Epilepsy

Summary
By Shorooq Abdou

Epilepsy
Definition :
- a state of 2 or > unprovoked seizures .
- caused by abnormal synchronized electrical discharge in the brain, between
which the patient is his normal self.
** acute provoking factors :
- electrolytes disturbances - trauma

- metabolic causes - fever - drugs

Etiology :
1) idiopathic 75 %
2) Familial
3) Mesial sclerosis in the temporal Lobe !
4) secondary epilepsy ; due to an underlying pathology in the brain .
Age related epilepsy :
** In extreme ages .
eg. Neonatal epilepsy

International classification :
Generalized
- no warning or aura.
- usually complete loss of consciousness
- post ictal state >>more sever
symptoms >> amnesia , headache
Confusion .
- Prodrome: apathy/ fatigue ..

partial
almost always with aura .
-level O.C maybe only
-less sever post-ictal

Primary generalized epilepsy

There are three common manifestations of primary generalized
epilepsy:
primary generalized tonicclonic seizures;
absence seizures;
myoclonic seizures.
** Individual patients often have a mixture of these seizure types. Tonic or
clonic separately . there is also Atonic seizures .
tonicclonic seizures:
* grand mal

Tonic phase :
** 10-15 sec ..
- The patient loses consciousness and suddenly stiffens, as all the muscles in
his body enter a state of sustained (tonic) contraction .
- He makes a loud groan as air is forced out of the chest through
tightened vocal cords.
- He does not breathe and becomes cyanosed.
Clonic phase :
** 1-2 min
- relaxation of contracted muscles .
- repetitive jerky movement .
- tongue biting & Urinary incontinence are frequent.
Terminal phase: coma, pupils react, breathing resume ..
Absence seizures
* petit mal
- Whole attack lasts less than 10 seconds
- usually school aged children (5-15 yrs)
- Sudden onset, sudden end . . . ; may pass unnoticed
- the patient is Unaware, still, staring during the attack .
- no falling down .
- May occur several times a day .
- Activated by hyperventilation

Myoclonic seizures
- sudden brief involuntary jerky movement .
- Coexists with tonic-clonic and absence seizures a specific syndrome called
juvenile myoclonic epilepsy
- Isolated myoclonic jerks can occur in a wide range of conditions with no
relation to epilepsy can be metabolic cause : - hepatic encephalopathy
- uremia . Etc .

Atonic seizures
sudden loss of postural tone. If standing, the patient falls suddenly to the
floor and may be injured Although most often seen in children, this seizure
type is not unusual in adults. Many patients with atonic seizures wear
helmets to prevent head injury..

partial seizures :
** focal seizures
>> simple
- usually no loss of consc.

>> complex
level O.C maybe impaired .

>>Partial seizures evolving to secondary generalized

** in general :
- theres visual impairment or smell abnormality during the seizure & other
symptoms , all of which entirely depend on the location of the epileptogenic
focus .
frontal lobe epilepsy:
- Strong convulsive movements of one part of the contralateral face, body or
limbs >> the localized epileptic discharge is in part of the motor cortex
(precentral gyrus) of one cerebral hemisphere.
- complex posturing with one arm flexed and one arm extended like a fencer
(epileptic activity in the supplementary motor area)
- personality changes during the attack .
- Aphagia . Remember : brocas area in the inf. frontal gyrus .
- Todds paralysis : post-epileptic unilateral weakness lasting for few hrs .

temporal lobe epilepsy :

** the commonest form of focal epilepsy
** is a complex partial sz . ; theres loss of cons.
- Hallucination of smell/taste.
- Repetitive movements (automatisms) .
- Lip-smacking and sniffing movements.
- Memories rushing through the brain !
Occipital Lobe
- visual Loss , during the attack .

Any warning or aura in the moments before a tonicclonic

seizure indicates that it is a manifestation of focal epilepsy
rather than primary generalized epilepsy .

** an example of focal seizures is :

Jacksonian epilepsy
* is a simple partial sz >> no loss of consciousness .
If the focal discharge begins in one part of the motor cortex, eg : on the left ,
the first symptom might be convulsive twitching of the right side of the face,
spreading rapidly into the right arm and then the right leg before affecting the
whole body in a secondarily generalized tonicclonic seizure. This particular
kind of attack is known as Jacksonian epilepsy.

Unclassified Epilepsy syndromes

- Juvenile myoclonic epilepsy

** This is the commonest cause of tonicclonic seizures starting in teenagers.
** not usually fully controlled by carbamazepine or phenytoin, but it is by
sodium valproate or lamotrigine.

LennoxGastaut syndrome
** Lennox (no relation) and Gastaut described one of the most severe forms of
so-called epileptic encephalopathy, where a range of metabolic and genetic
disorders of brain development give rise to severe learning disability and
epilepsy .
- very poor prognosis >> resistant to medications .

