epilepsy

Definition

Seizure : abnormal neural discharge in the cerebral cortex that result in abnormal function, the nature of clinical manifestations depends on the regions of the brain affected.

Epilepsy : Recurrent seizures unrelated to fever or acute cerebral insult.

Epilepsy- questions ?

1- seizure?
2- seizure-type?
3- fits a syndrome?
4- identifiable cause?
5- anti-epileptic drug (AED)?
6- when to stop treatment?
7- surgery?

History of events

Frequency
Timing
Duration * Triggers
Warning
Color change- pallor, cyanosis
Alteration in consciousness
Motor phenomena
Associated s/s- incontinence, injury
Symptoms following attack- postictal

Differential diagnosis

Pseudo seizure- psychiatric
Syncope- cardiac or neurological
Movement disorder
Migraine
Transient ischemic attack
Metabolic disorders- hypoglycemia
Anoxia/hypoxia

Epilepsy: Classification

Generalized tonic clonic seizures

• Main seizure type: In -10% epileptics

• Tonic phase:

Stiff, crying out, tongue bite, apnea, cyanosed
Increase heart rate, blood pressure
Fall, labored breathing, salivation

• Clonic phase:

Intermittent clonic movements of muscles
Brief relaxations, involves all limbs
Incontinence at the end of clonic phase, lasts for few minutes

• Post-ictal period:

Drowsiness, confusion, headache, deep sleep

Causes of Epilepsy

Idiopathic: 72%
Can be determined: 28% case

Determined causes:

- Inherited genetic:

- Acquired :Trauma, Neuro surgery. Inflammatory, Metabolic, Infections, Tumor, Toxic disorders, drugs
- Congenital: Inborn error of metabolism.
- Withdrawal of drugs:

Alcohol

Barbiturates

Anti-Epileptics

Benzodiazepines

Management

First priorities:

- Attention to vital signs

- Respiratory and cardiovascular support

- Treatment of seizures if they resume

To be followed by:

Management of life-threatening conditions CNS infection, metabolic derangement and drug toxicity

When the patient is not acutely ill:

Evaluation should initially focus on whether there is a history of earlier seizures

Anti Epileptic Drugs (AED) Classification

Older AEDs:

- Phenobarbital, Phenytoin, Primidone

- Ethosuximide , Carbamazepine , Valporate

Newer AEDs:

- Lamotrigine, Topiramate, Tiagabine

- Oxcarbazepine, Zonisamide, Levetiracetam

- Vigabatrin, Felbamate, Pregabalin

- Rufinamide, Lacosamide, Stiripentol, Clobazam

- Eslicarbazepine, Ezogabine, Perampanel

Seizure: Types and choice of AEDs

Facilitation of GABA mediated Chloride channel opening

Drugs acting through this mechanism are

• Barbiturate

• Benzodiazepine

• Vigabatrin

• Valproate

• Gabapentin

Glutaminergic synapse

Type: Excitatory
Permeable to: Na+, Ca2+ and K+
Blocked by:

Magnesium ions in resting state

Enhancement:

Glycine (GLY) binding enhances the ability of GLU or NMDA to open the channel

Agonists:

NMDA, AMPA, Kianate

Ethosuximide

• Mechanism of action:

- It has an important effect on Ca 2+ currents, reducing the low-threshold (T-type) current.

• Pharmacokinetics:

- t1/2 :40 hours

- Metabolism: Hydroxylation inactive products

• Adverse reactions:

- Gastric distress including pain, nausea, and vomiting

• Dose: 20-30mg/kg/day

Comments

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