyanotic apnu During seizure may bite their tongue

Lose of sphincter control

Physical exam. : truncal ataxia, deep tendon reflexes , clonus & babinsky (+)

2.2.3 Myoclonic epilepsies :

Repetitive seizures

Symmetric muscular contraction, loss of body tone

& falling or slumping foward

Divide 5 subgroup

2.2.3.1 Benign myoclonus of infancy Clusters of myoclonic movements neck, trunk & extremities EEG : normal Prognosis : good, normal development & the cessation of myoclonus by 2 yr of age

2.2.3.2 Typical myoclonic epilepsy of early childhood :

The mean age of onset : 2 yr, but range :

6 month 4 year

The frequency : occur several times daily or may be

seizure free for weeks

Approximately half of patients : tonic clonic seizure

EEG : fast spike complex & normal background

rhythm
History of epilepsy (+)

Mental retardation (+) minority

2.2.3.3 Complex myoclonic epilepsies : Focal or generalized tonic clonic 1st year of life A history of hypoxia ischemic encephalopaty in perinatal period UMN & extrapyramidal signs (+), with micro cephaly Triad of intractable seizure of various types, a slow spike wave EEG awake state, mental retardation

2.2.3.4 Juvenile myoclonic epilepsy : Ages : 12 16 year

Frequent myoclonic jerks on awakening

A few years later : early morning generalized tonic

clonic seizures myoclones

EEG : irregular spike & wave pattern

2.2.3.5 Progressive myoclonic epilepsies :

La. ford disease (+)

Age : 10 18 year

Generalized tonic clonic seizure

Myoclonic jerks (+) Mental deteoration is characteristic Cerebral & extrapyramidal signs (+) EEG : poly spike wave discharge occipital region

3. DIAGNOSIS
1. First step : the diagnosis of epileptic seizure Paroxysmal clinical events epileptic seizure

The differentiation between : seizure & other causes

of transient neurological disturbance & collapse fits, faints & funny turns Distinguishing epileptic (fits) from non epileptic disorders, particularly vasovagal (faints) or psicogenic attacks (funny turns) all trained physiciars Types of epileptic seizure : - focal seizure

- generalized seizure

2. Second step : The diagnosis of epileptic syndromes

Syndromic diagnosis of epileptics provide a firm

foundation for short long therapeutic decisions & enable natural history, inheritance, treatment efficacy & prognosis of epileptic The benefit : avoid mis categorysation in difficult

cases

4. TREATMENT
First step : to ensure that patient has a seizure disorders & not a condition that mimic epilepsy

Second step : choosing an anti convulsant

4.1 Benzodiazepines : Binding to spesific GABA site enhance opening frequency of the chloride channel Status epilepticus 4.2 Carbamazepine : Blocking sodium dependent channels Decreasing depolarization dependent calcium uptake Effective for generalized tonic clonic & partial

4.3 Ethosuximide : Blocking calcium channels thalamo cartial circuity Effective for typical absence epilepsy 4.4 GABAPENTIN : Add on drug for refractory complex partial & secondary generalized tonic clonic seizures Binding of the drug to neuronal membrane (Glutamate synapses) & increased brain GABA turn over

4.5 Lamotrigine : Add on drug for complex partial & generalized tonic clonic seizures Monotherapy with Lennox gestaut syndrome

4.6 Phenobarbital and primidone :

Seizure behavioral changes 25%

GABA reseptor to increase the chloride channel

open duration

4.7 Phenytoin :

Blocking sodium dependent channels & decreasing

depolarization dependant calcium uptake

4.8 Tiagabite :

Blocking reupatke of the neuro inhibitory transmitter

GABA into neuronal & glial cells

4.9 Topiramate :
Blocking voltage dependent sodium channels

4.10 Valproic acid : Blocking voitage dependent sodium channels Irereased calcium dependent potassium

conductance

4.11 Vigabatrin :

Binding to the degradative enzym GABA transaminase reseptor irerease in GABA levels & inhibitors of

neuro transmitter

4.12 Levinaetam :

Unknown mechanism

4.13 Oxcarbazepine :

Similary to carbamazepine

4.14 Zoni samide :

Adjunctive treatment for partial seizures & myoclonic

syndrome 4.15 ACTH : infantile spasme