Transcript Document

Epilepsy
Shi Xue Chuan
General Considerations



A seizure is a sudden, transient disturbance of brain
function, manifested by involuntary motor, sensory,
autonomic, or psychic phenomena, alone or in any
combination, often accompanied by alteration or loss
of consciousness.
A seizure may occur after a metabolic, traumatic,
anoxic, or infectious insult to the brain.
Repeated seizures without evident cause justify the
label of epilepsy.
General Considerations



Incidence is greatest in early and late
life, with a prevalence of approximately
3～6 ‰.
Chance of having a second seizure after
an initial unprovoked episode is 30%.
Chance of remission from epilepsy in
childhood is 80%.
General Considerations

Recurrence rate after the withdrawal of
drugs is about 30%.

Idiopathic or genetic epilepsy most often
appears between ages 4 and 16 yaers.
General Considerations

Factors adversely influencing
recurrence include:





Difficulty in getting the seizures under
control
Neurologic dysfunction or mental
retardation
Age at onset under 2 years
Abnormal EEG at the time of discontinuing
medication
Type of epilepsy
Etiology

Genetic factor

Brain damage and dysmetabolism


Inborn

Acquired
Causative factor
Classification

Classified by etiology

Idiopathic (essential) epilepsy

Symptomatic (secondary) epilepsy

Cryptogenic epilepsy
Classification

Classified by epileptic seizures

Partial (foal, local) seizures
 Simple
partial seizures, without
impairment of consciousness




With motor signs
With somatosensory or specialsensory symptoms
With autonomic symptoms or signs
With psychic symptoms
Classification

Classified by epileptic seizures

Complex partial seizures, with
impairment of consciousness

Partial seizures evolving to
secondarily generalized seizures
Classification

Classified by epileptic seizures

Generalized seizures

Absence seizures









Typical absence
Atypical absence
Myoclonic seizures
Clonic seizures
Tonic seizures
Tonic-clonic seizures
Atonic seizures
Infant spasm, tonic-spasm
Unclassified epileptic seizures
Classification

Classification of epilepsy and epilepsy
syndromes




Benign children epilepsy with centroltemporal spike
Lennox-Gastaut syndrome
Infantile spaams
Juvenile myoclonic
Clinical manifestation

Partial epilepsy



Focal epilepsy may arise from an intracerebral
structural defect, causing motor or sensory
symptoms localized to one body part, which may
then spreads to contiguous regions of the cortex
(e.g. jacksonian seizures).
There are simple partial seizures without
impairment of consciousness.
Complex partial seizures associated with
disturbance of consciousness usually arise in the
temporal lobe.
Clinical manifestation

Partial epilepsy

Seizures arising in the medial temporal lobe may
produce disturbances of smell and taste, visual
hallucinations.

These may evolve to a tonic-clonic seizures
( secondary generalization).

Weakness following the event may occur for
minutes or hours (todd’s paresis).
Clinical manifestation

Generalized seizures

Absence attacks usually consist of a brief
interruption of activity, sometimes with
complex motor activity (such as fumbling
with clothes), but without collapse.

EEG during this event shows a three-persecond spike-and-wave activity.
Clinical manifestation

Generalized seizures



In a generalized tonic-clonic seizures, the
tonic phase is a sudden tonic contraction of
muscles usually with upward eye deviation.
The clonic (‘with clonus-type activity’)
phase follows.
Initial EEG changes are often bilateral.
This condition usually has its onset in
childhood.
Diagnosis of epilepsy


The integrate diagnosis should include
seizure type, anatomy, etiology and
concomitant mental disorders.
For example:


Epilepsy--grand mal—secondary
(symptomatic)— mental retardation
Epilepsy—centrotemporal spike wave-benign childhood epilepsy
Diagnosis of epilepsy

