Meiti Frida
Department of Neurology
Andalas University
Padang
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
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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
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Asynchronous burst firing in some
hypocampal and cortical neurons
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Generalized epileptogenesis :
asynchronous burst firing in abnormal
thalamocortical interaction
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Developed countries :
annual incidence 50-70 cases per 100.000
Developing countries : prevalence 1%
Incidence varies with age
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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
0
1
5
10
20
Age (years)
60
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
Partial seizures (beginning locally)
 Simple partial seizures (without impaired
consciousness)
with motor symptoms
 with somatosensory or special sensory symptoms
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Complex partial seizures (with impaired
consciousness)
simple partial onset followed by impaired consciousness
 impaired consciousness at onset
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Partial seizures evolving into secondary
generalized seizures
Generalized seizures (convulsive or nonconvulsive)
 Absence seizures
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Typical
Atypical
Myoclonic seizures
Clonic seizures
Tonic seizures
Tonic clonic seizures
Atonic seizures
Unclassified seizures
Partial seizures
 Simple – preservation of awarness
 Complex – impairment of consciousnesss
 Secondary generalized
Generalized seizures
 Absence
 Myoclonic
 Tonic-clonic
 Tonic
 Atonic
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
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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 Gaucher’s disease or Lundborg’s
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
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Interviews with patients or witness
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Circumstances surrounding the attacks
idiopathic and generalized
No seizure worning
No underlying brain lesions
Associated with a family history
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Symptomatic and localization related
Aura
Specific site of onset
Identifiable cause
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Recurrent episodes of seizures
Symptoms occured during and after seizures
Recording symptomatic events with videocamera and
continous ambulatory EEG monitoring
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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
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Essential, particularly in partial onset
seizures
Computerized tomography (CT)
Magnetic resonance imaging (MRI)
Structural lesion
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
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Migraine
Transient Ischaemic Attacks
Hyperventilation
Tics
Myoclonus
Hemifacial spasm
Syncope
Sleep disorders
Non Epileptic Attacks
Narcolepsy
Metabolic disorders
Transient global amnesia
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
Proposed Indications for resective epileptic
surgery
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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
Newly diagnosed epilepsy
47%
First drug
Seizure-free
13%
Second drug
Seizure-free
40%
Refractory
Rational duotherapy
Surgical assessment
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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 side-effects
Keep the regiment simple with once- or twicedaily dosing, if possible
Measure drug concentration when seizures are
controlled or if control is not readily obtained (if
possible)
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Counsel the patient early regarding the
implications of the diagnosis and the
prophylactic nature of drug therapy
Try two reasonable monotherapy options
before adding a second drug
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
Seizure type
First line
Second line
•Sodium valproate
•Carbamazepine
•Phenytoin
•Lamotrigine*
•Oxcarbamazepine*
Absence
•Sodium valproate
•Ethosuximide
•Lamotrigine*
Myoclonic
•Sodium valproate
•Lamotrigine*
•Carbamazepine
•Phenytoin
•Lamotrigine*
•Oxcarbamazepine*
•Sodium valproate
Tonic clonic
Partial
Unclassifiable •Sodium valproate
•Lamotrigine*
*Lamotrigine and oxcarbamazepine are regarded as first-line drugs in some countries
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
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Life threatening medical defined as frequent
and / or prolonged epileptic seizure
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
Wrong patient
 Poor compliance with medication
 Inappropriate lifestyle (e.g. alcohol or drug abuse)
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After 2-3 years period of seizure’s free, must
be tappering off in six month
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Dependent with underlying syndrome and /
or its cause
Patient’s compliance
Reciprocal illness or medications
60-70% controlled by first-line drug of
epilepsy
10% of the rest controlled by new drugs
The rest :
surgery
Institution
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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
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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
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Driving lisence
 Free of seizure after 6 months controlled epilepsy
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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
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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
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Marriage and pregnancy
Health education
Impairment, disability and handicap