| ID | 393 |
|---|---|
| Name | SEIZURE DISORDERS : EPILEPSIES |
| Cause | Various factors, including: Genetic influence. Head trauma. Infections. Meningitis, HIV, viral encephalitis and some parasitic infections can cause epilepsy. Risk factors Certain factors may increase your risk of epilepsy: Age. The onset of epilepsy is most common in children and older adults, but the condition can occur at any age. Family history. Head injuries. Dementia. Dementia can increase the risk of epilepsy in older adults. Brain infections. Infections such as meningitis. Seizures in childhood. High fevers in childhood can sometimes be associated with seizures. Children who have seizures due to high fevers generally won't develop epilepsy. The risk of epilepsy increases if a child has a long fever-associated seizure, another nervous system condition or a family history of epilepsy. |
| Signs Symptoms | Temporary confusion. A staring spell. Stiff muscles. Uncontrollable jerking movements of the arms and legs. Loss of consciousness or awareness. Psychological symptoms such as fear, anxiety or deja vu |
| 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 mos cases furnish pointers to the etiology of fits and hence to the need for sp cial investigations. An E.E.G. and skull radiographs should be obtained. |
| Investigations | Electroencephalogram (EEG). ... High-density EEG . ... Computerized tomography (CT) scan. ... Magnetic resonance imaging (MRI). ... Functional MRI (fMRI). ... Positron emission tomography (PET). ... Single-photon emission computerized tomography (SPECT). |
| Management | Treatment: General measures; Usually an epileptic patient comes to a physician when the fit is already been overcomed. If the patient is brought to the physician, unconcious or in persistent seizure, the initial management should be as follows- 1. Clear the airway- suckout sceretions, loosen clothing about the neck. 2. Oxygen supplement at high concentration during convulsions or if cyanosed (if available). 3. Protect from bodily injury- restraints; prevent tongue biting by using a padded gag or tightly rolled handkerchief, or metallic or plastic objects (but not fingers) in between the teeth. 4. Turn on the side- to prevent aspiration of pooled secretions. Note: Padded gag between the teeth to prevent bitting of tongue, only done if jaw is relaxed; other wise more damage with use of force. 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. Preferably one drug and no more than two drugs should be used in combination therapy at one time i.e 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:2'13-21-31 Selection of antiepileptic drugs-37 Seizure type 1st line drug Alternative Generalized tonic-clonic Valproic acid, Phenytoin seizure Lamotrigine Phenobarbitone Carbamazepine Clobazam Topiramate* Partial seizure Carbamazepine Topiramate* (All types) Phenytoin Gabapentin* Lamotrigine Clobazam Valproic acid Phenobarbitone Absence seizure Valproic acid Lamotrigine Ethosuximide Clonazepam Myoclonic seizure Valproic acid Clobazam Clonazepam Lamotrigine Infantile spasm ACTH/prednisolone Valproic acid Vigabatrine Clonazepam Clobazam Topiramate* Mixed, atypical Valproic acid Lamotrigine absence, atonic Clonazepam Topiramate* * These drugs are preferabale as adjunctive therapy. Dosages of common antiepileptic drugs: Primary generalised tonic-clonic (grandmal) epilepsy: 1. First-line drugs: i. Valproic acid: Child, up to 20kg, initially lOmg/kg daily in divided doses, may be increased gradually to 30-60mg/kg daily; over 20kg initially 400mg daily in divided doses increased until control to a range of 20-35mg/kg daily. Preferably after food, ii. Lamotrigine: Initially 25mg daily for 14 days then 50mg daily for further 14 days; usual maintenance as monotherapy, 100-200mg daily in 1-2 divided doses (up to 500mg daily has been required). Elderly not recommended, iii. Carbamazepine: Starting dose, l0mg/kg/day orally in 2 or 3 divided doses; max. 20-30mg/kg/day in 3 divided doses. 2. Alternative drugs: i. Phenytoin: 3-10mg/kg/day orally in 3 divided doses. In case of i.v administration starting loading dose may be 20mg/kg; for neonate loading dose is 20-30mg/kg. ii. Phenobarbitone: 5mg/kg/day orally in 2 divided doses. iii. Clobazam: 0.25-lmg/kg/day, orally in 2 or 3 divided doses, iv. Topiramate: l-9mg/kg/day, orally in 2 divided doses. Partial &/or secondary generalised tonic clonic epilepsy: 1. First-line drugs: i. Carbamazepine: Dose, see above ii. Phenytoin: Dose, see above iii. Lamotrigine: Dose, see above iv. Valproic acid: Dose, see above 2. Alternative drugs: i. Topiramate: l-9mg/kg/day, orally in 2 divided doses. ii. Gabapentin: Child, 6-12 years (specialist use only) lOmg/kg on day 1. then 20mg/kg on day 2, then 25-35mg/kg daily, in 3 divided doses approx. every 8 hours; maintenance, 900mg daily (body-weight 26-36kg) or 1200mg daily (body-weight 37-50kg) iii. Clobazam: 0.25-lmg/kg/day, orally in 2 or 3 divided doses. iv. Phenobarbitone: 5mg/kg/day orally in 2 divided doses. Absence (petitmal) epilepsy: 1. First-line drugs: i. Valproic acid: Dose, see above ii. Ethosuximide: Begin with 20mg/kg/day, increase to maximum of 50mg/kg/day or 1500mg/day (whichever is less) in 3 divided doses. 2. Alternative drugs: i. Lamotrigine: Dose, see above ii. Clonazepam: Up to 1 year 0.25mg increased as above to 0.5-lmg; 1-5 years, 0.25mg increased up to l-3mg, 5-12 years, 0.5mg increased up to 3-6mg daily orally in 2 or 3 divided doses. Myoclonic epilepsy: 1. First-line drugs: i. Valproic acid: Dose, see above, ii. Clonazepam: Dose, see above. 2. Alternative drugs: i. Clobazam: 0.25-lmg/kg/day, orally in 2 or 3 divided doses, ii Lamotrigine: Dose, see above. Duration of treatment: The treatment regimen should be continued for 3 years after the last attack of epileptic seizure. General advice for epilepsy- 1. Education: In normal school with normal intelligence; should carry a card with name & address of the patient & the treating doctor. 2. Free-mixing & normal activities should be allowed. 3. Employment: All patients of epilepsy should be employed in some form of work which should not endanger their lives. 4. They should not be allowed to work near fire, machinaries, or at a height. 5. Swimming, cycling or driving cars should be abandoned. 6. Whould not marry in a family where there is a strong tendency of epilepsy. 7. Precipitating factors: hunger, emotional upset, fever etc. should be attended duly. |
