If you are on right path and you are If you are on right path and you are not facing difficulties… then think for not facing difficulties… then think for a while: you may be on wrong path…a while: you may be on wrong path…because right path always contains because right path always contains difficulties.difficulties.

HAZRAT ALI R.AHAZRAT ALI R.A

DR. ARSHAD RABBANI

CASE 1CASE 1

A young girl of age 10 is brough to A young girl of age 10 is brough to medical OPD with c/o deteriorating medical OPD with c/o deteriorating performance in her studies. performance in her studies. According to her teacher, she stops According to her teacher, she stops doing her work & seems to have day-doing her work & seems to have day-dreaming. This happens at home too. dreaming. This happens at home too. No h/o loss of consciousness or any No h/o loss of consciousness or any altered mental status.altered mental status.

What may be the possible cause?What may be the possible cause?

CASE 2CASE 2

A 40 yrs old A 40 yrs old gentleman is gentleman is brought to ER with brought to ER with h/o GTCF.patient is h/o GTCF.patient is drowsy. there is h/o drowsy. there is h/o low grade fever, low grade fever, cough & anorexia cough & anorexia for last 1 month. for last 1 month. CXR is shown. Give CXR is shown. Give your diagnosis.your diagnosis.

His CT brain is shownHis CT brain is shown

CASE 3CASE 3

A 35 years old lady is brought to ER A 35 years old lady is brought to ER with c/o left sided weakness. Pt is with c/o left sided weakness. Pt is slightly confused & shows features of slightly confused & shows features of left UMN lesion. There is history of left UMN lesion. There is history of epilepsy for which she takes epilepsy for which she takes medicine continuously.her weakness medicine continuously.her weakness recovered within 6 hrs. give your recovered within 6 hrs. give your diagnosis.diagnosis.

Case 4Case 4

A 67 yrs old man is brought to ER A 67 yrs old man is brought to ER with H/O focal fits in right arm. There with H/O focal fits in right arm. There is h/o some neurosurgical procedure is h/o some neurosurgical procedure 14 yrs back. Pt remained well since 14 yrs back. Pt remained well since then. then.

What may be the cause?What may be the cause?

CASE 5CASE 5

A 34 yrs old gentleman with history A 34 yrs old gentleman with history of epilepsy for last 15 yrs, on regular of epilepsy for last 15 yrs, on regular treatment presents with c/o multiple treatment presents with c/o multiple swellings over his body. No h/o fever, swellings over his body. No h/o fever, anorexia or weight loss. o/E there is anorexia or weight loss. o/E there is generalised lymphadenopathy.generalised lymphadenopathy.

What rare possibility comes to your What rare possibility comes to your mind?mind?

CASE 6CASE 6

A 34 yrs old lady comes to A 34 yrs old lady comes to gynaecology OPD with bad obstetric gynaecology OPD with bad obstetric history. There is h/o 2 abortions & 1 history. There is h/o 2 abortions & 1 baby with cleft palate. She is also an baby with cleft palate. She is also an epileptic and takes medicine epileptic and takes medicine irregularly/irregularly/

What advice should be given to her?What advice should be given to her?

CASE 7CASE 7

A 13 yrs old boy is brought to ER with A 13 yrs old boy is brought to ER with c/o GTCF at home about 30 min c/o GTCF at home about 30 min back. In ER again he has an episode back. In ER again he has an episode of GTCF. He is given INJ DIAZEPAM of GTCF. He is given INJ DIAZEPAM 10mg IV. The boy is mentally 10mg IV. The boy is mentally retarded. Examination reveals small retarded. Examination reveals small white oval lesions on skin. There is white oval lesions on skin. There is family history of epilepsy.family history of epilepsy.

What condition comes to your mind?What condition comes to your mind?

CASE 8CASE 8

A 65 yrs old gentleman is brought to A 65 yrs old gentleman is brought to OPD with c/o abnormal movements OPD with c/o abnormal movements of right hand. According to patient, of right hand. According to patient, this problem aggravates when he this problem aggravates when he attempts to write or perform some attempts to write or perform some skilled work .his uncle also had skilled work .his uncle also had similar problem. No other finding in similar problem. No other finding in history and examination. history and examination.

What may be the cause?What may be the cause?

CASE 9CASE 9

A 45 yr old diabetic is brought to OPD A 45 yr old diabetic is brought to OPD with 2 days history of difficulty in with 2 days history of difficulty in walking and inability to hold the objects. walking and inability to hold the objects. O /E: O /E:

Pt is conscious orientedPt is conscious orientedThere are intention tremors on right side There are intention tremors on right side Patient falls to right side when asked to Patient falls to right side when asked to

walk.walk.What is your diagnosis?What is your diagnosis?

