Epilepsy L5 PDF

Epilepsy Objective Definition and classification of epilepsy &seizure Causes and trigger factor of seizure Differential diagnosis of seizure Differentiate between seizure and pseudoseizure Management of seizure Management of status epilepticus Epilepsy is as a disorder of brain characterized...

Epilepsy Objective Definition and classification of epilepsy &seizure Causes and trigger factor of seizure Differential diagnosis of seizure Differentiate between seizure and pseudoseizure Management of seizure Management of status epilepticus Epilepsy is as a disorder of brain characterized by an ongoing liability to recurrent seizures. epileptic seizure is defined as the transient clinical manifestations that result from an episode of epileptic neuronal activity. epileptic neuronal activity is a specific of brain electricity dysfunction, characterized by abnormal synchronization, excessive excitation and/or inadequate inhibition, and can affect small or large neuronal populations. The clinical manifestations are sudden and according to the lobe involved usually brief. They include motor,abnormal psychic, behavior autonomic and sensory sweating, abd.pain phenomenon, with or flashes of light without alteration in consciousness or awareness, and the symptoms depend on the part of the brain involved in the epileptic neuronal discharge, and the intensity of the discharge 1-Generalised seizures all brain involved Tonic–clonic most common Absence ‫تصفن وترجع‬ Myoclonic Clonic mainly pediatrics Tonic Atonic loss of tone (walks and then suddenly fall) 2-Focal seizures Without impairment of consciousness or a wareness (simple partial( Focal motor frontal mainly Focal sensory mainly parietal lobe with impairment of consciousness or awareness (complex partial ) (starts as focal (partiel) then 3-Secondarily generalised seizure becomes generalized) most common Causes of seizures Idiopathic Genetic Dysembryonic eg(Cortical dysgenesis) Cerebral birth injury (anoxic damage ischemia Cerebral anoxia instrumal induced) Cerebrovascular disease (Intracerebral (10-15% of stroke are haemorrhage, infarction,) Arteriovenous epileptic) malformation  mainly young aged Tumours (primary and secondary) 30-35 Trauma (including neurosurgery) there may be gliosis like after tumor extraction Infective eg (Meningitis,Cerebral abscess, Encephalitis,.) Inflammatory eg (Vasculitis) like SLE Drugs eg (Psychotropic agents) heroin amphetamin Alcohol (especially withdrawal) especially if they were daily consumers Toxins eg.Organophosphates (sarin) ‫اسلحه كيمياويه‬ Metabolic disease eg., Hypocalcaemia parathyrodectomy by mistake or overdose insulin without eating Hypomagnesaemia, Hypoglycaemia, Hyponatraemia, Renal failure, Liver failure Bec. brain require these materials Trigger factors for seizures of pt. already epileptic  Sleep deprivation Missed doses of anti-epileptic drugs in treated patients Alcohol (particularly withdrawal) Recreational drug misuse  Physical and mental exhaustion  Flickering lights, including TV and computer Intercurrent infections and metabolic disturbances  Uncommon: loud noises, reading, hot baths investigations **always send for investigations From where is the epilepsy arising? and is it fit or psychofit Standard EEG ectal --> 100% post ectal (50%) --> not exclude epilepsy if -ve  Sleep EEG What is the cause of the epilepsy? Structural lesion(tumor ,stroke,…)? CT, MRI Metabolic disorder? Urea and electrolytes Liver function tests Blood glucose most imp. (bec. with no associated Serum calcium, magnesium Inflammatory or infective disorder?  Full blood count Chest X-ray Connective tissue disease eg SLE CSF examination most. imp. bec. of infections like encephalitis maniditory  seizure Pseudo seizure mostly seizure Precipitating Rare Common, emotional and 1- cause stress-related When alone or Common ‫هو ونايم واالم تسمعه يشوخر‬ rare 2- she wants to get attention on front other asleep Duration Usually short Longer 3- Body movement Tonic,clonic ,tonic clonic Asynchronous flailing of 4- synchronous small amplitude limbs; pelvic thrusting; atonic associated with ‫يفتعل هذا الشي لو يتگلب لو يضرب‬ jerks fall injury mostly opisthotonos ‫ ماله علفراش‬pelvis ‫ال‬ injury Tongue biting usually lateral May bite tongue usually 5- side , fall anterior, throw self to ground, Directed violence ‫ميطلع دم من اللسان وماكو‬ 4-5 times a day ‫جرح بللسان‬ Consciousness Complete loss in generalized Variable, often 6- tonic–clonic; may be inconsistent with seizure *without movement incomplete in complex partial type *not drowsy after attack Eye Usually open Usually closed‫يحاول يغمض عينه‬ 7- Incontinence Common (not manditory) Rare 8- Management