1. Seizure & Epilepsy

2. Definitions

3. Seizure A sudden surge of electrical activity in brain that usually affects how a person feels or acts for a short time. Some seizures can hardly be noticed, while others are totally disabling.

4. Epilepsy A condition that affects central nervous system (CNS) had at least 2 seizures not caused by some known medical condition like alcohol withdrawal or extremely low blood sugar. not indicate anything about the cause of the seizures, what type they are, or how severe they are.

5. Momentary loss of consciousness Fit Faint Fake

6. Transient loss of consciousness History and Physical Witness account Déjà vu Jamais vu Aphasia Olfactory aura Epigastric sensation Tongue biting Post event delirium Focal neurodeficit Light-headedness Sweating Prolonged standing Precipitants eg.micturition Chest pain Palpitation Slow heart rate Low blood pressure Aphasia Delirium Head turn Automatism Posturing Convulsion Postictal delirium Myoclonus or convulsion after pallor, sweating and collapse Pallor Sweating Slow pulse Low BP Convulsive syncope Seizure Syncope Syncope Seizure

9. Nonepileptic causes for spells Physiologic Tremor Vasovagal syncope Cardiac arrhythmias Migraine Medication adverse effects Transient ischemic attacks Autonomic dysfunction

10. Nonepileptic causes for spells Psychologic Anxiety Panic attacks Mood disorder Personality disorder Psychosis Somatiform illness Psychogenic seizures

11. Phase of seizures Preictal phase or aura or warning Ictal phase : simple or complex partial or generalized tonic-clonic seizure Postictal phaseor recovery period : last from seconds to minutes to hours

12. Precipitants of seizure Sleep and lack of sleep Drugs and alcohol Intercurrent illness : infection, electrolyte imbalance Menstruation Stress and worry Other precipitants-reflex epilepsy

13. Classification of seizure Partial (focal, localized) seizures Generalized seizures (convulsive or non-convulsive) Unclassified epileptic seizures

14. Partial (focal, localized)seizures Simple partial seizures (preserved consciousness) Complex partial seizures (impaired consciousness) Partial seizures evolving to secondarily generalized seizures

15. Simple partial seizures (preserved consciousness) With - motor signs - somatosensory or special sensory systems - autonomic symptoms or signs - psychic symptoms

16. Complex partial seizures (impaired consciousness) - Simple partial onset followed by impairment of conscious - With impairment of consciousness at onset

17. Partial seizures evolving to secondarily generalized seizures - Simple partial seizures evolving to generalized seizures - Complex partial seizures evolving to generalized seizures - Simple partial seizures evolving to complex partial seizures evolving to generalized seizures

18. Generalized seizures (convulsive or nonconvulsive) - Absence seizures Typical absences Atypical absences - Myoclonic seizures - Clonic seizures - Tonic seizures - Tonic-clonic seizures - Atonic seizures (astatic seizures)

19. Unclassified epileptic seizures - Neonatal seizures - Recurrent status epilepticus - Rare or ‘isolated’ seizures

20. Epileptic seizure All clinical and laboratory data neuroimaging Seizure description and EEG Etiology Seizure type (s)

21. Seizure Idiopathic Generalized epilepsy likely Features of focal epilepsy Epilepsy or PNES Provoked seizures Treat cause +/- AED EEG EEG MRI/CT brain Video EEG PNES=psychogenic non-epileptic seizures AED=antiepileptic drug

22. Laboratory investigation CBC FBS, BUN, Creatinine Electrolyte , Liver function test , Ca+2 Mg+2 Electro-encephalography (EEG) Video EEG Neuroimaging : CT Scan, MRI, MR Spect, PET Special investigation : ammonia, lactate, pyruvate etc.

