1 / 47

Epilepsy Overview for 3rd year medical students

Epilepsy Overview for 3rd year medical students. SAID S. DAHBOUR,MD Associate professor of Medicine and Neurology Faculty of Medicine – Jordan University Amman - Jordan. Outline. General Aspects New AED Epilepsy Surgery Drugs used for Status Epilepticus Conclusions.

fritz-ramsey
Download Presentation

Epilepsy Overview for 3rd year medical students

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Epilepsy Overview for 3rd year medical students SAID S. DAHBOUR,MD Associate professor of Medicine and Neurology Faculty of Medicine – Jordan University Amman - Jordan

  2. Outline • General Aspects • New AED • Epilepsy Surgery • Drugs used for Status Epilepticus • Conclusions

  3. Seizures and Epilepsy • Seizure: abnormal hypersynchronous electrical discharge form cerebral cortical neurons. • Clinical seizure: the clinical manifestation of the electric seizure that depends on the site of onste and path of propagation • Epilepsy =Recurrent Unprovoked Seizures

  4. International classification of epileptic seizures NEJM 2002:344(15)1145-51 • Partial (focal, local) seizures simple complex evolving to generalized seizures • Generalized seizures absence : typical atypical tonic clonic (grand mal)myoclonicclonic tonicatonic • Unclassified neonatal infantile spasm febrile seizures

  5. Modified ILAE classification of epilepsy syndromes Idiopathic : no cause identified; presumed genetic- inherited

  6. Modified ILAE classification of epilepsy syndromes Symptomatic: of underlying structural disease

  7. Modified ILAE classification of epilepsy syndromesCryptogenic: presumed underlying structural disease

  8. Modified ILAE classification of epilepsy syndromesSpecial syndromes or undetermined epilepsies • Febrile convulsions • Isolated unprovoked seizures or isolated status epilepticus • Neonatal seizures of any etiology • Epilepsy with continuous spike-wave during slow wave sleep (electric status epilepticus of sleep) • Acquired epileptic aphasia (Landau-Kliffner syndrome)

  9. a Rochester Minnesota Epilepsy Study (1935-1974)

  10. Epilepsy: Diagnosis • History • Physical examination • EEG • MRI • Special testing

  11. RIGHT ANTERIOR TEMPORAL SHARPS.

  12. INTERICTAL GENERALIZED 3 HTZ SPIKE-WAVE DISCHARGE

  13. GENERALIZED SEIZURE

  14. Differential diagnosis of seizures in adults • Vasovagal syncope • Cardiogenic syncope • Migraine • TIA • Psychogenic pseudosizures • Panic attacks • Rage attacks

  15. Differential diagnosis of seizures in children • Tics • Infantile syncope • Breath holding spells • Night terrors • Gastroesophegeal reflux • Shudder attacks • Benign sleep myoclonus

  16. DIFFERENCES BETWEEN SYNCOPE AND SEIZURES

  17. DIFFERENCES BETWEEN SEIZURES AND PSEUDOSEIZRUES

  18. DIFFERENCES BETWEEN SEIZURES AND PSEUDOSEIZRUES

  19. ADVERSE PROGNOSTIC FACTORS IN EPILEPSY • SYMPTOMATIC ETIOLOGY. • PARTIAL ONSET SEIZURES. • ATONIC SEIZURES. • LATE ONSET OR FIRST YEAR EPILEPSY • ADDITIONAL MENTAL OR MOTOR HANDICAP. • LONG DURATION PRIOR TO THERAPY. • POOR INITIAL RESPONSE TO THERAPY.

  20. Intractable Epilepsy • Impairment of quality of life due toSeizures &/ or Drugs • 20-30% of epileptics are intractable • Patients failing 2 drugs are likely to be intractable • 30-40% newly diagnosed partial epilepsy will not attain a seizure remission with pharmacotherapy.

