1. Epilepsy
The prevalence of active epilepsy is 8.2 per of the general population
An annual incidence of epilepsy is 50 per of the general population
Around 50 million people in the world
(1 % of the general population) have epilepsy at any one time.

2. Epilepsy is a chronic disorder, or group of chronic disorders, in which the indispensable feature is recurrence of seizures that are typically unprovoked and usually unpredictable.

3. What causes epilepsy? Inheritance - genetic low seizure threshold
The injury of the brain (due to a road traffic accident, tumour, stroke or trauma at birth )
An infection that affects the brain, such as meningitis or encephalitis

4. How is epilepsy diagnosed?
Unlike most other neurological conditions, there may be no physical sign that a person has epilepsy when they are not having a seizure.
Therefore the diagnosis is based on a history of more than one epileptic seizure.
An eyewitness account may provide useful information in reaching an accurate diagnosis, as the person experiencing the seizure will not usually remember what has happened.

5. I. A. General seizures
initial stage
tonic stage
clonic stage
recovery stage
B. Without seizure attacks (Absentia epileptica)
II. Focal attacks.

6. Can epilepsy be treated?
With the appropriate drug treatment, seizures can be completely controlled in up to 80% of people
Some people continue to have seizures despite treatment. A small proportion of these people may benefit from neurosurgery (brain surgery).

7. TREATMENT FOR EPILEPSY
Drug treatment
Surgical treatment
Complementary treatment

8. Epilepsy is the most common serious neurological condition.
Anyone can develop epilepsy; it occurs in all ages, races and social classes.
Labelling people as 'epileptics' on the basis of a medical diagnosis of epilepsy ignores the rest of their attributes and characteristics

9. The Treatment of Epilepsy
The incidence and prevalence
Aetiologies and risk factors
Aims of treatment
Clinical settings
Principles of treatment
Medical treatment
Surgical treatment
Guidelines
Conclusions

10. Incidence and Prevalence
Incidence of new cases of epilepsy:
50/100,000/year
Incidence of single seizures:
/100,000/year
Prevalence of active epilepsy
5 - 10/1, (50% because on AEDs)
Severe epilepsy: 1 - 2/1,000
Cumulative Incidence (lifetime prevalence):
2 - 5%

11. Incidence and Prevalence in the UK
new cases a year
cases
cases of severe epilepsy

12. Incidence and Prevalence in the UKGP
1 - 2 new cases of epilepsy/year
cases of active epilepsy
Neurologist
150 cases of epilepsy/single seizures/year
1,200 cases of active epilepsy

13. Epilepsy: Aetiologies and Risk Factors
Risk factors varies with age and geographic location
Congenital, developmental and genetic conditions in childhood, adolescence and young adults
Head trauma, infection and tumours at any age although tumours more likely over age 40
Cerebrovascular disease common in elderly
Endemic infections are associated with epilepsy in certain areas
malaria, neurocysticercosis, paragonomiasis,
no adequate large scale study of attributable risk yet

14. Antiepileptic Treatment
AEDs are mainstay treatment
Non-pharmacological options feasible in only few selected cases
Surgery
Curative
Palliative
Ketogenic diet (children)
Behaviour modification
Avoidance therapy in cases with clear precipitants

15. Aims of Antiepileptic Treatment
Complete seizure freedom
50% seizure reduction of little benefit
No adverse effects
long term treatment - long term effects ?
cognitive effects debilitating
teratogenicity
Non-obtrusive treatment
once or twice daily
No PK or PD interactions
Maintenance of a normal lifestyle
Reduction in morbidity and mortality

16. AED Treatment: Clinical Settings
Prophylactic Treatment
Newly Diagnosed Epilepsy
Single seizure
Recurrent seizures
Chronic Epilepsy

17. Prophylactic use of AEDs
Often advocated after
Head injury
Craniotomy
There are considerable compliance problems
There is no evidence of a protective effect of this policy
No place for this!
Better wait for the event to happen

