epilepsy

Epilepsy
• Epilepsy is a chronic noncommunicable disease of the brain that affects around 50

million people worldwide.
• It is characterized by recurrent seizures, which are brief episodes of involuntary

movement that may involve a part of the body (partial) or the entire body
(generalized) and are sometimes accompanied by loss of consciousness and
control of bowel or bladder function.
• Epilepsy has a profound impact on a patient’s life.

Etiology
• The most common causes of epilepsy are head trauma and stroke.
• Developmental and identifiable genetic defects cause about 5% of cases.
• Brain tumors, central nervous system (CNS) infections, and neurodegenerative diseases
are other common causes.
• Human immunodeficiency virus infection and neurocysticercosis infection are also

important causes.
• Seizures attack could be resulted from various causes, like electrolyte disturbance,
hypoxia, toxicity, or some drugs
Pathophysiology
• Groups of neurons fires rapidly and
repetitively for seconds to minutes.
• Cortical electrical discharges become
excessively rapid, rhythmic, and
synchronous.
• This phenomenon is presumably related to
an excess of excitatory neurotransmitter
action, a failure of inhibitory
neurotransmitter action, or a combination
of the two.
• In individual patients, it is usually
impossible to identify which
neurochemical factors are responsible.
• The primary excitatory neurotransmitter is glutamate. The result is the opening of
membrane channels allowing sodium or calcium to flow into the neuron,
depolarizing it, and transmitting an excitatory signal.
• The primary inhibitory neurotransmitter is γ-aminobutyric acid (GABA). It

attaches to neuronal membranes and opens chloride channels. Chloride flow into
the neuron causes hyperpolarization and less excitability.
• Is there a difference between seizure, epilepsy, and convulsions?
Types of epilepsy:
• 1- Focal:
- with preserved awareness (partial simple)
- with impaired awareness
- with secondary generalization
• 2- Generalized
- abscent seizure
- myoclonic seizure
- tonic –clonic seizure
Signs and symptoms
• Patients who experience seizures may complain of paroxysmal spells of:
• Lapses in memory, periods of altered consciousness
• Warnings or auras consisting of various sensations or automatic, uncontrolled
movements
• Daydreaming
• Jerks, shoulder shrugs, sudden chills of spine
• Falling out
• Associated Symptoms
• Incontinence, usually of urine
• Tongue or cheek biting
• Traumatic injuries, usually associated with falling during a seizure
Diagnosis
• Description of events
• Electroencephalogram (EEG)
• Neuroimaging (preferably an MRI of the brain)

Treatment
• The goal for any patient with epilepsy is elimination of all seizures without
adverse effects from treatment. An effective treatment plan allows the patient to
live a normal lifestyle with complete control of seizures. The treatment should
enable the patient to drive, perform well in school, hold a reasonable job, and
function effectively in the family and community
• If no risk factors are present, the risk of another seizure is 10% to 15%. However,
if two or more risk factors are present, the risk of another seizure is 100%.
Non-pharmacological treatment
• surgery,
• vagal nerve stimulation,
• deep brain stimulation, and
• dietary modifications. [ketogenic diet]

Pharmacologic Therapy
• The use of medications presents some unique challenges due to their pharmacokinetic and
pharmacodynamic properties.
• protein Binding Some ASMs, especially phenytoin and valproate, are highly bound to
plasma proteins. When interpreting a reported concentration for these drugs, it is
important to remember the value represents the total (ie, bound and unbound) con-
centration in the blood.
• Autoinduction Carbamazepine is a potent inducer of hepatic microsomal enzymes. It

increases the rate of metabolism for many other drugs and the rate of its own metabolism.
• Zero-order Pharmacokinetics
Some important notes about treatment
Drug Selection and Seizure Type
The key to selecting effective pharmacotherapy is to base the decision on the seizure
type.
Switching Drugs Changing from one ASM to another can be a complex process. If
the first drug is stopped too abruptly, breakthrough seizures may occur.
Stopping Therapy Epilepsy is generally considered to be a lifelong disorder
requiring ongoing treatment. And these points must be considered:
• No seizures for 2 to 5 years
• Normal neurologic examination
• Normal intelligence quotient
• Single type of focal or generalized seizure
• Normal EEG with treatment

