Dr. Mohammed Aziz F.I.B.M.S Neuro. Epilepsy Dr. Mohammed Aziz F.I.B.M.S Neuro.

Sentinel headache (SH) is a kind of secondary headache and is characterized as sudden, intense, and persistent, preceding spontaneous subarachnoid hemorrhage (SAH) by days or weeks

Epilepsy Common neurologic disorder with sudden and recurring seizures Caused by abnormal electrical impulses in the brain

Epilepsy defined as electric storm in brain Not contagious Not psychosis Onset peak in young child & adolescent 1% of population

65% controlled 35% uncontrolled which is more than all brain tumors + MS + muscle dystrophy + GBS + MND

Epilepsy In the U.S., 2.5 million people are affected. Not all seizure disorders are epilepsy.

Definitions  Seizure: the clinical manifestation of an abnormal and excessive excitation and synchronization of a population of cortical neurons  Epilepsy: two or more recurrent seizures unprovoked by systemic or acute neurologic insults

Etiology of Seizures and Epilepsy  Infancy and childhood Prenatal or birth injury Inborn error of metabolism Congenital malformation  Childhood and adolescence Idiopathic/genetic syndrome CNS infection Trauma

Etiology of Seizures and Epilepsy  Adolescence and young adult Head trauma Drug intoxication and withdrawal  Older adult Stroke Brain tumor Acute metabolic disturbances Neurodegenerative

Pathophysiology of Seizures Increased excitability Increased excitatory ( glutamate) input Decreased inhibitory (GABA) input

The brain’s major excitatory neurotransmitt Epilepsy—Glutamate The brain’s major excitatory neurotransmitt B-Slide 12

Major inhibitory neurotransmitter in the CNS Epilepsy—GABA Major inhibitory neurotransmitter in the CNS . B-Slide 13

Normal CNS Function Inhibition Excitation glutamate, aspartate GABA Modified from White, 2001 B-Slide 14

Hyperexcitability reflects both increased excitation and decreased inhibition glutamate, aspartate GABA Excitation B-Slide 15 Modified from White, 2001 Modified from White, IGES, 2001

Classification of Seizures 1. -Partial seizures a. Simple partial seizures (with motor, sensory, autonomic, or psychic signs( b. Complex partial seizures c. Partial seizures with secondary generalization -2. Primarily generalized seizures a. Absence (petit mal) b. Tonic-clonic (grand mal) c. Tonic d. Atonic e. Myoclonic 3. -Unclassified seizures a. Neonatal seizures b. Infantile spasms

The types of epilepsy Generalized Partial Simple-partial Complex-partial Association

Simple Partial Seizures Simple partial seizures cause motor sensory autonomic psychic without an obvious alteration in consciousness.

Partial Seizures Partial seizures occur within discrete regions of the brain. If consciousness is fully preserved during the seizure, the clinical manifestations are considered relatively simple and the seizure is termed a simple partial seizure.

Partial Seizures If consciousness is impaired, the symptomatology is more complex and the seizure is termed a complex partial seizure.

An important additional subgroup comprises those seizures that begin as partial seizures and then spread diffusely throughout the cortex, i.e., partial seizures with secondary generalization.

Simple partial motor seizure partial motor seizure in primary motor cortex hand area lead to involuntary movements of the contralateral, hand..

in some patients the abnormal motor movements may begin in a very restricted region such as the fingers and gradually progress (over seconds to minutes) to include a larger portion of the extremity. This phenomenon, known as a “Jacksonian march,

" patients may experience a localized paresis (Todd's paralysis) for minutes to many hours in the involved region following the seizure

epilepsia partialis continua, in rare instances the seizure may continue for hours or days. This condition, termed epilepsia partialis continua,

Simple partial sensory seizure Simple partial seizures may also manifest as changes in somatic sensation (e.g., paresthesias), vision (flashing lights or formed hallucinations), equilibrium (sensation of falling or vertigo), or autonomic function (flushing, sweating, piloerection). Simple partial seizures arising from the temporal cause alterations in hearing

This includes the sensation of unusual, intense odors (e. g This includes the sensation of unusual, intense odors (e.g., burning rubber or kerosene) or sounds (crude or highly complex sounds). or an epigastric sensation that rises from the stomach or chest to the head.

psychic symptoms déjà vu, jamais vu. Some patients describe odd, internal feelings such as fear, a sense of impending change, detachment, depersonalization, déjà vu, jamais vu. or illusions that objects are growing smaller (micropsia) or larger (macropsia

Complex Partial Seizures Complex partial seizures are characterized by focal seizure activity accompanied by a transient impairment of the patient's ability to maintain normal contact with the environment. The seizures frequently begin with an aura (i.e., a simple partial seizure) that is stereotypic for the patient.

Complex Partial Seizures The start of the ictal phase is often a sudden behavioral arrest or motionless stare,. The behavioral arrest is usually accompanied by automatisms,

Complex Partial Seizures Automatisms may consist of very basic behaviors such as chewing, lip smacking, swallowing, or "picking" movements of the hands, or more elaborate behaviors such as a display of emotion or running.