18. Careful diagnostic assessment a must in all cases
Is it Epilepsy ?
Newly diagnosed or suspected cases at Primary Care level
> 50% not epilepsy
commonest differential diagnosis: syncope
Chronic cases
% not epilepsy
mostly psychological in nature
Careful diagnostic assessment a must in all cases

19. The Single Seizure A controversial area!
Single unprovoked attack usually not treated: practice to defer treatment until 2 or more seizures, although patients at high risk may be treated after a first attack
Incidence of epilepsy much greater than of single seizures
Community-based studies show that overall risk of a second seizure greater than previously accepted
selection bias
Patients
Seizure type
time to entry bias

20. The Single Seizure - for six months, for a year?
AED treatment following a single seizure reduce risk of recurrence in the short term although long term prognosis not changed
This may eventually lead to changes in the way single seizures are managed
treatment after first seizure
- for six months, for a year?
tailored treatment and not symptomatic
Meanwhile, involve patient and or guardians in the decision

21. Recurrent Seizures Treatment recommended after two or more seizures
Exceptions:
- Long interval between seizures
- Clear identifiable precipitant factor
- Patient against treatment
- Unlikely compliance

22. Precipitating Factors
Fever
Drugs
Alcohol
Photo-Sensitivity
Sleep Deprivation
Reflex Mechanisms
Acute Metabolic Stress
Emotional Stress/Major Life Events

23. Starting an AED
Starting AED treatment is a major event and should not be undertaken without careful evaluation of all relevant factors
Therapy is a long term prospect
All implications must be fully explained to the individual and or guardian
Paramount that the patient or guardians are kept informed about the treatment process and the rationale behind it

24. Starting Treatment
Treatment should always be started with a single drug at a small dose
All common side-effects must be discussed
teratogenicity and contraception if applicable
Importance of compliance should be stressed
Careful titration is a must
- start low, go slow

25. Choice of AEDs treatment
Choice of AED influenced by:
Type of seizure and or epileptic syndrome
Individual circumstances of patient
Side effect profile of drug
Personal preferences
No clear cut evidence based medicine is available!
Clinical practice is based more on dogmatic teaching than on scientific knowledge
Empirical rather than rational

26. Principles of AED treatment
Diagnosis clearly established
Appropriate first line drug for syndrome and patient
One drug at a time as a rule:
If first drug ineffective add another first line drug and then withdraw first drug
Combination therapy only when single drug ineffective

27. What Is Chronic Epilepsy ?
Active 2 years after onset
Failed 2 first line AEDs
Great number of seizure in early history

28. Chronic Epilepsy 1 Review history of epilepsy Review diagnosis
- Obtain and review old notes if possible
- Interview patient and witness
- Classify seizures
Review diagnosis
- Non-epileptic events
- Identifiable aetiology
- High resolution MRI scanning
Question Compliance
Check serum AED levels
Review past and present AED treatment for efficacy and side-effects

29. Chronic Epilepsy 2
Select the AED that is most likely to be efficacious and with the least side-effects
Adjust the dose of the selected drug to the optimum
Attempt to reduce and taper other AEDs
If seizures continue despite a maximally tolerated dose of a first-line drug:
- Check compliance
tablet count, serum levels, counselling
Commence another first-line AED if there is one that has not been used to its optimum

30. Chronic Epilepsy 3 If seizures continue try a combination of two AEDs
If combination unhelpful, AED which appears most effective and with fewer side-effects should be continued and the other AED replaced
If this drug is effective, withdrawal of the initial agent should be considered; if not, it should be replaced by another AED
Consider the possibility of surgical treatment
Consider using an experimental AED

31. Inappropriate use of AEDs
Inappropriate treatment of people who do not have epilepsy
Inappropriate drug treatment of patients who do have epilepsy
JME easily treated with some AEDs but poorly controlled with others
Partial epilepsies often misdiagnosed as generalised epilepsy
Incorrect dosages or inappropriate use of polytherapy
Overzealous adherance to “therapeutic” AED drug levels

32. AED drug levels monitoring
Measurement of AED levels:
drug toxicity occurs and needs to be documented
suspected non-compliance
suspected drug interactions
during pregnancy (free levels)
during systemic illness
phenytoin therapy
Not a guide to dosing!