It is important to explain the nature and cause of seizures to patients and their relatives, and to instruct relatives in the first aid management of seizures How to administer first aid for seizures Move person away from danger (fire, water, machinery, furniture) After convulsions cease, turn person into ‘recovery’ position (semi-prone) left lateral position Ensure airway is clear but do NOT insert anything in mouth (tongue-biting occurs at seizure onset and cannot be prevented by observers) Never put your finger in mouth  If convulsions continue for more than 5 mins or recur without person regaining consciousness, summon urgent medical no need if he is already epileptic unless prolong more attention than 5 min. but first attack reffer to ER Do not leave person alone until fully recovered (drowsiness and confusion can persist for up to 1 hr) Many people with epilepsy feel stigmatised and may become unnecessarily isolated from work and social life. It should be emphasised that epilepsy is a common disorder that affects 0.5–1% of the population, and that full control of seizures can be expected in approximately 70% of patients indications of drugs 1-first presentation of status epilepticus 2-imaging shows abnormally 3-family history 4-recurrent not first time 5-EEG +ve (still firing) 6-any case above 65 7-occupations Anticonvulsant therapy Anticonvulsant drug treatment (anti-epileptic drugs, or AEDs) should be considered after more than one unprovoked seizure. The decision to start treatment should be shared with the patient, to enhance compliance. A wide range of drugs is available. These agents either increase inhibitory neurotransmission in the brain or alter neuronal sodium channels to prevent abnormally rapid transmission of impulses. In the majority of patients, full control is achieved with a single drug Guidelines for anticonvulsant therapy Start with one first-line drug at least 2 years on the drug and may be life long Start at a low dose; gradually increase dose until effective control of seizures is achieved or side-effects develop (drug levels may be helpful) usually drowsness  Optimise compliance (use minimum number of doses per day)  If first drug fails (seizures continue or side- effects develop), start second first-line drug, followed if possible by gradual withdrawal of ‫ اذا مفاد ننطي‬nd line 2 ‫ فشل ننطي‬1st line ‫اذا ال‬ first should give 1 drug 1st + 2nd line ‫ اذا منجح نخبط‬2nd line ‫الالخ من ال‬ ‫ بل‬maximum dose ‫ اال نوصل لل‬2nd line ‫*منغير لل‬ side effect ‫ او صار‬1st line different mechanism of action ‫*من نخبط الزم‬  If second drug fails (seizures continue or side- effects develop), start second-line drug in combination with preferred first-line drug at maximum tolerated dose (beware interactions)  If this combination fails (seizures continue or side-effects develop), replace second-line drug with alternative second-line drug  If this combination fails, check compliance and reconsider diagnosis (Are events seizures? Occult lesion? Treatment compliance/alcohol?) Consider alternative, non-drug treatments (e.g. epilepsy surgery, vagal nerve stimulation) Use minimum number of drugs in combination at any one time  Epilepsy First-line Second-line Third-line type Focal onset Lamotrigine Carbamazepine Gabapentin and/or Levetiracetam Oxcarbazepine secondary Sodium- Phenobarbital GTCS valproate Phenytoin Generalised tonic-clonic Topiramate seizure GTCS Sodium - Lamotrigine Carbamazepine valproate Topiramate Phenytoin Levetiracetam Absence Ethosuximide Sodium- Lamotrigine ‫ينحل مع تقدم العمر لحد‬ ١٢ ‫العمر‬ valproate Clonazepam Myoclonic Sodium - Levetiracetam Lamotrigine valproate Clonazepam Phenobarbital Lifestyle advice Patients should be advised to avoid activities where they might place themselves or others at risk if they have a seizure. This applies at work, at home and at leisure. At home, only shallow baths (or showers) should be taken. Prolonged cycle journeys should be discouraged until reasonable freedom from seizures has been achieved. Activities requiring prolonged proximity to water (swimming, fishing or boating) should always be carried out in the company of someone who is aware of the risks and the potential need for rescue measures. Driving regulations vary between countries, and the patient should be made aware of these. Certain occupations, such as firefighter or airline pilot, are not open to anyone who has a previous or active diagnosis of epilepsy Differential diagnosis of epilepsy oSyncope when see blood or something oHypoglycaemia manditory to do blood sugar oTransient ischemic attack oPseudoseizures Idiopathic generalized epilepsy This term should be used to denote presumed