Clinical picture

Clinical history

Description of Sz

Symptomatology

Physical/Neurologic
examination

Therapy

EEG

Background activity

Epileptiform activity

Interictal

Ictal

Postictal

Laboratory tests

Neuroimaging
Differenial diagnosis

Febrile Seizures






Ages 3 months to 5 years
Fever
Non-CNS infection
Generalized seizures
Last less than 5 minutes
Migraine





Positive family history.
Pulsatile headache
Manifestations of autonomic nerve disorder
Visual disorder
Sensory disturbance
Differenial diagnosis

Breath-holding spells






Age 6 months to 3 years,
Cry, loss of consciousness
Apnea and cyanosis
Family historypositive in 30%
Normal EEG.
Sleeping disturbance
 Sleepwalking ,
 Nightmare

Night terrors
Differenial diagnosis

Masturbation



Pseudoseizures



Consciousness not impaired
Normal EEG
Effectual Suggestive therapy
Normal EEG
Tourette sydrome




Simple or complete stereotyped jerks or
movements
Cough and grunt
Normal EEG
Positive Family history
An approach to Seizures
Is it a seizure?
Yes
No
Is it symptomatic of an acute illness
No
What is the probable cause?
natural history
investigation
treatment
Yes
Diagnose and Treat
Treatment of epilepsy

Therapeutic principle of ntiepilepsy
drugs (AEDs)







Early treatment
Treatment as the types of epileptic seizure
Treatment with one drug
Individual therapy
Long course of treatment
Slow drug withdrawal
Periodic re-examination
Treatment of epilepsy
AEDs selection on types of epileptic seizure
types
drugs
Tonic-clonic seizures
VPA, PB, CBZ, PRM or PHT
Absence seizures
VPA, ES, CNP
Myoclonic seizures
VPA, CNP, PRM, Topamax
Partial seizures
CBZ, VPA, PB, PHT, PRM, T
Infantile spasms
CNP, ACTH, Prednison, VPA
Antiepilepsy drugs,AEDs
drug
Dosage
mg/kg
Effective blood
level ug/ml
T1/2
Side effect
VPA
15-50
50-120
8h
Ganstric discomfort,
sthenic
apptite , hepatic dysfunction
CBZ
15-30
4-12
15h
Drowsiness, Skin rash, WBC
decrease, hepatic dysfunction
PHT
4-8
10-20
22h
Skin rash,ataxia, WBC decrease,
unsteady gait
PB
4-6
20-40
4d
Hyperkinesia, inattention, Skin
rash
ESX
20
40-120
55h
CZP
0.01-0.2
20-80
55h
ACTH
25-40u
Gastrointestinal
disorder,
headache , WBC decrease,
Drowsiness, Skin rash, unsteady
gait, ataxia, salivate
Hyperfuction of the adrenal
cortex
Update on newer AEDs
drug
Dosage
mg/kg
TMP
3-10
LTG
5-15 (used
with VPA
1-5)
GBP
20-50
Effective blood
level ug/ml
T1/2
Side effect
1.1-3.0
20-30h
infant
15h
20-30h
Drowsiness, inattention, slow
reaction, lose appetite, weight
lose
Drowsiness, Skin rash, ataxia,
headache, gastric discomfort
2-3
5-7
Drowsiness, ataxia, nystagmus,
personality and behavioral
changes
Treatment of epilepsy
1 種抗癲癇藥物
30% 難以控制
70% 控制良好
2 種抗癲癇藥物
25% 難以控制
5% 控制良好
3 種抗癲癇藥物
20% 難以控制
10% 難以控制
試用新藥
10% 難以控制 3% 控制良好
VNS
7% 難以控制
3% 控制良好
5% 控制良好
10% 手術治療
3% 難以控制
7% 控制良好
Status epilepticus






Status epilepticus is a clinical or electrical
seizure lasting at least 30 minutes, or a series
of seizures without complete recovery over the
same period of time.
Emergency Treatment
ABC(airway, breathing, circulation)
Diazepam 0.3-0.5mg/kg ;may repeat in 15-30 minutes
Phenytoin 10-20mg/kg
Phenobarbital 5-20mg/kg
Thank you