Approach to Epilepsy

Approach to Epilepsy:

Approach to Epilepsy Dr Rahul Chakor MD, DM Neurologist & Epileptologist

Outline :

Outline Diagnostic Issues Is it a Seizure Is it Epilepsy Management Issues Seizures Epilepsy History and EEG Decision to treat Choice of AED

Seizure:

Seizure 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 Epilepsy: enduring tendency for seizures

Epileptic Seizure:

Epileptic Seizure Abrupt onset and offset Stereotyped manifestation Sleep and wakefulness Loss of consciousness Tonic, clonic Injury to self Tongue bite Incontinence

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Patient 1

Wrong diagnosis of Epilepsy:

Wrong diagnosis of Epilepsy Psychogenic nonepileptic seizures (90%) Syncope (9%) Others (1%)

Psychogenic Nonepileptic Seizures/Pseudoseizures:

Psychogenic Nonepileptic Seizures/ Pseudoseizures Gradual onset and offset Stop and go Prolonged duration In presence of audience, consulting room Consciousness is preserved, no amnesia Never in sleep Out of phase motor activity No injury Non responsive to medications

Psychogenic Nonepileptic Seizures/Pseudoseizures:

Psychogenic Nonepileptic Seizures/ Pseudoseizures Odd triggers –pain, stressful event Associated psychiatric disease Somatization - aches and pains Social history - abuse Fibromyalgia EEG is normal Frequent attacks, resistance to medications

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Patient 2

Syncope:

Syncope Gradual – loss of tone, blackout, sinking feeling Upright posture Sweating Pupillary dilatation Incontinence - ± Few clonic jerks- convulsive syncope No tongue bite

Uncertainity:

Uncertainity Unwitnessed loss of consciousness No clear evidence of seizure Err on the side of caution Diagnosis – possible seizure Err on side of not treating

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EEG in the diagnosis of Epilepsy

EEG :

EEG Normal interictal EEG does not rule out Epilepsy Single EEG may be normal in 50% cases of Epilepsy Sleep deprivation increases the possibility of detecting abnormalities Epileptiform abnormality may be detected in 90% of patients with Epilepsy after 4 routine EEGs

Case Scenario:

Case Scenario 13 yr old girl Single GTC today morning Febrile seizure at age 4 yr No myoclonic jerks CT Brain is normal

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Idiopathic Generalized Epilepsy

Case Scenario:

Case Scenario 42 yr old lady 3 episodes of loss of consciousness over last 20 years – few mins to ½ hr, no tongue bite No sleep attacks No witness available MRI is normal Interictal EEG -

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Generalized Spike and waves

Case Scenario:

Case Scenario 20 yr old boy 2 GTCs in the morning Shivering ( Jhatka ) in the morning H/O seizures in sister CNS exam is normal CT brain is normal

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Photoparoxysmal Response

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Generalized Spike and waves Juvenile Myoclonic Epilepsy

Case Scenario:

Case Scenario 10 yr old boy Right focal with secondarily generalized seizures since last 7 yrs Birth asphyxia Mild mental retardation Right hemiparesis

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Left Frontal Focal Epilepsy

Misread (Overread) EEGs:

Misread (Overread) EEGs 1/3 pts with a erroneous diagnosis due to over interpretation of EEG Fluctuation of background Artifacts – Electrode, movement Slow waves Sleep rhythms Overemphasis on phase reversals

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Vertex waves POSTS

Epilepsy:

Epilepsy Single unprovoked seizure with negative workup – Not Epilepsy Single provoked seizure (Alcohol withdrawal, Hypoglycemia, Drug induced) negative workup – Not Epilepsy Single seizure with abnormal EEG, MRI, physical examination, acute CNS insult- Not Epilepsy 2 Seizures six months apart with negative workup Two or more seizures within six months

Type of epilepsy:

Type of epilepsy Generalized Focal Idiopathic (Genetic) Absence, Myoclonic, GTCs Centrotemporal , Occipital Symptomatic (Cause known) Cryptogenic (Cause unknown) West syndrome, Lennox Gastaut syndrome Temporal, frontal, Occipital etc

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Focal or Partial Generalized

Management:

Management To treat or not to treat Choice of AEDs

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Single unprovoked seizure Provoked symptomatic seizure Uncertainity (Possible seizure) The key : candid discussion with the patient and family IS TREATMENT NEEDED? (To treat or not to treat)

Epilepsy:

Epilepsy Monotherapy Choice of first AED New vs old AEDs

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Efficacy spectrum of AEDs in different seizure types lacosamide

Newer drugs:

Newer drugs Efficacy – 25 to 50% reduction in seizure frequency in clinical trials Less sedation and cognitive disturbances Better side effect profile – Tolerability & Safety Fewer drug interactions Beneficial side effects

Newer drugs:

Newer drugs Approved as add on for partial seizures Indications may broaden – Monotherapy GTCs, other epilepsies Pediatrics

Type of epilepsy:

Type of epilepsy Generalized Focal Idiopathic (Genetic) Absence, Myoclonic, GTCs Centrotemporal , Occipital Symptomatic (Cause known) Cryptogenic (Cause unknown) West syndrome, Lennox Gastaut syndrome Temporal, frontal, Occipital etc DANGER !

Choice of AED in IGE:

Choice of AED in IGE Wrong choice of AEDs – Phenytoin, Carbamazepine Pseudo intractability Aggravation of seizures Levetiracetam, Valproate When in doubt - Broad Spectrum AEDs

Broad Spectrum AEDs:

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

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 TPM PB LEV ZNS LTG VLP ZNS LCM LCM BZD VLP

Newer AEDs:

Newer AEDs Lateral benefits Weight loss - TPM Anxiety - PGB, GBP, CLB Migraine - TPM Neuropathic pain - PGB, GBP Bipolar depression- LTG

Case Scenario:

Case Scenario 25 yr old adult 1 -2 GTCs every year since 2 yrs – sleep attacks No aura No myoclonus CNS normal MRI – normal EEGs - normal

Focal or primary generalized:

Focal or primary generalized

Focal or primary generalized:

Focal or primary generalized We do not know When in doubt, use only broad spectrum AEDs

Conclusion:

Conclusion Diagnosis Everything that shakes is not a seizure Every seizure is not epilepsy Every seizure need not be treated History is the key EEG supports the diagnosis Treatment Monotherapy Use least effective dosage AED choice – Broad spectrum , safety and tolerability, lateral beneficial effects

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THANK YOU FOR YOUR ATTENTION