BIKHA Prof. Bikha Ram Devrajani FCPS,FACP, FRCP Professor Medicine& Director MRC Liaquat University of Medical & Health Sciences Jamshoro

PAROXYSMAL EXCESSIVE NEURONAL DISCHARGE CORTICAL/SUBCORTICAL STRUCTURES CLINICAL DEFINITION: Abrupt onset and end of one or more of the following; 1. Disconnection/Loss of consciousness. 2. Loss of postural control. 3. Motor, sensory or psychic symptoms. 4. Autonomic dysfunction. DEFINITION OF EPILEPSY

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CLASSIFICATION OF SEIZURE TYPES Partial seizures. - Simple Partial - Complex partial Generalized seizures - Tonic clonic - Absence - Myoclonic, tonic, atonic Secondarily generalized seizures

BIKHA SIMPLE PARTIAL SEIZURES Focus - Central

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SIMPLE PARTIAL SEIZURES Focus – Left Central

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SIMPLE PARTIAL SEIZURES Focus – Occipital

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COMPLEX PARTIAL SEIZURES Temporal lobe

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COMPLEX PARTIAL SEIZURES Focus - Temporal

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COMPLEX PARTIAL SEIZURES Parietal lobe

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PRIMARY GENERALIZED SEIZURES Childhood non-convulsion

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PRIMARY GENERALIZED SEIZURES Simple Absence Childhood non convulsive

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PRIMARY GENERALIZED SEIZURES Childhood non convulsive (with facial clonus)

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PRIMARY GENERALIZED SEIZURES Adolescent Myoclonic (upper limb)

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PRIMARY GENERALIZED SEIZURES Adolescent myoclonic

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PRIMARY GENERALIZED SIEZURES Adolescent clonic-tonic-clonic

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PRIMARY GENERALIZED SEIZURES Childhood atonic

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SECONDARY GENERALIZED SEIZURES Focus left occipital

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SECONDARY GENERALIZED SEIZURES Frontal Lobe

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SECONDARY GENERALIZED SEIZURES Focus central

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NON-EPILEPTIC ATTACKS Breath holding Spells

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NON-EPILEPTIC ATTACKS Psychogenic Seizures

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NON-EPILEPTIC ATTACKS Psychogenic Seizures

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Management of Epilepsy

BIKHA DIAGNOSIS OF EPILEPSY SEIZURE HISTORY Circumstances/Precipitant Timing/Duration Symptoms: preceding, during, after Frequency MEDICAL HISTORY PATIENT WITNESS

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DD OF EPILEPSY SYNCOPE: Vasovagal, Cardiac, Cough, Micturation, etc. HYSTERIA, Swoon, Malingering, Simulation, Expressions of Immature Emotions OTHER PSYCHIATRIC ILLNESSES ACUTE VERTIGO MIGRAINE

BIKHA PSYCHIATRIC DIFFERENTIAL DIAGNOSES Conversion disorder Panic disorder Dissociative disorders Psychotic disorders Post-traumatic stress disorder Impulse control disorders Malingering etc.

BIKHA MEDICAL MANAGEMENT ? OBSERVATION ONLY…. No “Trial” treatment INFREQUENT FITS…. No treatment FREQUENT FITS…. Drug treatment. REGULAR REVIEW, Compliance, Drug S/E ADDITIONAL PROBLEMS Medical, Psychiatric, etc.

BIKHA PRINCIPLES OF DRUG TREATMENT Monotherapy better than polytherapy Slow introduction (1/4th dose) Increase weekly, titrate to optimal dose. Compliance Choice of drug depends on seizure type, side effects availability, cost

BIKHA CHOICE OF DRUGS (AEDs) GENERALISED TONIC-CLONIC, PARTIAL, OTHERS (95%) Carbamazepine (Tegral, Seizunil, Teril) Phenytoin ( Dihyden, Epilantin) Phenobarbitone Valproate (Epilim, Epival, Depakan) GENERALISED ABSENCE (5%) Ethosuximide (NA) Valproate (Epilim, Epival, Depakan)

BIKHA CHOICE OF DRUGS (AEDs) NEWER DRUGS Topiramate (Topamax) Lamotrigine (Lamictal) Gabapentin (Neurontin) Vigabatrin, Tiagabin, Levetiracetam SECOND LINE DRUGS Benzodiazepines (Clonazepam, Nitrazepam, Clobazam) Acetazolamide (Diamox, AZM)

BIKHA NON-PHAMACOLOGICAL AND NON- VALIDATED TREATMENTS VAGAL STIMULATION- Helpful in upto 30% reduction in seizures KETOGENIC DIET (Medium Chain Glyderides) HERBAL HOMEOPATHIC YOGA MUSIC MEDITATION

BIKHA STATUS EPILEPTICUS Def: Convulsions lasting > 5-10 min (single or serial). Potentially fatal…. Must hospitalize. Commonest cause…. low compliance. All steps of “Coma Management”. Asses cause…. investigate while controlling fits. IV 50 ml 25% glucose, B1 (1 ampule neurobion). Diazepam 10 mg IV…. Repeat every 30 min if recur. Or 200 mg in 500 ml drip at rate 20 drops/min. Phenytoin 18mg/kg; rate not more than 50mg/min Valproate IV … mg 6-8 hourly.

BIKHA SIMPLE FEBRILE CONVULSION (SFC) 5% of all normal Children Age-Specific…. 6m-5y. Generalized convulsion Duration of fit…. <5 min. No neurological deficit No F/H/O of epilepsy Total number of fits <6 in the age 6m-5y. If all above + …. good prognosis.

BIKHA COMPLEX FEBRILE CONVULSION (CFC) Patient who do not fulfill SFC criteria Multiple fits in the same febrile episode Focal seizures High risk children…. focal n. sign or handicap Single generalized seizure > 5 min. Suspected with CNS infection…Meningitis, Encephalitis

BIKHA COUNSELLING IS CRUCIAL Explain nature of disorder; “electric model” Reinforce compliance Discuss expectations, limitations and S/E of AEDs Driving, employment, Leisure activities Education Marriage, children, hereditary

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