EPILEPSY

Dr. Hj. Meiti Frida, Sp.S

Bagian Neurologi FK-Unand

RS. DR. M. Djamil Padang

DEFINITION
Abnormal and recurrent excessive synchronized discharge of
cerebral neuron with clinical manifestation of epileptic seizure
which are an intermittent stereotypical behavior, emotion, motor
function or sensation

PATHOPHYSIOLOGY
Paroxysmal depolarization shift (PDS) of the resting membrane
potential, which triggers a brief rapid burst of action potentials
terminated by a sustained after hyperpolarization
PDS : result of imbalance between excitatory (glutamate and
aspartate) and inhibitory (GABA) neurotransmitters
Abnormalities of voltage controlled membrane ion channels
Imbalance between endogenous neuromodulators, acetylcholine
favoring depolarization and dopamine enhancing neuronal membrane
stability

FOCAL EPILEPTOGENESIS
Asynchronous burst firing in some hypocampal and cortical
neurons

Generalized epileptogenesis :
asynchronous burst firing in abnormal
thalamocortical interaction

EPIDEMIOLOGY
Developed countries :
annual incidence 50-70 cases per 100.000
Developing countries : prevalence 1%
Incidence varies with age

Incidence of epilepsy in relation to age

ETIOLOGY
Idiopathic
Cryptogenic
Symptomatic

Congenital anomalies
Tuberous sclerosis
Storage diseases
Birth trauma

Cerebral tumours

Genetic epilepsies

Intracranial
haemorrhage

Intracranial

Head Injuries

Infections
Febrile
Seizures
Hypoxia

Drugs
and

Hypoglycaemia

alcohol

Cerebrovascular
degenerations

Hypocalcaemia

10
20
Age (years)

60

Factors lowering seizure threshold

Common
Sleep deprivation
Alcohol withdrawal
Television flicker
Epileptogenic drugs
Systemic infection
Head trauma
Recreational drugs
AED non-compliance
Menstruation

Occasional
Barbiturate withdrawal
Dehydration
Benzodiazepine
withdrawal
Hyperventilation
Flashing lights
Diet and missed meals
Specific reflex triggers
Stress
Intense exercise

International Classification of Epileptic Seizures

Partial seizures (beginning locally)

Simple partial seizures (without impaired
consciousness)
with motor symptoms
with somatosensory or special sensory symptoms

Complex partial seizures (with impaired

consciousness)

simple partial onset followed by impaired consciousness

impaired consciousness at onset

Partial seizures evolving into secondary generalized

seizures

Generalized seizures (convulsive or nonconvulsive)

Absence seizures
Typical
Atypical

Myoclonic seizures
Clonic seizures
Tonic seizures
Tonic clonic seizures
Atonic seizures

Unclassified seizures

Simplified Classification of Epileptic Seizures

Partial seizures
Simple preservation of awarness
Complex impairment of consciousnesss
Secondary generalized
Generalized seizures
Absence
Myoclonic
Tonic-clonic
Tonic
Atonic

International Classification of Epilepsies and

Epileptic Syndrome
Localization-related (focal, local or partial)
epilepsies and syndromes
Idiopathic epilepsy with age-related onset
- benign childhood epilepsy with
centrotemporal spikes
- chilhood epilepsy with occipital
paroxysms
Symptomatic epilepsy

Generalized epilepsies and syndromes

Idiopathic epilepsy with age-related onset (listed in order
of age at onset)
- benign neonatal familial convulsions
- benign neonatal non-familial convulsions
- benign myoclonic epilepsy in infancy
- childhood absence epilepsy (formerly known as
pyknolepsy)
- juvenile absence epilepsy
- juvenile myoclonic epilepsy (formerly known as
impulsive petit mal)
- epilepsy with generalized tonic-clonic seizures
on awaking
Other idiopathic epilepsies

