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EPILEPSI & PARKINSON

EPILEPSI

Pendahuluan
Epilepsi
Berasal dari bahasa Yunani epilepsia to take hold
atau to seize

Epilepsi
Suatu gangguan yang ditunjukkan adanya kejang
berulang

Kejang
Gangguan aktivitas listrik pada otak yang bersifat
sementara atau sesaat

Kejang adalah gejala pada epilepsi


Angka prevalensi: 1% dari populasi, semua usia

Diagnosis Banding Kejang

Patofisiologi Kejang
Normal GABA inhibisi discharge listrik yang berlebihan
GABA reseptor diblok Rhythmic and repetitive
hypersynchronus discharge of neurons kejang
Eksitatorik NT Ach, Aspartat, dan Glutamat juga
berpengaruh terjadi kejang
Intracellular recording shows burst of rapid action potential
firing with reduction of transmembrane potential.
inhibitory system + excitation genesis of
seizures
Abnormalitas pada kanal ion Na+, K+, Ca- kejang
(Prolongation of depolarization state)

Klasifikasi & Sindrom Epilepsi

Epilepsi vs Pseudoepilepsi
Karakteristik

Epilepsi

Pseudoepilepsi

Onset

Tiba-tiba

bertahap

Gerakan tubuh

Tonik, tonik-klonik

Dibuat-buat, asinkron

Gigitan

Lidah

Bibir, tangan, lainnya

Miksi

Sering

Jarang

Defekasi

Sesekali

Jarang

Self-injury

Sering

Jarang

Postictal Confusion

Ada

Tidak ada

Kesadaran

Turun

Retensi komplit/parsial

Durasi

30 detik beberapa menit

Lebih lama

Stop /Muncul dg sugesti

Tidak

Ya

Interiktal

Abnormal

Abnormal

Ictal

Abnormal

Artifak tetap

Meningkat

Tetap

Kejang meningkat

Tidak ada peningkatan

Gambaran Klinis

EEG

Neuroendokrin
Prolaktin
Withdrawal antikonvulsan

Gangguan Perilaku
Fenomena Iktal
Simple-partial seizures
Complex-partial seizures

Fenomena Post-Iktal
Automatisme pada post-ictal confusional state
Pasien bicara sendiri, mondar-mandir, disorientasi,
amnesia

Fenomena Inter-Iktal
Aura kognitif derealisasi, depersonalisasi, dreamy
states, forced thought, gangguan persepsi waktu

Perubahan Perilaku pada Kejang Parsial


GEJALA INTELEKTUAL

GEJALA PSIKOMOTOR

Afasia

Embarassment

Automatisme simpel

Verbal reiteration

Gang. Memori

Anger, irritabel

Inkoordinasi

Affective automatism

Dj vu, Jamais vu

Psiko sensori

Negativism

Gelastic epilepsy

Deja /jamais entendu

Ilusi

Staring

Dacrystic epilepsy (Cry)

Deja pensea

Halusinasi

Pushing

Complex automatism

Perubahan kognitif

Auditorik

Groping

Cursive epilepsy (run)

Dreamy state

Visual

Searching

Drinking

Depersonalisasi

Gustatorik

Chewing

Undressing

Forced thingking

Olfaktorik

Swallowing

Masturbation

Thought blocking

Taktil

Spitting

Prolonged twilight states w/


automatism

Gejala mood

Gejala experential

Lip smacking

Compund forms

Rasa takut

Feeling a presence

Rubbing

Temporal lobe march

Depresi

Feeling possessed

Plucking

Ictal psychosis

Pleasant experience, serenity,


ecstasy

Feeling dead

Speech automatism

Unpleasant experience

Feeling of impending
doom

Shouting

Anxiety

Screaming

Psikopatologi
20-60% gangguan psikiatri terjadi pd pasien
epilepsi
Psikosis, depresi, gangguan kepribadian, ggn
perilaku lain
MMPI: peningkatan skala skizofrenia dan paranoia
Psikosis, ggn kepribadian 2-3x lebih banyak
pada kejang parsial komplek
60-76% pasien epilepsi dewasa ada fokus pada
lobus temporal
Psikis aura yg disertai perasaan negatif
(ketakutan, jamais vu) predisposisi psikosis
atau gangguan kepribadian

Psikopatologi pada Epilepsi


PERUBAHAN KEPRIBADIAN
Hasil kejang berulang tidak terkontrol
Anoxia berulang atau cedera kepala
Akibat terapi obat toksik
Efek perawatan lama
Isolasi sosial

Dissociative experience, Fugue states, Wondering


epilepsy, Borderline personality disorder, Multiple
personality

Psikopatologi pada Epilepsi


PSIKOSIS
Schizophrenia-like psychosis
100 anak dengan kejang partial komplek30
thn10% gang. psikotik
2x lebih besar pd epilepsi dibanding umum
Resiko: epilepsi dg fokus Lobus Temporal
Fokus sebelah kiri 2x lebih sering
PET: predominan hipometabolisme dari lobus
temporal

