1. Dr. Mohammed Aziz F.I.B.M.S Neuro.
Epilepsy 2
Dr. Mohammed Aziz F.I.B.M.S Neuro.

2. Epilepsy Syndromes 1-Juvenile Myoclonic Epilepsy
2-Mesial Temporal Lobe Epilepsy Syndrome
3-Lennox-Gastaut Syndrome

3. Lennox-Gastaut Syndrome
occurs in children and is defined by the following triad:
multiple seizure types (usually including generalized tonic-clonic, atonic, and atypical absence seizures);
impaired cognitive function in most but not all cases
an EEG showing slow (<3 Hz) spike-and-wave discharges and a variety of other abnormalities.

4. Epilepsy & pregnancy
-Enzyme inducer AED associated OCP failure - -AED associated congenital malformation like cleft lip , spina bifida , cardiac defect -Hemorrhagic disease of newborn due to VitK deficiency may increases with maternal used Enzyme inducer AED so 20mg vit k orally daily in last month of pregnancy & 1mg inj. At birth

5. Seizure Precipitants  Metabolic and Electrolyte Imbalance
 Sedative or ethanol withdrawal
 Sleep deprivation
 Antiepileptic medication reduction or inadequate AED treatment
 Hormonal variations
 Stress
 Fever or systemic infection
 Concussion and/or closed head injury

6. NEW CASE OF EPILEPSY
1-a seizure or not 2-if seizure , what type 3- rule out serious causes 4-choose suitable medication 5-balance seizure & side effects 6-consider non-medical therapies 7-help patient & family psychosocial issues

7. Seizure imitators
1- medical
-Syncope
-Arrhythmia
-Hypoglycemia
-Hypoxia

8. 2-neurological -TIA -Migraine -Narcolepsy -Vertigo
-Involuntary movement

9. 3-Psychological -Panic attack -Hyperventilation spells -Night terrors
Pseudosiezure

10. NEW CASE OF EPILEPSY
1-a seizure or not 2-if seizure , what type 3- rule out serious causes 4-choose suitable medication 5-balance seizure & side effects 6-consider non-medical therapies 7-help patient & family psychosocial issues

11. Dx start with good story -alteration in-sensory-motor function
-Behavior
-Consciousness
-clear start & finish
-time course 5sec-5min
-stereotyped
Not one of imitators
Tests EEG,MRI

12. Physical examination. Useful to detect -underlying focal lesion
-Stigmata of genetic diseases
-S/E of medication

13. NEW CASE OF EPILEPSY
1-a seizure or not 2-if seizure , what type 3- rule out serious causes 4-choose suitable medication 5-balance seizure & side effects 6-consider non-medical therapies 7-help patient & family psychosocial issues

21. Indication of neuroimaging
-Epilepsy start after age of 20 years
-Partial epilepsy
-EEG show focal features
-Difficult to control fit or deteriorated

22. NEW CASE OF EPILEPSY
1-a seizure or not 2-if seizure , what type 3- rule out serious causes 4-choose suitable medication 5-balance seizure & side effects 6-consider non-medical therapies 7-help patient & family psychosocial issues

23. 50%of patient respond to old medication 10% of patient respond to new medication 5%of patient candidate for surgery 35% not respond to medication 2/3 respond to AED 1/3 not respond to AED

24. AED
Surgery
Ketogenic diet
Non-medical therapy
Stimulator

35. AED Enzyme Inducers Broad Spectrum Inducers: Broad Spectrum Inhibitor
Carbamazepine
Phenytoin
Phenobarbital
Broad Spectrum Inhibitor
Valproic acid

36. Weight Change Weight Gain Weight Loss Weight Neutral Felbamate (2-75%)
Valproate (50%)
Carbamazepine
Gabapentin (15-20%)
Weight Loss
Felbamate (2-75%)
Topiramate (50%)
Zonisamide (20-50%)
Weight Neutral
Phenytoin
Lamotrigine
Levetiracetam
Tiagabine

37. Phenytoin Dose related vestibular/cerebellar effects
Behavioral changes
Gingival Hyperplasia
GI Disturbances
Sexual-Endocrine Effects:
Osteomalacia
Hirsutism
Hyperglycemia

39. Candidates Fit For Epilepsy Surgery
Patient has tried 2 or 3 drugs for more then 2 years
Patient has at least one fit minor/major per week on an average.
Patient has side effects from taking drugs to control epilepsy

40. Temporal Lobectomy
Lesionectomy
Hemispherectomy
Corpus Callosotomy
Stereotactic surgery by Gama knife

42. Vagus Nerve Stimulator

43. Status Epilepticus  Definition
More than 30 minutes of continuous seizure activity or
Two or more sequential seizures spanning this period without full recovery between seizures

44. More than 5 min of seizure or
New definition
More than 5 min of seizure or
Two or more sequential seizures without full recovery between seizures

45. Types
Repeated generalized tonic and/or clonic convulsive seizures where the patient does not fully recover between attacks
Non-convulsive status: prolonged state
Continuous focal epileptic activity without alteration of consciousness

46. Etiology of status epilepticus
Medication non-complaince 30% Ethanol withdrawal 25% CNS infection 10% Refractory epilepsy 5% Trauma Tumor Metabolic Stroke Anoxia others

47. A B C Oxygen, oral airway. Avoid hypoxia!
Consider bag-valve mask ventilation.
Consider intubation
IV access. Treat hypotension, but NOT hypertension B C

48. Anticonvulsants
Rapid acting
Plus
Long acting

49. Compensatory phase -Catecholamine increase -C.O. increase
-CBF increase
-Glucose level increase

50. Non-compensotary phase
-failure of cerebral autoregulation
-increase ICP
-decrease CO
-HOT
-metabolic derangement
-DIC

52. Current Treatment Paradigm for Status Epilepticus
Lorazepam 0.1 mg/kg by IV push (<2 mg/min)
Seizures continue
Fosphenytoin 20 mg PE/kg (up to 150 mg PE/min).
If only phenytoin is available: 20 mg/kg (<50 mg/min)
Seizures continue
Additional fosphenytoin 5-10 mg PE/kg
Seizures continue
Phenobarbital (PB) 20 mg/kg (<60 mg/min)
Valproate 25 mg/kg (3 mg/kg/min) is an alternative to PB
Call for help OR
IV anesthesia Pentobarbital ,propofol Midazolam
Time (Minutes) 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95
100

53. Purple Glove Syndrome
Hanna DR. J Neurosci Nur. 1992;24:

54. Complications Hypoxia Lactic acidosis
Rhabdomyolysis, hyperkalaemia, ARF
Hyperpyrexia
Hypoglycaemia
Hyper/hypotension
initial hypertension, subsequent hypotension
Cardiac arrhythmias
Pulmonary oedema
Aspiration pneumonitis
Intracranial hypertension

55. QUESTIONS?