  21. Intractable Epilepsy • Treatment options New AED surgeryVagus nerve stimulation special diets in children

  22. New Anti Epileptic Drugs

  23. “There is scarcely a substance in the world ,capable of passing through the gullet of man , that has not at one time or the other enjoyed a reputation of being an anti-epileptic “ Sieveking 1858

  24. Potential benefits of AED related seizure control • Reduced social stigma • Reduced negative cognitive effects from frequent seizures. • Reduced risk of status epilepticus ( if compliant) • Reduced risk of physical injury • Improve employment likelihood • Helps maintain driving privileges

  25. Risks of AED related adverse effects • Behavioral problems • Cognitive impairment • Idiosyncratic reactions • Systemic toxicity • Teratogenicity • Expense

  26. Ideal Antiepileptic Drug • Antiepileptogenic • Complete Seizure Suppression • Minimal Side Effects

  27. FACTS: • 50 % of patients fail to achieve the goal of treatment. (1985) NEJM • 1/3 of patients treated 1984-1997 failed to become seizure free in the first year of treatment. (2000) NEJM

  28. Possible Advantages of New AED • More effective • Better tolerated • Safer • Better for women • Less interaction • Broader spectrum

  29. New AED Label Indications

  30. New AED: common concern • High cost • Dose related toxicity • Pharmacodynamic interactions • Drug levels of limited use

  31. New AED : how they compare • Similar in : Responder rate  40% Seizure free rate < 10% • Differ in : Adverse effects Pharmacokinetic profile Efficacy for seizure type(s)

  32. AED: Future Development • Actions at NMDA receptors • Actions at AMPA receptors • GABA B receptors and absence seizures • GABA and Glutamate transporters • Metabotropic glutamate receptors • Seretonin • Neurosteroids • Genetic studies and the nicotinic acetylcholenergic system

  33. Epilepsy Surgery

  34. Surgical Candidates • Medically refractory seizures • Physically, socially disabled • Localization-related epilepsy • Low risk of morbidity • Potential for rehabilitation

  35. Response to AED in newly diagnosed epileptics. Kwan et al NEJM, 2000

  36. Epilepsy Surgery: Types • Medial temporal lobe epilepsy: MTS Most common Most successful • Lesionectomy: Tumor Vascular anomaly Cortical malformation • Hemispherectomy: Rausmusen’s encephalitis • Corpus callosotomy: LGS • Vagal nerve stimulation: intractable, not surgical candidates • Multiple subpial transection: elequent areas

  37. CONTRAINDICATIONS TO EPILEPSY SURGERY • Absolute: Primary generalized epilepsy Minor seizures that do not impair quality of life • Relative: Progressive medical or neurological disorders Behavioral problems that impair post op rehabilitation Serious medical disorder that may increase surgical mortality Poor memory function in the opposite hemisphere Active psychosis not related to peri-ictal period

  38. Pre surgical evaluation • Routine EEG • Brain MRI (seizure protocol) • Long term video EEG monitoring • Visual perimetry • Neuropsychometry • Sodium amobarbital test

  39. Epilepsy surgery : Risks • Visual field loss < 10% (temporal lobectomy) • Any surgical complication < 5% • Death or serious complication <0.5% • Memory or cognitive deterioration ( predictable) • Aphasia 1% ( reversible) • Psychosis or depression 5% ( treatable) • Most serious adverse outcomes occur when surgery is unsuccessful controlling seizures

  40. Temporal lobectomy efficacySperling et al, JAMA 1996: 276:470-75 Long term (5 yr) operative outcome of 89 patients %

  41. Vagus nerve stimulation • Indicated for patients with intractable epilepsy who are not surgical candidates

  42. Status Epilepticus • Continuous or recurrent seizures without recovery of consciousness for 30 minutes or more ( tendency now to use shorter time definition like 5 minutes and more.

  43. AED in Status Epilepticus

  44. AED in Status Epilepticus

  45. CONCLUSIONS: • Epilepsy is still a challenge • New AED improved our treatment • Need for more understanding of basic mechanism of epilepsy and its genesis • Need to develop specific and target specific treatment • Surgery is quite effective in properly selected patients but quite underused • Intravenous benzodiazepines, phenytoin, phenbarb and valproic acid are available, effective and safe Rx for status epilepticus

  46. THANK YOU

More Related