CASE 10CASE 10

A young girl of age 17 is brought to A young girl of age 17 is brought to hospital with c/o difficulty in walking hospital with c/o difficulty in walking and increasing clumsiness of hands and increasing clumsiness of hands for last 6 months. o/e a young girl for last 6 months. o/e a young girl with rapid involuntary movements of with rapid involuntary movements of both hands. She has a broad-based both hands. She has a broad-based gait. eye examination reveals a gait. eye examination reveals a characteristic lesion. What is your characteristic lesion. What is your impression? impression?

DEFINITIONDEFINITION

Epilepsy is a tendency to have Epilepsy is a tendency to have recurrent seizures. It is a symptom of recurrent seizures. It is a symptom of brain disease rather than a disease brain disease rather than a disease itself.itself.

A seizure is any clinical event caused A seizure is any clinical event caused by abnormal electrical discharge in by abnormal electrical discharge in the brain.the brain.

Seizures types

ETIOLOGYETIOLOGY

Incidence according to ageIncidence according to age

PRIMARY GENERALISED EPILEPSYPRIMARY GENERALISED EPILEPSY

SECONDARY GENERALISED EPILEPSYSECONDARY GENERALISED EPILEPSY

PARTIAL EPILEPSYPARTIAL EPILEPSY

It has four types:It has four types:

1)1) Childhood absence epilepsyChildhood absence epilepsy

2)2) Juvenile absence epilepsyJuvenile absence epilepsy

3)3) Juvenile myoclonic epilepsyJuvenile myoclonic epilepsy

4)4) GTCS on awakeningGTCS on awakening

PRIMARY GENERALISED EPILEPSYPRIMARY GENERALISED EPILEPSY

Onset mostly in childhood or Onset mostly in childhood or adolescenceadolescence

Mostly due to genetic predisposition Mostly due to genetic predisposition without a structural causewithout a structural cause

It comprises upto 10% of all epilepsies It comprises upto 10% of all epilepsies and upto 40% of tonic clonic seizures.and upto 40% of tonic clonic seizures.

It may be caused by:It may be caused by:Spread of partial seizures due to Spread of partial seizures due to

structural disease ORstructural disease ORMay be secondary to drugs or May be secondary to drugs or

metabolic disorders.metabolic disorders.Epilepsy presenting in adult life is Epilepsy presenting in adult life is

almost always secondarily generelised.almost always secondarily generelised.

CAUSES OF SECONDARY GENERALISED CAUSES OF SECONDARY GENERALISED EPILEPSYEPILEPSY

secondary secondary generalisation from generalisation from partial seizurespartial seizures

GeneticGenetic Cerebral birth injuryCerebral birth injury AlcoholAlcohol Toxins Toxins Infective:Infective: meningitismeningitis Postinfectious Postinfectious

encephalopathyencephalopathy

Inflammatory:Inflammatory: Multiple sclerosisMultiple sclerosis SLESLEMetabolic:Metabolic: HypocalcemiaHypocalcemia Hyponatremia Hyponatremia HypoglycemiaHypoglycemia Renal failureRenal failure Liver failureLiver failureDrugsDrugsDegenerative Degenerative

diseasedisease

FOCAL LESIONS IN BRAIN FOCAL LESIONS IN BRAIN CAUSING EPILEPSYCAUSING EPILEPSY

DRUGS CAUSING SEIZURESDRUGS CAUSING SEIZURES

Penicillin, isoniazid , metronidazolePenicillin, isoniazid , metronidazoleChloroquine, mefloquineChloroquine, mefloquineCiclosporinCiclosporinLidocaine, disopyramideLidocaine, disopyramideAmphetamines (withdrawal)Amphetamines (withdrawal)Psychotropic agents:Psychotropic agents: phenothiazines, tricyclic phenothiazines, tricyclic

antidepressantsantidepressants lithiumlithium

1: IDIOPATHIC1: IDIOPATHIC2: FOCAL STRUCTURAL2: FOCAL STRUCTURAL LESIONS:LESIONS: Genetic:Genetic: Tuberous sclerosisTuberous sclerosis NeurofibromatosisNeurofibromatosis CVACVA TraumaTrauma tumourstumours