23. Electroencephalogram

25. Aid classification of epilepsy

27. Normal EEG

28. Primary generalized epilepsy—ictal EEG

29. Primary generalized epilepsy- interictal EEG

30. Burst of generalized spike and wave discharges—typical absence seizure

31. EEG monitoring

32. Video Monitoring Helpful in determining nature of seizure disorder (epilepsy, convulsive syncope, or psychogenic seizures)

33. Indication for neuroimaging in patients with seizures Partial seizure Late onset unprovoked seizure (age > 25) Unexplained neurological signs Focal slow waves EEG poor control or new symptoms / signs

34. Neuroimaging In the absence of trauma: CT and MRI brain for patients presenting with suspected first unprovoked seizure or with a focal neurological deficit. MRI is preferable for looking for neuronal migrational disorders, major malformations, vascular anomalies, tumors

35. The causes of epilepsy Genetic factor Congenital abnormalities Trauma and the effect of craniotomy CNS infection Cerebrovascular disease Cerebral tumors Alzheimer’s disease and other degenerative disease Others

36. Neurocysticercosis

37. Cerebral infarction

38. Intracerebral hemorrhage

39. Brain tumor or metastasis

40. Lt mesial temporal sclerosis

41. Cortical dysplasia

42. 52 year old woman with intractable seizure PET scan

43. PET using F-18 FDG-- Decreased FDG uptake in both temporal lobes, right worse then left but otherwise relatively symmetric

44. What to do? Generalized seizure Loosening the patient’s clothing Lower the patient gently to the floor, turn them onto their side and cushion head Nothing is put into the mouth Remove any items that could cause injury

45. What to do? ---Generalized seizure When the seizure is over, allow the patient to rest or sleep If they are able to return to their feet, help them home Obtain medical help if they continue to experience breathing problems once the seizure is over, or if the seizure lasts a long time(over 10 mins), or when another attack quickly follows the first

46. What to do? Partial seizures Stay with the patients throughout the seizure Protect them from any dangerous object Taking care not to restrain them in anyway

47. First aids

48. Treatment

49. จะต้องให้ยากันชักหรือไม่? รักษา ไม่รักษา ผลข้างเคียงของยา โอกาสจะชักซ้ำ

50. Choose a drug : considering the following factors The seizure type and prognosis Age The possibility of pregnancy Toxicity Drug interaction Price

51. RISK OF RECURRENT SEIZURE The recurrence risk follow a first unprovoked seizure 27%-52% 50% recurrence occur within 6 months over 80% within 2 years of initial seizures twice as likely to have another seizure if you have a known brain injury or brain abnormality.

52. RISK OF RECURRENT SEIZURE(cont) If you do have two seizures, there's about 80% chance that you'll have more.

54. EEG abnormalities (especially epileptiform)

56. Starting antiepileptic treatment Prospective risks Usual clinical Factors that may modify of epilepsy practice usual practice Single seizure No treatment Progressive cerebral disorder (clinically Dx) Clearly epileptic EEG 2 or more seizure Monotherapy Seizures widely separated (clinically Dx) in time (> 1 year) Identified precipitating, factors (eg, drugs, alcohol,reflex stimuli) Probability of poor compliance (eg, personality disorder) Attitude of patients/parents

57. More Antiepileptic drugs 20 Pregabalin Levetiracetam Oxcarbazepine Tiagabine Fosphenytoin 15 Topiramate Gabapentin Felbamate Lamotrigine Zonisamide 10 Vigabatrin Sodium Valproate Carbamazepine Benzodiazepines Ethosuximide 5 Phenytoin Primidone Phenobarbital Bromide 0 1840 1860 1880 1900 1920 1940 1960 1980 2000 Calendar year Antiepileptic Drug Development

58. First-line choice of AEDs according to seizure type

59. Advantages of Monotherapy Better seizure control Reduced side effects Absence of drug interactions Reduced teratogenic effects Better compliance Reduced cost of medication Improved quality of life

60. Expected outcomes of AED therapy Well controlled 65% Unsatisfactorily controlled 35% Monotherapy Well controlled 10% Unsatisfactorily controlled 25% Add-on therapy Unsatisfactorily controlled 20% Well controlled 5% Multiple drug therapy

61. Managing newly diagnosed epilepsy Newly diagnosed epilepsy 47% Seizure free First drug 13% Seizure free Second drug Refractory Surgical assessment Rational duotherapy

