Epilepsy

Epilepsy is defined as recuurent tendenct to spontaneous, intermittent, abnormal

electrical activity in part of the brain, manifesting as seizues
Epidemiology
Aetiology
2/3 are idiopathic (often familial
Structural causes
o Cortical scarring (e.g. head injury years before onset)
o Developmental (e.g. dysembryoplastic neuroepithelial tumour or cortical
dysgenesis)
o Space occupying lesion
o Stoke
o Hippocampal sclerosis (e.g. after febrile convulsions
Other:
o Tuberous sclerosis
o Sarcoidosis
o Systemic Lupus erythematous
o Polyarteritis nodosa
Causes of Seizures (non-epileptic)
Trauma Metabolic disturbance
Stroke Liver disease
Haemorrage Infection
Increased ICP Fever
Alcohol or benzodiazepine Drugs
withdrawl Pseudoseizures
Pathophysiology
Signs/symptoms
Prodrome
o Lasts hours or day before the seizure
o Change in mood or behaviour
Aura
o Part of seuzire that patient is aware and preceeds the seizure
o Can be strange feeling in the gut, or dj vu
Seizure
o Tonic = contraction of muscles
o Clonic = jerking
Post-ictal
o Headache, confusion, myalgia, sore tongue, temporary weakness after focal
seizure in Motor cortex (Todds Palsy)
o Dysphasia after focal seizure in temporal lobe
Types of Seizures
Partial
Simple partial
o Awarness unimpaired with focal motor, sensory, autonomic and psychic
symptoms
o No post-ictal symptoms
 Complex partial
o Awareness impaired. May have a simple partial onset (=aura), or impaired
awareness at onset.
o Commonly arise from the temporal lobe. Post-ictal confusion is common with
seizures arising from temporal lobe. Recovery is quick from seizures in the
frontal lobe
Partial with secondary generalised
o 2/3 patients have focal seizures that spread widely (to the second
hemisphere) causing a generalised seizure
Generalised
Absence
o Brief (<10secs) pauses
Tonic-Clonic
o Loss of consciousness. Limbs stiffen up (tonic phase), before jerking heavil
(clonic). May have one without the other. Post ictal drowsiness and
confusion.
Myoclonic
o Sudden jerk of a limb, face or trunk. Patient may be suddenly thrown flying to
the ground.
Atonic seizures
o Sudden loss of muscle tone causing a fall. No loss of consciousness
Infantile spasms
o Often associated with tuberous sclerosis
Diagnosis (and subtypes)
Syndrome Notes

Infantile spasms Brief spasms beginning in first few months of life

(West's syndrome)

1. Flexion of head, trunk, limbs extension of

arms (Salaam attack); last 1-2 secs, repeat up to
50 times
2. Progressive mental handicap
3. EEG: hypsarrhythmia
usually 2nd to serious neurological abnormality
(e.g. TS, encephalitis, birth asphyxia) or may be
cryptogenic
poor prognosis

Lennox-Gastaut May be extension of infantile spasms (50% have hx)

syndrome

onset 1-5 yrs

atypical absences, falls, jerks
90% moderate-severe mental handicap
EEG: slow spike
 Syndrome Notes

ketogenic diet may help

Benign rolandic paraesthesia (e.g. unilateral face), usually on

epilepsy waking up

Juvenile myoclonic Typical onset in the teens, more common in girls

epilepsy (Janz
syndrome)
1. Infrequent generalized seizures, often in
morning
2. Daytime absences
3. Sudden, shock like myoclonic seizure
usually good response to sodium valproate

Medications
Carbamazepine
Na+ channel blocker
Generally used as first line for partial seizures
Side effects include: Leucopenia, diplopia, blurred vision, impaired balance,
drowsiness, mild generalised erythematous rash, SIADH (and hyponatraemia)
P450 inducer
Lamotrigine
Na+ channel blocker
Side effects include: Maculopapular rash (10%) (note 1/1000 develop Stevens-
Johnson syndrome- especialy if on Valproate), diplopia, blurred vision,
photosensitivity, tremor, agitation, vomiting, aplastic anaemia
Levetiracetam
Ca2+ blocker
Side effects: Psychiatric side effects (depression, agitation); Diarrhoea and vomiting;
dyspepsia; drowsiness; diplopia; blood dyscrasias
Phenytoin
Na+ channel blocker
Zero order kinetics
o Give loading dose
Side effects: Nystagmus, diplopia; tremor; dysarthria; ataxia; reduced intellect;
depression; coarse facial features; acne; gum hypertrophy; polyneuropathy; blood
dyscarasias
P450 inducer
Valproate
Na+ channel blocker
Generally used
 Side effects: Appetite increase, weight gain; Liver failure (LFTs); Pancreatitis;
Reversible hairloss (grows back curly); Oedema; Ataxia; Teratogenicity, tremor,
thrombocytopenia; Encephalopathy (due to hyperammoniaemia)
P450 enzyme inhibitor

Management
Absence seizures Ethosuximide, Sodium Valproate, Lamotrigine
Generalised tonic-clonic seizures Valproate (1st line); Lamotrigine (1st line); Carbamazepine;
topirmate. Others include: levetiracetam, oxcarbazepine, clobazam
Partial seizures secondary generalisation Carbemazapine (1st line); Lamotrigine;
Levitiracetam; Valproate
Tonic, atonic, myoclonic seizures same as generalised tonic-clonic but avoid
Carbamazepine and Oxcarbazepine which may make them worse.

Women of child bearing age Take folic acid with anti-epileptics, avoid Valproate (use
lamotrigine. Preconception councelling.
Breast feeding Most AEDs are present in breast milk (except carbamazepine and
valproate). Lamotrigine is not harmful to infants
The pill Non-enzyme inducing AEDs have no effect on pill. Other AEDs may need increase
in Progestoren or Oestrogen pills.

Prognosis
Complications
Status epilepticus
A seizure that lasts more than 30 minutes minutes, or repeated seizures that occur without
consciousness returning.
Aim to treat as quickly as possible
Investigations
Bedside glucose

Treatment
Benzodiazapines
o Lorazapam (IV)
o Rectal Diazepam
o Buccal midazolam
Phenytoin infusion
o If no response in 10 mins add Phenytoin
Diazepam infusion
Dexamethasone
o If cerebral oedema (tumour) possible
General anaesthesia
o If no response within 30 minutes
The priority is termination of seizure activity, which if prolonged will lead to irreversible
brain damage. First-line drugs are benzodiazepines such as diazepam or lorazepam. If
ineffective within 10 minutes it is appropriate to start a second-line agent such as
phenytoin, sodium valproate, levetiracetam, or phenobarbital. If no response within 30
minutes from onset, then the best way to achieve rapid control of seizure activity is
induction of general anaesthesia.