EPILEPSY

Dr. FITRIYANI Sp.S

DEFINITION
Abnormal and recurrent excessive
synchronized discharge of cerebral
neuron with clinical manifestation of
epileptic seizure which are an
intermittent stereotypical behavior,
emotion, motor function or sensation

FOCAL EPILEPTOGENESIS
Asynchronous burst firing in some
hypocampal and cortical neurons

 Generalized epileptogenesis :
asynchronous burst firing in abnormal
thalamocortical interaction

EPIDEMIOLOGY
Developed countries :
annual incidence 50-70 cases per
100.000
Developing countries : prevalence 1%
Incidence varies with age

ETIOLOGY
Idiopathic
Cryptogenic
Symptomatic

Congenital anomalies
Tuberous sclerosis
Storage diseases
Birth trauma

Cerebral tumours

Genetic epilepsies

Intracranial
haemorrhage

Intracranial

Head Injuries

Infections
Febrile
Seizures
Hypoxia

Drugs
and

Hypoglycaemia

alcohol

Cerebrovascular
degenerations

Hypocalcaemia

10
20
Age (years)

60

Factors lowering seizure threshold

Common
Sleep deprivation
Alcohol withdrawal
Television flicker
Epileptogenic drugs
Systemic infection
Head trauma
Recreational drugs
AED non-compliance
Menstruation

Occasional
Barbiturate withdrawal
Dehydration
Benzodiazepine
withdrawal
Hyperventilation
Flashing lights
Diet and missed meals
Specific reflex triggers
Stress
Intense exercise

International Classification of Epileptic Seizures

Partial seizures (beginning locally)
Simple partial seizures (without impaired
consciousness)
with motor symptoms
with somatosensory or special sensory symptoms

Complex partial seizures (with impaired

consciousness)

simple partial onset followed by impaired consciousness

impaired consciousness at onset

Partial seizures evolving into secondary generalized

seizures

Generalized seizures (convulsive or nonconvulsive)

Absence seizures
Typical
Atypical

Myoclonic seizures
Clonic seizures
Tonic seizures
Tonic clonic seizures
Atonic seizures
Unclassified seizures

Simplified Classification of Epileptic Seizures

Partial seizures
Simple preservation of awarness
Complex impairment of consciousnesss
Secondary generalized
Generalized seizures
Absence
Myoclonic
Tonic-clonic
Tonic
Atonic

 Interviews with patients or witness

Diagnosis

Circumstances surrounding the attacks

idiopathic and generalized

No seizure worning
No underlying brain lesions
Associated with a family history
Symptomatic and localization related

Aura
Specific site of onset
Identifiable cause
Recurrent episodes of seizures
Symptoms occured during and after seizures

Recording symptomatic events with videocamera and continous

ambulatory EEG monitoring

EEG

To confirm the clinical diagnosis

To support the classification of partial or
generalized seizures
Routine trace
50% normal
Diagnostic in non convulsion state
epileptic activities :
Hyperventilation
Photic stimulations
Sleep deprivation

EEG

EEG

BRAIN IMAGING
Essential, particularly in partial onset
seizures
Computerized tomography (CT)
Magnetic resonance imaging (MRI)

Structural lesion

MRI

MRI

MRI

Scan
Scan should be repeated periodically :
Suspicion of a tumour
Worsening in neurological examination
or cognitive function
Deterioration in the frequency or
severity of the seizures

Single Photon Emission CT (SPECT)

Positron Emission Tomography (PET)
MRI spectroscopy
Functional MRI

Functional cerebral changes

Useful adjuncts in candidate epileptic
surgery

DIFFERENTIAL DIAGNOSIS

Migraine
Transient Ischaemic Attacks
Hyperventilation
Tics
Myoclonus
Hemifacial spasm
Syncope
Sleep disorders
Non Epileptic Attacks
Narcolepsy
Metabolic disorders
Transient global amnesia

Management
Medical treatment :
Establish a correct diagnosis of epileptic
seizure type and epileptic syndrome
Decide treatment with epileptic drugs is necessary
Decide which drug should be used
Patients and their families should receive
counselling regarding :
Aims of treatment
Prognosis and duration of the expected
treatment
Importance of compliance
Side effects

Surgical treatment
Proposed Indications for resective epileptic
surgery
Intractable seizures
Resectable structural abnormality as identified on
magnetic resonance imaging
Confirmation that seizures arise from a visible lesion
(using video telemetry)
Over 20% of seizures arising from the contralateral
temporal lobe in temporal lobe seizures
Intelligence quotient > 70 points
No significant psychiatry morbidity
No medical contraindications
Age < 45 years

Strategies for managing newly diagnosed

epilepsy
Newly diagnosed epilepsy

47%
First drug

Seizure-free
13%

Second drug

Seizure-free

40%
Refractory

Rational duotherapy

Surgical assessment

Drug choice in newly diagnosed epilepsy in

adolescents and adults
Seizure type
First line
Second line
Tonic clonic

Sodium valproate
Carbamazepine
Phenytoin

Lamotrigine*
Oxcarbamazepine*

Absence

Sodium valproate

Ethosuximide
Lamotrigine*

Myoclonic

Sodium valproate

Lamotrigine*

Carbamazepine
Phenytoin

Lamotrigine*
Oxcarbamazepine*
Sodium valproate

Partial

Unclassifiable Sodium valproate

Lamotrigine*

*Lamotrigine and oxcarbamazepine are regarded as first-line drugs in some countries

Prognosis
Dependent with underlying syndrome and / or
its cause
Patients compliance
Reciprocal illness or medications
60-70% controlled by first-line drug of epilepsy
10% of the rest controlled by new drugs
The rest :
surgery
Institution

Special Problems of Epilepsy

Behavioral problem :
-Label of epilepsy
racial disadvantage
-Brain function, medication, type of seizure
-Attitudes of helpers and helped
Education :
-Discussion between doctors, families,
schools teachers and the patient, steps
which might be taken to promote normal
education and personal development

 Employment :
-Personal and racial states as well as
financial reward
-Understanding of the employee of their illness in
the context of particular employment, safety for
their selves and environment
-People around in working hours need to know
what to do if the attack occurred
The law
Driving lisence
Free of seizure after 6 months controlled epilepsy

 No permitting to drive if :
Have suffered of epileptic attack at the age before
adolescent
Medical condition caused driving a source of danger to
them selves and to the public

Leisure :
Swimming, water sport, cycling, horse riding in groups
with safety controlled
Boxing, climbing, sport with body contact are prohibited
Television and video games, avoid flickering of the screen

Marriage and pregnancy

Health education
Impairment, disability and handicap