genetic basis.. Idiopathic generalized epilepsy (IGE) accounts for about 10–20% of all patients with epilepsy Childhood absence epilepsy This condition, more common in girls, appears in childhood (peak age 6–7 years), and is not associated with learning disability or other neurological problems. The seizures take the form of generalized absence attacks. These comprise an abrupt sudden loss of consciousness and the cessation of all motor activity. Tone is preserved, and there is no fall. The patient is not in contact with the environment, The attack ends as abruptly as it Is started, and previous activity is resumed as if nothing had happened. There is no confusion and the patient is often unaware that an attack has occurred. Juvenile myoclonic epilepsy This is the most common subtype of IGE, and accounts for up to 10% of all epilepsies. The characteristic seizures are brief myoclonic jerks, occurring in the first hour or so after awakening, and usually in bursts. These are sudden, shock- like jerks, affecting mainly the shoulders and arms, usually but not always symmetrically. It is often not clear whether consciousness was retained or lost. the myoclonus develops between the ages of 12 and 18 years. In about 80% of cases, generalized tonic– clonic seizures also occur, usually months or years after the onset of myoclonus, Complete response to treatment can be expected in 80– 90% of cases, but lifelong therapy may be needed. Withdrawing anticonvulsant therapy Withdrawal of medication may be considered after a patient has been seizure-free for more than 2 years. Childhood-onset epilepsy, particularly classical absence seizures, carries the best prognosis for successful drug withdrawal. Other epilepsy syndromes, such as juvenile myoclonic epilepsy, have a marked tendency to recur after drug withdrawal. Seizures that begin in adult life, particularly those with partial features, are also likely to recur, especially if there is an identified structural lesion Overall, the recurrence rate after drug withdrawal depends on the individual’s epilepsy history. Patients should be advised of the risks of recurrence, to allow them to decide whether or not they wish to withdraw. If undertaken, withdrawal should be done slowly, reducing the drug dose gradually over weeks or months. Withdrawal may necessitate precautions around driving or occupation. Epilepsy surgery Some patients with drug-resistant epilepsy benefit from surgical resection of epileptogenic brain tissue. Less invasive treatments, including vagal nerve stimulation ,lobectomy, lesionectomy. All those who continue to experience seizures despite appropriate drug treatment should be considered for surgical treatment Status epilepticus Status epilepticus is seizure activity not resolving spontaneously,or recurrent seizure with no recovery of consciousness in between. Persisting seizure activity has a recognised mortality and is a medical emergency.Diagnosis is usually clinical and can be made on the basis of the description of prolonged rigidity and/or clonic movements with loss of awareness. In patients with pre-existing epilepsy, the most likely cause is a fall in anti-epileptic drug levels , In de novo status epilepticus, it is essential to exclude precipitants such as infection (meningitis, encephalitis), neoplasia and metabolic derangement (hypoglycaemia, hyponatraemia, hypocalcaemia). Management of status epilepticus Initial Ensure airway is patent; give oxygen to prevent cerebral Hypoxia  Check pulse, blood pressure, and respiratory rate Secure intravenous access Send blood for: Glucose, urea and electrolytes, calcium and magnesium, liver function, anti-epileptic drug levels ,full blood count ,Storing a sample for future analysis (e.g. drug misuse) Correct any metabolic trigger, e.g. hypoglycaemia If seizures continue for > 5 mins: give diazepam 10 mg IV (or rectally) or lorazepam 4 mg IV; repeat once only after 15 mins Ongoing If seizures continue after 30 mins IV infusion (with cardiac monitoring) with one of: oPhenytoin: 15 mg/kg at 50 mg/min oFosphenytoin: 15 mg/kg at 100 mg/min oPhenobarbital: 10 mg/kg at 100 mg/min Give attention for cardiac monitor and pulse oximetry Monitor neurological condition, blood pressure, respiration; check blood gases If seizures still continue after 30–60 mins o Transfer to intensive care oStart treatment for refractory status with intubation,ventilation and general anaesthesia using propofol or thiopental oEEG monitor Once status controlled Commence longer-term anticonvulsant medication with one of: Sodium valproate 10 mg/kg IV over 3–5 mins, then 800–2000 mg/day Carbamazepine 400 mg by nasogastric tube, then 400–1200 mg/day