EPILEPSY

Mrs. Rihana Begum

Assistant Professor
 Introduction
Definition: The occurrence of transient
paroxysms of excessive or uncontrolled
discharges of neurons, which may be
caused by a number of different etiologies,
leading to epileptic seizures.
Synonyms: Seizure Disorder
 Historical Background
Epilepsy derived from a Greek
term: Epilambanei -to posses, to
take hold of, to grab or to seize.

Vedic period of 4500-1500BC :

.
. Ancient Indian Medicine refined and
developed the basic concept of
epilepsy

Charaka Samhita- The Ayurvedic

literature 400 BC: Describe
epilepsy as Apasmara means loss
of consciousness.
 Historical Background contd

Hippocrates 400 BC: This is not

a sacred disease rather disorder of
brain . He described some
physical treatment of epilepsy and
stated it is an incurable chronic
illness.
Ibn Sina 370 AH:
describe epilepsy as a
brain disease.
 Historical Background contd

Europe and USA 1857: Bromide was used as

first anti-epileptic drugs.
1873 H. Jackson: Neurologist of London-
described relationship of electrochemical
discharge of brain and seizure.
1920 H. Berger: German Psychiatrist developed
EEG to measure brainwaves and its application in
the field of epilepsy.


Historical Background contd

1909: Formation International league against epilepsy (ILAE).

1912: Use Phenobarbitone as AED.
1938: Use Phenytoin as AED.
1950-1970: Developed many AED.
1981: ILAE classified epilepsy.
1997: ILAE, IBE and WHO jointly established Global campaign
against epilepsy.
Epilepsy synonyms in South East Asia

India: Apasamra, Mirgee,Lata, Laran

Srilanka: Apasamra
Indonesia: Ayan
Thailand: Rake Lom Ba Mu, Role Lom Chak
Bangladesh: Khichuni, Mrigee, Batash (bad wind)
 Epidemiology of Epilepsy

Epilepsy knows no geographical, racial or social

boundaries. About 50 million people in World have
Epilepsy.
It occurs in men and women and can begin at any age, but
is most frequently diagnosed in infancy, childhood,
adolescence and old age.
Prevalence:
Developed countries- 0.5% (0.4% - 1%)
Developing countries- five times higher
Incidence:
After infancy annual incidence- 20-70/100000 in
developed countries.
Developing countries- Incidence is double. (100/100000)
The life time risk of having a single seizure:
About 5%.


Prevalence in South East Asian Countries

Bangladesh: 0.1% (in adult population.)
India: 0.9% in Bangalore,
0.5% in Mumbai,
0.4% in Delhi and
0.3% in Kolkata.

Sri Lanka: 0.9% (In Kandy District)

Pakistan: 0.99%
Nepal: 0.73%
Thailand: 0.72%
Myanmar: 0.1%
 Classification of Seizures
ILAE Classification (1981)
I. Partial (Focal)seizures
A. Simple partial seizures
B. Complex Partial
Seizures
C. Partial Seizures
evolving to secondary
generalized seizures
(tonic-clonic, tonic or
clonic)
II. Generalized seizures
(Convulsive and non-convulsive)
A. Absence seizures
i) Typical ii) Atypical
B. Myoclonic seizures
C. Clonic seizures
D. Tonic seizures
E. Tonic-Clonic seizures F.
Atonic seizures (Combinations
may occur: myoclonic
and atonic or myoclonic and tonic)
III. Unclassified epileptic
seizures

Drugs That Induce Seizu res
 Drugs That Induce Seizures
Antidepressant: TCA- (Amitriptaline, Imipramine,
Clomipramine), Dosulepin, Buproprion. Venlafaxine,
Duloxitine,Reboxetine
Antipsychotics: Chlorpromazine, Zotepine,
Loxapine,Depot Anti-psychotics,Clozapine
Mood Stabilizer: Lithium
Psycho stimulant: Amphetamine

Safe Psychiatric medication in Epilepsy

Antidepressant: Moclobemide, SSRI (with cautious)
Antipsychotics: Haloperidol, Trifluphenazine, Sulpiride
Generalized Tonic-clonic (grand mal)

Definition:
 Clinical Presentations
Myoclonic seizures
Abrupt , very brief, involuntery flexion movements.
Involve whole body or part of the body
Occur most commonly at morning, shortly after walking.
May occur in healthy people (physiological)
Atonic Seizures
Brief loss of muscle tone.
Heavy fall , with or without loss of consciousness.
Versive seizures
A frontal epileptic foci may involve the frontal eye field.
Force deviation of the eyes and turning head to the opposite
side.
Status Epilepticus
Series of recurrent Tonic-Clonic seizures occurs without
regaining consciousness over 30 min.
Waist Syndrome: Infantile spasm, hypsarrhythmic patterns of
EEG, severe encepalopathy with mental retardation.
 Clinical Presentations
Infantile Spasm: Sudden brief seizures, typically tonic flexor
spasm of waist, extremities and neck. 20% mortality, who
survive 75% have mental retardation, 50% have life long
seizures.
Juvenile myoclonic epilepsy: Inherited condition.Under
recognized syndrome with myoclonic jerks, tonic-clonic or
clonic- tonic-clonic seizures or absence seizures. EEG shows
spike and wave pattern of 3.5-6 Hz.
Lennox-Gastaut syndrome: Devastating disorder in children.
Mixed types of seizures and mental retardation. Usually
cognitive deficit present. EEG shows slow (<2.5 Hz ) spike
and wave patterns.
Catamenial epilepsy: Epileptic women experienced that their
seizures worsen during menstruation; due to the imbalance
between the proconvulsant estrogen and anticonvulsant
progestogen.
Diagnosis of Epilepsy
Thorough History taking :
From patients
From reliable valid informants
From observer (who observed seizures)
Physical Examination:
Specially neurological system
Higher Psychic function
Laboratory Investigation:
S. Electrolytes, S. Prolactin, Blood sugar, CBC, TFT,
LFT, RFT, CSF study
Imaging:
EEG, Video EEG telemetry, CT Scan of Brain, MRI of
Brain, MRS, PET, SPECT.
Polysomnography
 Differential Diagnosis
True Seizure Vs Pseudoseizure
Condition mimicking
Seizures: Features & Lab findings True Seizure Pseudoseizure

