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• Definitions
• Incidence
• causes
• Pathophysiology
• Types of seizures
• Clinical manifestation
• Differential diagnosis
• Management

• 3
What is epilepsy??

• An epileptic seizure is an intermittent
stereotypical, usually unprovoked,
disturbance of consciousness, behavior,
 emotion, motor function or sensation that on
 clinical grounds results from cortical neuronal
 Discharge.
• Epilepsy is a disorder characterized by the
occurrence of at least 2 unprovoked
seizures 24 hours apart.

• Paroxysmal disorders of the nervous system
result in sudden, reversible changes in
mental status or somatosensory function
that tend to be stereotyped and repetitive in
nature. They have a variable duration from
seconds to minutes (rarely hours), end
abruptly, and are followed by a gradual
return to baseline. There may be a warning
before (aura) or a state of altered
awareness afterward (postictal state).

Status Epileptics
• More than thirty minutes of continuous seizure activity, or recurrent
seizures without intercurrent recovery of consciousness .

• status epilepticus is the first ictal manifestation in 77% of patients.
• is the most serious seizure disorder and a medical emergency
because the seizure does not stop.

• -People have convulsions with intense muscle contractions and
cannot breathe adequately.
• Body temperature increases.
• Without rapid treatment, the heart and brain can become overtaxed
and permanently damaged, sometimes resulting in death.
• About 50 million people worldwide have epilepsy, with
almost 90% of these people being in developing
• Epilepsy is more likely to occur in young children, or
people over the age of 65 years, however it can
occur at any time.
• Epilepsy is usually controlled, but cannot be cured with
medication, although surgery may be considered in
difficult cases. However, over 30% of people with
epilepsy do not have seizure control even with the
best available medications.
• Not all epilepsy syndromes are lifelong – some forms
are confined to particular stages of childhood.

Two basic types of seizures
A. Epileptic (idiopathic):
- These seizures have no apparent cause (or trigger)
and occur repeatedly. These seizures are called a
“seizure disorder” or “epilepsy.”
-It often begins at the age of 20 and rarely begin to the
age of 30.
B. Non-epileptic (secondary epilepsy):
 These seizures are triggered (provoked) by a disorder or
another condition that irritates the brain. In children, a
fever can trigger a nonepileptic seizure.
-Psychogenic nonepileptic seizures
-Certain mental disorders can cause symptoms that
resemble seizures.

Causes of Seizures

• Perinatal Conditions:
• Cerebral malformation
• Intrauterine infection
• Hypoxic-ischemic
• Trauma
• Hemorrhage
• Infections
• Encephalitis
• Meningitis
• Brain abscess
• Metabolic Conditions
• Hypoglycemia
• Hypocalcaemia
• Hypomagnesaemia
• Hyponatremia
• Hypernatremia
• Storage diseases
• Reye syndrome
• Degenerative disorders
• Porphyria
• Pyridoxine dependency and deficiency

• Poisoning
• Lead
• Cocaine
• Drug toxicity
• Drug withdrawal
• Neurocutaneous Syndromes
• Tuberous sclerosis
• Neurofibromatosis
• Sturge-Weber syndrome
• Klippel-Trenaunay-Weber syndrome
• Linear sebaceous nevus
• Incontinentia pigmenti

• Systemic Disorders
• Vasculitis (CNS or systemic)
• Hypertensive encephalopathy
• Renal failure
• Hepatic encephalopathy
• Other
• Trauma
• Tumor
• Febrile
• Idiopathic
• Familial

Pathophysiology (I)

•Normal brain function involves "communication"

between millions of nerve cells (neurons)
•A nerve cell is made up of a cell body and branches
called axons and dendrites which join other
neurons at junctions called synapses
•At any one time, there are nerve cells which are
resting, exciting or inhibiting other nerve cells
•Electrical signals are sent from the cell body along
the axon to the synapse, these electrical signals
being the result of ion (Na+, K+ , Ca2+) currents
across channels in the nerve cell membrane
•Chemical signals (neurotransmitters) pass across
synapses between neurons

Pathophysiology (II)
•Neurotransmitters cross the synaptic gap between neurons and fix to
receptor points of the adjoining neuron
•Some neurotransmitters function to excite the joining neuron (eg.
glutamate) to send a further electrical signal. Other neurotransmitters
function to inhibit the joining neuron (eg. GABA) and inhibit electrical
signals passing down that neuron
•It is by these electrical and chemical pathways that the millions of neurons
within the brain communicate and function normally
•seizures occur when there is an imbalance within these excitatory and
inhibitory circuits in the brain, either throughout the brain (generalised
epilepsy) or in a localised part of the brain (focal epilepsy), such that
neurons fire off in an abnormal fashion
•Mechanism of AEDs to prevent
–Altering electrical transmission along neurons by affecting ion
(Na+, K+ , Ca2+) channels in the cell membrane.
–Altering chemical transmission between neurons by affecting
neurotransmitters (GABA,glutamate) in the synapes

What types of seizures
do you know?

