Transcript PPT

A. LeBron Paige, M.D.
Clinical Associate Professor
Department of Neurology
Iowa EFA Seizure Smart Conference – 3/2/2013
 Epilepsy is a medical condition that produces seizures affecting a variety
of mental and physical functions. When a person has two or more
unprovoked seizures, they are considered to have epilepsy.
 A seizure is the result of a strong sustained surge of electrical activity
(discharges) that affects part or all of the brain.
 Seizures can be brief or prolonged, typically less that 3 minutes, and can
cause unusual movements, sensations, thinking, or can disturb many
other body functions.
 Seizures can be a subtle unresponsive staring (partial), a frighteningly
dramatic convulsion (generalized), or in between.
 Seizures can be caused by anything that can affect the brain, such as
tumors, strokes, bleeding, infection, trauma, or unknown factors.
 Treatments for epilepsy include medications, surgery, diet, electrical
stimulators, and other emerging options.
Epilepsy Around the World
 Epilepsy is one of the world’s oldest diseases.
 Worldwide, 50-65 million people are living with epilepsy
 80% of all people with epilepsy live in the developing regions.
 75% of affected people in these developing countries do not get the
treatment they need (9 out of 10 in Africa).
 The World Health Organization (WHO) estimates that 6-10 people
per 1000 have active epilepsy in the developing world. (conservative)
 Epilepsy accounts for 0.5% of the global burden of disease
 The social stigma surrounding epilepsy worldwide is often more
difficult to overcome than the seizures themselves
Epilepsy - US Incidence
 200,000 new epilepsy cases diagnosed annually in the US
o
50,000 new cases of Parkinson’s Disease in the US annually
 67 new cases of epilepsy per 100,000 population each year
o
62.6 individuals with lung cancer per 100,000 population per year
 100 individuals with first convulsion per 100,000 population each year
o
124 women with breast cancer per 100,000 population
 50% of new onset epilepsy cases present w/ Generalized Sz
 70% of these new cases have no apparent cause
 Incidence is greater in Black and socially disadvantaged populations
 Highest epilepsy incidence is in > 65 y/o & is increasing in recent years
 Partial seizures predominate in patients >10 y/o
Childhood Epilepsy – US Incidence
 120,000 children per year will experience their first seizure
o
75,000 – 100,000 of these are < 5 y/o with febrile seizures
 45,000 children will receive a diagnosis of epilepsy per year
 Highest incidence found in < 2 y/o, with adult levels in those > 5y/o
 Childhood epilepsy incidence has been trending down in recent years
 Generalized seizures are the most common in patients < 10 y/o
 Most children with seizures will not develop epilepsy
 Most children with epilepsy will outgrow the condition
 Most children with epilepsy are normal in every other respect
Incidence Per 100,000 Patient Years
300
Alcohol
Neonatal
Other provoked
Epilepsy
Single
Total
250
200
150
100
50
0
0
20
40
60
Age
80
100
Children <15 Years
Unknown/
multiple
9%
Other
partial
7%
Adults 35-64 Years
Tonic-clonic
19%
Simple
partial
21%
Myoclonic
2%
Absence
13%
Complex
23%
Myoclonic
7%
l 4):S6-S14.
Simple
partial
11%
Other
generalized
11%
Tonic-clonic
25%
Other
partial
9%
Complex
partial
39%
Other
generalized
4%
Infectious 2.5 %
Degenerative 3.5%
Neoplastic 4.1%
Trauma 5.5%
Congenital 8.0%
Vascular 10.9%
Idiopathic 65.5%
Epilepsy in the Elderly
ELDERLY (>65 y/o)
18 y/o <
ADULTS < 65 y/o
Stefan, H. Epilepsy in the Elderly, Acta Neurol Scand., 124: 223-237: 2011.
Epilepsy Prevalence - US
 2.7 - 3 million active epilepsy patients in the US (~1% of the population)
 30,000 Iowans carry a diagnosis of epilepsy
 1% of Americans aged birth to 20 y/o have a diagnosis of epilepsy
 3% of Americans aged birth to 75 y/o have a diagnosis of epilepsy
 10% of Americans aged birth to 80 y/o have had at least one seizure
 There are more Americans living Epilepsy than MS, Cerebral Palsy,
Muscular Dystrophy, Parkinson’s Disease, ALS, and Tourette’s
syndrome combined.
 Of all neurological Dz, only Migraine & Stroke is more prevalent than Epi
 70% of people with epilepsy are controlled (> 5yr) on medications
 Overall almost 10 % of new patients fail to gain control of seizures
despite optimal medical management.
The basic underlying risk of developing epilepsy is about 1%,
but individuals in certain populations are at higher risk.
• 25.8% of children with mental retardation
• 13% of children with cerebral palsy
• 50% of children with both disabilities
• 10% of Alzheimer patients
• 22% of stroke patients
• 8.7% of children of mothers with epilepsy
• 2.4% of children of fathers with epilepsy
• 33% of people who have had a single, unprovoked seizure
Seizure Freedom by Seizure Type
One year seizure free rates in patients treated with medications alone.
Epilepsy Mortality
Cause of death among 3340 Epilepsy patients over 30 years
Cause of Death
Proportion
of all Deaths
Non-CNS Tumors
23%
CNS Tumors
5%
Heart Disease
26%
Stroke
15%
Epilepsy
7%
Trauma
9%
Respiratory Disease
3%
Pneumonia
1%
Other
11%
Epilepsy Mortality - SUDEP
 Sudden, Unexpected, Death in Epilepsy
1.
2.
3.
4.
5.
6.
7.