63. Idiosyncratic / allergic

64. Chronic toxicity

66. AED interactions CBZ : autoinduction, VPA, PHT, -PB PHT : CBZ, VPA, PB PB : CBZ, VPA, PHT VPA : CBZ, PB, PHT

67. AEDs Drug interaction with AED and other drugs: via effect on hepatic CYP450 enzyme system PB, primidone, PHT, CBZ induce CYP enz. : Accelerate breakdown of many prescribed lipid-soluble drugs metabolized by the same system: OCP, cytotoxic, antiarrythmic, warfarin VPA is a weak CYP enz. Inhibitor: Slow clearance of other AEDs such as PHT, LTG. Newer AEDs : less likely to interfere with hepatic metabolism. GBP, LEV,PGB,VGB do not undergo hepatic metabolism

68. Newer AEDs Adjunctive treatment of refractory epilepsy Some of these AEDs: LTG, GBP, OXC, TPM have also demonstrated efficacy as monotherapy

69. Effects of phenytoin levels Level (mg/ml) Effect 0-10 Subtherapeutic 10-20 Therapeutic 20-30 Mild toxicity; nystagmus, mild ataxia30-40 Moderate toxicity ; ataxia prominent > 40 Severe toxicity; ataxia, conscious - ness, encephalopathy

70. Potential Causes of Treatment Resistant Epilepsy Diagnostic errors: Non-epileptic events Wrong diagnosis of seizure types/ epileptic syndrome Missing of underlying causes/lesions Patient’s errors: Non-compliance Inappropriate life style, inappropriate metabolism

71. Potential Causes of Treatment Resistant Epilepsy Treatment errors: Wrong choice of drugs Less optimal doses of drugs Inadequate dosing schedules Antiepileptic drug toxicity Disease itself: Treatment resistant epilepsy metabolic disorder

72. Stopping antiepileptic treatment Absolute requirement 2-3 years free of all seizures Patient’s informed agreement

74. Primary generalized epilepsy

75. Absence of cerebral disorder

76. Short duration of epilepsy

77. Normal EEG

79. Features common to the surgically privileged seizure disorders Presence of a well-circumscribed structural lesion on the MRI (lesional epilepsy) Presence of well-localized interictal epileptiform discharged on the EEG Clinical features of habitual seizures indicating focal onset Absence of discordance between above feature Focus localized by above features is surgically accessible and involves little or no eloquent cortex Absence of other potentially epileptogenic abnormalities

80. Status epilepticus A condition in which epileptic activity persists for 30 minutes or more

81. Common etiologies for status epilepticus in children and adolescents Idiopathic Acute symptomatic Electrolyte disturbance Encephalitis Head trauma Remote symptomatic Past stroke CNS infection Cerebral palsy Progressive encephalopathy Tuberous sclerosis Other neurodegeneration Febrile

82. Status epilepticus management

85. Epilepsy and pregnancy Seizure control Obstetric complication Neonatal outcome

86. Neonatal outcome Risk of seizure (3 times > normal population) developmental outcome congenital anomalies 4-8% (2-3 times > normal population)

87. The most common malformation Congenital heart disease orofacial cleft neural tube defect intestinal atresia urogenital defects Neural tube defect

88. Fetal antiepileptic drug syndrome (minor anomalies) Facial dysmorphism Distal digital hypoplasia Developmental delay Mental deficiency

89. Factors affecting neonatal outcome AED genetics folic acid socioeconomic maternal health

90. Recommendations for managing Women With Epilepsy Before Conception Educate the family regarding risks Review classification of epilepsy Determine most appropriate medicine for seizure control

91. Determine need for continued medication - may discontinue if seizure-free for 2 or more years - do not discontinue medication if epilepsy syndrome suggests continued need for treatment Reduce medicines to monotherapy, lowest dose possible Start folic acid 1 mg/day Eliminate other risk factors – smoking, drugs, alcohol

92. After conception Do not change antiepileptic medication Refer for prenatal care Prescribe vitamins, including folic acid Check ‘free’ drug levels every trimester and change doses as needed Evaluate for neural tube defects at 12 to 16 weeks (ultrasound, alpha-fetoprotein, amniocentesis)

93. Consider vitamin K predelivery Check antiepileptic drug levels prior to delivery and increase doses if needed

94. After Delivery Check levels Examine infant

95. ควรคลอดโดยวิธีใด ? ถ้าไม่มีข้อห้าม สามารถคลอดทางช่องคลอด แต่อาจช่วยคลอดเมื่อมีข้อบ่งชี้