sailu epilepsy

Epilepsy: 

Epilepsy Dr .B. Shailaja

Plan of presentation: 

Plan of presentation Introduction Definitions Epidemiology Etiology Classification of seizures Differential diagnosis Diagnosis and evaluation Treatment Epilepsy in special groups Psychiatric and epilepsy

Definitions: 

Definitions Seizure Epilepsy Aura Automatism

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What Is the Difference Between Epilepsy & Seizures? A seizure is a brief, temporary disturbance in the electrical activity of the brain Epilepsy is a disorder characterized by recurring seizures (also known as “seizure disorder”) A seizure is a symptom of epilepsy

The Brain Is the Source of Epilepsy: 

The Brain Is the Source of Epilepsy All brain functions -- including feeling, seeing, thinking, and moving muscles -- depend on electrical signals passed between nerve cells in the brain A seizure occurs when too many nerve cells in the brain “fire” too quickly causing an “electrical storm”

Pathogenesis : 

Pathogenesis The 19th century neurologist Hughlings Jackson suggested “a sudden excessive disorderly discharge of cerebral neurons“ as the causation of epileptic seizures. Recent studies in animal models of focal epilepsy suggest a central role for the excitatory neurotransmiter glutamate (increased in epi) and inhibitory gamma amino butyric acid (GABA) (decreased)

Epidemiology and course: 

Epidemiology and course Epilepsy usually presents in childhood or adolescence but may occur for the first time at any age.

Epidemiology and course: 

Epidemiology and course 5% of the population suffer a single sz at some time 0.5-1% of the population have recurrent sz = EPILEPSY 70% = well controlled with drugs (prolonged remissions); 30% epilepsy at least partially resistant to drug treatments = INTRACTABLE EPILEPSY.

Epilepsy: 

Epilepsy is a symptom of numerous disorders, but in the majority of sufferers the cause remains unclear despite careful history taking,examination and investigation !

What Causes Epilepsy?: 

What Causes Epilepsy? In about 70% of people with epilepsy, the cause is not known In 30%, most common causes are: - Head trauma Infection of brain tissue Brain tumor and stroke Heredity - Prenatal disturbance of brain development

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Etiology of the epilepsy by age group ______________________________________________________________________ 0-14yrs 15-34yrs _________ __________________ Birth trauma CNS infections CNS infections Trauma CNS hemorrhages CNS tumours Congenital malformation Vascular dilsease Genetic Predisposition Metabolic defect Tumors

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Etiology of the epilepsies by age group. 35-64yrs over65yrs _______________________________________________________________________ Vascular disease Vascular disease CNS tumors CNS tumors CNS infections Degenerative Trauma CNS infections Trauma

Seizure Triggers: 

Seizure Triggers Missed medication (#1 reason) Stress, anxiety Hormonal changes, Menses Dehydration Lack of sleep, extreme fatigue Photosensitivity Illicit Drug, alcohol use Certain Medications Fever in Some Children

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Groups at Increased Risk for Epilepsy About 1% of the general population develops epilepsy The risk is higher in people with certain medical conditions: Mental retardation Cerebral palsy Alzheimer’s disease Stroke Autism

Epilepsy - Classification: 

Epilepsy - Classification The modern classification of the epilepsies is based upon the nature of the seizures rather than the presence or absence of an underlying cause. Seizures which begin focally from a single location within one hemisphere are thus distinguished from those of a generalised nature which probably commence in a deeper structures (brainstem? thalami) and project to both hemispheres simultaneously .

