National Epilepsy Awareness Week

“BASIC CLINICAL EPILEPSY”

Dr. Jona C. Handumon

 Case
 18-year-old male student attending the EDSA rally
 The patient collapsed, lost consciousness with
stiffening of the arms and legs lasting a few seconds.
This was followed by repeated jerking movements of the
arms and legs. He was observed to have frothing of the
mouth and upward rolling of the eyeballs. These lasted
about 2 min.
The patient was brought to the First Aid Center at
EDSA still unconscious. He woke up after 10 minutes.
He was confused and disoriented and complained of a
headache.
History revealed that 3 months ago, he suffered a
similar episode while asleep.
1. Which of these conditions do you think the
patient has?

A. Syncope
B. Epilepsy
C. Hyperventilation Syndrome
 Seizure

 Attack of cerebral origin

 Sudden and transitory abnormal phenomena

 motor, sensory, autonomic, or psychic

 Transient dysfunction of part or all of the brain

Epileptic Seizure

Seizure resulting from excessive

electrical

neuronal discharges
 Epilepsy

A chronic brain disorder of various etiologies

characterized by recurrent seizures due to

excessive electrical discharge of cerebral

neurons (epileptic seizures) associated with a

variety of clinical and laboratory

manifestations.
 Syncope
 Abrupt and transient loss of consciousness

 Loss of muscular tone

 Sudden global reduction in cerebral perfusion

 Clinical recovery with restoration of cerebral

blood flow
 SEIZURES
 Epileptic Seizures
 Non-epileptic Events

PHYSIOLOGIC
PSYCHOGENIC
Pseudoseizure
Hysterical Sz
Fit
 TIA(including
Migraine
Non-Epileptic
Myoclonus
Paroxysmal
Toxic

Nonepileptic
Event of Non-Toxic
Paroxysmal Physiologic
Movement Organic
Disorder Origin Hallucinosis

Paroxysmal Paroxysms of Acute

Endocrine
Disturbances Neurologic Insults

Syncope Sleep
Disorders
Hyperventilation
Syndrome

Modified from Gates,John.AAN 1998.

 Nonepileptic
Event of
Psychogenic
Origin

Gates,John.AAN 1998.
DDx of GTCSz vs. Syncope vs. HVS
GTC Sz Syncope HVS
Precipitant +/- + +
Circumstances Any Special Emotional event
Onset Abrupt Gradual/Abrupt Gradual
Motor + - +/-
Pallor +/ - + +/-
Cyanosis +/ - - -
Respiration Stertorous Shallow Rapid
Incontinence + - -
Tongue-biting +/- - -
Injury + - -
Post-ictal + - -
Duration 1-2 Minutes Seconds > 2 minutes
2. Should you undertake further diagnostic
procedures for this patient?
A. Yes
B. No
Basic Laboratory Tests

 CBC
 Random Blood Sugar
 Electrolytes,BUN, Creatinine
 ECG
Neurodiagnostic Procedures

 EEG with sleep recording

 CT Scan

 MRI
 EEG

 Epilepsy is essentially a clinical diagnosis

 The most important single diagnostic procedure in patients

with epilepsy

 10% of epileptics will have a normal EEG despite multiple

recordings

 A normal EEG does not exclude epilepsy

 Not all abnormal EEGs mean epilepsy

 ROLE OF INTERICTAL EEG IN
EPILEPSY
 Confirms clinical diagnosis of epilepsy
 classification of seizure types
 definition of epileptic syndromes
 monitoring of response to AED
treatment
 evaluation of patients with single
seizures
 guide in the decision to discontinue
AED treatment
 LONG TERM EEG MONITORING
INDICATIONS:
1. Diagnosis of Epileptic Sz vs. Non- epileptic
Events
2. Medically intractable Seizures
3. Candidates for Epilepsy Surgery
 Indications for Neuroimaging
 partial seizures especially in adults
 conditions which suggest
progressive neurologic disease or
structural lesion that may be
surgically correctible
 intractable seizures
 Seizure Etiology

 Epilepsy is a symptom of disease

rather than a disease itself
 The investigation of epilepsy depends
on the knowledge of possible
etiologies
 Probable etiology depends on:
– Age of the patient at onset
– type of seizures
 Seizure Etiology
Newborn
 Metabolic disorders
 Hypoxic Ischemic Encephalopathy
 CNS Infection
 Intracranial hemorrhage
 Cerebral dysgenesis
 Idiopathic (genetic)
 Seizure Etiology
Infants, children and adolescents
1. Febrile seizures
2. Idiopathic
3. CNS Infection
4. Head Injury
5. Toxic/Metabolic
6. Vascular
7. Tumor
8. Degenerative
 Seizure Etiology
Adults
1. Cerebrovascular disease
2. Tumors
3. Head Injury
4. CNS Infection
5. Toxic /Metabolic
6. Degenerative
7. Idiopathic
3. Will you start this patient on anti-epileptic
drugs?

