| ID | 118 |
|---|---|
| Name | EPILEPSY |
| Cause | |
| Signs Symptoms | |
| Diagnosis | Diagnosis: Observation of an episode by a trained person is the best and most certain method of diagnosis. The history and examination will in most cases furnish pointers to the etiology of fits and hence to the need for special investigations. An E.E.G and skull radiographs should be obtained. |
| Investigations | |
| Management | |
| Introduction | Epilepsy indicates a neurological manifestation of recurrent seizures or a tendency to have recurrent seizures. Currently, epilepsy is not considered as a disease entity itself, but a symptom or manifestation of brain disease. A seizure is a transient disturbance of cerebral function due to an abnormal paroxysmal neuronal discharge of the brain. A single seizure does not indicate epilepsy, but in about 70% cases recurrent seizures develop within the first year, mostly in the first or second month of the first seizure. There is a group of brain disorders in which epilepsy is the only or main symptom; some other disorders, where epilepsy may be one of the many symptoms. The clinical manifestations of epileptic seizures vary from brief lapses of awareness to prolonged bouts of unconsciousness, limb jerking and incontinence in behavior. |
| History | |
| Etiology | Etiology: See under etiological classification |
| Clinical Features | Clinical features: Absence (petitmal) epilepsy: The absence epilepsy occurs with three types of clinical manifestations- 1. The most common variety of attack takes the form of a transient loss of consciousness. The whole episode usually lasts only 10 to 15 seconds. Absences invariably starts in childhood but may persist into adult life. 2. Less commonly loss of consciousness is accom-panied by myoclonic jerking of the arms. 3. In the least common type, the patient falls to the ground unconscious but recovers consciousness and is able to rise again, almost immediately Generalised tonic clonic (grandmal) epilepsy: It is divided into several phases - 1. Prodromal phase- lasting hours or days, may warn the patient that an attack is impending, there is a change of mood. 2. An aura- refers to the symptoms immediately before a seizure and will localise the attack to its point of origin within the nervous system. 3. The tonic stage- the patient loses consciousness and, if upright, fall to the ground, A sustained tonic spasm of all the musculature occurs and there is a charcteristic cry, cyanosis occurs. 4. A clonic phase- interrupted powerful jerking movements of face, body and limbs, there is froth or saliva in the mouth. The patient may bite or chew of tongue and may be incontinence of urine or faeces. 5. The stages of relaxation- patient lies in a flaccid comatose state which evolves into normal sleep. After regaining consciousness patient is confused and may suffer from headache. Focal or Partial epilepsy: 1. Jacksonian or focal motor seizures- These are simple partial seizures, that originate in a focus of the cerebral motor cortex of one side; seizures usually start as involuntary twitching or jerking movements, which may begin at the angle of the mouth or thumb and index finger or any part of a limb, & then spread to involve the whole limb on the side opposite the affected hemisphere. In simple partial seizure, consciousness usually not impaired. Sometimes after recovery from a Jacksonian fit the parts affected may remain paralysed for several hours, known as Todd’s palsy. 2. The temporal lobe seizures- the temporal lobe is the commonest site of partial or focal epilepsy. The seizures originated in temporal lobe may be either ‘simple’ or ‘complex’ in type. Clinical manifestations are usually hallucinations of smell, taste, hearing or sight; sometimes associated with intense emotional or mood changes. In complex partial seizures, consciousness is impaired. |
| Preventions | |
| Treatment | Treatment: Immrtimte can for seizures:2 1. Move the person from the place of danger e.g fire, water, machinary etc. 2. Turn the patient to semiprone position & ensure the airway clear. 3. Prevent tongue biting by padded gag. 4. Give O2 at high concentration if available. 5. If convulsions continue for more than 5 minutes or recur, give i.v diazepam 10mg immediately; it may be repeated for once after 15 minutes if seizures are not controlled. If still continuous or repeated manage as for status epilepticus and transfer the patient to the hospital with intensive care arrangement (if available). Guidelines for epilepsy treatment:2 1. Treatment should be started with one first-line drug. 2. Start with low dose, and then increase gradually to a quantity effectively controls seizures with minimum side-effects. 3. If the first drug fails, start a second-line drug & withdraw the first one gradually by tailing the doses. If second one fails, try with a third one before giving combined therapy. 4. Don’t give more then two drugs in combination therapy. 5. If all the treatments fail, find the other causes of seizures. Drug choice for different epilepsies: Primary generalised tonic-clonic epilepsy: 1. First-line drug: Sodium valproate- Adult, initially 400-600mg daily in 2 divided doses, increasing by 200mg/day at 3-day intervals to a max. of 2.5gm daily in divided doses; usual maintenance l-2gm daily. Child, up to 20kg, initially 20mg/kg daily in divided doses, may be increased gradually up to 35mg/kg daily; over 20kg initially 400mg daily in divided doses increased until control to a range of 20-35mg/kg daily. Preferably after food. 2. Second-line drugs: Lamotrigine, Topiramate or Carbamazepine Dosage- see therapeutic section (if available). 