Idiopathic or symptomatic epilepsy (listed in order of age

at onset)
- West syndrome (infantile spasms)
- Lennox-Gastaut syndrome (childhood epileptic
encephalopathy)
- epilepsy with myoclonic-astatic seizures
- epilepsy with myoclonic absence seizures
Symptomatic epilepsy
Non-specific syndromes
- early myoclonic encephalopathy
- early infantile epileptic encephalopathy
Specific syndromes (epileptic seizures as a complication
of a disease, such as phenylketonuria, juvenile Gauchers
disease or Lundborgs progressive myoclonic epilepsy)

Epilepsies and syndromes with both generalized and focal seizures

Neonatal seizures
Severe myoclonic epilepsy in infancy
Epilepsy with continuous spike waves during slow-wave sleep
Acquired epileptic aphasia (Landau-Kleffner syndrome)

Epilepsies without unequivocal generalized or focal

features
Special syndromes
Situation-related seizures
- febrile convulsions
- seizures related to other identifiable
situations,
such as stress, hormonal changes, drugs,
alcohol withdrawal or sleep deprivation
Isolated, apparently unprovoked epileptic events
Epilepsies characterized by specific modes of
seizure precipitation
Chronic progressive epilepsia partialis continua of
childhood

Diagnosis
Interviews with patients or witness
Circumstances surrounding the attacks

idiopathic and generalized

No seizure worning
No underlying brain lesions
Associated with a family history

Symptomatic and localization related

Aura
Specific site of onset
Identifiable cause

Recurrent episodes of seizures

Symptoms occured during and after seizures

Recording symptomatic events with videocamera and

continous ambulatory EEG monitoring

EEG
To confirm the clinical diagnosis
To support the classification of partial or generalized seizures
Routine trace

50% normal

Diagnostic in non convulsion state epileptic activities :

Hyperventilation
Photic stimulations
Sleep deprivation

EEG

BRAIN IMAGING
Essential, particularly in partial onset seizures
Computerized tomography (CT)
Magnetic resonance imaging (MRI)

Structural lesion

MRI

MRI

MRI

Scan
Scan should be repeated periodically :
Suspicion of a tumour
Worsening in neurological examination or cognitive function
Deterioration in the frequency or severity of the seizures

Single Photon Emission CT (SPECT)

Positron Emission Tomography (PET)
MRI spectroscopy
Functional MRI

Functional cerebral changes

Useful adjuncts in candidate epileptic

surgery

DIFFERENTIAL DIAGNOSIS
Migraine
Transient Ischaemic Attacks
Hyperventilation
Tics
Myoclonus
Hemifacial spasm
Syncope
Sleep disorders
Non Epileptic Attacks
Narcolepsy
Metabolic disorders
Transient global amnesia

Management
Medical treatment :
Establish a correct diagnosis of epileptic
seizure type and epileptic syndrome
Decide treatment with epileptic drugs is necessary
Decide which drug should be used
Patients and their families should receive counselling
regarding :
Aims of treatment
Prognosis and duration of the expected
treatment
Importance of compliance
Side effects

Surgical treatment
Proposed Indications for resective epileptic surgery
Intractable seizures
Resectable structural abnormality as identified on magnetic
resonance imaging
Confirmation that seizures arise from a visible lesion (using video
telemetry)
Over 20% of seizures arising from the contralateral temporal lobe in
temporal lobe seizures
Intelligence quotient > 70 points
No significant psychiatry morbidity
No medical contraindications
Age < 45 years

Strategies for managing newly diagnosed

epilepsy
Newly diagnosed epilepsy

47%
First drug

Seizure-free
13%

Second drug

Seizure-free

40%
Refractory

Rational duotherapy

Surgical assessment

Ten commandments in the pharmacological treatment

of epilepsy

Choose the correct drug for the seizure type or epilepsy syndrome

Start at low dosage and increase incrementally

Titrate slowly to allow tolerance to central nervous system sideeffects

Keep the regiment simple with once- or twice-daily dosing, if possible

Measure drug concentration when seizures are controlled or if control

is not readily obtained (if possible)

 Counsel the patient early regarding the implications of the

diagnosis and the prophylactic nature of drug therapy
When seizures persist, combine the best tolerated first-line drug
with one of the newer agents depending on seizure type and
mechanism of action
Simplify dose schedules and drug regimens as much as
possible in patients receiving polypharmacy.

