Complex Partial seizures

introduction

A 25-year-old woman has a history of black-outs.She had these black-outs since she was a child.She is now pregnant and she would like to stop taking her medication.

when she was 8 years old her teacher noticed the seizures.

The patient doesn’t remember them.

These attacks takes only few seconds.

And were frequent.

The EEG she had was abnormal with generalized spikes

and waves.

When she was 14, she had a different kind of episodes with tinnitus and everything going black.

She can feel the attacks coming.

She feels tired after the attack.

The EEG reveals no abnormality.

Absence

seizures ?

Based on the characteristics of the

attack she had:

• Aura “ I can feel it coming “

• Sometimes this attack occurs during sleep ( kick her husband)

• The duration of the attack (5-10 min)

• The frequency of the attack ( 1 or 2/ year)

• She feel tired and confused after the attack

• Tinnitus or ringing during the attack

Learning Objectives:

• What’s Complex Partial seizure ?

• How the seizure happens?

• Etiology

• Clinical manifestation

• Diagnostic evaluation

• Treatment

• Prevention

• Case questions

Why is it important to study epilepsy ?

• There are around 40 different types of seizure and a person may have more than one type.

• Epilepsy can affect anyone, at any age and from any walk of life.

• Around 5 people in every 100 will have an epileptic seizure at some time in their life. Out of these five people, around four will go on to develop epilepsy.

• Epilepsy affect nearly 50,000,000 people worldwide.

• Epilepsy imposes an annual economic burden of $15.5 billion.

Types

of

epilepsy

:epilepsy

partial

simple

Complex

Secondary generalized

generalized

Absencec

Tonic

Tonic-clonic

Atonic

Myoclonic

Complex Partial seizures

• is an epileptic seizure that is associated with unilateral cerebral hemisphere involvement and causes impairment of consciousness, it occurs in all age groups.

• This type of seizures was previously know as psychomotor epilepsy , or temporal lobe epilepsy. It is due to a lesion or disturbance in the limbic system usually in the temporal lobe, and sometimes in the frontal lobe.

Complex Partial seizures cont…

• complex partial seizures are called "complex" because they impair consciousness and "partial" because they begin in a limited area of the brain then spread to the whole brain hemisphere.

How the seizure happens?

• Normally brain neurons pass signals among themselves using both electrical current and chemicals.

• In a seizure, the brain's electricity is not passed in an organized way from one neuron to the next, but spreads over a cluster of cells or the whole brain hemisphere all at once.

Etiology

• In the majority of cases,complex partial seizures are of unknown etiology.

• Potential causes include the following:

perinatal lesion (e.g. temporal sclerosis).

congenital developmental anomalies, trauma, and brain tumors.

Clinical manifestation

the episodes are often preceded by

a seizure aura. The aura may manifest itself as a feeling

of déjàvu , fear,euphoria or depersonalization.

The seizure aura might also occur as a visual disturbance,

such as tunnel vision or a change in the size of objects (macropsia or micropsia).

Aura

Clinical manifestation cont...

• Complex partial seizures have:sensory, behavioral, psychomotor , and autonomic manifestations.

• Which of theses manifestation will be present in the patient depend on the prices location of the epileptic focus.

• The manifestation could be very mild in some patients, and very sever in others.

Sensory disturbances

• dizziness

• Gustatory sensations

• Unpleasant olfactory sensations.

Autonomic disturbances

• Shortness of breath

• Palpitations

• Nausea

• Salivation or dry mouth

• Hunger

• Urge to urinate

Behavioral and psychomotor disturbances

• Traumatic experience

• Feeling of unreality

• Anxiety

• Rage

• Hallucinations.

Clinical manifestation cont...

• The seizure begins suddenly, Then the patient loses awareness and stares blankly, makes chewing and swallowing movements, or perform other purposeless actions. These movements are called "automatisms"

• The seizure usually last between 30 seconds and 5 minutes. Afterward, the person may be tired or confused for about 15 minutes and may not be fully normal for hours.

Diagnostic evaluation

• Complex partial seizure activity can generally be diagnosed from its typical clinical picture.

• The EEG reveals temporal slow waves or spikes.But in the interictal period, however, it is usually normal.

Treatment

• the treatment line for Complex partial seizure is anti-epileptic medications.

anti-epileptic drugs:

• Drugs which decrease the frequency and/or the severity of the epilepsy.

• Treat the symptoms of the seizures not the underlying condition.

• Their goal is to maximize the quality of life by minimizing seizures.

anti-epileptic drugs cont…

• The drugs of choice in complex partial seizures are:

Carbamazepine

ValporateLamotrigine

• Pregnancy category D• Side effects :Drowsiness, loss of coordination , Leukopenia, hepatotoxicity, and increased risk of teratoginicity.

Carbamazepine

• Pregnancy category D• Side effects: Hepatoxicity, GI irritation, weight gain, hair loss.

• Highest risk of congenital malformation.

Valporate

• Pregnancy category C• Side effects: nausea, dry mouth, constipation , skin rash

Lamotrigine

PreventionP

rev

ent

epil

epsy

Idiopathic epilepsy is not preventable.

Adequate perinatal care can reduce new cases of epilepsy

Preventing head injury to prevent post-traumatic epilepsy.

Pre

ven

t se

izu

res Take the

prescribed medications at time without missing doses.

Avoid crowded places

Avoid standingup quickly.

stop the medication, yes or No ?

• The answer is No.

• In pregnant women with epilepsy usually the risk of harm to the mother and fetus from convulsive seizure itself outweighs the risk of continued therapy.

• The best way to manage the situation is to: continue with a low dose of the prescribed

drug (Lamotrigine) 25 mg/day, because itthe safest drug.

and a high dose of folic acid 5mg/day

• New researches reveals a shared genetic susceptibility to epilepsy and migraine.

• people with epilepsy are substantially more likely than the general population to have migraine headache

• The patients who have migraine should take some medication to relive that migraine attacks.

Migraine and epilepsy.

Is epilepsy hereditary?

• certain types of epilepsy do seem to run in families.

• People who have a generalized epilepsy seem somewhat more likely to have other family members with seizures than those with a partial epilepsy.

• However most people with epilepsy do not have any relatives with seizures, and the great majority of parents with epilepsy do not have children with epilepsy.

• But in our patient situation, since her nephew has epilepsy from birth that is affecting his development, there is a chance that her baby will have also epilepsy.

the patient in our case has an attacks since she

was 14 with the special characteristics such as:

aura , tinnitus, attacks during sleep, these attacks

takes 5-10 min.

Based on these characteristics we diagnose the

patient with complex partial epilepsy.

Since the patient is pregnant, she is not advised to

stop the medication, the proper treatment for her is

low dose of Lamotrigine, with high dose of folic acid.

References:

Books:• Mumenthaler M, & Mattle H.(2002) Fundamentals of Neurology, an illustrated

guide.

• Courtenay M. (2012) British National Formulary.

• Bromfield EB, Cavazos JE, Sirven JI. (2006) An Introduction to Epilepsy.

• Kaplan PW, Fisher RS. (2005) Imitators of Epilepsy, second edition.

Websites:• http://www.who.int//

• http://www.epilepsyfoundation.org

• http://emedicine.medscape.com

• http://www.ncbi.nlm.nih.gov//