1. LAFAYETTE HOME HOSPITAL: EPILEPSY; 2004 LAFAYETTE HOME HOSPITAL: EPILEPSY; 2004

2. Most important question: is ictus a seizure CONCEPTS –Most unidentified spells are not seizures –If a diagnosis of a seizure is not definite, do not treat patient –Seizures most commonly dx. on history Have family act out seizure Video picture of event is extension of the history

3. HISTORYHISTORY Seizures; small spells, migraines big spells Moment by moment –Sudden onset –Post ictal episode Defined episode

4. Generally, episodes associated with event are not seizures Paroxysmal choreoathetosis Stretch syncope Night terrors Hyperventilation Breath holding spells

5. Common episodes which are not seizures Infant jerking during feeding Nocturnal myoclonic jerks Migraine headaches –Confusional –Post traumatic\ –Episodic vertigo Periodic syndromes Syncope daydreaming

6. ILAE classification Brain made up of very different cells “cerebrocyte” –Metabolism of different areas different Generalized –Some TC seizures –Myoclonic seizures –Akinetic seizures –Absence episodes Partial –Simple –Complex

7. Seizure syndromes museum

8. Infantile spasms Many causes 20% Tuberous sclerosis If identifiable cause, treatment probably does not change course West Syndrome –Onset 5-8 months –Whiff of ACTH helpful –Outcome Pyridoxine

9. Doos syndrome 2/3 boys Onset 2-4 yr of age Absence episodes Myoclonic, astatic episodes 50% with life long seizures and mental handicap Other uncommon types with myoclonic sz

10. Childhood absence epilepsy Peak onset 5-6 years 2/3 are girls ppt by hyperventilation 90% remission before 12 yr of age Rarely, uncommon GTCS as adult

11. BCECTSBCECTS Commonest pediatric epilepsy syndrome Onset between 1-14 years 1.5 male preponderance Hemifacial sz Nocturnal May not need to treat 2-3% normal children with CT spikes; <10% with seizures

12. Juvenile Myoclonic epilepsy 90% misdiagnosed Onset 5-16 yr of age Irregular shock like myoclonic jerks in AM –Can be myoclonic status 1/3 with absence attacks gen t-c seizures Sleep deprivation, alcohol ppt sz Occipital Lobe epilepsy

13. Photosensitive epilepsy Occurs with several seizure syndromes Seizure occurs during the photic stimulation Seizure occurs while exposed to flashing light –Pre TV stim –TV worst culprit Preventing –Polarized sunglasses –Small screenCover one eye –Oblique viewing

14. TESTING: ROUTINE EEG EEG best done to classify seizure If partial sz, EEG often normal Members of family with genetic epilepsy can have abnormal EEG without seizures

15. TESTING: 24 hr EEG Best if ictus occurs during EEG Video EEG Ambulatory EEG

16. TESTING: Imaging Studies CT scan –Good for trauma –In all other cases, MRI is best –Not a good screening tool MRI –Developmental abnormalities –Assessment of hippocampus

17. EFFECTIVENESS OF AED No real change in patients with uncontrolled seizures? All agents with same effectiveness Decision to use AED based on classification of seizure and side effects of AED

18. STARTING AED If one seizure: 30% will have recurrance If abnormal EEG: 60% will have seizure

19. SEIZURE CONTROL 60% controlled on first anticonvulsant 20% controlled on second anticonvulsant 5% controlled on third anticonvulsant

20. AED and ring structure

21. AED;MonomechanismAED;Monomechanism Carbamazepine Oxcarbazine Zarontin

22. AED affecting thinking Phenobarbitol Valproate Topomax Keppra

23. AED with particular side effects Lamotrigine; rash Keppra; major thinking disorder Topomax; word finding, acidosis

24. Use of meds One drug first Try for monotherapy If sz correctly dx and 3 meds no help, consider –VNS –Surgery –KGD