Psikopatologi pada Epilepsi


GANGGUAN MOOD
Common epilepsi
30% gejala depresi
Parietal, ictal, postictal, & interictal
Common TLE
Left-side > Right-side
Epilepsi + Suicidality kepribadian borderline &
impulsif

Psikopatologi pada Epilepsi


ANSIETAS
Timbul akibat reaksi psikologis terhadap diagnosa
epilepsi
Perubahan psikologis sebelum terjadi kejang
Sebagai aura
Bagian dari psikosis atau gang, mood pada
epilepsi
Akibat brain injury
Perubahan mood akibat obat antikonvulsan

Patofisiologi gejala neuropsikiatri pada


pasien dengan epilepsi
No more understood than that of the idiopathic
psychiatric disorders
Mencari tahu
Faktor risiko yang dapat menyebabkan gejala
neuropsikiatri
Letak anatomi lesi yang berhubungan dengan kondisi
neuropsikiatri
Efek obat yang dapat menghilangkan gangguan epilepsi
dan perilaku

Faktor risiko
Onset kejang pada remaja muda, perempuan,
gangguan kognitif

Obat Anti Epilepsi


Epilepsy Type
Partial and /or
Secondary GTCS

First-Line

Second-Line

Third-Line

Carbamazepine
Lamotrigine
Oxcarbazepine
Topiramate
S. Valproate(in
children)

S. Valproate
Tiagabine
Gabapentin

Clobazam
Phenytoin
Phenobarbital
Vigabatrin
Acetazolamide

Primary GTCS

S. Valproate

Lamotrigine
Topiramate
Carbamazepine

Phenytoin
Gabapentin
Phenobarbital
Tiagabine
Acetazolamide

Absence

S. Valproate
Lamotrigine

Ethosuximide

Clonazepam
Acetazolamide

Myoclonic

S. Valproate

Clonazepam

Piracetam
Lamotrigine
Phenobarbital

Indikasi & Dosis


AED

Seizure type

Carbamazepi Partial,Secondary GTCS,


ne
Sodium
Primary & Secondary
GTCS,
Valproate
Absence, Myoclonus
Phenytoin
Partial, Secondary GTCS
Lamotrigine
Partial, secondary GTCS
Lorazepam
Status Epilepticus
Clonazepam Partial (adjunctive),
Myoclonus
Ethosuximide Childhood Abssence
Topiramate
Partial, secondary GTCS
Phenobarbital Partial, secondary GTCS

Dose
range
(mg/day)

Doses
per
day

2502000
4002500

2-3

Therapeuti
c
range
(mol/L)
30-50

1-2

NA

150-350
25-500
4 i.v.
1-8

1
1-2
-2-4

40-80
NA
NA
NA

5001500
200-600
60-100

200-700

1-2
1

NA
50-150

PARKINSON & GANGGUAN


PERGERAKAN LAINNYA

Gangguan pergerakan sering terjadi


neuropsikiatri
Skizofrenia sterotipi, manerism, katatonia
Efek samping terapi gang. Perilaku
parkinsonism, tremor, distonia
Penyakit Ganglia Basalis
Gejala neuropsikiatri
Depresi, ansietas, waham, apatis, iritabel, disinhibisi
Gangguan kognitif
Gang. Fungsi eksekutif & dementia

Penyakit Ganglia Basalis


Parkinsons
Dementia
Idiopathic
Corticobasal
Progressive
Wilson's
Other
Huntington's
Sydenham's
Neuroacan
Tremor
Ataxias
Dystonia
Disease
with
Basal
disease
Chorea
Disease
Ganglia Calcification

Sikuit Frontal Subkortikal

Gangguan motorik

Gangguan pergerakan Ekstrapiramidal


Akinetic
rigid
syndome

Parkinsons disease, Parkinsonism in other neurodegenerative disorders, Secondary


parkinsonism (drugs, toxins, tumors, hydrocephalus, cerebrovascular disease)

Dystonia

Idiopathic Familial/non-familial dystonia, Spasmodic torticollis, Idiopathic orofacial dystonia,


Blepharospasm (Meiges syndrome), Paroxysmal dystonia, Secondary dystonia

Tremor

Essential Tremor, Intention tremor (Cerebellar Tremor), Rest Tremor (isolated or with
parkinsonism), Physiologic Tremor, Other specific tremors (rubral, dystonic, orthostatic, etc),
Secondary

Myoclonus

Essential Myoclonus, Infectious, Secondary, with epilepsy

Chorea

Huntingtons disease, syndenham chorea, chorea Gravidarum, Benign Hereditary chorea,


Neuroacanthocytosis, Senile chorea, Kinesiogenic choreathetosis, with other neurodegenerative
disorders, secondary

Athetosis

Perinatal ischaemic disorder, kernicterus

Balism

Subthalamic infarction, neoplasma

Tics

Idiopathic (Transient, persistent, chronic), Gilles de la Tourettes syndrome, secondary