Epilepsy - Classification: 

Epilepsy - Classification Focal seizures – account for 80% of adult epilepsies Simple partial seizures Complex partial seizures Partial seizures secondarilly generalised Generalised seizures Unclassified seizures

PowerPoint Presentation: 

Classifying Epilepsy and Seizures Classifying epilepsy involves more than just seizure type Seizure types: Partial Generalized Simple Complex Absence Convulsive Consciousness is maintained Consciousness is lost or impaired Altered awareness Characterized by muscle contractions with or without loss of consciousness

Focal (partial) seizures: 

Focal (partial) seizures Simple partial seizures Motor , sensory, vegetative or psychic symptomatology Typically consciousness is preserved

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Simple Partial Seizures Discriminating features No impairment of consciousness Stereotyped Focal spikes in interictal EEG Consistent Features Brief duration Paroxysmal No impairment of consciousness No post-ictal period Variable Features May manifest abnormal sensations Associated with a focal structural lesion May occur independent of or prior to a complex partial seizure

Focal (partial) seizures: 

Focal (partial) seizures Complex partial seizures (= psychomotor seizures) Initial subjective feeling (aura), loss of consciousness, abnormal behavior (perioral and hand automatisms) Usually originates in TL

Focal (partial) seizures: 

Focal (partial) seizures Partial seizures evolving to tonic/clonic convulsions – secondary generalised tonic/clonic seizures (sGTCS)

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Complex Partial Seizures Discriminating features Consciousness is altered Stereotyped Focal spikes in interictal EEG Consistent Features Approximately 60-180 second duration Paroxysmal Post-ictal confusion Variable Features Presence of aura Automatisms Automatic features May secondarily generalize to a tonic-clonic seizure Associated with focal structural lesion May elevate prolactin level

Generalized seizures (convulsive or non-convulsive): 

Generalized seizures (convulsive or non-convulsive) Absences Myoclonic seizures Clonic seizures Tonic seizures Atonic seizures

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Generalized tonic-clonic seizures Discriminating features Initial tonic phase followed by clonic activity involving all extremities Consistent Features Loss of consciousness Typically 60 second duration Post-ictal period associated with confusion and drowsiness Variable Features Tongue biting or injury Urinary incontinence Nonspecific prodrome post-ictal paralysis

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Absence seizures Discriminating features Very brief duration (5-15 seconds) Family H/O of typical absence seizures Response to ethosuximide and valproate Consistent Features EEG-3 cycles/ sec of generalized spike and wave(typical) EEG-1.5 to 2.5 cycles/ sec of generalized spike and wave(typical) No aura Impaired consciousness No post- ictal state Variable Features Automatisms Change in body tone Precipitation by hyper ventilation

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Myoclonic seizures Discriminating features Shock-like muscle contractions No impairment of consciousness Consistent Features Brief duration No aura No post ictal period Generalized spike wave in the interictal EEG Variable Features Specific muscle groups involved (isolated or whole body, unilateral or bilateral) Association with a Progressive neurological syndrome Occur spontaneously or may be provoked by sensory stimulion

Different parts have different functions, and different seizures!: 

Different parts have different functions, and different seizures!

Epileptic Syndromes: 

Epileptic Syndromes Temporal lobe epilepsy – Most common of anatomically defined syndromes accounting for 60% Most frequent cause- hippocampal sclerosis Includes both simple and complex partial seizures Auras- epigastric aura Affective experiences- anxiety Cognitive abnormalities- disturbances of speech, memory and thought. Automatisms- most frequent oro elemental and gestural

Frontal lobe epilepsy: 

Frontal lobe epilepsy Accounts for 20-30% Post traumatic etiology most common Begin and end abruptly (less than 1min) Motor phenomena (complex posturing and behavioural automatisms) are the most conspicuous features Partial motor seizures of Jacksonian type Focal clonic motor seizures

Parietal lobe epilepsy: 

Parietal lobe epilepsy Rare (<5%) Most common cause- Tumours Somatosensory auras Foci in posterior region- Distortions of body image, illusions that parts of the body are moving and ictal ideo -motor apraxia

Occipital lobe epilepsy: 

Occipital lobe epilepsy Accounts for 5-7% Elementary visual hallucinations are the hallmark Negative phenomena such as scotoma , black or white outs Primary occipital motor phenomena include eye deviation both tonic and oculoclonic , forced eyelid closure and palpable jerks Post ictal blindness (important clue to occipital lobe onset) Common causes include tumours , trauma and developmental malformations.