Classification of seizures
Seizure Classification

Partial Generalized
seizure activity starts in one area of the seizure involves whole brain &
brain consciousness is affected

Simple Complex
Retains awareness Altered awareness and behavior

Secondary generalization
(spreading from one area to the whole
brain) "jacksonian" seizure

Tonic Clonic Absence Tonic or Atonic Myoclonic

‘drop attack”
“grand-mal” or convulsion “petit mal” or starting fit or Sudden muscle jerks
Abrupt fall, either with
Loss of consciousness, trance like state
stiffening (tonic) or with
stiffening of body then
loss of muscle tone (atonic
jerking of limbs
or “astatic” attacks)

Classification of Epileptic Seizures

– seizures:
– Simple partial (consciousness retained)
• Motor
• Sensory
• Autonomic
• Psychic
– Complex partial (consciousness impaired)
• Simple partial, followed by impaired
• Consciousness impaired at onset
– Partial seizures with secondary
Clinical manifestations

 Aura: Abnormal – smells or tastes Butterflies in the stomach

feeling of déjà vu. An intense feeling that a seizure is about
to begin.
Base on the Classification:
Partial Seizures
Only one side of the brain is affected. Partial seizures
may be simple or complex.
A). simple partial seizures- abnormal electrical
discharges begin a small area of the brain and remain
confined to that area.
-no loss of consciousness And the most common type
of seizure.
B). Complex partial seizures-
abnormal electrical discharges begin in a small
area of the temporal lobe or frontal lobe and
quickly spread to other nearby areas.

-The seizures usually begin with an aura that

lasts 1 to 2 minutes. During the aura, people
start to lose touch with the surroundings. During
the seizure, consciousness is impaired but not
completely lost.
2 types of complex seizure
a) complex partial with automatism:

• Stop and Stare

• Chew or smack the lips involuntarily
• Move the hands, arms, and legs in strange,
purposeless ways
• Utter meaningless sounds
• Not understand what other people are saying
• Resist help
b) Partial seizure evolving into generalized


Generalized seizures
– Absence
• Typical (petit mal)
• Atypical
– Generalized tonic clonic
– Tonic
– Clonic
– Myoclonic
– Atonic
– Infantile spasms
• Unclassified seizures
Generalized (tonic-clonic)
• The attack begins abruptly .
• - tonic phase- characterized by contraction and the
body becomes rigid- the client may fall, “cry may be
• and it may last for 30-60 seconds
• -clonic phase- characterized by jerky, rhythmic contraction
and relaxation of all body muscles
• -accompanied by drooling, dyspnea and urinary incontinence
• - during the post-ictal phase there:
1. cessation of tonic-clonic phase
2. characterized by exhaustion, headache
and drowsiness, deep sleep of 1-2 hours and

Absence seizures
• may be typical (petit mal) or atypical
• usually begin between 4 and 6 years of age.
• staring episodes for 10-30seconds with fluttering eyelids and
sometimes twitching facial muscles.

• not preceded by an aura
• has no tonic-clonic movement.
• provoked by hyperventilation or strobe light stimulation.

• People abruptly stop what they are doing and resume it just
as abruptly.

• 26The characteristic EEG patterns consist of synchronous 3-Hz
spike-and-wave activity with frontal accentuation.
• Atypical absence seizures manifest as
episodes of impaired consciousness
with automatisms, autonomic
phenomena, and motor manifestations,
such as eye opening, eye deviation, and
body stiffening.
• The EEG shows slow spike-and-wave
activity at 2 to 3 Hz.

Astatic-akinetic or atonic seizures
• onset between 1 and 3 years of age.
• The seizures last 1 to 4 seconds
• characterized by a loss of body tone, with falling to
the ground, dropping of the head, or pitching
forward or backward. A tonic component usually
is associated.
• They are most frequent on awakening and on
falling asleep; 50 or more daily seizures are
• Children with astatic-akinetic seizures usually
have mental retardation and underlying brain
Infantile spasm (west syndrome)
• brief contractions of the neck, trunk, and arm muscles,
followed by a phase of sustained muscle contraction lasting
2 to 10 seconds.
• The initial phase consists of flexion and extension in various
combinations such that the head may be thrown either
backward or forward.
• Spasms occur most frequently when the child is awakening
from or going to sleep.
• The peak age of onset is 3 to 8 months.
• The EEG during the waking state, hypsarrhythmia,
consisting of high-voltage slow waves, spikes, and
polyspikes accompanied by background disorganization.
• flexion of the thighs and crying can be mistaken for colic.
• The commonest recognized cause is tuberous sclerosis

Generalized Seizures
Generalized seizures happen when the
electrical disturbance sweeps through
the whole brain at once, causing loss
of consciousness, falls, convulsions
or massive muscle spasms.

