epilepsy & status epilepticus

1. Epilepsy & Status Epilepticus

2. Introduction
• ILAE DEFINITION:
1. This definition is usually practically applied as having two
unprovoked seizures >24 h apart.
2. One unprovoked (or reflex) seizure and a probability of further
seizures similar to the general recurrence risk (at least 60%) after
two unprovoked seizures, occurring over the next 10 years;
3. Diagnosis of an epilepsy syndrome.
• A seizure can be defined as the occurrence of signs and/ or
symptoms due to abnormal, excessive neuronal activity in the brain.
(Davidson) ‘

3. Classification(2017 Revised Classification of
Seizures)
• The basic classification is a simple version of the major
categories of seizures. The new basic seizure classification is
based on 3 key features.
1.Where seizures begin in the brain
2.Level of awareness during a seizure
3.Other features of seizures

4. Defining Where Seizures Begin
• The type of seizure onset is important because it affects choice of seizure
medication, possibilities for epilepsy surgery, outlook, and possible causes.
1. Focal seizures: Previously called partial seizures, these start in an area or
network of cells on one side of the brain.
2. Generalized seizures: Previously called primary generalized, these
engage or involve networks on both sides of the brain at the onset.
3. Unknown onset: If the onset of a seizure is not known, the seizure falls
into the unknown onset category. Later on, the seizure type can be
changed if the beginning of a person’s seizures becomes clear.
4. Focal to bilateral seizure: A seizure that starts in one side or part of the
brain and spreads to both sides has been called a secondary
generalized seizures. Now the term generalized refers only to the start of
a seizure.

5. Describing Awareness
• Whether a person is aware during a seizure is of practical importance because it is one of
the main factors affecting a person’s safety during a seizure. Awareness is used instead of
consciousness, because it is simpler to evaluate.
1. Focal aware: If awareness remains intact, even if the person is unable to talk or
respond during a seizure, the seizure would be called a focal aware seizure. This
replaces the term simple partial.
2. Focal impaired awareness: If awareness is impaired or affected at any time during a
seizure, even if a person has a vague idea of what happened, the seizure would be
called focal impaired awareness. This replaces the term complex partial seizure.
3. Awareness unknown: Sometimes it’s not possible to know if a person is aware or not,
for example if a person lives alone or has seizures only at night. In this situation, the
awareness term may not be used or it would be described as awareness unknown.
4. Generalized seizures: These are all presumed to affect a person’s awareness or
consciousness in some way. Thus no special terms are needed to describe awareness
in generalized seizures.

6. Describing Motor And Other Symptoms In Focal
Seizures
• Many other symptoms may occur during a seizure. In this basic system, seizure
behaviors are separated into groups that involve movement.
1. Focal motor seizure: This means that some type of movement occurs during the
event. For example twitching, jerking, or stiffening movements of a body part or
automatisms (automatic movements such as licking lips, rubbing hands, walking,
or running).
2. Focal non-motor seizure: This type of seizure has other symptoms that occur
first, such as changes in sensation, emotions, thinking, or experiences.
3. It is also possible for a focal aware or impaired awareness seizure to be sub-
classified as motor or non-motor onset.
4. Auras: The term aura(sensation perceives by the pt that precedes the condition
of affecting the brain), which describes symptoms a person may feel in the
beginning of a seizure, is not in the new classification. Yet people may continue
to use this term. It’s important to know that in most cases, these early
symptoms may be the start of a seizure.

7. Aura Symptom
Visual Bright lights and blobs, Zigzag lines,
Distortions in the size or shape of
objects, Temporary blindness in one or
both eyes, Heightened sensitivity to
light
Auditory 1. Hearing voices or sounds that do not
exist: true auditory hallucinations
2. Modification of voices or sounds in
the environment: buzzing, tremolo,
amplitude modulation or other
modulations
3. Heightened sensitivity to hearing

8. Describing Generalized Onset Seizures
1. Seizures that start in both sides of the brain, called generalized
onset, can be motor or non-motor.
2. Generalized motor seizure: The generalized tonic-clonic seizure
term is still used to describe seizures with stiffening (tonic) and
jerking (clonic).
3. Generalized non-motor seizure: These are primarily absence
seizures, and the term corresponds to the old term "petit mal."
These seizures involve brief changes in awareness, staring, and
some may have automatic or repeated movements like
lipsmacking.

11. Pathophysiology
• To function normally, the brain must achieve an ongoing balance
between excitation and inhibition

13. Clinical Features
• To classify seizure type, the clinician
should ask first whether there is a
focal onset, and second whether the
seizures conform to one of the
recognised pattern
• Occipital onset will cause visual
changes (lights and blobs of colour),
temporal lobe onset will cause false
recognition (déjà vu), sensory strip
involvement will cause sensory
alteration (burning, tingling), and
motor strip involvement will cause
jerking.
Risk Factors
1. Premature Infants
2. Brain infection
3. Brain Tumors
4. Stroke
5. Drug abuse
6. Cerebral palsy
7. Family hx of epilepsy

14. Focal Seizure

17. Generalized
• Includes
1. Tonic – Stiff/flexed
2. Atonic – Relaxed
3. Clonic – Convulsion
4. Tonic-clonic – Mixed
5. Myonic – short muscle twitching
6. Absence – spaced out

18. Tonic clonic
• An initial ‘aura’ may be experienced by the patient
• Pt then becomes rigid (tonic) and unconscious, falling heavily if standing (‘like a
log’) and risking facial injury. During this phase, breathing stops and central
cyanosis may occur.
• As cortical discharges reduce in frequency, the limbs produce jerking (clonic)
movements for a variable time.
• Afterwards, there is a flaccid state of deep coma, which can persist for some
minutes.
• The patient may be confused, disorientated and/or amnesic after regaining
consciousness. During the attack, urinary incontinence and tongue-biting may
occur. A severely bitten, bleeding tongue after an attack of loss of
consciousness is pathognomonic of a generalised seizure