3. Third-line drugs: Phenytoin, Gabapentin, primidone, Phenobarbitone, Tiagabine or Acetazolamide Dosage- see therapeutic section (if available). Absence epilepsy: 1. First-line drug: Ethosuximide- 750mg to I500mg in 2 divided doses. 2. Second-line drug: Sodium valproate- dose, see above. 3. Third-line drugs: Lamotrigine, Clonazepam or Acetazolamide Dosage- see therapeutic section (if available). Myoclonic epilepsy: 1. First-line drug: Sodium valproate- dose, see above. 2. Second-line drug: Clonazepam- dose, see therapeutic section. 3. Third-line drug: Piracetam, Lamotrigine or Phenobarbitone Dosage- see therapeutic section (if available). Partial and/or secondary generalised tonic clonic epilepsy: 1. First-line drug: Carbamazepine- dose, see therapeutic section. 2. Second-line drugs: Lamotrigine, Sodium valproate, Topiramate, Tiagabine or Gabapentin Dosage- see therapeutic section (if available). 3. Third-line drugs: -Clobazam, Phenytoin, Primidone, Phenobarbitone, Oxcarbazepine, Levetiracetam, Vigabatrin or Acetazolamide Dosage- see therapeutic section (if available). Duration of treatment: The treatment regimen should be continued for 3 years after the last attack of epileptic seizure. Advice: 1. The patients and their relatives should be explained the nature and cause of seizures, and the relatives should be instructed for first aid management in epileptic attack. 2. All patients of epilepsy should be employed in some form of work which should not endanger their lives. 3. They should not be allowed to work near open fire or water, machinaries, or at a height. 4. Epileptic patients should take only a shallow bath and should not lock the bathroom door. 5. Swimming, cycling or driving cars should be abandoned. 6. Free-mixing, normal activities e.g. going to school, participating social functions etc. should be allowed. 7. Precipitating factors should be avoided. |
| Complications | Factors which may trigger epileptic seizures:2 1. Sleep deprivation 2. Emotional stress 3. Physical and mental exhaustion 4. Infections, pyrexia 5. Drug or alcohol ingestion, or withdrawal 6. Flickering light, visual patterns, proximity to TV screens 7. Uncommon triggers- loud noise, hot baths, music, reading. |
| Prognosis | |
| Types | |
| Classification | Classification of epilepsy and seizure:12 The classification of epilepsy or seizure can be done based on aetiological factors and clinically on the character of the seizures. Etiological classification: A. Idiopathic or constitutional epilepsy: Most seizures in the early life, usually between 5 and 20 years- no specific cause including neurologic abnormality can be identified. B. Symptomatic epilepsy: 1. Pediatic age groups: Epileptic seizure in infancy or childhood due to congenital abnormalities or perinatal injuries. 2. Trauma: Traumatic brain injury is the most important cause of seizure in all age group, but particularly in young adults. 3. Tumors and other space-occupying lesion (SOL): These are also common causes of seizure in all age patients, but specially important in middle and later life. These are usually considered after 30 years of age; therefore all seizures of this age group must be examined by imaging. 4. Metabolic disorders: Seizures due to metabolic causes (such as-uraemia, hypo- or hyperglycaemia) are usually reversible on the correction of the causes, so, these are not considered as epilepsy. 5. Drugs and alcohol- sudden withdrawal from alcohol or drug. 6. Vascular diseases: In the later part of life (60 years or older), vascular diseases become the frequent cause of seizures. 7. Degenerative disorders: Such as Alzheimer’s disease & other degenerative disorders may cause seizures in old age. 8. Infection & infectious diseases: Such as bacterial or viral meningitis, encephalitis, longstanding or chronic disorders such as neurosyphilis or cerebral cysticercosis and other infective or inflammatory brain disease may cause potentially reversible seizures in all age groups. Clinical classification: According to the International League Against Epilepsy (ILAE) epileptic seizures are classified clinically as following: 1. Generalised epilepsy: In this seizures occur due to generalised involvement of the brain. This may be ‘primary’ or ‘secondary generalised epilepsy’* In primary generalised epilepsy, there is no structural abnormality; onset is usually in childhood or adolecence; in most cases, cause is genetic or idiopathic. Secondary generalised epilepsy presents almost in adult life; usually arises as a generalisation of partial seizure due to structural disease, or secondary to many drugs or metabolic diseases. Primary generalised epilepsies: a. Absence (petitmal) seizures (childhood & juvenile) b. Atypical absences (more marked changes in tone, attacks may have a more gradual onset and termination than in typical absences), c. Generalised tonic-clonic (grandmal) seizures (GTCS) d. Tonic or clonic or atonic seizures e. Myoclonic seizure (juvenile) f. Status epilepticus (repeated seizures without recovery, lasting about 30 minutes). Secondary generalised epilepsy. 2. Partial or focal epilepsy: In this variety, seizures occur by activation of a group of neurones limited or restricted to one part of one hemisphere (e.g temporal lobe) of the ceberal cortex; causes may be congenital or acquired. Character of the seizures usually depends on the affected part of the cortex. The partial seizures are divided into- a. Simple partial (consciousness preserved) b. Complex partial (consciousness impaired) c. Partial seizure with secondary generalisation. |
| Observation | |
| Pathology |
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