Infective:Infective: Cerebral abscessCerebral abscess ToxoplasmosisToxoplasmosis TuberculomaTuberculoma Subdural empyemaSubdural empyema EncephalitisEncephalitis Inflammatory:Inflammatory: SarcoidosisSarcoidosis vasculitisvasculitis

Sleep deprivationSleep deprivation Alcohol withdrawalAlcohol withdrawal Physical & mental exhaustionPhysical & mental exhaustion Recreational drug misuseRecreational drug misuse Intercurrent infectionsIntercurrent infections Metabolic disordersMetabolic disorders Flickering lights including TV & computerFlickering lights including TV & computer Loud noise, music, hot bath, reading Loud noise, music, hot bath, reading

(uncommon)(uncommon)

EEGEEGCT scan brainCT scan brainMRIMRITESTS FOR SECONDARY CAUSES:TESTS FOR SECONDARY CAUSES:RFTs, LFTs , blood glucose, s RFTs, LFTs , blood glucose, s

electrolyteselectrolytesCXRCXRCP, ESR, CRP,CP, ESR, CRP,CSF examinationCSF examination

IMMEDIATE CAREIMMEDIATE CARE

FIRST AID BY RELATIVESFIRST AID BY RELATIVES IMMEDIATE MEDICAL ATTENTION:IMMEDIATE MEDICAL ATTENTION:

ENSURE PATENT AIRWAYENSURE PATENT AIRWAY

GIVE OXYGENGIVE OXYGEN

GIVE IV ANTICONVULSANTGIVE IV ANTICONVULSANT

TAKE BLOOD FOR DRUG LEVELSTAKE BLOOD FOR DRUG LEVELS

INVESTIGATE THE CAUSEINVESTIGATE THE CAUSE

ANTICONVULSANT DRUGSANTICONVULSANT DRUGS

CarbamazepineCarbamazepine Sodium valproateSodium valproate diazepamdiazepam ClonazepamClonazepam PhenytoinPhenytoin phenobarbitonephenobarbitone TopiramateTopiramate GabapentinGabapentin LamotrigineLamotrigine ethosuximideethosuximide

Guidelines for anticonvulsant Guidelines for anticonvulsant therapytherapy

Start with one first-line drug.Start with one first-line drug.Start with low dose & increase to Start with low dose & increase to

effective dose.effective dose. If first drug fails, start second drug If first drug fails, start second drug

while gradually withdrawing first.while gradually withdrawing first.Try three agents singly before using Try three agents singly before using

combination.combination.Don’t use more than 2 drugs at a time.Don’t use more than 2 drugs at a time.

Withdrawal of AEDsWithdrawal of AEDs

After complete control of seizures for 2-4 yrs, After complete control of seizures for 2-4 yrs, consider AED withdrawal.consider AED withdrawal.

Childhood epilepsy carries the best prognosis Childhood epilepsy carries the best prognosis for successful drug withdrawal.for successful drug withdrawal.

Seizures that begin in adult life particularly Seizures that begin in adult life particularly those with partial features are likely to recur those with partial features are likely to recur esp if there is underlying structural cause.esp if there is underlying structural cause.

Overall recurrence rate after withdrawal is 40%Overall recurrence rate after withdrawal is 40% Withdrawal should be gradual over 6-12 Withdrawal should be gradual over 6-12

months.months.

Status epilepticus exists when a Status epilepticus exists when a series of seizures occur without the series of seizures occur without the patient regaining awareness between patient regaining awareness between attacks over a period of 30 minutes.attacks over a period of 30 minutes.

MANAGEMENTMANAGEMENT GENERAL CAREGENERAL CARE IV lineIV line Diazepam 10mg IV or rectally, can be Diazepam 10mg IV or rectally, can be

repeated once OR lorazepam 4mg IVrepeated once OR lorazepam 4mg IV If seizures continue after 30 minutesIf seizures continue after 30 minutes: : IV infusion phenytoin or phenobarbitalIV infusion phenytoin or phenobarbital If seizures still continue after 30 -60 min:If seizures still continue after 30 -60 min: Intubation & ventilationIntubation & ventilation Once status controlled:Once status controlled: Commence longterm anticonvulsant Commence longterm anticonvulsant

medicationmedication

EPILEPSY OUTCOME AFTER 20 YRSEPILEPSY OUTCOME AFTER 20 YRS

50% seizure free 50% seizure free without drugs for without drugs for last 5 yearslast 5 years

20% seizure-free for 20% seizure-free for last 5 years but last 5 years but continue to take continue to take medicationmedication

30% seizures 30% seizures continue inspite of continue inspite of anti-epileptic anti-epileptic therapytherapy