Treatment of Epilepsy

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Treatment of Epilepsy:

Dr Rahul Chakor Associate Prof of Neurology T. N. Medical College B. Y. L. Nair Ch Hospital Neurologist & Epileptologist Prince Aly Khan Hospital Masina Hospital Treatment of Epilepsy

Outline:

Outline Is it a seizure Is it epilepsy Type of seizure Type of Epilepsy Etiology Electroclinical Syndrome Management Issues Antiepileptic Drug Choice

Is it a seizure:

Is it a seizure Epileptic Seizure - Occasional, sudden, episodic, localized or generalized discharge of cortical neurons Abrupt, stereotype disturbance in sensory, motor, psychic, autonomic functions Non epileptic seizures – Psychogenic seizures Syncope

Psychogenic Seizures:

Psychogenic Seizures Young women Gradual in onset Non stereotype Longer duration No self injury, no tongue bite In presence of observers Never in sleep Gain Stressors, abuse Resistant to antiepileptic therapy

Syncope:

Syncope In upright posture Lasts for < minute Sweating, pallor, No tongue bite May have few clonic jerks, incontinence Never in sleep

Uncertain diagnosis:

Uncertain diagnosis Unwitnessed episodes No positive evidence of seizure Better to err on side of caution Diagnosis of possible seizure Err on side of not treating if single event

Type of seizure:

Type of seizure Focal – Begins in a localized region of brain Simple – preserved consciousness Complex – impaired consciousness Sensory Motor Special sensory Psychic Autonomic

Epilepsy:

Epilepsy Recurrent unprovoked seizures Enduring tendency of brain to cause seizures Usually genetic or combination of genetic and environmental factors Structural lesion Abnormal CNS examination

Single Seizure:

Single Seizure Not epilepsy May be symptomatic seizure (Alcohol, hypoglycemia, encephalitis, neurocysticercosis) First seizure in a patient who has Epilepsy Should be investigated for the cause Long term AED prophylaxis may not be needed

Management Issues:

Management Issues Type of epilepsy Etiology of Epilepsy Anti epileptic choice

Type of epilepsy:

Type of epilepsy Generalized Focal Idiopathic Absence, Myoclonic, GTCs Centrotemporal, Occipital Symptomatic West syndrome, Lennox Gastaut syndrome Temporal, frontal, Occipital etc

Electroclinical Diagnosis:

Electroclinical Diagnosis Childhood Absence Epilepsy Juvenile Myoclonic Epilepsy IGE with GTCs only Benign Focal Epilepsy with centrotemporal spikes

Electroclinical Diagnosis :

Electroclinical Diagnosis May not be possible though desirable Seizure classification is a must Focal Generalized Onset in a focal region Onset is bilateral generalized Aura (psychic, deja, vu, jamais vu) Sudden onset loss of consciousness Generalized tonic activity Visual hallucinations (colored balls) Absence seizures with staring lasting few seconds Focal motor onset with Jacksonian march Generalized myoclonus Focal epileptiform abnormalities on EEG Generalized epileptiform activity

Evaluation:

Evaluation History - (from the patient and a reliable eyewitness) is the key to diagnosis Neurologic examination EEG- routine, video EEG Neuroimaging - CT, MRI

Treatment:

Treatment General principles Efficacy Safety and tolerability Dosing and titration Treatment in Children, young women, pregnancy, elderly

Is treatment necessary:

Is treatment necessary Uncertainty (? Possible seizures) Single seizure Very infrequent seizures The key – candid discussion with patient and family

Single unprovoked seizure:

Single unprovoked seizure Normal examination Normal EEG and MRI Risk of recurrence ≈ 50% in 3 yrs Usually not to treat Informed decision with patient and family

General principles:

General principles Monotherapy Initial choice of AED based on seizure & epilepsy New vs old AEDs

Slide 20:

Efficacy spectrum of AEDs in different seizure types lacosamide

Choice of AED:

Choice of AED Partial GTCs Myoclonic Absence Epileptic Spasms Multiple types CBZ CBZ VLP VLP ACTH VLP OXC OXC LEV LEV VLP LEV PHT PHT CLZ BZD LCM PB LEV TPM VLP ZNS LTG BZD VLP LCS

Broad Spectrum AEDs:

Broad Spectrum Not Broad Spectrum VLP LEV TPM BZD PB LTG ZNS CBZ OXC PHT PG GBP Broad Spectrum AEDs

Thank You:

Thank You