| Introduction | Seizure: a seizure is a sudden, transient disturbance of brain function, manifested by involuntary motor, sensory, autonomic or psychic phenomena, alone or in any combination, often accompanied by alteration or loss of consciousness. A seizure may occur after a transient metabolic, traumatic, anoxic or infectious insult to the brain, i.e seizures are caused by any factor that can disturb brain function.14 Epilepsy: it is defined as a group of disorders in which there are recurrent episodes of altered cerebral function associated with paroxysmal excessive and hypersynchronous discharge of cerebral neurones. The clinical accompaniments of these episodes or seizures vary in manifestation from brief lapses of awareness to prolonged bouts of unconsciousness, limb jerking and incontinence in behavior.2 The incidence of seizures & epilepsies is highest in the newborn and higher in childhood than in later life.14 Epileptic seizures either of- a. Unknown etiology (idiopathic or primary epilepsy). Or, b. Congenital or acquired brain lesions (symptomatic, organic or secondary epilepsy). |
| History | |
| Etiology | An imbalance of nerve-signaling chemicals called neurotransmitters, tumors, strokes, and brain damage from illness or injury, or some combination of these |
| Clinical Features | Staring. Jerking movements of the arms and legs. Stiffening of the body. Loss of consciousness. Breathing problems or breathing stops. Loss of bowel or bladder control. Falling suddenly for no apparent reason, especially when associated with loss of consciousness. |
| Preventions | Don't drink alcohol, use illegal drugs, or smoke. Protect your head with a helmet during any sport or activity that could result in a head injury. Get plenty of sleep every night. Do your best to avoid getting a cold or the flu. Talk with your doctor about all of your prescription medications to be sure they won't aggravate seizures. Always take all of your epilepsy medications as prescribed. Find healthy ways to cope with stress. |
| Treatment | Brivaracetam. Brivaracetam is the generic name (non-brand name) of a seizure medicine with the brand name Briviact® from UCB. ... Cannabidiol oral solution. ... Carbamazepine. ... Carbamazepine-XR. ... Cenobamate. ... Clobazam. ... Clonazepam. ... Diazepam Nasal. For Dose reffer under Clinical Pharmacology |
| Complications | Falling.Patient can injure your head or break a bone. Drowning.While swimming or bathing than the rest of the population because of the possibility of having a seizure while in the water. Car accidents. A seizure that causes either loss of awareness or control can be dangerous if driving a car or operating other equipment. Problems with sleep. People who have epilepsy also tend to have sleep problems, such as trouble falling asleep or staying asleep, known as insomnia. Pregnancy complications. Seizures during pregnancy pose dangers to both mother and baby, and certain anti-epileptic medicines increase the risk of birth defects. If have epilepsy and patient considering becoming pregnant, get medical help as She plan her pregnancy. Memory problems. People with some types of epilepsy have memory problems. Emotional health issues People with epilepsy are more likely to have psychological problems. . Emotional health problems that may affect people with epilepsy include: Depression. Anxiety Suicidal thoughts and behaviors. Other life-threatening complications of epilepsy are uncommon but may happen These include: Status epilepticus. Increased risk of permanent brain damage and death. Sudden unexpected death in epilepsy (SUDEP). People with epilepsy also have a small risk of sudden unexpected death. The cause is unknown, but some research shows it may occur due to heart or respiratory conditions. |
| Prognosis | |
| Types | |
| Classification | Classification: Epilepsy may be classified as: 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. Generalised epilepsies are- a. Absence (petitmal) seizures (childhood & juvenile) b. Generalised tonic clonic (grandmal) seizures (GTCS) c. Tonic or clonic or atonic seizures d. Myoclonic seizure (juvenile) e. Infantile spasm 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 ‘simple’ & ‘complex’ types. Partial seizures are frequently become secondarily generalised. 3. Unclassified seizures. 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- is uncommon in grandmal fits, it is brief there is an apprehension that a fit is about to happen or a feeling in the epigastrium. Aura may be sensory, visceral, motor or autonomic. 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 feces. 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 moveme-nts, 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. 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. |
| Observation | |
| Pathology |
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