LAFAYETTE HOME HOSPITAL: LAFAYETTE HOME HOSPITAL: EPILEPSY; 2004EPILEPSY; 2004

LAFAYETTE HOME HOSPITAL: LAFAYETTE HOME HOSPITAL: EPILEPSY; 2004EPILEPSY; 2004

Most important question: is ictus a Most important question: is ictus a seizureseizure

Most important question: is ictus a Most important question: is ictus a seizureseizure

• CONCEPTS– Most unidentified spells are not seizures– If a diagnosis of a seizure is not definite, do not treat

patient– Seizures most commonly dx. on history

• Have family act out seizure

• Video picture of event is extension of the history

HISTORYHISTORYHISTORYHISTORY

• Seizures; small spells, migraines big spells• Moment by moment

– Sudden onset– Post ictal episode

• Defined episode

Generally, episodes associated with Generally, episodes associated with event are not seizuresevent are not seizures

Generally, episodes associated with Generally, episodes associated with event are not seizuresevent are not seizures

• Paroxysmal choreoathetosis• Stretch syncope• Night terrors• Hyperventilation• Breath holding spells

Common episodes which are not Common episodes which are not seizuresseizures

Common episodes which are not Common episodes which are not seizuresseizures

• Infant jerking during feeding• Nocturnal myoclonic jerks • Migraine headaches

– Confusional– Post traumatic\– Episodic vertigo

• Periodic syndromes• Syncope• daydreaming

ILAE classificationILAE classificationILAE classificationILAE classification

• Brain made up of very different cells “cerebrocyte”– Metabolism of different areas different

• Generalized– Some TC seizures– Myoclonic seizures– Akinetic seizures– Absence episodes

• Partial– Simple– Complex

Seizure syndromes museumSeizure syndromes museumSeizure syndromes museumSeizure syndromes museum

Infantile spasmsInfantile spasmsInfantile spasmsInfantile spasms

• Many causes• 20% Tuberous sclerosis• If identifiable cause, treatment probably does not change

course• West Syndrome

– Onset 5-8 months– Whiff of ACTH helpful– Outcome

• Pyridoxine

Doos syndromeDoos syndromeDoos syndromeDoos syndrome

• 2/3 boys• Onset 2-4 yr of age• Absence episodes• Myoclonic , astatic episodes• 50% with life long seizures and mental handicap• Other uncommon types with myoclonic sz

Childhood absence epilepsyChildhood absence epilepsyChildhood absence epilepsyChildhood absence epilepsy

• Peak onset 5-6 years• 2/3 are girls• ppt by hyperventilation• 90% remission before 12 yr of age• Rarely, uncommon GTCS as adult

BCECTSBCECTSBCECTSBCECTS

• Commonest pediatric epilepsy syndrome• Onset between 1-14 years• 1.5 male preponderance• Hemifacial sz• Nocturnal• May not need to treat• 2-3% normal children with CT spikes;• <10% with seizures

Juvenile Myoclonic epilepsy 90% Juvenile Myoclonic epilepsy 90% misdiagnosedmisdiagnosed

Juvenile Myoclonic epilepsy 90% Juvenile Myoclonic epilepsy 90% misdiagnosedmisdiagnosed

• Onset 5-16 yr of age• Irregular shock like myoclonic jerks in AM

– Can be myoclonic status• 1/3 with absence attacks• gen t-c seizures• Sleep deprivation, alcohol ppt sz

• Occipital Lobe epilepsy

Photosensitive epilepsyPhotosensitive epilepsyPhotosensitive epilepsyPhotosensitive epilepsy

• Occurs with several seizure syndromes• Seizure occurs during the photic stimulation• Seizure occurs while exposed to flashing light

– Pre TV stim– TV worst culprit

• Preventing– Polarized sunglasses– Small screenCover one eye– Oblique viewing

TESTING: ROUTINE EEGTESTING: ROUTINE EEGTESTING: ROUTINE EEGTESTING: ROUTINE EEG

• EEG best done to classify seizure• If partial sz, EEG often normal

• Members of family with genetic epilepsy can have abnormal EEG without seizures

TESTING: 24 hr EEGTESTING: 24 hr EEGTESTING: 24 hr EEGTESTING: 24 hr EEG

• Best if ictus occurs during EEG• Video EEG• Ambulatory EEG

TESTING: Imaging StudiesTESTING: Imaging StudiesTESTING: Imaging StudiesTESTING: Imaging Studies

• CT scan– Good for trauma– In all other cases, MRI is best– Not a good screening tool

• MRI– Developmental abnormalities– Assessment of hippocampus

EFFECTIVENESS OF AEDEFFECTIVENESS OF AEDEFFECTIVENESS OF AEDEFFECTIVENESS OF AED

• No real change in patients with uncontrolled seizures?• All agents with same effectiveness• Decision to use AED based on classification of seizure

and side effects of AED

STARTING AEDSTARTING AEDSTARTING AEDSTARTING AED

• If one seizure: 30% will have recurrance• If abnormal EEG: 60% will have seizure

SEIZURE CONTROLSEIZURE CONTROLSEIZURE CONTROLSEIZURE CONTROL

• 60% controlled on first anticonvulsant• 20% controlled on second anticonvulsant• 5% controlled on third anticonvulsant

AED and ring structureAED and ring structureAED and ring structureAED and ring structure

AED;MonomechanismAED;MonomechanismAED;MonomechanismAED;Monomechanism

• Carbamazepine• Oxcarbazine• Zarontin

AED affecting thinkingAED affecting thinkingAED affecting thinkingAED affecting thinking

• Phenobarbitol• Valproate• Topomax• Keppra

AED with particular side effectsAED with particular side effectsAED with particular side effectsAED with particular side effects

• Lamotrigine; rash• Keppra; major thinking disorder• Topomax; word finding , acidosis

Use of medsUse of medsUse of medsUse of meds

• One drug first• Try for monotherapy• If sz correctly dx and 3 meds no help, consider

– VNS– Surgery– KGD