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1 Epilepsy in Munster 2011 Dr Brian Sweeney Consultant Neurologist CUH.

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Presentation on theme: "1 Epilepsy in Munster 2011 Dr Brian Sweeney Consultant Neurologist CUH."— Presentation transcript:

1 1 Epilepsy in Munster 2011 Dr Brian Sweeney Consultant Neurologist CUH

2 2 Target population Munster 1.2 million Parts of Kilkenny and Wexford If Epilepsy prevalence is 0.65% c people have epilepsy in this region 30-40% have drug resistance All need proper counselling and discussion re diagnosis and its management

3 3 Irish and UK data Up to Irish people have epilepsy At least 2-3 seizures present to CUH Casualty each day (Audit August/September 2004) UK people will require hospital treatment > 1 major seizure/month > 1 minor seizure/month patients have severe disabilities requiring institutional care

4 4 Epilepsy Definition Classification Prevalence Pathogenesis Investigation Treatment Long term prognosis

5 5 Definition Recurring unprovoked seizures due to paroxysmal neuronal discharge

6 6 Classification Can be based on cause or mode of onset. Mode of Onset Partial (Focal) onset Generalised Unclassifiable

7 7 Partial Seizures Partial - onset in a focal region of cortex Simple partial - sensory, motor, autonomic or psychic - without loss of consciousness Complex Partial - consciousness impaired Complex Partial with Secondary Generalisation - evolving into a full-blown seizure Temporal, Frontal, Parietal or Occipital in origin

8 8 Generalised Bilateral synchronous cortical spike and wave discharge generated by thalamic slow calcium channels Tonic-Clonic Typical Absence Atypical Absence Myoclonic Tonic Atonic

9 9 Frequency of different types 1/3 generalised in onset 2/3 partial in onset, most commonly temporal lobe attacks

10 10 Status Epilepticus Recurring seizures without recovery of consciousness in between Convulsive status Absence status Complex partial status Epilepsia partialis continuans

11 11 Secondary (‘Symptomatic’) Seizures Seizures secondary to an acute metabolic, drug-induced or neurological condition Patients usually not vulnerable in the long term if underlying cause is reversed.

12 12 Incidence Developed countries 50/100000/year (range 40-70) Underdeveloped countries /year - only 6%of PWE in Pakistan or Phillipines on rx at any one time Patients may not be aware that they have epilepsy

13 13 Prevalence 5-10/1000 persons Lifetime prevalence is 2-5% As the population ages there will be an increased incidence and prevalence of epilepsy - at least 20% of new onset cases will be over 60 Febrile seizures prevalence - 5%

14 14 Aetiology General Data 60-70% no clear cause (‘Cryptogenic epilepsy) Cerebrovascular disease/Brain tumour/Alcohol- induced/Post-traumatic With the advent of MRI increasing numbers of structural lesions such as HS, Cortical dysplasia, Small foreign tissue lesions Some patients may be reclassifed as having a generalised syndrome with analysis of EEG records Recent NSE data - up to 60% of a community based MRI series have some structural lesion

15 15 Pathogenesis Still not fully elucidated Discharges occur in the neocortex and limbic structures such as the Amygdala and Hippocampus Large 20-40mV discharges in a group of at least neurones (‘minimum aggregate zone’ Giant EPSPs - glutamate dependent, voltage- sensitive calcium channels, voltage sensitive sodium channels Excitatory neurones must be connected into a synaptic network

16 16 Pathology Seizures complicate many brain diseases eg Alzheimer disease Hippocampal Sclerosis Cortical dysplasia Lesion-associated - tumours/AVMs Inflammatory, Traumatic, Hypoxic-|schaemic lesions Conditions and lesions secondary to seizures Dual pathology

17 17 Investigation Brain structural imaging -CT and MRI Functional imaging -fMRI/Ictal SPECT/PET

18 18 Hippocampal sclerosis

19 19 Dysembryoblastic Neuroepithelial Tumour

20 20 Left Temporal AVM

21 21 Focal Cortical Dysplasia

22 22 Investigation EEG - only 50% will have interictal abnormalities - a normal EEG does not exclude Epilepsy! Some patients may never have any EEG findings Sleep EEG Video-EEG - at least 70% of our recordings do not have demonstrate attacks With sphenoidal leads Cortical monitoring - Depth electrodes Therapeutic trial

