1. Meiti Frida Department of Neurology Andalas University Padang

2. Abnormal and recurrent excessive synchronized discharge of cerebral neuron with clinical manifestation of epileptic seizure which are an intermittent stereotypical behavior, emotion, motor function or sensation

3.  Paroxysmal depolarization shift (PDS) of the resting membrane potential, which triggers a brief rapid burst of action potentials terminated by a sustained after hyperpolarization  PDS : result of imbalance between excitatory (glutamate and aspartate) and inhibitory (GABA) neurotransmitters  Abnormalities of voltage controlled membrane ion channels  Imbalance between endogenous neuromodulators, acetylcholine favoring depolarization and dopamine enhancing neuronal membrane stability

4.  Asynchronous burst firing in some hypocampal and cortical neurons

5.  Generalized epileptogenesis : asynchronous burst firing in abnormal thalamocortical interaction

6.  Developed countries : annual incidence 50-70 cases per 100.000  Developing countries : prevalence 1% Incidence varies with age

8.  Idiopathic  Cryptogenic  Symptomatic

9. Hypoxia Hypoglycaemia Hypocalcaemia Febrile Seizures Intracranial Infections Birth trauma Intracranial haemorrhage Congenital anomalies Tuberous sclerosis Storage diseases 1 510020 Head Injuries Drugs and alcohol Genetic epilepsies Cerebral tumours 60 Cerebrovascular degenerations Age (years)

10. CommonOccasional Sleep deprivation Alcohol withdrawal Television flicker Epileptogenic drugs Systemic infection Head trauma Recreational drugs AED non-compliance Menstruation Barbiturate withdrawal Dehydration Benzodiazepine withdrawal Hyperventilation Flashing lights Diet and missed meals Specific “reflex” triggers Stress Intense exercise

11. Partial seizures (beginning locally)  Simple partial seizures (without impaired consciousness)  with motor symptoms  with somatosensory or special sensory symptoms  Complex partial seizures (with impaired consciousness)  simple partial onset followed by impaired consciousness  impaired consciousness at onset  Partial seizures evolving into secondary generalized seizures

12. Generalized seizures (convulsive or non- convulsive)  Absence seizures  Typical  Atypical  Myoclonic seizures  Clonic seizures  Tonic seizures  Tonic clonic seizures  Atonic seizures  Unclassified seizures

13. Partial seizures  Simple – preservation of awarness  Complex – impairment of consciousnesss  Secondary generalized Generalized seizures  Absence  Myoclonic  Tonic-clonic  Tonic  Atonic

20. Localization-related (focal, local or partial) epilepsies and syndromes  Idiopathic epilepsy with age-related onset - benign childhood epilepsy with centrotemporal spikes - chilhood epilepsy with occipital paroxysms  Symptomatic epilepsy

21. Generalized epilepsies and syndromes  Idiopathic epilepsy with age-related onset (listed in order of age at onset) - benign neonatal familial convulsions - benign neonatal non-familial convulsions - benign myoclonic epilepsy in infancy - childhood absence epilepsy (formerly known as pyknolepsy) - juvenile absence epilepsy - juvenile myoclonic epilepsy (formerly known as impulsive petit mal) - epilepsy with generalized tonic-clonic seizures on awaking  Other idiopathic epilepsies

22.  Idiopathic or symptomatic epilepsy (listed in order of age at onset) - West syndrome (infantile spasms) - Lennox-Gastaut syndrome (childhood epileptic encephalopathy) - epilepsy with myoclonic-astatic seizures - epilepsy with myoclonic absence seizures  Symptomatic epilepsy  Non-specific syndromes - early myoclonic encephalopathy - early infantile epileptic encephalopathy  Specific syndromes (epileptic seizures as a complication of a disease, such as phenylketonuria, juvenile Gaucher’s disease or Lundborg’s progressive myoclonic epilepsy)

23. Epilepsies and syndromes with both generalized and focal seizures  Neonatal seizures  Severe myoclonic epilepsy in infancy  Epilepsy with continuous spike waves during slow-wave sleep  Acquired epileptic aphasia (Landau-Kleffner syndrome)

24. Epilepsies without unequivocal generalized or focal features Special syndromes  Situation-related seizures - febrile convulsions - seizures related to other identifiable situations, such as stress, hormonal changes, drugs, alcohol withdrawal or sleep deprivation  Isolated, apparently unprovoked epileptic events  Epilepsies characterized by specific modes of seizure precipitation  Chronic progressive epilepsia partialis continua of childhood

25.  Interviews with patients or witness  Circumstances surrounding the attacks idiopathic and generalized No seizure worning No underlying brain lesions Associated with a family history  Symptomatic and localization related Aura Specific site of onset Identifiable cause  Recurrent episodes of seizures  Symptoms occured during and after seizures  Recording symptomatic events with videocamera and continous ambulatory EEG monitoring

26.  To confirm the clinical diagnosis  To support the classification of partial or generalized seizures  Routine trace 50% normal  Diagnostic in non convulsion state epileptic activities : Hyperventilation Photic stimulations Sleep deprivation

28.  Essential, particularly in partial onset seizures Computerized tomography (CT) Magnetic resonance imaging (MRI) Structural lesion

