Epilepsy 5.Year Prof.Dr.S.Naz Yeni

Objectives and method To learn general concepts about epilepsy and seizures Learn how to diagnose and classify epilepsy Brief rules regarding laboratory investigations Brief rules regarding treatment There will be a presentation of videos of different type of epileptic seizures

Definitions: Epileptic seizure is a transitory clinical manifestation as a result of an abnormal excessive hypersynchronous discharges arising from a group of neurons. Manifestations consist of transitory motor sensory pyschic phenomena and/or loss of consiousness. Epilepsy: epilepsy is a chronic condition. Seizures are spontaneous and recurrent.

Definitions Acute symptomatic seizures: these seizures are provoked as a result of a metabolic/infectious/traumatic events. Acute symptomatic seizures are not as a result of primarily nervous system lesions. Examples: febrile seizures seizures during acute head injury

Epilepsy clasification etiology Structural/metabolic (formerly symptomatic) Genetic (formerly idiopathic) Unknown (formerly cryptogenic)

Epidemiology Incidence: 20-120/100000 depending on the developing underdeveloped developed countries There is a bimodal distribution. The first peak in the first 2 decades and the second peak is after the age 65. Prevalence: 6-18/1000

Etiology Chidhood Perinatal hypoxia Perinatal insults CNS infections Congenital malformations Adulthood Neoplasms Vascular malformations Head injury Elderly Cerebrovascular diseases Degenerative diseases (Alzheimer disease)

ILAE (International League against Epilepsy) Classifications Proposal 1981 Proposal 1989 Proposal 2001 Proposal 2010

ILAE 2010 Focal Originating at some point within networks limited to one hemisphere Generalised Originating at some point within and rapidly engaging bilaterally distrubuted networks. Unclassified

Focal seizures Focal seizure with motor manifestations (with or without jacksonien march) somatosensory manifestations special sensory manifestations adversive features dysphasic manifestations postural manifestations dyscognitive features hyperkinetic manifestations

Subtypes Characterizes accoeding to one or more features Aura Motor Autonomic Awareness/responsiveness: Altered (dyscogntive) or retained May evolve into Bilateral convulsive seizure

Generalised seizures Tonic-clonic Absence Tonic Atonic Myoclonic

Diagnosis Detailed description of seizures from the patient and/or observers The role of EEG CT /MR

Differential diagnosis Depends on the seizure type Frequenty misdiagnosed conditions Seizures Syncopes Nonepileptic pyschogenic attacks

Epilepsy Nonepileptic physogenic Injury Yes No Sphinctary disturbance Eyes Open Closed Color Cyanosis Pallor? Tongue bite Rare (front) During sleep Duration Short Variable

EEG Does not diagnose epilepsy It is helpful in: diagnosis classification seizure type classification electroclinical syndromes decision of starting and discontinuing treatment for epilepsy surgery

Radiology Emergency room: CT scan (helps to reveal acute lesions such as intracranial hematoma fractures of the skull etc. Each patient with a diagnosis of epilepsy has a right to have at least one cranial MR scan to understand the underlying etiology.

Treatment Rules and steps Start with monotheraphy Increase the dose in case of recurrence of seizures Increase the dose until the patient can not tolerate to side effects. If there is no response switch the drug (monotherapy) If no response increase the dose If no response combine two (later three) effective drugs If no response take a look at the diagnosis/classification of the seizures/syndrome Think about epilepsy surgery

Treatment If there is a good response to treatment: The drug may be withdrawn after a seizure-free period of 2-5 years. In some cases treatment is lifelong. Patients with a high risk of recurrence: Mental retardation Neurologic deficit Lesions on MR Difficult to stop the seizures at the beginning

Drugs Acting on focal seizures Carbamazepine Oxcarbazepine Diphenyl hidantoin Phenobarbital Acting on generalised seizures Valproic acide Lamotrigine Levetiracetam Topiramate