4. How long should you give the medications?

Initiation of AED Treatment

Q . When should AED treatment be started?

A. When the diagnosis of epilepsy is made

Diagnosis of epilepsy – recurrence of

two or more nonprovoked epileptic

seizures
 Indication for AED Rx in a
single non-provoked seizure
 Focal seizure

 Signs of a focal lesion on neurologic exam

 Abnormal EEG

- focal slowing
- epileptiform activity
 Abnormal neuroimaging
General Principles for Initiation of
Antiepileptic Drug (AED) Treatment

Aim for monotherapy: AED

choice dependent on seizure

type or epileptic syndrome

 International Classification of Epileptic
Seizures
I. Partial (focal, local) seizures
A. Simple partial seizures
1. With motor signs
2. With somatosensory or special sensory symptoms
3. With autonomic symptoms or signs
4. With psychic symptoms
B. Complex partial seizures
1. Simple partial onset followed by impairment of consciousness
2. With impairment of consciousness at onset
C. Partial seizures evolving to secondarily generalized seizures
1. Simple partial seizures evolving to generalized seizures
2. Complex partial seizures evolving to generalized seizures
3. Simple partial seizures evolving to complex partial seizures
evolvingto generalized seizures

From: (Commission on Classification and Terminology of the International

League Against Epilepsy 1981)
 International Classification of Epileptic
Seizures

II. Generalized seizures (convulsive or

nonconvulsive)
A. Absence seizures
1. Typical absences
2. Atypical absences
B. Myoclonic seizures
C. Clonic seizures
D. Tonic seizures
E. Tonic-clonic seizures
F. Atonic seizures (astatic seizures)
III. Unclassified epileptic seizures

From: (Commission on Classification and Terminology

of the International League Against Epilepsy 1981)
General Principles for Initiation of
Antiepileptic Drug (AED) Treatment
 Start at a low dose and gradually increase until

seizures are controlled or toxic effects appear (be

guided by pharmacokinetics)

 If first drug fails, try a second drug with similar

efficacy and withdraw the previous drug gradually

(overlap according to half-lives)

 Antiepileptic Drug Treatment
Generalized Seizures

Seizure type Conventional New Drugs

Drugs
Tonic Clonic CBZ, Pb, PHT, LTG, OXC,TPM
VPA
Myoclonic VPA, LTG, TPM
Clonazepam
Absence Ethosuximide, LTG, TPM
VPA
Atonic VPA
Tonic VPA
Partial Seizures
with or without secondary generalization

Conventional Drugs New Drugs

CBZ, Pb, PHT VPA GBN, LTG,

OXC,TPM
 Drug Usage in Adults
Drug Dose Range Titration
Phenytoin 300-400mg/day Can be loaded PO or IV
(BID or QD)

Phenobarbital 60 -180mg/day Can be loaded PO, IM,or

(BID or QD) IV
Carbamazepine 400 -2000mg/day Moderate
(BID,TID)
VPA 500-3000mg/day (BID) Moderate
Gabapentin 900 -6000mg/day Moderate
(BID,QID)
Lamotrigine 200-1000mg/day Very Slow
(BID)
Topiramate 200-400mg/day(BID) Slow
to start at 25 mg/day
Oxcarbazepine 900- 3000mg/day(BID) Moderate
 Pediatric Dosage
Drug Starting Dose Dosing Dose Escalation Rate Maintenance
Regimen Dose
Carbamazepine <6yr: 10- TID <6yr:5mg/kg/1wk 10-30mg/kg/d
15mg/kg/d >6yr:100-200mg/1wk
6-12yr:100mg
BID
Clonazepam <10yr or TID-QID <10yr:.02mg/kg/1wk .1-.3mg/kg/d
<30kg: .01-
.3mg/kg/d >10yr: .5mg/1wk
>10yr:1-
1.5mg/d
Gabapentin 10mg/kg/d TID 300mg/1d 30-100mg/kg/d

