Definitions

Seizure: the clinical

manifestation of an abnormal
and excessive excitation and
synchronization of a
population of cortical
neurons
Epilepsy: two or more
recurrent seizures
unprovoked by systemic or
 Definition
Two or more unprovoked
Seizures constitute epilepsy
Derived from a Greek verb
epilamvanein (to be
seized)
John Hughlings Jackson
described various
categories of seizures
Your mind is
Your force
 Partial Generalized
Seizures Seizures
John H Jackson
 Seizure
Classification
Partial Seizures:
Simple partial: Motor,
Somatosensory, Autonomic,
Psychic
Complex partial
Partial seizures with
secondary generalization
Seizure
Generalized Seizures:
Classification
Absence
Atypical absence
Tonic-clonic
Atonic
Tonic, clonic-tonic-clonic
Myoclonic
Seizure
Classification
Unclassified Seizures:
Inadequate or incomplete
data
Neonatal seizures
Infantile spasms
Status Epilepticus:
Partial or Generalized
What it feels like!
 Simple Partial
seizures
Preserved consciousness
Motor: Jacksonian, Aphasia,
Contraversive, EPC
Sensory: Somatosensory,
Olfactory, Gustatory, Auditory,
Lights, Vertigo
Autonomic: Visceral
(epigastric)
Psychic:
S
P
S
 Complex Partial
seizures
Aura
Altered consciousness; Staring
Stereotypic movt.s, automatisms
Dj vu, Jamais vu, Gelastic,
Cursive or volvular, Procursiva
(run), Poriomania (wander)
Postictal symptoms
Epilepsy stare
Depersonalization
Dystonic hand
Metamorphosia
Dr. John Todd
 GTCS
Usually no aura
Epileptic cry, version, jerk
LOC, tonic phase (10-20S),
cyanosis
Clonic phase (>30S);
Autonomic, apnea
Postictal symptoms
Complications
 Tonic Clonic

Post-ictal
 Absence seizures
Children; No aura
Interruption of ongoing
activity with unresponsiveness
(2-10S)
Eyelid, facial clonia (3/sec)
No postictal symptoms
Poor school performance
Great frequency (Pykno )
3 Hz Spike-Wave
 CPS Absence
Age Any Children
Aura Present Absent
Automatism Present Uncommo
s n
Duration 20S-2min 2-10S
Postictal Confusion Normal
EEG Focal Gen 3Hz SW
 Absence variants
Atypical absence:
Incomplete LOC; EEG: 2-
2.5 Hz spike-waves
Lennox Gastaut: Multiple
seizure types; EEG: 1-2 Hz
spike-waves; Preceding
West syndrome
 Other seizures
Myoclonic: Brief jerks:
Few muscles, a limb or
generalized; No LOC
Akinetic/Atonic: Sudden
fall with or without LOC
(drop attacks)
 Epidemiology of
Seizures and Epilepsy
Seizures
Incidence: approximately
80/100,000 per year
Lifetime prevalence: 9%
(1/3 benign febrile
convulsions)
Epilepsy
Incidence: approximately
45/100,000 per year
Point prevalence: 0.5-1%
7
6.34
6.05
6 5.59
5.18 4.94
5
4
3
2
1
0
Overall Men Women Urban Rural
 Epilepsy in India
42/100,000/yr
Worldwide incidence
20-70 per 100,000
Some developing
countries: >100 per
100,000 Neurology Asia 2008;13:41-48
 Risk factors in
India
Head injury
Febrile seizures
Developmental delay
FH of epilepsy
Infections yet to be
identified
 Seizures precipitated by
bathing with hot water
pouring over the head
6.9% of all epilepsies in
South
M > F
Usually CPS; 1/3 have GTCS
EEG usually normal
History from eye-
witness
EEG
Neuroimaging
LP
Other tests
Dr. Hans Berger
 EEG
Indicated in all
Diagnosis of seizure type,
epilepsy syndrome
Prediction of recurrence after
1st seizure and AED
discontinuation
Activation procedures, Sleep
deprivation
EEG: Simple Partial
Seizure
Right
temporal
seizures
with
maximal
phase
reversal in
the
right
sphenoid
al
electrodes

Continued
on C-
Slide9
EEG: Simple Partial Seizure
Continuation
of same
seizure
(C-slide-8)

Right
temporal
seizures
with
maximal
phase
reversal in
the right
sphenoidal
electrodes
Hypsarrhythmia
JME
 MRI brain
Adult onset
AbN exam, Partial seizure
Presentation with SE
Refractory epilepsy
Seizures with trauma,
infections, HIV
MTS
Other Pathologies
MYTH
Oh No! Seizure Again!
Fraisenkette
Peony
Convulsion
Seeds
Chain

Mugwort
Skull Powder
 Confirm diagnosis and
identify seizure type/s or
syndrome
Monotherapy: Start slow, go
slow
Optimize the first drug
Add second drug with
different mechanism of action
when necessary
 Dosing interval < drugs half life
Assess response at steady state
Treat the patient and not the
drug level: Toxicity, compliance
Be aware of drug interactions
Co-morbid conditions
 Type of seizure
Timing of seizures
Frequency of seizures
Effects of age on
consequences of seizures
Consequences of
treatment
Normal EEG AbN EEG AbN MRI
Normal MRI Normal MRI EEG N/AbN