Partial Seizures
Partial seizures happen when the disturbance
occurs in just one part of the brain, affecting
whatever physical or mental activity that area
Types of epilepsy (I)
1 Partial epilepsies 2 Generalized idiopathic epilepsies

These are epilepsies with a clearly defined Generalized epilepsies are those which have
focal area within the brain. As a result, they no defined focal area within the brain.
have high characteristic symptoms, such as Idiopathic is a medical term meaning that
visual hallucinations, or motor difficulties on there is no clear environmental cause for the
one side of the body epilepsy and it is presumed that genetic
factors predominate

Types of Partial epilepsy Types of Generalized idiopathic epilepsy

•Benign occipital epilepsy •Benign myoclonic epilepsy in infants
•Benign rolandic epilepsy •Juvenile myoclonic epilepsy
•Frontal lobe epilepsy •Childhood absence epilepsy
•Occipital lobe epilepsy •Juvenile absence epilepsy
•Mesial temporal lobe epilepsy
•Parietal lobe epilepsy

Differential Diagnosis
• seizures,
• migraine,
• transient ischemic attack,
• syncope,
• vertigo,
• hypoglycemia,
• breath-holding spells,
• tics, and conversion reactions.

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34 Ma
Immediate treatment for status epileptics
a) Stabilization:

• ABCs (airway, breathing, circulation)
• ECG monitoring
• Oxygen and pulse oximetry
• IV access
• Immediate laboratory tests
• a rapid infusion of 5 mL/kg of 10% dextrose
• Basic metabolic panel (sodium, calcium,
• Antiepileptic drug levels
• Toxicologies
 B)Pharmacologic Management:
• Benzodiazepine
• Lorazepam 0.05-0.2 mg/kg
• Diazepam 0.2-0.5 mg/kg
• Midazolam 0.2 mg/kg
• Fosphenytoin 10-20 mg/kg (phenytoin
• Phenobarbital 10-20 mg/kg
• Valproic acid 20 mg/kg
• General anesthesia
• 36
Laboratory investigation
ØComplete blood count
Ømeasurement of blood chemistries, including
glucose, calcium, sodium, potassium, chloride,
bicarbonate, urea nitrogen, creatinine, magnesium,
and phosphorus; blood or urine toxicology

Treatment Options
• There are four main categories of epilepsy

Ø Medications
Ø Surgery
Ø Ketogenic Diet
Ø Vagus Nerve Stimulation
Source :

• Suppress discharge of neurons in seizure focus and

propagation of seizure activity
• Mechanisms of action:
• block voltage-gated Na+ channels from return to
activated state (↓ rapid repetitive neuronal firing)

• block T-type Ca2+ channels that control oscillatory
responses in thalamic neurons (absence seizures).

• potentiate inhibitory neurotransmitter GABA (open Cl-
• 39
Seizure type First line drugs Second line drugs

Partial (simple, Carbamazepine Clobazam

complex, with or Lacosimide Clonazepam
without secondary Leveiiracetam Gabapentin

generalization Sodium valproate Lamotrigine






Generalized absence Sodium valproate Clobazam

Ethosuximide Clonazepam


Generalized tonic- Levetiracetam Carbamazepine

clonic Sodium valproate Clobazam





Myoclonic Leveitiracetam  Phenobarbital

Sodium valproate

lve removal of epileptogenic tissue from the area where seizures arise or interruption of nerve pathways alon

nd Cortical Resection
most common form of epilepsy surgery is a lobectomy or cortical resection.
•The operations usually involve removal of a relatively small area of the brain s
part of a left or right lobe may be removed surgically

Multiple Sub- pial Transection
•This operation also seeks to control seizures by cutting nerve pathways
•It is used when the seizure focus is located in a vital area of the brain that cannot be

to identify a single epileptic focus

but leaves some connections in place. If the generalized seizures stop, no further surgery is done. If they continue, a

Ketogenic Diet
• The ketogenic diet is primarily used in childhood epilepsy.

• The mechanism of ketogenic diet is unknown. The high-fat,
low-protein, no-carbohydrate diet mimics some effects of
starvation that seem to inhibit seizures.

• The diet is very rigid and carefully controlled and must be
supervised by a physician -- sometimes in a hospital

• Ketogenic diets have been used for children with epilepsy for
many years with a success rate of approximately 50
Vagus Nerve Stimulation (VNS)
•Vagus nerve stimulation (VNS) is approved to
treat partial seizures in patients 12 years of
age or older
•Approximately 30 to 50 percent of patients can
be expected to have less seizure activity with
•The vagus nerve stimulator is surgically
implanted under the skin in the chest. The
device is attached to a wire that is tunneled
under the skin and attached to the vagus
nerve, which is located in the left side of the
•The vagus nerve stimulator is adjusted to
automatically stimulate the vagus nerve from
every few seconds to every few minutes.
•The device does not detect seizure activity. It
can be adjusted easily in a physician's office
using a laptop computer

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