Epilepsy

Shi Xue Chuan

General Considerations

A seizure is a sudden, transient disturbance of brain

function, manifested by involuntary motor, sensory,
autonomic, or psychic phenomena, alone or in any
combination, often accompanied by alteration or loss
of consciousness.
A seizure may occur after a metabolic, traumatic,
anoxic, or infectious insult to the brain.
Repeated seizures without evident cause justify the
label of epilepsy.

General Considerations

Incidence is greatest in early and late

life, with a prevalence of approximately
3 6 .
Chance of having a second seizure after
an initial unprovoked episode is 30%.
Chance of remission from epilepsy in
childhood is 80%.

General Considerations

Recurrence rate after the withdrawal of

drugs is about 30%.

Idiopathic or genetic epilepsy most often

appears between ages 4 and 16 yaers.

General Considerations

Factors adversely influencing

recurrence include:

Difficulty in getting the seizures

under control
Neurologic dysfunction or mental
retardation
Age at onset under 2 years
Abnormal EEG at the time of
discontinuing medication
Type of epilepsy

Etiology

Genetic factor

Brain damage and

dysmetabolism

Inborn

Acquired

Causative factor

Classification

Classified by etiology

Idiopathic (essential) epilepsy

Symptomatic (secondary)
epilepsy

Cryptogenic epilepsy

Classification

Classified by epileptic
seizures

Partial (foal, local) seizures

Simple

partial seizures, without

impairment of consciousness
With motor signs
With somatosensory or specialsensory symptoms
With autonomic symptoms or signs
With psychic symptoms

Classification

Classified by epileptic seizures

Complex partial seizures, with

impairment of consciousness

Partial seizures evolving to

secondarily generalized seizures

Classification

Classified by epileptic seizures

Generalized seizures

Absence seizures

Typical absence
Atypical absence

Myoclonic seizures
Clonic seizures
Tonic seizures
Tonic-clonic seizures
Atonic seizures
Infant spasm, tonic-spasm

Unclassified epileptic seizures

Classification

Classification of epilepsy and epilepsy

syndromes

Benign children epilepsy with centroltemporal spike

Lennox-Gastaut syndrome
Infantile spaams
Juvenile myoclonic

Clinical manifestation

Partial epilepsy

Focal epilepsy may arise from an intracerebral

structural defect, causing motor or sensory
symptoms localized to one body part, which may
then spreads to contiguous regions of the cortex
(e.g. jacksonian seizures).
There are simple partial seizures without
impairment of consciousness.
Complex partial seizures associated with
disturbance of consciousness usually arise in the
temporal lobe.

Clinical manifestation

Partial epilepsy

Seizures arising in the medial temporal lobe may

produce disturbances of smell and taste, visual
hallucinations.

These may evolve to a tonic-clonic seizures

( secondary generalization).

Weakness following the event may occur for

minutes or hours (todds paresis).

Clinical manifestation

Generalized seizures

Absence attacks usually consist of a

brief interruption of activity, sometimes
with complex motor activity (such as
fumbling with clothes), but without
collapse.

EEG during this event shows a threeper-second spike-and-wave activity.

Clinical manifestation

Generalized seizures

In a generalized tonic-clonic seizures, the

tonic phase is a sudden tonic contraction of
muscles usually with upward eye deviation.
The clonic (with clonus-type activity)
phase follows.
Initial EEG changes are often bilateral.
This condition usually has its onset in
childhood.

Diagnosis of epilepsy

The integrate diagnosis should include

seizure type, anatomy, etiology and
concomitant mental disorders.
For example:

Epilepsy--grand malsecondary
(symptomatic) mental retardation
Epilepsycentrotemporal spike wave-benign childhood epilepsy

Diagnosis of epilepsy

Clinical picture

Clinical history

Description of Sz

Symptomatology

Physical/Neurologic
examination

Therapy

EEG

Background activity

Epileptiform activity

Interictal

Ictal

Postictal

Laboratory tests

Neuroimaging

Differenial diagnosis

Febrile Seizures

Ages 3 months to 5 years

Fever
Non-CNS infection
Generalized seizures
Last less than 5 minutes

Migraine

Positive family history.