Symptoms That May Indicate a Seizure Disorder: 

Symptoms That May Indicate a Seizure Disorder Periods of blackout or confused memory Occasional “fainting spells” Episodes of blank staring Sudden falls for no apparent reason Episodes of blinking or chewing at inappropriate times A convulsion, with or without fever Clusters of swift jerking movements in babies

EEG TRACING OF EPILEPTIC SIEZURE: 

EEG TRACING OF EPILEPTIC SIEZURE

Epilepsy Differential Diagnosis: 

Epilepsy Differential Diagnosis The following should be considered in the diff. dg. of epilepsy: Syncope attacks Cardiac arrythmias Hypoglycemia Panic attacks Paroxysmal Neurological Disorders Transient PSEUDOSEIZURES – psychosomatic and personality disorders

PowerPoint Presentation: 

Psychogenic Seizures Discriminating features Gradual onset Variability in duration of episodes No increase in serum prolactin Induced by suggestion Consistent Features Normal EEG during Seizures and in interictal state Never occur during sleep Variable Features Manifestations of episodes(altered responsiveness, motor activity, vocalizations) Asynchronous extremity movements MMPI suggestive of conversion

Epilepsy – Investigation: 

Epilepsy – Investigation The concern of the clinician is that epilepsy may be symptomatic of a treatable cerebral lesion. Routine investigation: Haematology, biochemistry (electrolytes, urea and calcium), chest X-ray, electroencephalogram (EEG). Neuroimaging (CT/MRI) should be performed in all persons aged 25 or more presenting with first seizure and in those pts. with focal epilepsy irrespective of age. Specialised neurophysiological investigations: Sleep deprived EEG, video-EEG monitoring. Advanced investigations ( in pts. with intractable focal epilepsy where surgery is considered): Neuropsychology, Semiinvasive or invasive EEG recordings, MR Spectroscopy, Positron emission tomography (PET) and ictal Single photon emission computed tomography (SPECT )

PowerPoint Presentation: 

Tools to Confirm the Diagnosis of Epilepsy EEG Imaging Scans (Abnormal electricity) (Lesions)

EEG in epilepsy: 

EEG in epilepsy A normal single EEG does not exclude the diagnosis of epilepsy. If a normal awake EEG is obtained in an individual with the clinical suspicion of seizures, one should repeat the EEG capturing sleep because many epileptic abnormalities appear only in sleep Interictal findings in the EEG are invaluable aids for classifying seizures and epilepsy syndromes

Treatment Goals in Epilepsy: 

Treatment Goals in Epilepsy Help person with epilepsy lead full and productive life Eliminate seizures without producing side effects Tailor treatment to needs of individuals/special populations : Women, Children, Elderly, Hepatic or renal failure and other diseases

What if not treated?: 

What if not treated? Seizures can be potentially life threatening with brain failure, heart and lung failure, trauma, accidents Sudden Unexpected Death in Epilepsy (SUDEP) Even subtle seizures can cause small damage in brain Long Term problems: fall in IQ, depression, suicide, Social Problems, Quality of Life

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Types of Treatment Medication Surgery Non-pharmacologic treatment Ketogenic diet Vagus nerve stimulation Life style modifications

SEIZURE INHIBITING DRUGS: 

SEIZURE INHIBITING DRUGS SEIZURES CAN ARISE FROM REMOVAL OF GABA INDUCED INHIBITION WHEN GABA LEVELS DROP VITAMIN B6 (PYRIDOXAL PHOSPHATE) IS IMPORTANT FOR GABA SYNTHESIS MOST GABA IS EVENTUALLY CONVERTED TO SUCCINATE BY GABA AMINOTRANSFERASE A GABA AMINOTRANSFERASE INHIBITOR, SODIUM DIPROPYLACETATE, IS WIDELY USED AS AN ANTICONVULSANT GABA IS MOST COMMONLY FOUND IN LOCAL-CIRCUIT INTERNEURONS DRUGS THAT ACT AS AGONISTS OR MODULATORS FOR POSTSYNAPTIC GABA RECEPTORS, SUCH AS BARBITURATES, ARE ALSO USED TO TREAT EPILEPSY

Epilepsy - Treatment: 

