Epilepsy & Seizures

Dr. Abdul Rabb

MBBS, FCPS
Assistant Professor &
Head of Medical Unit II
Department of Medicine
ATMC, Karachi
 Introduction; definitions
• Epilepsy is a disorder characterized by recurring seizures (also
known as “seizure disorder”)

• A seizure is a brief, temporary disturbance in the electrical activity

of the brain

• A seizure is a symptom of epilepsy

 More terminology
Convulsion:
– An intense paroxysm of involuntary repetitive
muscular contractions.
• Convulsive seizure or motor seizure.
• Non convulsive seizure
– Sensory seizure.
– Psychic seizure.
– Autonomic seizure.

• All seizures are not convulsions.

 Who Has Epilepsy?
• About 3 million Americans have epilepsy

• Roughly 200,000 new cases of seizures and

epilepsy occur each year

• About 1% of the general population develops

epilepsy
 Causes
• In about 70% of people with epilepsy, the cause is
not known
• In the remaining 30%, the most common causes
are:
– Head trauma
– Brain tumor and stroke
– Lead poisoning
– Infection of brain tissue
– Heredity
– Prenatal disturbance of brain development
Groups at Increased Risk for Epilepsy

• The risk is higher in people with certain

medical conditions:
– Mental retardation
– Cerebral palsy
– Alzheimer’s disease
– Stroke
 Trigger factors for seizures
• Sleep deprivation
• Missed doses of anti-epileptic drugs in treated patients
• Alcohol (particularly withdrawal)
• Physical and mental exhaustion
• Flickering lights, including TV and computer screens
(generalized epilepsy syndromes only)
• Inter-current infections and metabolic disturbances
• Uncommon: loud noises, music, reading, hot baths
Classification
 Classification of seizures
(Adopted by The International League Against Epilepsy -1981 )

• Partial seizures
– Simple partial seizures
• (with motor, sensory,
psychic or autonomic signs.)
– Complex partial seizures
• Partial seizures with
secondary generalization
• Generalized seizures
– Absence (petit mal)
– Tonic-clonic (grand-mal)
– Tonic
– Atonic
– Myoclonic
Classification of seizures
 Simple Partial Seizures
Cause motor, sensory, autonomic, or psychic
symptoms without an obvious alteration in
consciousness
 Motor seizures
Arise from the contralateral motor cortex
– Jacksonian march: movements arise from a
restricted region and progresses over seconds to
minutes to a larger portion of the extremity
– Todd’s paresis: localized paresis for minutes to
hours following a seizure
– Epilepsia partialis continua: simple motor seizure
that continue for hours or days
 Sensory seizures
• Somatosensory seizures:
– Paraesthesias or numbness
– Epigastric sensation that rises from the stomach or chest
to the head

• Special sensory seizures:

– Visual: flashing lights, hallucination
– Auditory: crude sounds to music
– Gustatory: taste hallucinations
– Olfactory: unusual odours (burning rubber, kerosene)
– Vertiginous: falling in space or floating
Partial seizures
 Complex Partial Seizures
• Patient is unable to respond appropriately to
visual or verbal commands during the seizure
• Impaired recollection or awareness of the ictal
phase
• Aura is stereotypic for patient
• Sudden behavioral arrest or motionless stare
• Patient is typically confused following the seizure,
and the transition to full recovery of
consciousness may range from seconds up to an
hour
 COMPLEX PARTIAL SEIZURES
Clinical features
• Psychomotor triad: Motor changes, automatism,
psychic changes
• Aura: (focal symptoms and signs as in simple
partial seizures)
• Absence: (altered consciousness)
• Automatism: eg mimicry (lacrimic) ambulatory,
verbal, oro-alimentary
• Sudden onset and gradual recovery
• Complex partial seizures arise from temporal
• lobe (60%), or frontal lobe (30%).
 Automatisms
Consist of very basic behaviors such as chewing,
lip smacking, swallowing, or "picking"
movements of the hands, or more elaborate
behaviors such as a display of emotion or
running
Complex partial seizures
 Generalized Seizures
• Generalized tonic clonic seizures(Grand mal)
• Absence seizures (petit mal)
• Myoclonic seizures
• Atonic seizures
• Clonic seizures
• Tonic seizures
 Generalized seizures
• Seizure that begin over the entire surface of
the brain are called generalized seizure.

