DR MOHAMMAD A.S. KAMIL

CONSULTANT NEUROLOGIST

NEUROSCIENCES HOSPITAL

among the myriad of human

afflictions,perhaps none has

terrified,amazed and inspired more than

epilepsy.

One of every ten people will have at least one epileptic seizure during a normal life span, and a third of these will develop epilepsy.

Worldwide, epilepsy affects 50 million people.

According to a World Health Organization (WHO) survey, epilepsy accounts for 1% of the global burden of disease, a figure equivalent to breast cancer in women and lung cancer in men.

80 to 90 percent of epileptics in the developing world never receive treatment.

The frequency of epilepsy is slightly higher in lower socio-economic classes.

The incidence of seizures is age dependent, with the highest rates in the first year of life and a second peak in late life.

About 40% of patients develop epilepsy below the age of 16 years of age and about 20% over the age of 65 years.

the prognosis is generally good, and within 5 years of the onset of seizures 50–60% of patients will have entered long remission.

However, in about 20% of cases, epilepsy, once developed, never remits.

Standardized mortality rates are also 2–3 times higher in patients with epilepsy than in others in the population.

The excess mortality is caused largely by the underlying

cause of the epilepsy.

An epileptic seizure is ‘‘a transient occurrence of

signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain’’ .

Acute symptomatic seizures, sometimes called

provoked seizures, occur in the setting of acute medical and neurological illnesses in people with no prior history of seizures . typically occur within the first 1-2 weeks of an acute illness, although this time division is somewhat arbitrary. Common causes of acute symptomatic seizures are high fever (e.g. febrile seizures in young children), severe sleep deprivation, stimulant drugs , withdrawal from sedative drugs or alcohol, hypoglycemia, electrolyte disturbances, hypoxia, eclampsia, and acute neurological illnesses such as stroke, head trauma, and CNS infection .

Epilepsy is characterized by (1) at least one epileptic seizure; (2) an enduring predisposition to epileptic seizures; and (3) associated with neurobiologic ,cognitive, psychological, and social consequences.

Convulsion: intense paroxysm of involuntary repetitive muscular contractions.

FIT:??

epilepsy syndrome is an epileptic disorder characterized by similar features, including seizure type(s), precipitating factors, age of onset, etiology,neurologic and neuropsychological abnormalities,interictal and ictal EEG findings, and neuroimaging findings .

An epileptic disease is a specific pathologic entity with a single, well described etiology. An example of an epileptic disease would be Unverricht-Lundberg disease, while progressive myoclonic epilepsy, with many different etiologies, would be an epilepsy syndrome.

Simple Focal seizure : with no change in consciousness.

Complex Focal seizure :with altered consciousness.

Aura :Subjective symptoms attributable to a seizure (patient experiences but not seen by an observer), e.g., sensory symptoms, psychic symptoms such as déjà vu, abdominal sensations; essentially a simple partial seizure.

Prodrome :Vague sense, agitation preceding seizure.

Reflex epilepsy :Precipitated by stimulus (visual, eating, contemplating music, reading, startle).

Postictal :Following a seizure.

Automatism :Coordinated, involuntary movement during altered consciousness or postictal.

Semiology :Clinical seizure manifestations.

Idiopathic: Unknown cause, often used to describe genetic-related epilepsies, e.g., benign rolandic epilepsy.

Symptomatic Seizures with an identifiable cause (e.g., brain lesion, metabolic).

Cryptogenic :Suspected to be symptomatic, but no symptomatic cause identified on imaging (e.g., infantile spasms with normal MRI).

History of epilepsy 1) Antiquity to medieval period ;were widly

regarded as an attack,possession or seizure of human victim by supranatural being.

2) Reniassance until the mid of 19th century,were the development of anatomy, physiolog and medicine.

3) Modern era:can be traced the 1860s when the continouse studies of Jhon Hughling Jackson intiated a remarkable transformation in the medical and physiological understanding of seizure.

Sakkiku The oldest medical reference to epilepsy

consists of two clay tablets written in Assyrian-Babylonian, which are copies of portions of a comprehensive medical textbook known as Sakkiku that dates to (1067 -1046 BCE).

Although written over 3,000 years ago, they provide remarkably accurate accounts of some characteristic clinical manifestations of the disease.

Gelastic epilepsy was reported for the first time.

China 770-220 BCE Epilepsy was apparently known in ancient

China, but no chapter devoted to epilepsy is known to exist in the ancient Chinese medical literature.

Epilepsy was generally considered congenital, but other causes including phlegm and insufficiency of blood or kidney were mentioned.

India

The most elaborate descriptions are found in the Ayurveda (science of life), the oldest known

medical system that evolved continuously from

4500 to 1500 BCE. The views on epilepsy are

attributed to the physician Atreya (about 900

BCE).

The compendium of Ayurvedic medicine known

as Charaka Samhita (6th century BCE) used the term apasmara (apa, loss of; smara,

consciousness or memory) for epilepsy.

Hippocrates 400 BCE

The Hippocratic treatise On the Sacred Disease ; It begins with an attack against common popular superstitions.