33. Partial seizures: simple, complex, sec gen. Stereotyped onset
Who Should be Evaluated for Surgery
Partial seizures: simple, complex, sec gen.
Stereotyped onset
No non-epileptic attacks
No contraindication for Neurosurgery
Active epilepsy for >2-3 yr, despite 3 + AEDs
Inadequate seizure control: > 1-2 c p s /month
Acceptance of best risk / benefit ratio

34. Chance of seizure control 10% 70% Risk
Best risk vs benefit ratio of
temporal lobe epilepsy surgery
Medical Surgical
Chance of seizure control
10% %
Risk
Morbidity from seizures 1/100 long-lasting impairment
Psychosocial handicap hemiparesis, aphasia
1/100 Annual mortality 1/20 quandrantanopia prevents driving

35. Range of Epilepsy Surgery
70% Anterior temporal lobe resection
20% Extra-temporal cortical resection
Lesionectomy
10% Palliative Procedures
Hemispherectomy
Corpus callosotomy
Subpial transection
Vagal Nerve Stimulation

36. Components of Presurgical Evaluation
Convergence of data
One epileptogenic & dysfunctional area
Rest of brain normal
Clinical
Neuro-Imaging
EEG
Neuropsychology
Neuropsychiatry
Psychosocial

37. Psychosocial Realistic expectations?
Improvement in life from seizure control?
Intelligence, memory will not improve
Not more attractive, employable
Need to continue AEDs after
Social support
Family, friends, community, finances

38. Neuro-imaging Fundamental MRI predicts nature and extent of pathology
Unusual to resect area with normal imaging
Poor results if imaging normal

39. Pathology and Outcome TLE: Anterior Temporal Lobe resection
Focal pathology: 70% seizure free, 25% >90% reduced
DNT, cavernoma>HS>AVM>trauma>MCD
20% seizure free if no focal pathology
Extra Temporal Lobe
Focal pathology: 60% seizure free, 20% >90% reduced
DNT, cavernoma, glioma>AVM>trauma
MCD 20-30% seizure free, if focal
<20% seizure free if no focal pathology

40. Treatment Guidelines for Epilepsy
NICE = – National Institute for Clinical Excellence (England and Wales)
SIGN = – Scottish Intercollegiate Guidelines Network (Scotland)
AAN = – American Academy of Neurology (USA)

41. Primary Care Guidelines for Epilepsy
Referral of ALL who experience a suspected seizure
Seen within 14 days by specialist
Risk and safety precautions documented
Care Plan in place
At least a yearly review
Early re-referral if
Treatment failure
Seizures not controlled
Diagnostic uncertainty
Considering pregnancy
Considering drug withdrawal

42. Managing People With Epilepsy
Holistic issues:
Interest and continuity of care
Clear plan
Information provision
SUDEP
Easy access
- Practical Issues:
Cooking, Bathing, Driving, Contraception, Conception
- Reasonable Expectations:
Prognosis, Independent Living, Employment

43. AED Treatment: Conclusions
Correct diagnosis and classification paramount to treatment
AEDs are mainstay treatment
Treatment empirical rather than rational!
> 70% of patients become seizure free
Potential complications: toxicity
Low threshold for s/effects

44. AED Treatment: Conclusions
Potential for misuse of AEDs not to be dismissed
New AEDs may be better tolerated, but more effective?
Chronic side effect profile of new AEDs not fully known
Surgical treatment very successful but only possible in a few selected cases
Consider stopping AED if seizure free for years
New treatment still needed!