• Convulsion start in generalized seizure

because of the involvement of motor system.
 TONIC-CLONIC (grand mal) :
Sudden loss of consciousness
Tonic phase:
• Pt become rigid & falls to the ground
• Respiration are interrupted
• Back arches
• Lasts about 1min
Clonic phase:
• Rapid muscle jerking
• Muscle flaccidity
• Incontinence, tongue biting, tachycardia,
heavy salivation
During postictal phase:
• Headache, confusion, nausea, drowsiness,
disorientation
• May last for hours
Tonic-clonic seizures
 Absence Seizures (Petit Mal)
• Alterations of consciousness (absence) lasting
10-30sec
• Staring (with occ. eye blinking) & loss in
postural tone
• 100 or more daily
• Onset occurs from 3-16yrs, disappear by 40yrs.
• No postictal confusion
Absence seizures
 Atonic Seizures
• Sudden loss of postural muscle tone lasting 1–2 s
• Consciousness is briefly impaired, but there is
usually no postictal confusion
• Also known as “drop attacks”
• EEG shows brief, generalized spike-and-wave
discharges followed immediately by diffuse slow
waves
• Usually seen in association with known epileptic
syndromes
Atonic seizures
 Generalized seizures
Myoclonic Seizures
• Sudden, Involuntary jerking of facial, limb or
trunk muscles, in rhythmic manner

Clonic
• Sustained muscle contractions alternating with
relaxations

Tonic
• Sustained muscle stiffening
Myoclonic seizures
Brain Lobe/area based classification
Investigations
 EEG
For diagnosis of epilepsy by providing findings of
epileptiform changes
To determine whether the seizure disorder is partial
onset or generalized.
To check for evidence of background
encephalopathy
All patients with a suspected seizure disorder
should have an EEG done
A normal Inter-ictal EEG does not rule out a seizure
disorder.
EEG
 MRI
Indications for MRI in evaluation of seizure disorders:

1. Partial seizures, on history and/or EEG.

2. Fixed or progressive neurological or psychological
deficit.
3. Onset of generalized seizures before the age of 1
year and after 20 years.
4. Difficulty obtaining seizure control with AEDs.
5. Unexplained loss of seizure control or status
Epilepticus.
 OTHER TESTS
• Functional imaging procedures such as positron
emission tomography (PET) and single photon emission
computed tomography (SPECT) are used to evaluate
patients with medically refractory seizures being
considered for surgery
• Routine blood tests and lumbar puncture are not
usually indicated in evaluation of patients but in
context of acute illnesses and also to provide a
baseline(in the case of biochemical tests) prior to
commencement of AEDS.
• Measurement of serum prolactin can be done to rule
out psychogenic seizures
 TREATMENT
• Drug therapy is the mainstay of treatment

• Seizure classification is important for

determining treatment

• Patients with recurrent seizures of unknown

should be treated
 TREATMENT
Single seizures should be treated in the
following situations:
1. An abnormal neurologic examination
2. Seizures presenting as status epilepticus
3. Postictal Todd's paralysis
4. A strong family history of seizures
5. An abnormal EEG
 First aid for seizures
• Move person away from danger ( re, water, machinery,
furniture)
• After convulsions cease, turn person into ‘recovery’
position (semi-prone)
• Ensure airway is clear but do NOT insert anything in
mouth (tongue-biting occurs at seizure onset and
cannot be prevented by observers)
• If convulsions continue for more than 5 mins or recur
without person regaining consciousness, summon
urgent medical attention
• Do not leave person alone until fully recovered
(drowsiness and confusion can persist for up to 1 hr)
 AEDs
Old New
1. Primidone 1. Levatiracetam
2. Phenobarbitone 2. Lamotrigine
3. Fosphenytoin 3. Oxcarbazepine
4. Phenytoin 4. Topiramate
5. Clobazam 5. Gabapentin
6. Clonazepam 6. Felbamate
7. Ethosuximid 7. Vigabatrin
8. Valproate 8. Zonisamide
9. Carbamazepine 9. Tiagabin
DISCONTINUATION OF TREATMENT
• Withdrawal of anti epileptic drug treatment
may be attempted in patients who have been
seizure free for 3 years and who have a
normal EEG at time of consideration

• Antiepileptic drug therapy should be tapered

off and not stopped abruptly
 OTHER MANAGEMENT OPTIONS
Surgical therapy
• Temporal lobectomy
• Frontal lobectomy
• Lesionectomy
• Corpus callosotomy
• Hemispherectomy

Non-pharmacologic treatment
• Vagal nerve stimulation
• Ketogenic diet
 Epilepsy: outcome after 20 years
• 50% are seizure-free, without drugs, for the
previous 5 years
• 20% are seizure-free for the previous 5 yrs but
continue to take medication
• 30% continue to have seizures in spite of anti-
epileptic therapy
 STATUS EPILEPTICUS
Status epilepticus refers to repeated seizures
with no intervening recovery of consciousness
OR a single seizure that lasts up to 30 mins.
Treatment of status epilepticus
Questions?
THANK YOU