Diagnosis
** remember : Not every seizure means epilepsy esp. if it was the first
attack .
- Hx : from the patient & from witness

- P/E : it will lead u for what investigations u need to do . >>>

* electrolytes > esp. dehydrated kid with hx of vomiting / diarrhea
* Glucose level .
* seizures with fever >> rule out meningitis do LP after fundoscope
& excluding a mass lesion by CT .

EEG :
- normal EEG doesnt rule out epilepsy .. esp. if its done b/w the attacks .
- abnormal one doesnt mean epilepsy if asymptomatic .( 10% of the
normal population show mild, non-specific EEG abnormalities)
*** a pathognomonic EEG finding in Absence sz :
3-4 Hz spike/sec , appear synchronously through out all the leads .
- found in 90 % of these patients .
photo-stimulation

Brain imaging :
- CT & MRI must be done whenever u suspect
focal lesion .

other tests :
- monitoring , photo-stimulation ,
hyperventilation .

Occasional patients with all

the types of primary
generalized epilepsy may
have seizures triggered by
flashing light, for example
from the television, computer
games or flickering sunshine
when driving past a row of
trees, and have to avoid such
stimuli. Almost all such
patients also get spontaneous
seizures unrelated to visual
stimulation

DDx
- syncope .
- vasovagal attacks
- Hysterical >> u do prolactine level if its mostly epilepsy rather than
hysterical attack . the Dr said .
- TIA

Drugs
Ill talk about some MOA so it will make more
sense !! , dont concentrate that much
** they will act by one of the following mechanisms :
1) Blockade of Voltage gadded Na-channels in
neuronal membrane :
phenytoin, carbamezepine, lamotrigine .

Neurotransmitters & ions

action in the brain :
- Glutamate : Excitatory.
- Na+, Ca ++ : Excitatory.
-GABA : inhibitory.
- K+ : inhibitory .

2) By the enhancement of GABA transmission:

*** through one of the following mechanisms :
- binding to Cl- channels , then binding to receptors of GABA; to produce an
inhibitory neural transmission Benzodiazepine (BDZ), Barbiturates .
- inhibition of the enzymes Responsible for inactivation of GABA : valproate
- by inhibiting GABA reuptake so it will be accumulated in the synaptic
cleft as Tiagabine
- GABA agonists such as Gabapentine
3) by the Blockade of Ca- channels inside the CNS:
Ethosuxamide , Valproate
4) Enhances K-channels permeability : Valproate
5) Block Glutamate receptors Phenobarbitone

u can see that

Valproate has Multiple
effects ; so its
regarded as broadspectrum AED >> its
useful in treatment of
almost all types of
epilepsy ..

some specific Notes , indications & SE :

** usually we start treatment as epilepsy after the 2nd attack .
- Ethosuxamide : for absence seizures .
- Carbamazepine : for partial seizures .
- Valporate & phenytoin : partial and generalized Sz .

imp. SE :
* Phenytoin :
- Dose related: ataxia, dysarthria, nystagmus
- Idiosyncratic: hirsutism, gingival hypertrophy, acne, coarsening facial
features .
- for the injectable form : consider arrhythmia **
* Valproic Acid :
** Strongly Teratogenic: spina bifida .
- somnolence(sleepiness), wt gain, tremor, hair loss
- Pancreatitis, hepatotoxicity, blood dyscrasias .
* Carbamazepine :
- somnolence, dizziness, blurred vision, diplopia nystagmus
- skin rash, hepatotxicity, blood dyscrasias
* Lamotrigine :
- Stevens Johnson Syndrome .
- influenza-like symptoms
* Felbamate: Aplastic anemia, Liver failure.
* Vigabatrin : Optic nerve demyelination.

U can refer to Dr.

khaled salem slides for
more details in pharma .

Status epilepticus
- life-threatening emergency, requiring immediate cardiovascular, respiratory,
and metabolic management as well as pharmacologic therapy .
- typically last >30 min , but any seizure lasting for (5-7) min u have to
consider It as status epilepticus >> u cant wait for 30 min !!!
Rx :
- ABC
- admit to ICU
** hypoxia > lactic acidosis > resp. muscles fatigue
** may hurt him self >> serious injuries .
** rhabdomyolysis >> RF ..
drugs :
1st : IV diazepam > DOC : lorazepam
2nd : IV phenytoin (phosphenytoin )
3rd : IV phynobarbitone .
4th : GA (metazolam? ) & intubation

the end
by Shorooq Abdoh
I used the following to prepare this summary:
- Drs explanation during the seminar.
- Firas & Firnas Notes for the previous year thanks a lot
- 3rd year pharma lecture .
** I hope this will be helpful . & Ill be very sorry for any deficits or mistakes
** any additions or corrections are the most welcomed , dont hesitate to send them

directly to SAWA grp

good luck

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