32. Scan should be repeated periodically :  Suspicion of a tumour  Worsening in neurological examination or cognitive function  Deterioration in the frequency or severity of the seizures

33. Single Photon Emission CT (SPECT) Positron Emission Tomography (PET) MRI spectroscopy Functional MRI Functional cerebral changes Useful adjuncts in candidate epileptic surgery

34.  Migraine  Transient Ischaemic Attacks  Hyperventilation  Tics  Myoclonus  Hemifacial spasm  Syncope  Sleep disorders  Non Epileptic Attacks  Narcolepsy  Metabolic disorders  Transient global amnesia

35. Medical treatment :  Establish a correct diagnosis of epileptic seizure type and epileptic syndrome  Decide treatment with epileptic drugs is necessary  Decide which drug should be used  Patients and their families should receive counselling regarding : Aims of treatment Prognosis and duration of the expected treatment Importance of compliance Side effects

36. Proposed Indications for resective epileptic surgery  Intractable seizures  Resectable structural abnormality as identified on magnetic resonance imaging  Confirmation that seizures arise from a visible lesion (using video telemetry)  Over 20% of seizures arising from the contralateral temporal lobe in temporal lobe seizures  Intelligence quotient > 70 points  No significant psychiatry morbidity  No medical contraindications  Age < 45 years

37. Newly diagnosed epilepsy First drug Second drug Refractory Rational duotherapy Surgical assessment Seizure-free 47% 13% 40%

38.  Choose the correct drug for the seizure type or epilepsy syndrome  Start at low dosage and increase incrementally  Titrate slowly to allow tolerance to central nervous system side-effects  Keep the regiment simple with once- or twice- daily dosing, if possible  Measure drug concentration when seizures are controlled or if control is not readily obtained (if possible)

39.  Counsel the patient early regarding the implications of the diagnosis and the prophylactic nature of drug therapy  Try two reasonable monotherapy options before adding a second drug  When seizures persist, combine the best tolerated first-line drug with one of the newer agents depending on seizure type and mechanism of action  Simplify dose schedules and drug regimens as much as possible in patients receiving polypharmacy  Aim for the best seizure control consistent with the optimal quality of life in patients with refractory epilepsy

40. Seizure typeFirst lineSecond line Tonic clonic Sodium valproate Carbamazepine Phenytoin Lamotrigine* Oxcarbamazepine* Absence Sodium valproateEthosuximide Lamotrigine* Myoclonic Sodium valproateLamotrigine* Partial Carbamazepine Phenytoin Lamotrigine* Oxcarbamazepine* Sodium valproate Unclassifiable Sodium valproateLamotrigine* *Lamotrigine and oxcarbamazepine are regarded as first-line drugs in some countries

41. Seizure typeFirst lineSecond lineThird line Tonic-clonicSodium valproate Carbamazepine Lamotrigine* Oxcarbazepine* Phenytoin MyoclonicSodium valproateLamotrigine*Clobazam Phenobarbital TonicSodium valproateLamotrigine*Clobazam Topiramate AbsenceSodium valproateLamotrigine* Ethosuximide Clobazam Partial Carbamazepine Phenytoin Sodium valproate Gabapentin Oxcarbazepine* Lamotrigine* Vigabatrin Clobazam Topiramate Infantile spasmsVigabatrin Corticosteroids Sodium valproate Nitrazepam Lamotrigine* Lennox-GastautSodium valproateLamotrigine* Topiramate Clobazam Felbamate

42.  Life threatening medical defined as frequent and / or prolonged epileptic seizure

43. Wrong diagnosis  Syncope, cardiac arrhythmia, etc.  Malingering, pseudoseizures  Underlying neoplasm Wrong drug(s)  Inappropriate for seizure type  Kinetic / dynamic interactions Wrong dose  Too low (ignore target range)  Side effects preventing dose increase Wrong patient  Poor compliance with medication  Inappropriate lifestyle (e.g. alcohol or drug abuse)

44.  After 2-3 years period of seizure’s free, must be tappering off in six month

45.  Dependent with underlying syndrome and / or its cause  Patient’s compliance  Reciprocal illness or medications  60-70% controlled by first-line drug of epilepsy  10% of the rest controlled by new drugs  The rest : surgery Institution

46.  Behavioral problem : -Label of epilepsy racial disadvantage -Brain function, medication, type of seizure -Attitudes of helpers and helped  Education : -Discussion between doctors, families, schools teachers and the patient, steps which might be taken to promote normal education and personal development

47.  Employment : -Personal and racial states as well as financial reward -Understanding of the employee of their illness in the context of particular employment, safety for their selves and environment -People around in working hours need to know what to do if the attack occurred  The law  Driving lisence  Free of seizure after 6 months controlled epilepsy

48.  No permitting to drive if :  Have suffered of epileptic attack at the age before adolescent  Medical condition caused driving a source of danger to them selves and to the public  Leisure :  Swimming, water sport, cycling, horse riding in groups with safety controlled  Boxing, climbing, sport with body contact are prohibited  Television and video games, avoid flickering of the screen  Marriage and pregnancy  Health education  Impairment, disability and handicap