Epilepsy - Treatment The majority of pts respond to drug therapy (anticonvulsants). In intractable cases surgery may be necessary. The treatment target is seizure-freedom and improvement in quality of life! Basic rules for drug treatment: Drug treatment should be simple, preferably using one anticonvulsant ( monotherapy ). “Start low, increase slow“. Polytherapy is to be avoided especially as drug interactions occur between major anticonvulsants. The commonest drugs used in clinical practice are: Carbamazepine , Sodium valproate , Phenytoin (first line drugs) Lamotrigine , Topiramate , Levetiracetam , Pregabaline (new AEDs)

Epilepsy – Treatment (cont.): 

Epilepsy – Treatment (cont.) If pt is seizure-free for three years, withdrawal of pharmaco therapy should be considered. Withdrawal should be carried out only if pt is satisfied that a further attack would not ruin employment etc. (e.g. driving licence ). It should be performed very carefully and slowly! 20% of pts will suffer a further sz within 2 yrs. The risk of teratogenicity is well known (~5%), especially with valproates , but withdrawing drug therapy in pregnancy is more risky than continuation. Epileptic females must be aware of this problem and thorough family planning should be recommended. Over 90% of pregnant women with epilepsy will deliver a normal child .

Effectiveness of antiepileptic drugs against different seizure types: 

Effectiveness of antiepileptic drugs against different seizure types Partial onset seizures First line drugs- Carbamazepine Lamotrigine Alternatives- Valproate Generalized onset tonic clonic seizures First line drug- Valproate Alternatives- Carbamazepine Absence seizures First line drug- Ethosuximide Alternatives- Valproate Lamotrigine

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Tolerating Medications Most Common Side Effects Rash Clumsiness Drowsiness Irritability Nausea Side effects may be related to dose Care must be taken in discontinuing drug due to risk of seizure recurrence Warning Signs of Possible Serious Side Effects Prolonged fever Rash, nausea/vomiting Severe sore throat Mouth ulcers Easy bruising Pinpoint bleeding Weakness Fatigue Swollen glands Lack of appetite Abdominal pain

Considerations in Epilepsy Management: 

Considerations in Epilepsy Management Age and Gender Seizure Frequency Underlying Pathology Comorbidities Medication Side Effects Syndrome vs Seizure Type

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Factors That Affect the Choice of Drug Seizure type/ Epilepsy syndrome Side effects & safety Patient age Ease of Use Lifestyle Age, Sex, Childbearing potential Other medications

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Consistent use Inadequate dosage or ineffective medication Drug factors Disease Seizures eliminated (50% of people) Seizures markedly reduced (30%) Seizures do not respond (20%) Factors That Influence Response to Medication

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Epilepsy Surgery Factors influencing decision Likelihood seizures are due to epilepsy Likelihood surgery will help Ability to identify focus of seizures Other treatments attempted, and seizures couldn’t be treated with 2-3 medications Benefits vs risks

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Vagus Nerve Stimulation Device is implanted to control seizures by delivering electrical stimulation to the vagus nerve in the neck, which relays impulses to widespread areas of the brain Used to treat partial seizures when medication does not work 

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Ketogenic Diet Based on finding that starvation -- which burns fat for energy -- has an antiepileptic effect Used primarily to treat severe childhood epilepsy, has been effective in some adults & adolescents High fat, low carbohydrate and protein intake Usually started in hospital Requires strong family commitment

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Other Treatment Approaches Behavioral therapy Biofeedback Relaxation Positive reinforcement Cognitive therapy Aromatherapy

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Stay calm and track time Protect head, remove glasses, loosen tight neckwear Move anything hard or sharp out of the way Turn person on one side, position mouth to ground Check for epilepsy or seizure disorder ID Understand that verbal instructions may not be obeyed Stay until person is fully aware and help reorient them Call ambulance if seizure lasts more than 5 minutes or if it is unknown whether the person has had prior seizures First Aid for Seizures

Potentially Dangerous Responses to Seizure: 

Potentially Dangerous Responses to Seizure Don’t restrain person Don’t put anything in the person’s mouth Don’t try to hold down or restrain the person Don’t attempt to give oral anti-seizure medication Don’t keep the person on their back face up

