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

2. 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

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

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

5. 65% controlled
35% uncontrolled which is more than
all brain tumors +
MS +
muscle dystrophy +
GBS +
MND

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

7. 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

8. 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

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

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

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

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

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

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

17. 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

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

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

20. 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.

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

22. 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.

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

24. 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,

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

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

27. 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

28. 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.

29. 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

30. 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.

31. 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,

32. 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.

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

34. 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

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

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

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

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

39. 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

40. 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

41. 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

42. EEG: Typical Absence Seizure

43. 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.

44. 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

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

47. 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.

48. 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

49. 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

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

51. 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

53. 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

54. Myoclonic Seizures

55. 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

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

57. 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

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

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

60. 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.

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

62. 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

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

65. 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

66.  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

67. QUESTIONS?