21. • Absence seizures. Absence seizures (previously ‘petit mal’) always
start in childhood. The attacks are rarely mistaken for focal seizures
because of their brevity. They can occur so frequently (20–30 times a
day) that they are mistaken for daydreaming or poor concentration
in school.
• Myoclonic seizures. These are typically brief, jerking movements,
predominating in the arms. In epilepsy, they are more marked in the
morning or on awakening from sleep, and tend to be provoked by
fatigue, alcohol or sleep deprivation.
• Atonic seizures. These are seizures involving brief loss of muscle
tone, usually resulting in heavy falls with or without loss of
consciousness.

22. • Tonic seizures. These are associated with a generalised
increase in tone and an associated loss of awareness. They
are usually seen as part of an epilepsy syndrome and are
unlikely to be isolated.
• Clonic seizures. Clonic seizures are similar to tonic– clonic
seizures. The clinical manifestations are similar but without a
preceding tonic phase.

23. Common Clinical Features
• Preictal=Aura( strange feeling in the gut,dejavu,strange
smells or flashing lights
• Ictal= according to the lobes
• PostIctal=headache,confusion,myalgia,sore
tongue,temporary weakness after focal seiru(Todd
Palsy),dysphasia

25. EEG
• Brain cells (neurones) work by sending nerve impulses(electric
signals) from one cell to another to transfer messages(action
potential) around the brain and the body.
• Electrical activity, sometimes called ‘brain waves’, that is picked
up on by EEG. They record the electrical activity from small
areas of the brain.

27. Investigation

29. Diagnosis
• Are these really seizures
• What type of seizure is it?
• Any triggers?
• In assessing a first seizure,consider also
1. Is it really the first
2. Was the seizure oprovoked
3. Prompt oinvestigation

30. D.D of Epilepsy

31. Management(Lifestyle modification)
• Shallow baths (or showers) should be taken.
• Prolonged cycle journeys should be discouraged
• Activities involving prolonged proximity to water
(swimming, fishing or boating) should always be carried
out in the company of someone
• Certain occupations, such as firefighter or airline pilot,
are not open to those with a previous or active

33. Management
•
• Focal (partial) seizures: 1st line: carbamazepine or lamotrigine.
2nd line: levetiracetam, oxcarbazepine, or sodium valproate
• Generalized tonic-clonic seizures: 1st line: sodium valproate or
lamotrigine. 2nd line: carbamazepine, clobazam, levetiracetam, or
topiramate.
• Absence seizures: 1st line: sodium valproate or ethosuximide. 2nd
line: lamotrigine.
• Myoclonic seizures: 1st line: sodium valproate.13 2nd line:
levetiracetam, or topiramate
• Tonic or atonic seizures: Sodium valproate or lamotrigine

38. • Stopping AEDS: May be done under specialist supervision if the
patient has been seizure-free for >2yrs and after assessing risks
and benefits for the individual (eg the need to drive). The dose
must be decreased slowly: over at least 2–3 months, or >6
months for benzodiazepines and barbiturate

39. Special Case
1.Pregnancy and reproduction= valproate affect menstruation
irregularity and infertility
2.Contraception= carbamazepine, phenytoin and barbiturates can
cause contraceptive failure. If the AED cannot be changed, this
can be overcome by giving higher-dose preparations of the
oral contraceptive

42. Other interventions:
• Psychological therapies: Eg relaxation, CBT. so only use as an adjunct
to medication.
• Surgical intervention: Some patients with drug-resistant epilepsy
benefit from surgical resection of epileptogenic brain tissue. Less
invasive treatments, including vagal nerve stimulation or deep brain
stimulation, may also be helpful in some patients
Epilepsy is considered to be resolved for
individuals who either had an age dependent
epilepsy syndrome but are now past the
applicable age or who have remained seizure-
free for the last 10 years and off antiseizure
medicines for at least
the last 5 years. “

43. Status Epilepticus
• seizures lasting for >30min, or repeated seizures without intervening
consciousness. Mortality and the risk of permanent brain damage
increase with the length of attack.
• Aim to terminate seizures lasting more than a few minutes as soon as
possible (<20min)
• Investigations:
1. Bedside glucose, the following tests can be done once tx has
started: lab glucose, ABG, U&E, Ca2+ , FBC, ECG.
2. Consider anticonvulsant levels, toxicology screen, LP, culture blood
and urine, EEG, CT, carbon monoxide level.
3. Pulse oximetry, cardiac monitor

44. Non-convulsive status epilepticus
•as a cause of confusion and may manifest as confusion,
impaired cognition/memory, odd behaviour
•Other features: aggression, psychosis ± abnormalities of eye
movement, eyelid myoclonus, and odd postures. It may
occur in the context of classic convulsive seizures (eg
prolonged ‘post-ictal’ state) or ischaemic brain injury
(especially haemorrhagic).
•Diagnosis: EEG evidence of rhythmical discharges (eg
prolonged 3-per-second spike-wave complexes

46. Beware respiratory arrest. The rectal route is an alternative for diazepam .
Buccal midazolam is an easier oral alternative where no IV access
Beware in low BP and do not use if bradycardic or heart block. Requires BP and
ECG
Monitoring(phenythoin)
Dexamethasone: 10mg IV if vasculitis/cerebral oedema (tumour)
possible