Decedent has diagnosis of epilepsy
Death is Sudden
Death is Unexpected
Death is not the result of trauma
Death is not the result of drowning
No evidence that death was associated with status epilepticus
No structural or toxicological cause on post-mortem examination
Factors that increase the risk of SUDEP
1.
2.
3.
4.
5.
6.
7.
Young adulthood (children at low risk)
Early epilepsy onset & long duration
Poorly controlled seizures
Poor medication compliance
Unsupervised sleep environment (prone position)
Generalized convulsion > Complex partial seizures >> myoclonic or absence
Epilepsy Surgical Candidates
SUDEP Incidence by Group
16
Information Sources

The Institute of Medicine (NAS), Epilepsy Across the Spectrum, 2012

The Epilepsy Foundation of America [http://www.epilepsyfoundation.org/]

The World Health Organization (WHO) [http://www.who.int/research/en/]

National Cancer Institute [http://seer.cancer.gov/statfacts/html/all.html]

Neurological disorders: public health challenges, World Health Organization, 2006

Hauser WA, Annegers JF, Kurland LT. Incidence of epilepsy and unprovoked seizures in Rochester,
Minnesota: 1935-1984. Epilepsia. 1993;34:453-468.

D. Hirtz, D. J. Thurman, K. Gwinn-Hardy, et al., How common are the ''common'' neurologic
disorders? Neurology 2007;68;326.

Ficker, DM, Sudden Unexplained Death and Injury in Epilepsy, Epilepsia, (Supp1.2):S7-S12, 2000

Thomson, T. , Sudden unexpected death in epilepsy: current knowledge & future directions. The
Lancet Neurology, Sept. 2008

Stefan, H. Epilepsy in the Elderly, Acta Neurol Scand., 124: 223-237: 2011.

Trinka, E, et al., Cause-specific mortality among patients with epilepsy: Results from a 30-year
cohort study, Epilepsia, ** (*):1–7, 2012
Epilepsy Discrimination
 The Code of Hammurabi (1780 B.C.) established that a person with
epilepsy could not marry, testify in court, and voided slave purchases
 In both China and India, epilepsy is commonly viewed as a reason for
prohibiting or annulling marriages.
 In the United Kingdom, a law forbidding people with epilepsy to marry
was repealed only in 1970.
 In the United States, until 1956 it was illegal in 17 states for people
with epilepsy to marry, and into the 1970s it was legal to deny them
access to restaurants, theatres, rec centers and other public buildings.
 1973 brought the first limited US laws to prohibit discrimination, but not
until 1990 with the Americans with Disabilities Act was there uniform
protection against discrimination.
Epilepsy Care Pathway
National Association of Epilepsy Centers
Level-4
Epilepsy Center
Seizures are Refractory
to two Medications
Spells are
Likely Seizures
General
Neurologist(s)
Level-4 Epilepsy Center
• Comprehensive Diagnostic Capability
• New & Experimental Medications
• Epilepsy Surgery Experience
PMD
Patient has “Spells”
• Implantable Stimulators
• Radiation treatment vs. Surgery
• Access to National Epilepsy Expertise
Englot, DJ, et al., Epilepsy Surgery Trends in the United States 1990-2008, Neurology, 78;1200 (2012)
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