Lamotrigine On enzyme TID-BID On enzyme inducers: On enzyme

inducers: 1mg/kg/2wk inducers:
1mg/kg/d On enzyme inducers 15mg/kg/d
On enzyme and inhibitors: .3- On enzyme
inducers and .5mg/kg/2wk inducers and
inhibitors: .3- On enzyme inhibitors: inhibitors:10mg
.5mg/kg/d .1-.3mg/kg/2wk /kg/d
On enzyme Monotherapy: On enzyme
inhibitors: .1- .5mg/kg/2wk inhibitors:
.3mg/kg/d 5mg/kg/d
Monotherapy:.5 Monotherapy:
mg/kg/d 10mg/kg/d
 Pediatric Dosage
(in mg/kg/day)

Drug Starting Dosing Dose Escalation Maintena

Dose Regime Rate/Titration nce Dose
n
Phenobarbital 3-5 OD-BID 1-2 every 2-3 weeks <1yr: 3-
5mg/kg
>1yr:2-
4mg/kg
Phenytoin 5 BID 1-2 every week 5-8mg/kg/d
(Dilantin)

Topiramate 0.5 - 1 BID - TID 0.5 - 1mg/kg/wk or 2 2-9

wk
Valproic Acid 15-20 TID-BID 5-10 15 - 60
 Choice of AED
 Efficacy

 Safety

 Side Effects

 Ease of use

 Cost

 Availability
 Treatment Goals for Epilepsy

 Treatment of underlying cause

 Control of seizures
 Quality of life
 Phenytoin
 Allergic rash 0.5%

 Saturation Kinetics(difficulty in

achieving stable blood levels)

 Hirsutism

 Ataxia(at high doses)

 Gum hyperplasia(after prolonged use)

 Phenobarbital

 Sedation

 Cognitive Deficits

 Depression

 Hyperactivity esp. in children

 Carbamazepine

 Hyponatremia

 Allergic rash

 Leukopenia

 Liver function abnormalities

 Valproic Acid
 tremor

 Weight gain

 Hair loss

 Disturbances in reproductive hormones in women

 Liver toxicity

 Thrombocytopenia
 Newer AEDs
Gabapentin
– Drowsiness
– GI upset
Lamotrigine
– Dose and time dependent rash
Topiramate
– Cognitive difficulties (5-15%)
– Weight loss
– Renal stone formation
Oxcarbazepine
– hyponatremia
Gradual Discontinuance of AED’s maybe
considered if the patient meets the following :

1. Seizure-free 2 to 5 years on AED’s (mean 3-5

years)

2. Single type of partial seizure or single type

of primary generalized tonic-clonic seizures

3. Normal neurologic examination/normal EEG

Factors associated with increased
risk of relapse
 Long duration of epilepsy

 Difficulty in achieving control of seizure

 Duration of remission

 Seizure type/ epilepsy syndrome

 Presence of additional handicaps

 Prognosis
 60-70% will respond to monotherapy

 10-15% will require 2 AEDs

 AEDs can be successfully withdrawn in

80% of children and 60% of adults(after 2-5

years)
5. Will you advise the patient to resume
his basketball activities and continue with
ROTC? What precautions should you
advise the patient and his family to take?
 SPORTS
 Epilepsy is never a reason for not partaking in
competitive sports at any level
 Epilepsy is never a reason for denial of membership in
a Sports Club
 Next to normal safety precautions, special guards need
to be available with sports in or around water

 Instructors and trainers need to know what to do when

a Seizure occurs

“Epilepsy and Sports” Symposium. Dutch League Against

@ Epilepsy, 1989
 SPORTS
 The risks following a Seizure during sports depend
on the type of Seizure
3 Categories of Sports
- No Restrictions
- Restrictions (safety precautions)
- Prohibited
 Sports, including contact sports (team sports) and
fighting sports, generally do not provoke more, or more
serious Seizures.

“Epilepsy and Sports” Symposium. Dutch League Against Epilepsy, 1989

@
 SCHOOL for PWE
Integration into Mainstream Schools
Child encouraged to participate in all
school activities and sports with the
possible exception of climbing
Special Schools(for those with associated
handicaps)
Factors Affecting Educational
Performance
Effect of medications
Subclinical Seizure discharges
Time “off” school
Associated handicaps
 RISKS AT SCHOOL
 Nothing must be left out of the lives of persons
with Epilepsy
 EDUCATION- will decrease unsubstantiated
fears and restrictions.
 DECISION- involves parents, teachers, PWE.
 Living a full, indepent life involves taking risk
for everybody, and taking risk implies with
statistical certainly that accidents will occur.