Aim for the best seizure control consistent with the optimal
quality of life in patients with refractory epilepsy

Drug choice in newly diagnosed epilepsy in

adolescents and adults
Seizure type

First line

Second line

Tonic clonic

Sodium valproate
Carbamazepine
Phenytoin

Lamotrigine*
Oxcarbamazepine*

Absence

Sodium valproate

Ethosuximide
Lamotrigine*

Myoclonic

Sodium valproate

Lamotrigine*

Carbamazepine
Phenytoin

Lamotrigine*
Oxcarbamazepine*
Sodium valproate

Sodium valproate

Lamotrigine*

Partial
Unclassifiable

*Lamotrigine and oxcarbamazepine are regarded as first-line drugs in some countries

Choice of antiepileptic drugs in children

Seizure type

First line

Second line

Third line

Tonic-clonic

Sodium valproate
Carbamazepine

Lamotrigine*
Oxcarbazepine*

Phenytoin

Myoclonic

Sodium valproate

Lamotrigine*

Clobazam
Phenobarbital

Tonic

Sodium valproate

Lamotrigine*

Clobazam
Topiramate

Absence

Sodium valproate

Lamotrigine*
Ethosuximide

Clobazam

Carbamazepine
Phenytoin

Sodium valproate
Gabapentin
Oxcarbazepine*

Lamotrigine*
Vigabatrin
Clobazam
Topiramate

Infantile spasms Vigabatrin

Corticosteroids

Sodium valproate
Nitrazepam

Lamotrigine*

Lennox-Gastaut Sodium valproate

Lamotrigine*
Topiramate

Clobazam
Felbamate

Partial

Status Epilepticus
Life threatening medical defined as frequent and / or
prolonged epileptic seizure

Some Reasons for Failure of Monotherapy

Wrong diagnosis
Syncope, cardiac arrhythmia, etc.
Malingering, pseudoseizures
Underlying neoplasm
Wrong drug(s) Inappropriate for seizure type
Kinetic / dynamic interactions
Wrong dose
Too low (ignore target range)
Side effects preventing dose increase
Poor compliance with medication
Inappropriate lifestyle (e.g. alcohol or drug abuse)

When to stop medication

After 2-3 years period of seizures free, must be tappering off
in six month

Prognosis
Dependent with underlying syndrome and / or its cause
Patients compliance
Reciprocal illness or medications
60-70% controlled by first-line drug of epilepsy
10% of the rest controlled by new drugs
The rest :

neurosurgery department

Special Problems of Epilepsy

Behavioral problem :
- Label of epilepsy

racial disadvantage

- Brain function, medication, type of seizure

- Attitudes of helpers and helped
Education :
Discussion between doctors, families, schools teachers and the patient, steps
which might be taken to promote normal education and personal development

Employment :
- Personal and racial states as well as
financial reward
- Understanding of the employee of their illness in
the context of particular employment, safety for
their selves and environment
- People around in working hours need to know
what to do if the attack occurred
The law
Driving lisence
Free of seizure after 6 months controlled epilepsy

No permitting to drive if :
Have suffered of epileptic attack at the age before adolescent
Medical condition caused driving a source of danger to them selves and
to the public

Leisure :
Swimming, water sport, cycling, horse riding in groups with safety
controlled
Boxing, climbing, sport with body contact are prohibited
Television and video games, avoid flickering of the screen

Marriage and pregnancy

Health education
Impairment, disability and handicap