Pulsatile headache
Manifestations of autonomic nerve disorder
Visual disorder
Sensory disturbance

Differenial diagnosis

Breath-holding spells

Age 6 months to 3 years,

Cry, loss of consciousness
Apnea and cyanosis
Family historypositive in 30%
Normal EEG.

Sleeping disturbance
Sleepwalking ,
Nightmare

Night terrors

Differenial diagnosis

Masturbation

Pseudoseizures

Consciousness not impaired

Normal EEG
Effectual Suggestive therapy
Normal EEG

Tourette sydrome

Simple or complete stereotyped jerks or

movements
Cough and grunt
Normal EEG
Positive Family history

An approach to Seizures
Is it a s e iz u r e ?
Yes

No

I s i t s y m p t o m a t ic o f a n a c u t e i lln e s s
No
W h a t is t h e p r o b a b l e c a u s e ?
n a t u r a l h is t o r y
in v e s t ig a t io n
tre a tm e n t

Yes
D ia g n o s e a n d T r e a t

Treatment of epilepsy

Therapeutic principle of ntiepilepsy

drugs (AEDs)

Early treatment
Treatment as the types of epileptic seizure
Treatment with one drug
Individual therapy
Long course of treatment
Slow drug withdrawal
Periodic re-examination

Treatment of epilepsy
AEDs selection on types of epileptic seizure
types

drugs

Tonic-clonic seizures

VPA, PB, CBZ, PRM or PHT

Absence seizures

VPA, ES, CNP

Myoclonic seizures

VPA, CNP, PRM, Topamax

Partial seizures

CBZ, VPA, PB, PHT, PRM, T

Infantile spasms

CNP, ACTH, Prednison, VPA

Antiepilepsy drugs,AEDs
drug

Dosage
mg/kg

Effective blood
level ug/ml

T1/2

Side effect

VPA

15-50

50-120

8h

Ganstric discomfort,
sthenic
apptite , hepatic dysfunction

CBZ

15-30

4-12

15h

Drowsiness, Skin rash, WBC

decrease, hepatic dysfunction

PHT

4-8

10-20

22h

Skin rash,ataxia, WBC decrease,

unsteady gait

PB

4-6

20-40

4d

Hyperkinesia, inattention, Skin

rash

ESX

20

40-120

55h

CZP

0.01-0.2

20-80

55h

ACTH

25-40u

Gastrointestinal
disorder,
headache , WBC decrease,
Drowsiness, Skin rash, unsteady
gait, ataxia, salivate
Hyperfuction of the adrenal
cortex

Update on newer AEDs

drug

Dosage
mg/kg

TMP

3-10

LTG

5-15 (used
with VPA
1-5)

GBP

20-50

Effective blood
level ug/ml

T1/2

Side effect

1.1-3.0

20-30h
infant
15h
20-30h

Drowsiness, inattention, slow

reaction, lose appetite, weight
lose
Drowsiness, Skin rash, ataxia,
headache, gastric discomfort

2-3

5-7

Drowsiness, ataxia, nystagmus,

personality and behavioral
changes

Treatment of epilepsy

1
30%

70%

2
25%

5%

3
20%
10%

10%
VNS
7%

3%

5%
10%

3%
3%

7%

Status epilepticus

Status epilepticus is a clinical or electrical

seizure lasting at least 30 minutes, or a series
of seizures without complete recovery over the
same period of time.
Emergency Treatment
ABC(airway, breathing, circulation)
Diazepam 0.3-0.5mg/kg ;may repeat in 15-30 minutes
Phenytoin 10-20mg/kg
Phenobarbital 5-20mg/kg

Thank you