• Drug dosing: should adjusted by monitoring symptoms and serum drug
concentarion.
• Drug interactions:
• Special population:
1- children
2- women in pregnancy period

Blocks Na channels, 1st line in focal seizure, 2nd line for
tonic-clonic, and use for --------.
-Enzyme inducer, and leading to megaloplastic anemia, is
tertatogenic, neural tube defect,
-It is autoinduction drug
Act on GABA, block Na, all types of epilepsy
management, causing NDA (nystagmus, diplopia, ataxia)
liver inducer, highly teratogenic and congenital
malformation
alopecia, pancreatitis
Block Na channel, use for tonic-clonic seizure, causing
NDA, liver inducer, which lead to megaloplastic anemia.
Teratogenic effect [neural tube defect]
Gingival hyperplasia, hirsuitism, osteomalacia
• Blocks T-type ca channel, 1st line for Absence seizures
• Lower side effect (GIT upset, dizziness)
• The least toxic antiepileptic drugs

seizure 1st line 2nd line
Focal-seizure Carbamazepine Lamotrigine, valproic acid
Tonic-clonic Valproic acid Lamotrigine, Carbamazepine
Childhood absence Ethosuxamide Lamotrigine, valproic acid
Seizure in pregnancy Lamotrigine
Status epilepticus Diazepam IV (adult), rectal

(children)
• Status epilepticus is a neurological emergency requiring immediate evaluation
and management to prevent significant morbidity or mortality.
• Clinical Symptoms
• Patients with SE usually present with generalized, convulsive, tonic-clonic

seizures. They may also be hypertensive, tachycardic, febrile, and diaphoretic,
which resolve after seizure termination. A loss of bowel or bladder function,
respiratory compromise, and nystagmus may also be observed.
• Diazepam Being extremely lipophilic, diazepam penetrates the CNS quickly but rapidly
redistributes into body fat and muscle.1 This results in a rapid decline in CNS levels and early
recurrence
• of seizures. Doses can be given every 5 minutes until seizure activity stops or toxicities are seen
(e.g., respiratory depression)
• IM not preferred due to erratic absorption
• After administering the first dose of benzodiazepine, an anticonvulsant such as phenytoin,

valproate sodium, levetiracetam, or phenobarbital should be started to prevent further seizures
(urgent therapy).

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Epilepsy

• Epilepsy is a chronic noncommunicable disease of the brain that affects around 50

• It is characterized by recurrent seizures, which are brief episodes of involuntary

• Epilepsy has a profound impact on a patient’s life.

• Developmental and identifiable genetic defects cause about 5% of cases.

• Human immunodeficiency virus infection and neurocysticercosis infection are also

• The primary inhibitory neurotransmitter is γ-aminobutyric acid (GABA). It

• Neuroimaging (preferably an MRI of the brain)

• vagal nerve stimulation,

• deep brain stimulation, and

• dietary modifications. [ketogenic diet]

• Autoinduction Carbamazepine is a potent inducer of hepatic microsomal enzymes. It

• No seizures for 2 to 5 years

• Normal neurologic examination

• Normal intelligence quotient

• Single type of focal or generalized seizure

• Normal EEG with treatment

2- women in pregnancy period

• Lower side effect (GIT upset, dizziness)

• The least toxic antiepileptic drugs

Focal-seizure Carbamazepine Lamotrigine, valproic acid

Tonic-clonic Valproic acid Lamotrigine, Carbamazepine

Childhood absence Ethosuxamide Lamotrigine, valproic acid

Seizure in pregnancy Lamotrigine

Status epilepticus Diazepam IV (adult), rectal

• Patients with SE usually present with generalized, convulsive, tonic-clonic

• IM not preferred due to erratic absorption

• After administering the first dose of benzodiazepine, an anticonvulsant such as phenytoin,

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