EPILEPSY

EPILEPSY
• Classify seizures and its management. Describe the management

protocol for Status Epilepticus.
EPILEPSY
• A seizure or Epilepsy ( Gk- epilepsia means to be attacked ) is a paroxysmal

uncontrolled event due to abnormal electrical discharge from the neurons of
central nervous system.
• Abnormal depolarisation of neurons by excitatory neurotransmitter GLUTAMATE.
• Balance between excitatory NT Glutamate / Aspartate and inhibitory NT GABA is
the deciding factor.
• More than one episode of seizure.
• Onset – usually in childhood or adolescence rarely > 65 years.
• Most of them controlled excellently by drugs however 30% maybe drug resistant.
STAGES
• Prodrome – mood and behavioural

changes.
• Aura – Hallucinations, abnormal smell or
taste, Déjà vu, abnormal stomach
sensation, blurring and darkening of
vision.
• ICTUS – attack
Tonic stage – stiffening
Clonic phase – jerking
• Post ictal stage – confusion, drowsiness,
tongue bite.
AURA AND AUTOMATISM
CLASSIFICATION OF EPILEPSY
PARTIAL SEIZURE
• Begins focally from a single location
• Depending on severity
• SIMPLE PARTIAL
consciousness preserved
• COMPLEX PARTIAL
impaired consciousness
• PARTIAL SEIZURE EVOLVING TO TONIC
CLONIC
PARTIAL SEIZURE
Depending on the site of onset

• FRONTAL
• PARIETAL – paraesthesia in face and
limb and weakness in limbs.
• TEMPORAL
• OCCIPITAL – visual hallucinations
FRONTAL LOBE SEIZURES
• Also known as JACKSONIAN MARCH

• Movement of one muscle group to
the next.
• Starts in the face and involves a large
group of muscles
TEMPORAL LOBE SEIZURES
• Complex aura with loss of

consciousness.
• VISCERAL – hallucinations, lip
smacking, epigastric fullness, palor
chocking.
• MEMORY – Déjà vu ( has happened
before) flashback and
depersonalisation.
• MOTOR – automatism
• Elation, fear displeasure.
GENERALISED SEIZURE
• Arises from deep subcortical TYPES

structures in the brain near the
midline. • TONIC CLONIC (Grand Mal)
• Spreads to both hemispheres. • ABSENCE SEIZURE (Petit Mal)
• Motor manifestations are bilateral. • MYOCLONIC
• Usually consciousness impaired. • TONIC
• ATONIC
TONIC CLONIC ( Grand Mal )
TONIC PHASE – 10 secs

• Loss of consciousness and fall.
• Eyes open and pupils dilated.
• Stiff flexed elbow and extended leg.
• Breath holding and cyanosis.
CLONIC PHASE 1-2 mins
• Violent generalised shaking.
• Rolling back of eyes.
• Tongue bite and frothing.
• Laboured respiration
ABSENCE SEIZURES ( Petit Mal )
• Usually in children
• Brief period of behavioural changes
lasting for few seconds.
• Stares vacantly.
• Turning of head.
• Blinking of eyes
• Resume normal activity after the
attack.
MYOCLONIC SEIZURE
• Starts with sudden myoclonic jerk.

• Typically attacks are in the morning.
• Drops objects in hand
• Later on becomes generalised tonic
clonic.
INVESTIGATIONS
• EEG – abnormal in 50% of cases.

Spike and wave discharges.
Sensitivity increase in sleep EEG.
• IMAGING – CT/MRI to rule out
structural lesions.
• INFLAMMATORY CAUSE – Blood
count, CRP, Chest Xray, HIV and
Lumber puncture for CSF study.
• METABOLIC CAUSE – Blood glucose,
Electrolytes, Liver function test and
Serum Calcium and magnesium.
TREATMENT
FIRST AID LIFESTYLE CHANGES

• Remove away from immediate danger • Avoid high risk activities in work and
– machinery / water. home.
• Turn to semi prone (recovery) position • Regulations in driving.
after attack.
• Ensure clear airway but do not insert
anything in mouth ( tongue bite is not
preventable )
• Do not leave the person alone until
full gain in consciousness.
• Seek help if duration > 5 mins.
MEDICAL THERAPY
• Excellent response to medicines in majority

• Should be started after one episode of spontaneous seizure.
• Monotherapy preferred over multiple drugs.
• Low dose therapy to minimise side effects.
• Second line therapy is started only after first line fails.
• Medicine withdrawal is considered if the patient is seizure free for 2 years.
DRUGS COMMENTS
LAMOTRIGINE Excellent first line drug
Minimal side effects.
VALPROIC ACID Foetal congenital malformations.
CARBAMAZEPINE Ataxia and diplopia
PHENYTOIN Foetal anomalies, gum bleeding and neuropathy
TOPIRAMATE Drowsiness and kidney stones.
LEVETIRACETAM Behavioural changes and weight loss.
SURGERY FOR EPILEPSY
• ANTERIOR TEMPORAL LOBECTOMY – most commonly done surgery.

Removes the epileptogenic focus of Hippocampus and Amygdala.
Cures more than 50%.
• EXTRA TEMPORAL CORTICAL RESECTION – removes frontal / parietal / occipital
focus.
• SELECTIVE REMOVAL OF AMYGDALA AND HIPPOCAMPUS – less effective
• SECTION OF CORPUS CALLOSUM – prevents generalized seizures.
• VAGAL NERVE STIMULATION – by an implant has limited role in refractory cases.
STATUS EPILEPTICUS
• Recurrent seizures with no recovery of consciousness in between.

• Considered as a medical emergency and carries a mortality of 5 – 10%.
• Prolonged rigidity and clonic movement with loss of consciousness.
• Cyanosis
• Fever acidosis
• May have the following complications
Aspiration
Cardiac arrythmia
Renal and hepatic failure
MANAGEMENT
INITIAL ONGOING
• Ensure patent airway. • If seizures continue > 30 mins IV
• Oxygen @ 10 L/min. PHENYTOIN or PHENOBARBITONE
under cardiac monitoring.
• IV access.
• If seizures still continue transfer the
• Check P R T BP patient to ICU general anesthesia with
• If seizure > 5 mins Injection PROPOFOL.
DIAZEPAM 10 mg IV or rectally • After control – long term IV
• Or Inj. Lorazepam 4mg IV. anticonvulsant like Sodium Valproate
or Phenytoin followed by
• Repeat if required Carbamazepine is used.
• Correction of blood glucose, acidosis
and electrolytes.

EPILEPSY

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EPILEPSY

• Classify seizures and its management. Describe the management

• A seizure or Epilepsy ( Gk- epilepsia means to be attacked ) is a paroxysmal

• Prodrome – mood and behavioural

Depending on the site of onset

• Also known as JACKSONIAN MARCH

• Complex aura with loss of

• Arises from deep subcortical TYPES

TONIC PHASE – 10 secs

• Starts with sudden myoclonic jerk.

• EEG – abnormal in 50% of cases.

FIRST AID LIFESTYLE CHANGES

• Excellent response to medicines in majority

• ANTERIOR TEMPORAL LOBECTOMY – most commonly done surgery.

• Recurrent seizures with no recovery of consciousness in between.

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