RR 24% at RR 48% at RR >65% at

2 years 2 years 2 years
 The first seizure
Higher chance of recurrence:
Occurrence during sleep
Abnormal EEG
Abnormal examination
Abnormal imaging
Partial seizure
 Children: 2 yrs and adults:2-3
yrs seizure-free interval
Predictors of recurrence:
Adult-onset epilepsy
Abnormal EEG, exam
Partial, symptomatic seizures
Certain epilepsy syndromes
Primary GTCS VPA=PHT=CBZ=PH
B
Other pri. gen. VPA
epi.
Simple partial PHT=CBZ=VPA
Complex partial CBZ
Infantile spasms ACTH, VGB, TPM,
VPA
Myoclonic VPA, LTG, TPM,
PRM
 Generalized
seizures
VPA drug of choice in general
LTG very useful as
monotherapy or as an adjunct
to VPA
Sleep GTCS: VPA+LTG
? TPM, Zonisamide
PHT, CBZ, Tiagabine
contraindicated for certain
generalized seizures
 Generalized Tonic Clonic Seizures:
Adults
Available Evidence
A total of 23 RCTs and 5 meta-analyses
examined initial monotherapy of adults
with generalized-onset tonic clonic seizures
Division of trials
Class I (n=0)
Class II (n=0)
Class III (n=10):CBZ, GBP, LTG, OXC, PB,
PHT, TPM, VPA
Generalized Tonic Clonic Seizures:
Adults
Recommendations
Level A: None
Level B: None
Level C: CBZ*,LTG,OXC*,
PB, PHT*,TPM,VPA
Level D: GBP,VGB
Level E: Others
Level F: None
*=may aggravate tonic clonic seizures and
more commonly other generalized seizure
types, should be used with caution
Generalized Tonic Clonic Seizures:
Children
Available Evidence

A total of 20 RCTs examined initial monotherapy of

children with generalized onset tonic clonic seizures
Division of trials
Class I (n=0)
Class II (n=0)
Class III (n=14): CBZ, CLB, OXC, PB, PHT, TPM, VPA
 Generalized Tonic Clonic Seizures:
Children
Recommendations
Level A: None
Level B: None
Level C: CBZ*,PB, PHT*,TPM,VPA
Level D: OXC*
Level E: Others
Level F: None
*may aggravate tonic clonic seizures and
more commonly other generalized
seizure types, should be used with
caution
 Childhood Absence Epilepsy:
Available Evidence
A total of 6 RCTs examined initial
monotherapy of children with Childhood
Absence Epilepsy
Division of trials
Class I (n=0)
Class II (n=0)
Class III (n=6) -3 Double Blinded

ETX, LTG, VPA

 Childhood Absence Epilepsy:
Recommendations
Level A: None
Level B: None
Level C: ESM, LTG, VPA
Level D: None
Level E: Others
Level F: CBZ, GBP, OXC, PB,
PHT,TGB,VGB
 Juvenile Myoclonic Epilepsy:
Available Evidence
A total of 0 RCTs examined initial
monotherapy of children with Juvenile
Myoclonic Epilepsy
Division of trials
Class I (n=0)
Class II (n=0)
Class IIII (n=0)
 Juvenile Myoclonic Epilepsy :
Recommendations

Level A: None
Level B: None
Level C: None
Level D: CZP, LTG*, LEV, TPM, VPA, ZNS
Level E: Others
Level F: CBZ*, GBP, OXC*, PHT*, TGB, VGB

*may aggravate myoclonic seizure types, should be

used with caution
 Partial seizures
CBZ or OXCBZ drug of
choice in general
All newer drugs could
be used
Useful combinations:
CBZ+VPA, CBZ+TPM
 Seizure-
free

Improve
Dont improve
 Febrile seizures
Most do not require treatment
Look for atypical features
Intermittent Diazepam, Clobazam
Long-term: VPA, PHB, Clobazam
PHT and CBZ do not prevent
febrile seizures and not helpful
 ABC, Blood tests, Glucose,
Thiamine
IV Lorazepam
IV Phenytoin loading
IV Valproate or Midazolam
drip or PHB
General anesthesia
Lenin
 PHT, CBZ, PHB, TPM reduce
efficacy of O.C. pills
Catamenial epilepsy
Sensitivity to side effects
Pregnancy counseling
Polycystic ovaries,
hormonal changes with VPA
 2 or more seizures per month
for at least 2 years on 2 mono-
and 1 poly-therapy trial
Revise diagnosis, seizure types
Appropriate doses of
appropriate drugs with proper
titration
Compliance
Antiepileptic soup
 MRI brain, EEG/VEEG
Depth electrode recording
Wada, neuropsych. Testing
Surgery: Temporal lobectomy,
lesionectomy,
hemispherectomy, corpus
callosotomy, multiple subpial
transections etc
 Consider enrollment in
newer drug trials
Vagus nerve stimulation
Ketogenic diet
Alternative therapies not
helpful
My VNS
Emily Kage
Psychiatric aspects
Depression: SSRIs
Psychosis: Pimozide
Side effects of antiepileptic
drugs
Pseudoseizures
Psychiatric effects after
surgery
 It all depends on
How you look at me!
 Cannot have a legally valid
marriage if properly certified
by a specialist! (removed in
99)
No specific driving guidelines
Not mandatory for doctor to
inform authorities
No job discrimination
No legal bar on education