Akathisia

With Parkinsons disease, Secondary

Other

Periodic leg movement ,painful legs and moving toes syndrome, restless legs syndrome,
stereotypies and mannerisms, hemifacial spasm, psychogenic

Penyakit Parkinson
Common lansia
prevalensi 160 per 100,000 orang
Kaukasia >> Afrika & Asia
Pria > Wanita
Sebelum terapi kontemporer durasi penyakit
antara 8-10 tahun
Pemakaian levodopa 15 tahun survival

Gejala Klinis
Gejala klasik
Tremor resting tremor
Rigiditas cogwheel, poker face
Bradikinesia gerakan lambat,
gang. Kunyah, telan, bicara

Postur abnormal instability,


membungkuk, resiko jatuh
Micrographia, tulisan semakin
lama semakin kecil
Shuffling gait, panjang langkah
berkurang, festination, tendensi
mempercepat (speech/gait)

Neuropatologi
Hilangnya neuron pada
substansia nigra, ventral
tegmental area, locus
ceruleus & nucleus
basalis
Lewy Bodies inklusi
eosinofilik sitoplasmik
pada sel-sel nigral
Temporal & frontal cortex,
entorhinal area, anterior
cingulate cortex, & insular
cortex

Neuropatologi
Cell loss in the

Diagnosis Banding
dementia with

Terapi
Dopaminergic (improve dopamin function)
Levodopa
Dopamine receptor agonis
Amantadine
Catechol-O-methyltransferase inhibitor
Selegiline,( MAO B Inhibitor) neuroprotective

Anticholinergic agents tremor, bradykinesia and


rigidity.
Pallidotomy or deep brain stimulation, thalmotomy.
Cholinesterase Inhibitors for cognitive
symptoms

Neuropsychiatric aspect
Cognitive deficits
Executive function disorder or mild subcortical
dementia
difficulty with word list generation
a retrieval deficit disorder type of memory impairment
abnormalities of organizational skills when copying
complex figures,

Depression
Anxiety
Apathy
Sleep attacks

Dementia with Lewy Bodies


Dementia in 30% - 40% of patients with
Parkinson's disease
Progressive dementia syndrome
Fluctuating cognition with pronounced variation in
attention & alertness
Recurrent visual hallusinations well formed &
detail
Parkinsonism

Dystonia
Genetic Basis: mutation in the DYT1 gene on 9q34
Secondary dystonias :
associated with movement disorders
induced by long-term use of dopamine-blocking agents

pathophysiology not certain.


PET studies :
abnormal brain networks involving the frontal lobe and basal
ganglia
dissociation between activity of the lentiform nucleus - thalamic
nuclei
hyperactivity of supplementary motor and prefrontal areas

Often misdiagnosed as a conversion disorder

Ataxia
Manifestation of cerebellar or sensory dysfunction
leading to disequilibrium.
finger-to-nose and heel-to-shin test, past pointing
when asked to touch a point
hypotonia and a variety of eye signs, reflecting
loss of coordination of ocular movements.
autosomal recessive/dominant, encephalopathies,
congenital malformations of the cerebellum, inborn
errors of metabolism; vitamin deficiencies;
hypothyroidism; infectious illnesses; vascular
disorders;multiple sclerosis; traumatic brain injury,
heatstroke, variety of toxins

Tremor
Common, neuropsychiatric disorders CNS
Tension, anxiety, and distress exaggerate any
existing tremor.
Psychiatic drugs induce tremor
Beta-blockers (propranolol and metoprolol),
primidone, or benzodiazepines central tremor.
Dopaminergic or anticholinergic agents
parkinsonian-type rest tremors

Catatonia
idiopathic psychiatric disorders, neurological
diseases, metabolic encephalopathy, or toxic
conditions
schizophrenia, catatonic symptoms commonly cooccur with features of formal thought disorder,
affective blunting, and neurological sign
patients must undergo comprehensive evaluation
for neurologic, metabolic, and toxic causes of
catatonic phenomenon
Benzodiazepine, ECT, Occasional mood
stabilizer, anticholinergic agents, atypical

Drug-Induced Movement Disorders


Acute dystonic reactions fenotiazin,
buterofenon, th/ antikolinergik, benzodiazepine
Akathisia antidepressant, etc. th/ beta blocker
Parkinsonism Akinetic-rigid syndrome, Rest
tremor, Rabbit syndrome
Tremor
Myoclonus
Choreoathetosis
Tardive dyskinesia
Neuroleptic malignant syndrome hyperthermia,
muscle rigidity, autonomic dysfunction, and mental
status changes

Parkinsonism
About 2 weeks of therapy with neuroleptic agents
detectable in 50-80% of patients
The elderly high risk
Induced by Higher-potency neuroleptics, Atypical
antipsychotics (less likely)
Management:
reducing the dose of the inciting agent
treatment anticholinergic drug

Typically resolves within 2-4 weeks of intervention,


but may persist for 12-18 months

TERIMA KASIH
September 2015