epilepsy by I66V751d

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									    Epilepsy

Dr. Shreedhar Paudel
      May, 2009
                 Epilepsy…
• Recurrent, paroxysmal, involuntary clinical
  events associated with abnormal electrical
  activity from the neurons

• Abnormal motor, sensory and psychomotor
  phenomenon
                     Epilepsy…
• Causes of Epilepsy in Childhood
   – The etiologies vary in an age-dependent fashion

   – Neonates, infants, and toddlers →
      • perinatal brain injury
      • congenital central nervous system malformations
      • metabolic derangements


     Poor myelination and incomplete dendritic
     arborization in neonates lead to clinical
     seizure characteristics different from that of
     older children
                   Epilepsy…
• Causes of Epilepsy in Childhood
  – Central nervous system infection, genetic
    epilepsies, and neurodegenerative disorders are
    more likely to present with seizures beginning in
    later childhood

  – These causes stand in contrast to the adult
    population, where traumatic brain injury,
    cerebrovascular disease, and neoplasms represent
    the most frequent causes of seizures
                       Epilepsy…
• Types:-
  – Generalised
     •   Tonic- clonic (grand mal)
     •   Tonic
     •   Clonic
     •   Absence (petit- mal)
     •   Atonic
     •   Epileptic myoclonus

  – Localised
     • Simple
     • complex
                  Epilepsy….
• TONIC – CLONIC SEIZURES

  – Phases:
    • 1. Aura
    • 2.Tonic
    • 3. Clonic
    • 4. Postictal phase
                  Epilepsy…
• ABSENCE SEIZURES
  – Age 6-8 yrs
  – Absence moments
  – < 30 seconds
  – Inattentive pupils
  – Hyperventillation – precipitates
  – Pyknolepsy
  – EEG: 3 Hz spike and slow wave pattern
                    Epilepsy…
• MYOCLONIC SEIZURES
  West syndrome- triad of
   - Infantile spasm
   -Mental retardation
   -Hypsarrhythmic EEG ( diffuse high voltage slow
                         spike and chaotic activity)
• Infants – 3-8 months

• Poor prognosis
                  Epilepsy…
• Management:-
 Under supervision of a physician for prolonged
 period extending over 1 to 4 years
  – Medical aspects
  – Emotional and psychosocial aspects (as chronic
    illness)
  – Identification of etiology
  – Side-effects of drugs
                   Epilepsy…
Type of epilepsy   Drug            Alternative drugs
Tonic- clonic      Carbamazepine   Phenobarbitone,
                                   Phenytoin
Complex - partial Carbamazepine
Absence seizures Ethosuximide      Sodium
                                   valproate,
                                   clonazepam
Myoclonic          ACTH            Prednisolone,
seizures                           sodium valproate
Drugs            Side effects
Carbamazepine    Relatively safe, GI
                 symptoms, hepatitis, skin
                 rashes, BM depression
Phenobarbitone   Drowsiness, dependency
Phenytoin        Hirsuitism, gum
                 hyperplasia, ataxia,
                 diplopia
Ethosuximide     Photophobia, leukopenia,
                 GI upset
ACTH             Hypercorticism
                   Epilepsy….
• Surgical treatment:-
  – Severely disabled cases

  – Resistant to medical treatment

  – Focal resection of parts of cerebral cortex
    (involved as epileptogenic foci)
                       Epilepsy
• Prognosis:-
  – 10- 15% recurrence even after adequate course of
    anticonvulsants
  – Recurrence less if child is seizure free within 2 yrs
    of start of treatment
  – Relapse low in
     • Generalised tonic- clonic
     • Absence fits
  – Juvenile myoclonic
     • Lifelong treatment
                    Epilepsy…
• Duration of therapy
  – Continued till 1-2 yrs in absence attacks and

  – 2 yrs seizure free period in tonic clonic seizures

  – Drug withdrawal should be attempted slowly over
    three months
            Status epilepticus
• Single seizure or multiple episodes of seizures
  lasting more than 30 minutes without
  regaining consciousness in between

• In around 50% of cases SE is the first episode
  of seizure
           Status epilepticus…
• Pathophysiology:-
  – Failure of mechanism that aborts the seizure


• Evaluation in ED:-
  – Good description of the event, surrounding
    circumstances, preliminary symptoms, progression
    of the clinical symptoms, duration of the event
    and postictal phase
           Status epilepticus…
• Evaluation in ED:-
  – Presence of incontinence or tongue biting

  – hypoglycemia, CNS infections, CNS vascular
    events, drug toxicity, psychiatric disorders should
    be ruled out
              Status epilepticus…
• Investigations:-
  – Serum glucose

  – Evaluation for underlying disorder if present

  – serum anticonvulsant level – patient with known
    seizure taking medications

  – CT, EEG
           Status epilepticus…
• Management goals:-
  – Ensure adequate systemic and cerebral oxygen
    delivery
  – Terminate seizure activity
  – Prevent seizure recurrence
  – Diagnose and treat underlying cause if present
           Status epilepticus…
• Management:-
  – Secure airway
  – Maintain oxygenation
  – Maintain blood pressure
  – Obtain IV access
  – Protect the patient from injury
  – If hypoglycemia suspected 25% dextrose given
    (2ml/kg) emperically
           Status epilepticus…
• Management:-
  – Specific treatment

  Prehospital management of status epilepticus
    -A single dose of rectal diazepam by the caretakers
    -Usual rectal dose is 0.2-1.0mg/kg
            Management of SE…
• Hospital treatment
      Diazepam IV or Lorazepam IV
                     ↓
   Repeat diazepam if seizure continues after 10 min
                     ↓
              IV Phenoitoin
                     ↓
              IV Phenobarbotal
                     ↓
              IM/PR Paraldehyde
                     ↓
              Midazolam infusion
            Management of SE..
• The benzodiazepine of choice is lorazepam for
  initial treatment
  – due to its long (2–8 hour) duration of action
  – rapid onset of action
     • thought to be due to its high affinity for GABA receptors and
       to its low lipid solubility which causes it to remain in the
       vascular compartment.
  – If lorazepam is not available, then diazepam should be
    given.[10]
  – the failure of lorazepam alone is considered to be
    enough to classify a case of SE as refractory.
               Refractory SE
• The seizure that lasts for more than 60 min
  after initiation of treatment
• Seizure that continues even after 2 doses of
  Lorazepam

Treatment is intubation and infusion of
  Midazolam or other forms of anaesthesia

								
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