Safety Issues for Patients with Epilepsy : 

Safety Issues for Patients with Epilepsy Cant Drive for about a year after the last seizure Climbing altitudes Swimming/ Bathing alone Operating heavy machinery or weapons that can be dangerous Cooking, hot water Taking care of babies Bone Health

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Epilepsy in Women Hormonal effects Hormonal changes during puberty, menopause, and the monthly cycle may affect seizure frequency Polycystic ovary syndrome Sexuality & contraception Sexual dysfunction Birth control pills may be less effective Pregnancy & motherhood Need to continue medication Slight increased risk for birth defects

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Epilepsy in Older Adults Epilepsy is common in the elderly, and is often unrecognized or misdiagnosed Older people face increased treatment risks Maintaining independence is a challenge after the diagnosis of epilepsy

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Epilepsy in Infants & Young Children Balancing normal development and the special concerns of epilepsy Good parenting skills Childcare Effects on brothers and sisters Early childhood intervention services

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Epilepsy in Children Aged 6-12 Handling feelings Family relationships Safety School and childcare Developmental stages

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Epilepsy in Teens & Young Adults Assuming responsibility Dealing with feelings Friends and social pressures School Driving Drinking Dating Employment

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Classification of psychiatric presentations and disorders in Epilepsy Disorders clearly attributable to the brain disorders causing epilepsy Learning disability Specific epileptic syndromes West syndrome Lennox- Gastaut syndrome Epilepsy with continuous spick and wave during slow-wave sleep. Progressive Myoclonic epilepsies Disorders strictly related in time to seizure occurrence Pre- ictal Ictal Psychiatric manifestations of seizure activity Aura Automatisms Non-convulsive status epilepticus Post-ictal Delirium psychosis

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Inter-ictal Psychiatric Disorders Affective disorder Schizophrenia-like psychosis Personality disorder or behavior disorder Dementia Dissociative Seizures

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Lennox- Gastaut syndrome Discriminating Features 1.mental retardation, 2.generalized slow spike-and wave on EEG, 3.multiple seizure type-atonic, atypical absence, myoclonic, partial, and tonic- clonic seizures. Consistent Features Atonic seizures Onset before age of 8 Seizures are refractory to treatment Poor prognosis Variable Features Association with symptomatic early brain insults Cryptogenic onset in 30% of cases Behavioral disturbances Disorders clearly attributable to the brain disorder causing epilepsy

Disorders temporally related to the occurrence of seizures: 

Disorders temporally related to the occurrence of seizures Pre ictal disorders prodromal symptoms Ictal disorders epileptic aura epileptic automatisms types Non covulsive status epilepticus

Post ictal disorders: 

Post ictal disorders Delirium Psychosis

Inter ictal disorders: 

Inter ictal disorders Depression Clinical presentation Risk factors Anxiety Epilepsy and suicide Schizophrenia like Psychosis Nature of Psychosis Risk factors Epilepsy and sexual dysfunction Crime and epilepsy Cognitive function in epilepsy

Epileptic personality: 

Epileptic personality Geschwind syndrome - Alteration in sexual behaviour ( hyposexuality ) Religiosity Hypergraphia ( tendency towards extensive and compulsive writing and drawing) Humourlessness Circumstantiality Dependence Sense of personal destiny Preoccupation with philosophical concerns

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References: 1.Comprehensive text book of psychiatry ,Kaplan and saddock (9 th edition ) 2.Text book of Organic psychiatry , Leishmann , ( 3 rd edition ) 3.Adult neurology , Jody Corey-Bloom , (2 nd edition ) 4.Text book of psychiatry , Neraj Ahuja , ( 2 nd edition ) 5. Text book of psychiatry by Allan Tasman , (3 rd edition ) 6. www.pubmed.com

SOME FAMOUS PEOPLE WHO WERE AFFLICTED: 

SOME FAMOUS PEOPLE WHO WERE AFFLICTED JULIUS CAESAR ALEXANDER THE GREAT NAPOLEON DOSTOEVSKY VAN GOGH

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