Pseudoseizure Resemble known seizure Yes No

Syncope Ttyopnegsue bite Yes No
Some sleep Duration Short Long
disorders Post-Ictal Phenomena Present Absent
Hypoperfusion in Injury Yes No
brain Occurs during sleep Yes No
Cardiac Arrhythmia Can be precipitated by No Yes
Emotional Outburst suggestion
Dissociative fugue EEG during attack Abnormal No Change
Drop Attacks EEG after attack Slowing No Change
pattern
Migraine
Serum prolactin (after attack) Raised No change
Hypoglycaemia
Anti Epileptic drug usage Suppress No Change
seizures (may worsen)
 Choice of Anti Epileptic Drugs
Epilepsy Type First-Line Second-Line Third-Line
Partial and /or Carbamazepine S. Valporate Clobazum
Secondary GTCS Lamotrigine Tiagabine Phynytoin
Oxcarbazepine Gabapentin Phenobarbital
Topiramate Vigabatrin
S. Valporate(in Acetazolamide
children)
Primary GTCS S. Valporate Lamotrigine Phynytoin
Topiramate Gabapentin
Carbamazepine Phenobarbital
Tiagabine
Acetazolamide
Absence S. Valporate Ethosuximide Clonazepum
Lamotrigine Acetazolamide

Myoclonic S. Valporate Clonazepum Piracetam

Lamotrigine
Phenobarbital
 AED: Indications and Dosage
AED Seizure type Dose Doses Therapeutic
range per day range
(mg/day) (mol/L)
Carbamazepin Partial,Secondary GTCS, 250-2000 2-3 30-50
e
Sodium Primary & Secondary GTCS, 400-2500 1-2 NA
Valporate Absence, Myoclonus
Phenytoin Partial, Secondary GTCS 150-350 1 40-80
Lamotrigine Partial, secondary GTCS 25-500 1-2 NA
Lorazepum Status Epilepticus 4 i.v. -- NA
Clonazepum Partial (adjunctive), 1-8 2-4 NA
Myoclonus
Ethosuximide Childhood Abssence 500-1500 2 200-700
Topiramate Partial, secondary GTCS 200-600 1-2 NA
Phenobarbital Partial, secondary GTCS 60-100 1 50-150
 AED: Side Effects
AED Sodium Carbamazepine Phenobarbital Topiramate Phenytoin
Side Effects Valporate
Neurological Ataxia, Ataxia, Ataxia, Ataxia Ataxia,
Nystagmus, Nystagmus, Nystagmus, Nystagmus,
Diplopia, Diplopia Diplopia Diplopia,
Tremor Neuropathy Tremor,
Dystonia,
Asterixis
Neuropathy
Cognitive & Drowsiness Drowsiness Drowsiness Confusion Drowsiness
behavioral Drowsiness
Dermatological Rashes, Rashes, SJS, Rashes ---- Rashes,
Alopecia Hirsutism,
Gum
Hypertrophy,

Hematological Blood Blood Megalobastic Anaemia, ---- Blood

dyscrasias Dyscrasias, Osteomalacia dyscrasias
Thrombo- Osteomalacia
-cytopenia
Endocrine Pancreatitis ---- ---- ---- ----
Hepatology & Liver ---- ---- Nephro- Liver damage
Kidney damage -lithiasis
Others Nausea, Hyponatremia Foliate deficiency, Nausea, SLE
Weight Gain Depression (adults), depression, Facial
Excitement (Children), Taste Dysmorphism
Foliate
SLE alteration, deficiency
Weight loss
Drug Interactions Other AEDs, Other AEDs, Other AEDs, Other AEDs,
Antimalarials OCP, CCB,OCP, Other AEDs, OCP, Anti
OCP Arrythmic,
Antimalarials, Digoxin,
Antimalarials,
Corticosteroids Antidepressant,
Corticosteroids
Antimalarials
Thyroxine
 Prognosis
Generalized seizures are more readily controlled than partial
seizures.
Childhood onset epilepsy (particularly classical absence
seizures) carries the best prognosis for successful drug
withdrawal.
The presence of a structural lesion makes complete control of
epilepsy less likely.
Epilepsy outcome: After 20 years
50% seizure-free, without drugs, for last 5 years
20% seizure-free, continue to take medication, for last 5 years
30% seizures continue in spite of adequate dose of AEDs.
Refractory epilepsy: When seizure control is not achieved
with the first two appropriate and well tolerated AED
schedules taken as mono therapy or in combination.
Psychiatric comorbidities in Epilepsy
Mood variation: Nearly 1 in 3 patients of epilepsy report
significant concern about their mood.

Depression: Upto 55% prevalent in patients with epilepsy.

Suicide rate: In depressed patients with epilepsy is 5 times
higher than that in the general population and 25 times higher
in patients with complex partial seizures of temporal lobe
origin.
Anxiety : Upto 50% prevalent in patients with epilepsy.
Psychosis: Incidence of Psychosis 3.3% in patients with
idiopathic generalized epilepsy, 14% in Temporal lobe
epilepsy. In the concern of severity; Psychosis occurs in
0.6-0.7% patients with epilepsy in community and 19-27% of
epilepsy patients who require hospitalization.
THANK YOU