Contrary to the Babylonian text, the Hippocratic writings challenged the widespread beliefs of the time that epileptic seizures were caused by actions of demons or gods.

The fundamental difference, however, between Hippocrates' and other contemporary or older medical explanations (Assyrian, Indian, and Chinese) lies in the unequivocal statement about the origin of the disease(the fact)¦that the cause of this affection (epilepsy)¦ is in the brain.

Hippocrates further recognized that all cognitive functions or emotional manifestations are related to the brain.

Thus, Hippocrates importantly dissociated epilepsy from religion and magic, arguing forcibly and eloquently that epilepsy was properly a subject not for incantation but for medical investigation and study.

Post-Hippocratic Hellenistic

and Roman Medicine

An interesting observation of that time was that sensory stimuli such as bad smell or the sight of whirling wheels were potentially epileptogenic.

Greeks and Romans used this knowledge to evaluate the fitness of slaves being sold by having them face the sun while looking through a turning potter's wheel.

Intermittent photic stimuli produced by his marching soldiers were reported to have triggered some of Julius Caesar's attacks.

In the 2nd century CE, the two main contributors to epileptology were Galen of Pergamon and Aretaeus of Cappadocia.

Galen (129 c 200AD):

- the 1st system of classification based on the behavioral manifestations (semiology )of seizure.

- 1st who describe aura:recognizes the importance of stereotyped warning of impending seizure and used the term aura.

Contributions from Islamic

Medicine

Islamic medicine, was strongly influenced by Galenic beliefs.

The two main Islamic physicians who mostly influenced the West were Rhazes (865 -925 CE) and Avicenna (980 -1037 CE).

Their opinions were based on personal observations of epileptic phenomena.

Avicenna considered two possible mechanisms, one originating in the brain and the other in the nerves, proposing that a putrid vapor from the distal part rose to affect the brain.

Rhazes used bleeding, emetics, and purgatives, while Avicenna used several traditional herbal and other pharmacologic agents.

Reniassance to the 19th century Remakable advances in neuroanatomy took place

in 16th and 17th ceturies by well known drawings of Vesalius,Lenardo Da Vinci and Thomas Willis.

1597 :benign Rolandic epilepsy by Martinus Rolandus.

1676: focal motor (jacksonian) seizures by the philosopher John Locke .

1667: juvenile myoclonic epilepsy by Thomas Willis .

1684: the 1st detailed discription of complex partial seizure by Thomas Willis (pathology of brain and nervous stock on convulsive diseases).

1772 :1st detailed description of absence seizure by Swiss neurologist Sameul August Tissot.

1789 :epilepsy no longer strictly associated with convulsion, fall and loss of body function(William Collens).

1850 :1st effective pharmacotherapy for epilepsy (Charles Locock) bromide of potassium when treated young womens with seizure associated with menstraul cycle(catamenial) 13 of 14 cured.

2nd half of 19th century: anumber of dedicated colonies and hospitals were established to house and care for patients with epilepsy :

- Bethel (Beilefeld)

- Chalfont(St.Peter , UK)

- Blackwell Island (New York)

- Ohio state hospital for epilepsy(Gallopitus)

- National hosp. for paralised and epilepsy (Queen Square, London)

1880 :the birth of modern neurosurgry with pioneers such as Rickman Godlee and Victor Horsley working closlely with neurlogists Ferrier and Jackson who become increaseingly confedent of the ability to localizing tumors and other epileptogenic lesions after careful study of seizure semiology and associted neurological defects.

modren period from jackson

s discharching lesion to the

EEG and beyond 1870 :the english neurologist Jhon Hughling Jackson

believing that careful examination of focal seizures would provides clues about the functional organization of the brain and the cause of seizure.

(loss of function result from tumour ,stroke ,convulsion result from discharching lesion).

1879:William McEwen(glasgow surgeon) had localized and removed a tumor of motor cortex in a teenage patient based solely on the presence of focal motor seizure invloving the arm and face.

The technological era Late 1920s EEG was developed by a German

neuropsychiatrist Hans Berger .

1935 (spike and dome)EEG of petit mal seizure after hyperventilation(Davis – Lennox –Gibbs).

1937 Boston group (paroxysmal cerebral dysrhythmia).

1938 :EEG use the precise loclization of the discharging lesion for surgical therapy of intractable epilepsy by Herbert Jasper published 1st criteria for localizing an epileptogenic lesion based on EEG.

The treatment not only for those with evidence of focal trauma ,focal neurological deficit or abnormal x ray.

Penefield operate on two Jasper patients whose EEG recordings alone suggested a focal abnormality .

1941 :1st atlas of EEG by Gibbs.

EEG become a fundamental axis in the 1st classification systems adopted by the ILEA in 1969.

Late 50s using EEG the surgical resection had become a safe

and effective treatment for mesial temporal lobe epilepsy with high rates of surgical cure (70%-80%) seizure free with low rate of morbidity and mortality

Recent development 1) Numerous effective antiepileptic drugs.

2) The pursuit of cellular,molecular and genetic mechanism in the production of seizure.

3) The rise or neuroimaging has profoundly impacted the diagnosis,classification and treatment of epilepsy.

NEUROSCIENCES HOSPITAL