LAFAYETTE HOME HOSPITAL: EPILEPSY; 2004 LAFAYETTE HOME HOSPITAL: EPILEPSY; 2004

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

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

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

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

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

Seizure syndromes museum

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

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

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

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

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

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

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

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

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

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

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

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

AED and ring structure

AED;MonomechanismAED;Monomechanism Carbamazepine Oxcarbazine Zarontin

AED affecting thinking Phenobarbitol Valproate Topomax Keppra

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

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