The patient is typically confused following the seizure, and the transition to full recovery of consciousness may range from seconds up to an hour.

impaired Aura 50-75% 1-2 min CPS SPS Criterion Retained Consciousness Always indicates A focal onset (1/3) No Aura 50-75% Automatism 1-2 min 10-20 sec Duration

Secondarily Generalized Seizures  Begins focally, then become generalized  Typical duration 1-3 minutes  Postictal confusion, with or without transient focal deficit

EEG: Partial Seizure Right temporal seizure with maximal phase reversal in the right sphenoidal electrode

EEG: Partial Seizure Continuation of same seizure Right temporal seizure with maximal phase reversal in the right sphenoidal electrode

Generalized Seizures By definition, generalized seizures arise from both cerebral hemispheres .defined as bilateral clinical and electrographic events without any detectable focal onset

Absence Seizures (Petit Mal) Absence seizures are characterized by sudden, brief lapses of consciousness without loss of postural control. The seizure typically lasts for only seconds, consciousness returns as suddenly as it was lost, and there is no postictal confusion

absence seizures are usually accompanied by subtle, bilateral motor signs such as rapid blinking of the eyelids, or small-amplitude, clonic movements of the hands

The electrophysiologic hallmark of typical absence seizures is a generalized, symmetric, 3-Hz spike-and-wave d Hyperventilation tends to provoke these electrographic discharges and even the seizures themselves and is routinely used when recording the EEG

EEG: Typical Absence Seizure

Atypical Absence Seizures the lapse of consciousness is usually of longer duration and less abrupt in onset and cessation, the seizure is accompanied by more obvious motor signs that may include focal or lateralizing features. The EEG shows a generalized, slow spike-and-wave pattern with a frequency of 2.5/s, as well as other abnormal activity.

Atypical Absence Seizures Atypical absence seizures are usually associated with diffuse or multifocal structural abnormalities of the brain and therefore may accompany other signs of neurologic dysfunction such as mental retardation. the seizures are less responsive to anticonvulsants compared to typical absence seizures

Generalized Tonic-Clonic Seizures Associated with loss of consciousness and post-ictal confusion/lethargy Duration 30-120 seconds Tonic phase Stiffening and fall Often associated with ictal cry Clonic Phase Rhythmic extremity jerking EEG – generalized polyspikes

Generalized, Tonic-Clonic Seizures (Grand Mal) The seizure usually begins abruptly without warning, .. The initial phase of the seizure is usually tonic contraction of muscles throughout the body,. Tonic contraction of the muscles of expiration and the larynx at the onset will produce a loud moan or "ictal cry.

Respirations are impaired, secretions pool in the oropharynx, and cyanosis develops. Contraction of the jaw muscles may cause biting of the tongue. A marked enhancement of sympathetic tone leads to increases in heart rate, blood pressure, and pupillary size

After 10–20 s, the tonic phase of the seizure typically evolves into the clonic phase, muscle relaxation on the tonic muscle contraction. The periods of relaxation progressively increase until the end of the ictal phase, which usually lasts no more than 1 min

The postictal phase is characterized by unresponsiveness, muscular flaccidity, and excessive salivation that can cause stridorous breathing and partial airway obstruction .

Bladder or bowel incontinence may occur at this point Bladder or bowel incontinence may occur at this point.Patients gradually regain consciousness over minutes to hours, and during this transition there is typically a period of postictal confusion headache, fatigue, and muscle ache that can last for many hours

Myoclonic Seizures  Brief, shock-like jerk of a muscle or group of muscles  Epileptic myoclonus Typically bilaterally synchronous Impairment of consciousness difficult to assess (seizures <1 second)  Differentiate from benign, nonepileptic myoclonus (e.g., while falling asleep)  EEG: Generalized 4-6 Hz polyspike- wave discharges

Myoclonic Seizures

Generalized Seizures Atonic Begins with sudden loss of muscle tone and consciousness Muscles relax, limbs go limp Lasts a few seconds to a minute, then patient can resume standing and walking

Tonic Seizures Tonic seizures Symmetric, tonic muscle contraction of extremities with tonic flexion of waist and neck Duration - 2-20 seconds.

Unclassified Seizures Not all seizure types can be classified as partial or generalized. This appears to be especially true of seizures that occur in neonates and infants

Neonatal Seizures  Incidence: 1.6 – 3.5 per 1000 live births  Major risk factors are prematurity, low-birth weight, Hypoxic ischemic encephalopathy 

Neonatal Seizures Association with increased morbidity and mortality  May be symptomatic of treatable, serious condition (hypoglycemia, meningitis)  Diagnosis: observation with vs. without EEG

Infantile spasms Infantile spasms are an epileptic syndrome and not a seizure type. The attacks although sometimes fragmentary are most often bilateral and are included, for pragmatic purposes with the generalized seizures implicated.

Characterized by recurrent myoclonic jerks with sudden flexion or extension of the body and limbs; the form of infantile spasms are, however, quite heterogeneous.

90% have their first attack before the age of 1 year. Most patients are mentally retarded, presumably from the same cause of the spasms. The cause is unknown. Infections, kernicterus, tuberous sclerosis and hypoglycemia have all been

Treatment Prognosis ACTH (Steroids) Vigabatrin Valproate , Clonazepam Mental Retardation in 90 % (severe in70 %) Epilepsy in 50-60 % 10 % will have normal mentality (from the idiopathic gp.)

Febrile convulsions  Febrile convulsions — 6 mo.-5 yrs. Simple: Duration less than 15 minutes, generalized, and do not recur within 24 hours Complex: Duration longer than 15 minutes, focal in nature or recur within 24 hours

 Febrile convulsions: Risk Factors for development of epilepsy: Complex febrile seizures Afebrile seizures in first-degree relatives Recurrent febrile seizures Febrile seizures following brief and low grade fever Febrile seizure onset in first year Neurodevelopmental abnormalities

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