EPILEPSY

Departement of Neurology
Christian University of Indonesia
Medical Faculty
Definitions

Seizure: the clinical manifestation of an abnormal and

excessive excitation and synchronization of a population
of cortical neurons

Epilepsy: two or more recurrent seizures unprovoked by

systemic or acute neurologic insults
Epidemiology of Seizures and Epilepsy

Seizures
Incidence: approximately 80/100,000 per year
Lifetime prevalence: 9%
(1/3 benign febrile convulsions)

Epilepsy
Incidence: approximately 45/100,000 per year
Point prevalence: 0.5-1%
General Considerations

Factors adversely influencing recurrence include:

Difficulty in getting the seizures under control
Neurologic dysfunction or mental retardation
Age at onset under 2 years
Abnormal EEG at the time of discontinuing
medication
Type of epilepsy
ETIOLOGIES
Provoked Unprovoked
Metabolic disorders TBI
Hypoglycemia Birth trauma
Electolyte imbalance Anoxia
Withdrawal from massive amounts of Brain tumors
alcohol or sedatives
Infectious diseases in the mother
Massive sleep deprivation
Parasitic infections
High fever
Genetic
Hypoxia
Vascular diseases affecting the brains
Substance abuse blood vessels
Excessive use of stimulants Neurotransmitter GABA imbalance
CONDITION THAT MAY LOOK LIKE A SEIZURE

Syncope
Psychogenic seizures
Breath-holding spells
Paroxysmal REM sleep behavior
Panic attacks
Types of Epilepsy
 Classification (ILAE 1981)

Partial (focal, local) seizures

 Classification (ILAE 1981)

Generalized Seizure Unclassified

Absence seizures
Typical absence
Atypical absence
Myoclonic seizures
Clonic seizures
Tonic seizures
Tonic-clonic seizures
Atonic seizures
Clinical manifestation
Partial epilepsy
Focal epilepsy may arise from an intracerebral structural
defect, causing motor or sensory symptoms localized to one
body part, which may then spreads to contiguous regions of
the cortex (e.g. jacksonian seizures).
There are simple partial seizures without impairment of
consciousness.
Complex partial seizures associated with disturbance of
consciousness usually arise in the temporal lobe.
Clinical manifestation
Partial epilepsy
Seizures arising in the medial temporal lobe may produce
disturbances of smell and taste, visual hallucinations.
These may evolve to a tonic-clonic seizures ( secondary
generalization).
Weakness following the event may occur for minutes or hours
(todds paresis).
Clinical manifestation
Generalized seizures
Absence attacks usually consist of a brief interruption of
activity, sometimes with complex motor activity (such as
fumbling with clothes), but without collapse.
EEG during this event shows a three-per-second spike-and-
wave activity.
Clinical manifestation
Generalized seizures
In a generalized tonic-clonic seizures, the tonic phase
is a sudden tonic contraction of muscles usually with
upward eye deviation. The clonic (with clonus-type
activity) phase follows.
Initial EEG changes are often bilateral.
This condition usually has its onset in childhood.
 Generalized Tonic-Clonic Seizure
Loss of concsiousness
Aura
Fall, cry
Muscular rigidity (tonic)
Rythmic jerking (clonic)
Respiration inhibited
Tongue bite / incontinence/
injury can occur
Usually lasts 1-3 minutes
Postical confusion
What is
AURA ??

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.
Diagnosis of epilepsy
History Imaging
Patients CT scan
Eyewitness MRI
Physical/ neuro exam Special studies
EEG Ictal SPECT
Photic stimulation PET
Hyperventilation Video EEG monitoring
Sleep deprivation Diagnostic
Presurgical
Status epilepticus
Definitions
2 or more seizure without recovery of concsiousness in
between
Single seizure > 20-30 minutes (operationally, >5 min)
Types:
Generalized convulsive
Non - convulsive
Simple partial
EPILEPSY SYNDROMES
Diagnosis made through determining
Seizure type
Etiology (cause)
Age of onset and natural history
Types :
Partial (localization related)
Generalized
Undetermined
Special syndromes
COMMON EPILEPTIC SYNDROMES

Temporal lobe epilepsy

Juvenile myoclonic epilepsy
Childhood absence epilepsy
TEMPORAL LOBE EPILEPSY

Defined in 1985 by ILAE as condition characterized by recurrent

unprovoked seizures originating from the medial or lateral
temporal lobe.
Lateral Temporal Lobe Epilepsy : arises in the neocortex
Medial Temporal Lobe Epilepsy : hippocampus, parahipoccampal
gyrus amigdala
Most common type comprising 70% of seizures with 1,5% of
population in world wide
 MRI in temporal lobe epilepsy

Normal Shrunken
hippocampus Hippocampus (MTS)
Treatment of epilepsy
Therapeutic principle of antiepilepsy drugs (AEDs)

Early treatment
Treatment as the types of epileptic seizure
Treatment with one drug
Individual therapy
Long course of treatment
Slow drug withdrawal
Periodic re-examination
 Treatment and Prognosis
Antiepileptic (anticonvulsant) medications
Carbamazepine (Tegretol)
Clobazam (Frisium)
Clonazepam (Rivotril)
Diazepam (Valium)
Divalproex sodium (Depakote)
Ethosuximide (Zarontin)
Phenobarbital (many different names)
Phenytoin (Dilantin)
Valproic Acid (Depakene)
Treatment of epilepsy
AEDs selection on types of epileptic seizure

types drugs
Tonic-clonic seizures VPA, PB, CBZ, PRM or PHT

Absence seizures VPA, ES, CNP

Myoclonic seizures VPA, CNP, PRM, Topamax

Partial seizures CBZ, VPA, PB, PHT, PRM, T

Infantile spasms CNP, ACTH, Prednison, VPA

Antiepilepsy drugs,AEDs
Update on newer AEDs
Surgery

Temporal Lobe surgery

removal of cortex of temporal lobe where the epileptic seizure starts.
May also remove hippocampus and amygdala.
Corpus Callostomy
the corpus callosum is cut to separate the right and left cerebral
hemispheres. This procedure is done to prevent the spread of the
seizure from one side of the brain to the next.
Hemispherectomy
one cerebral hemisphere is removed. Not done very often. Children
CAN function reasonably well, but often find using their arm on the
opposite side of the body to be difficult. Some surgeries remove just a
specific lobe of the brain.
Other treatments
Vagal nerve stimulation
Electrical stimulator placed in the
Vagus nerve (cranial nerve X)
Vagus nerve function: sensory,
motor and autonomic functions of
viscera (glands, digestion, heart
rate)
Ketogenic diet
High fat, low
protein/carbohydrate diet
Status epilepticus
Status epilepticus is a clinical or electrical seizure
lasting at least 30 minutes, or a series of seizures
without complete recovery over the same period of
time.
Emergency Treatment
ABC(airway, breathing, circulation)
Diazepam 0.3-0.5mg/kg ;may repeat in 15-30 minutes
Phenytoin 10-20mg/kg
Phenobarbital 5-20mg/kg
Thank you