Epilepsy 2

Epilepsy 2

Dr. Mohammed AzizF.I.B.M.S Neuro.
*

Epilepsy Syndromes

1-Juvenile Myoclonic Epilepsy 2-Mesial Temporal Lobe Epilepsy Syndrome 3-Lennox-Gastaut Syndrome
*

Lennox-Gastaut Syndrome

occurs in children and is defined by the following triad: multiple seizure types (usually including generalized tonic-clonic, atonic, and atypical absence seizures); impaired cognitive function in most but not all cases an EEG showing slow (<3 Hz) spike-and-wave discharges and a variety of other abnormalities.
*

Epilepsy & pregnancy

-Enzyme inducer AED associated OCP failure - -AED associated congenital malformation like cleft lip , spina bifida , cardiac defect -Hemorrhagic disease of newborn due to VitK deficiency may increases with maternal used Enzyme inducer AED so 20mg vit k orally daily in last month of pregnancy & 1mg inj. At birth
*

Seizure Precipitants

 Metabolic and Electrolyte Imbalance Sedative or ethanol withdrawal Sleep deprivation Antiepileptic medication reduction or inadequate AED treatment Hormonal variations Stress Fever or systemic infection Concussion and/or closed head injury *


NEW CASE OF EPILEPSY
1-a seizure or not 2-if seizure , what type 3- rule out serious causes 4-choose suitable medication 5-balance seizure & side effects 6-consider non-medical therapies 7-help patient & family psychosocial issues
*

Seizure imitators 1- medical -Syncope -Arrhythmia -Hypoglycemia -Hypoxia

*

2-neurological -TIA -Migraine -Narcolepsy -Vertigo -Involuntary movement
*

3-Psychological -Panic attack -Hyperventilation spells -Night terrors Pseudosiezure

*

NEW CASE OF EPILEPSY

1-a seizure or not 2-if seizure , what type 3- rule out serious causes 4-choose suitable medication 5-balance seizure & side effects 6-consider non-medical therapies 7-help patient & family psychosocial issues
*

Dx start with good story -alteration in-sensory-motor function -Behavior -Consciousness -clear start & finish -time course 5sec-5min -stereotyped Not one of imitators Tests EEG,MRI
*


Physical examination. Useful to detect -underlying focal lesion -Stigmata of genetic diseases -S/E of medication
*

NEW CASE OF EPILEPSY

1-a seizure or not 2-if seizure , what type 3- rule out serious causes 4-choose suitable medication 5-balance seizure & side effects 6-consider non-medical therapies 7-help patient & family psychosocial issues
*

*

*

*

*

*

*

*


Indication of neuroimaging -Epilepsy start after age of 20 years -Partial epilepsy -EEG show focal features -Difficult to control fit or deteriorated
*

NEW CASE OF EPILEPSY

1-a seizure or not 2-if seizure , what type 3- rule out serious causes 4-choose suitable medication 5-balance seizure & side effects 6-consider non-medical therapies 7-help patient & family psychosocial issues
*

50%of patient respond to old medication 10% of patient respond to new medication 5%of patient candidate for surgery 35% not respond to medication 2/3 respond to AED 1/3 not respond to AED
*

AED Surgery Ketogenic diet Non-medical therapy Stimulator

*

*

*

*

*


*

*

*

*

*

*

AED Enzyme Inducers

Broad Spectrum Inducers: Carbamazepine Phenytoin Phenobarbital Broad Spectrum Inhibitor Valproic acid
*

Weight Change

Weight Gain Valproate (50%) Carbamazepine Gabapentin (15-20%)
Weight Loss Felbamate (2-75%) Topiramate (50%) Zonisamide (20-50%) Weight Neutral Phenytoin Lamotrigine Levetiracetam Tiagabine
*


Dose related vestibular/cerebellar effects Behavioral changes Gingival Hyperplasia GI Disturbances Sexual-Endocrine Effects: Osteomalacia Hirsutism Hyperglycemia
Phenytoin
*

*

Candidates Fit For Epilepsy Surgery Patient has tried 2 or 3 drugs for more then 2 years Patient has at least one fit minor/major per week on an average. Patient has side effects from taking drugs to control epilepsy
*

Temporal Lobectomy Lesionectomy Hemispherectomy Corpus Callosotomy Stereotactic surgery by Gama knife
*

*

Vagus Nerve Stimulator

*

Status Epilepticus

 DefinitionMore than 30 minutes of continuous seizure activityor Two or more sequential seizures spanning this period without full recovery between seizures *

New definition More than 5 min of seizure or Two or more sequential seizures without full recovery between seizures


*

Types Repeated generalized tonic and/or clonic convulsive seizures where the patient does not fully recover between attacks Non-convulsive status: prolonged state Continuous focal epileptic activity without alteration of consciousness
*

Etiology of status epilepticus

Medication non-complaince 30% Ethanol withdrawal 25% CNS infection 10% Refractory epilepsy 5% Trauma Tumor Metabolic Stroke Anoxia others
*

Oxygen, oral airway. Avoid hypoxia!

Consider bag-valve mask ventilation. Consider intubation IV access. Treat hypotension, but NOT hypertension
A
B
C
*

Anticonvulsants

Rapid acting Plus Long acting
*


Compensatory phase -Catecholamine increase -C.O. increase -CBF increase -Glucose level increase
*

Non-compensotary phase -failure of cerebral autoregulation -increase ICP -decrease CO -HOT -metabolic derangement -DIC
*

*

65
70
75
80
85
90
95
100
Current Treatment Paradigm for Status Epilepticus
Lorazepam 0.1 mg/kg by IV push (<2 mg/min)
0
5
10
15
20
25
30
35
40
Time (Minutes)
Fosphenytoin 20 mg PE/kg (up to 150 mg PE/min). If only phenytoin is available: 20 mg/kg (<50 mg/min)
Additional fosphenytoin 5-10 mg PE/kg
Phenobarbital (PB) 20 mg/kg (<60 mg/min)
Seizures continue
Seizures continue
OR
IV anesthesia Pentobarbital ,propofol Midazolam
45
50
55
60
Seizures continue
Valproate 25 mg/kg (3 mg/kg/min) is an alternative to PB
Call for help
*


Purple Glove Syndrome
Hanna DR. J Neurosci Nur. 1992;24:340-345.
*

Complications

Hypoxia Lactic acidosis Rhabdomyolysis, hyperkalaemia, ARF Hyperpyrexia Hypoglycaemia Hyper/hypotension initial hypertension, subsequent hypotension Cardiac arrhythmias Pulmonary oedema Aspiration pneumonitis Intracranial hypertension
*

QUESTIONS?

*