23 EEG – 3/s spike and wave 23

24 24 Bloods/Cardiovascular FBC/U+E/Calcium/Magnesium/Glucose Toxicology ECG/Holter/ECHO/Syncope studies

25 25 Differential Diagnosis Cardiovascular Metabolic Psychogenic - ‘Non-Epileptic Attack Disorder’ aka Pseudoseizures Up to 1/3 of referrals to an Epilepsy Centre (Walton, Liverpool) were found to have alternative causes for episodes

26 26 Counselling/Treatment - General principles Generally not if only one episode (but maybe if +ve EEG/Structural brain lesion/Elderly/Severe episode) ‘Oligo-Epilepsy’ Treatment for at least 2 years Try to keep to once or twice per day Inform patient about side effects and the possibility of treatment failure Lifestyle issues – alcohol/drugs

27 27 General Principles Cannot drive until 12 months seizure-free Exceptions: Sleep attacks only for > 2 years May resume driving in 6 months if seizure related to medication change or surgery work- up Simple partial seizures without disturbance of consciousness or motor control All must be certified by a neurologist

28 28 Women with Epilepsy Inform re potential interactions of the specific drug with OCP Inform re teratogenic risk Potential changes in Pharmacology in pregnancy Folic Acid 5mg/day Vitamin K supplementation

29 29 Drug therapy Bromide - Sir Charles Locock - May to Royal Medical and Chirurgical Society Barbituric acid - Saint Barbara’s Day AE properties recognised by Hauptmann Phenytoin - Putnam and Merritt using Phenyl ring containing compounds provided by Parke- Davis Trimethadione succeeded by Ethosuximide

30 30 Drug therapy Carbamazepine - synthesised by Geigy chemists in 1953 Valproic acid - organic solvent synthesised AE properties recognised in France 1961 and first marketed in 1967

31 31 DrugGABA- mediated Blockade voltage gated Na channels Unknown PBZYes PHTYes CBZYes VALPYes ETHYes BENZYes VIGAYes LAMYes GABYes PRE-GYes LEVYes TOPYes OXCYes

32 32 Drug Choice? Age/Gender Need rapid onset of action? OCP/Pregnancy Prior drug history Efficacy vs Side Effects Status Epilepticus - drug has to be soluble

33 33 Drug Choice? Broad Spectrum - work in all types Valproate Lamotrigine Topiramate Levetiracetam Zonisamide Phenobarbitone Benzodiazepines

34 34 Drug Choice? Narrow spectrum Partial-onset Carbamazepine Phenytoin Vigabatrin Gabapentin Tiagabine Oxcarbazepine Pre-Gabalin Absence attacks - Ethosuximide

35 35 Most commonly used by me! Carbamazepine Valproate Lamotrigine Levetiracetam Phenytoin Topiramate

36 36 Combination Treatment/Polypharmacy May help some patients Increased risk of interactions In our QOL study of 90 consecutive patients most important discriminator was seizure freedom and not number of drugs taken

37 37 Prognosis 60-70% should expect to be seizure-free without major side effects In these patients the choice of drug may not matter that much - they might respond any drug they try However relapse rates as high as 40% if drugs are withdrawn even after good long term control Major socio-economic effects if seizures relapse Put pros and cons to patient and give them your assessment of their individual risk

38 38 Drug-resistance Seizures refractory for more than 2 years of trying more than 3-4 AEDs 30-40% of patients - pharmacogenomics an increasing area of interest Reassess diagnosis and other factors like compliance or lifestyle problems Video-EEG Repeat imaging

39 39 If focal onset…. Surgery may be an option High quality MRI Video-EEG - catch at least 2-3 attacks to ensure consistent seizure focus Neuropsychology Psychiatry review If there is congruence between MRI and EEG findings surgical resection is possible At least 3000 Irish patients might be suitable for such surgery

40 40 Surgery Best results with clear Temporal origin 50% become seizure free 20% significantly improved <1% risk of adverse outcome 10% risk of psychiatric problems Frontal <50% chance of good outcome Occipital/Parietal - greater risk of surgery causing deficit

41 Ictal PET Scan 41

42 42 Other options… Vagus nerve stimulation Deep brain stimulation Seizure detection and immediate response drug delivery systems Gamma knife

43 43 Prognosis Generally good However SMR x 3 times controls Due to cause of epilepsy/accidents Sudden Unexpected Death in Epilepsy (SUDEP) Young adults/Early age on onset/Generalised Tonic- Clonic seizures/High seizure frequency/Polypharmacy/Poor compliance

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