epilepsy shi xue chuan. general considerations a seizure is a sudden, transient disturbance of brain...
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Epilepsy
Shi Xue Chuan
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General Considerations 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 metabolic, traumatic, anoxic, or infectious insult to the brain.
Repeated seizures without evident cause justify the label of epilepsy.
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General Considerations Incidence is greatest in early and late
life, with a prevalence of approximately 3 ~ 6 ‰.
Chance of having a second seizure after an initial unprovoked episode is 30%.
Chance of remission from epilepsy in childhood is 80%.
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General Considerations Recurrence rate after the withdrawal of
drugs is about 30%.
Idiopathic or genetic epilepsy most often
appears between ages 4 and 16 yaers.
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General Considerations Factors adversely influencing
recurrence include: Difficulty in getting the seizures
under control Neurologic dysfunction or mental
retardation Age at onset under 2 years Abnormal EEG at the time of
discontinuing medication Type of epilepsy
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Etiology Genetic factor Brain damage and
dysmetabolism Inborn Acquired
Causative factor
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Classification
Classified by etiology Idiopathic (essential) epilepsy
Symptomatic (secondary)
epilepsy
Cryptogenic epilepsy
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Classification Classified by epileptic
seizures Partial (foal, local) seizures
Simple partial seizures, without impairment of consciousness With motor signs With somatosensory or special-
sensory symptoms With autonomic symptoms or signs With psychic symptoms
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Classification
Classified by epileptic seizures
Complex partial seizures, with
impairment of consciousness
Partial seizures evolving to
secondarily generalized seizures
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Classification Classified by epileptic seizures
Generalized seizures Absence seizures
Typical absence Atypical absence
Myoclonic seizures Clonic seizures Tonic seizures Tonic-clonic seizures Atonic seizures Infant spasm, tonic-spasm
Unclassified epileptic seizures
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Classification Classification of epilepsy and epilepsy
syndromes Benign children epilepsy with centrol-
temporal spike Lennox-Gastaut syndrome Infantile spaams Juvenile myoclonic
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Clinical manifestation Partial epilepsy
Focal epilepsy may arise from an intracerebral structural defect, causing motor or sensory symptoms localized to one body part, which may then spreads to contiguous regions of the cortex (e.g. jacksonian seizures).
There are simple partial seizures without impairment of consciousness.
Complex partial seizures associated with disturbance of consciousness usually arise in the temporal lobe.
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Clinical manifestation Partial epilepsy
Seizures arising in the medial temporal lobe may produce disturbances of smell and taste, visual hallucinations.
These may evolve to a tonic-clonic seizures ( secondary generalization).
Weakness following the event may occur for minutes or hours (todd’s paresis).
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Clinical manifestation Generalized seizures
Absence attacks usually consist of a brief interruption of activity, sometimes with complex motor activity (such as fumbling with clothes), but without collapse.
EEG during this event shows a three-per-second spike-and-wave activity.
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Clinical manifestation Generalized seizures
In a generalized tonic-clonic seizures, the tonic phase is a sudden tonic contraction of muscles usually with upward eye deviation. The clonic (‘with clonus-type activity’) phase follows.
Initial EEG changes are often bilateral. This condition usually has its onset in
childhood.
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Diagnosis of epilepsy The integrate diagnosis should include
seizure type, anatomy, etiology and concomitant mental disorders.
For example: Epilepsy--grand mal—secondary
(symptomatic)— mental retardation Epilepsy—centrotemporal spike wave--
benign childhood epilepsy
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Diagnosis of epilepsy Clinical picture
Clinical history
Description of Sz
Symptomatology
Physical/Neurologic
examination
Therapy
EEG Background activity Epileptiform activity
Interictal Ictal Postictal
Laboratory tests
Neuroimaging
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Differenial diagnosis Febrile Seizures
Ages 3 months to 5 years Fever Non-CNS infection Generalized seizures Last less than 5 minutes
Migraine Positive family history. Pulsatile headache Manifestations of autonomic nerve disorder Visual disorder Sensory disturbance
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Differenial diagnosis Breath-holding spells
Age 6 months to 3 years, Cry, loss of consciousness Apnea and cyanosis Family historypositive in 30% Normal EEG.
Sleeping disturbance Sleepwalking , Nightmare Night terrors
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Differenial diagnosis Masturbation
Consciousness not impaired Normal EEG
Pseudoseizures Effectual Suggestive therapy Normal EEG
Tourette sydrome Simple or complete stereotyped jerks or
movements Cough and grunt Normal EEG Positive Family history
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An approach to Seizures
natura l h istory
investiga tion
treatm ent
What is the probable cause?
N o
D iagnose and Treat
Yes
Is it symptomatic of an acute illness
Yes N o
Is it a seizure?
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Treatment of epilepsy Therapeutic principle of ntiepilepsy
drugs (AEDs) Early treatment Treatment as the types of epileptic seizure Treatment with one drug Individual therapy Long course of treatment Slow drug withdrawal Periodic re-examination
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Treatment of epilepsy AEDs selection on types of epileptic seizure
types drugs
Tonic-clonic seizures VPA, PB, CBZ, PRM or PHT
Absence seizures VPA, ES, CNP
Myoclonic seizures VPA, CNP, PRM, Topamax
Partial seizures CBZ, VPA, PB, PHT, PRM, T
Infantile spasms CNP, ACTH, Prednison, VPA
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Antiepilepsy drugs,AEDsdrug
Dosage mg/kg
Effective blood level ug/ml
T1/2 Side effect
VPA 15-50 50-120 8h Ganstric discomfort, sthenic apptite , hepatic dysfunction
CBZ 15-30 4-12 15h Drowsiness, Skin rash, WBC
decrease, hepatic dysfunction
PHT 4-8 10-20 22h Skin rash,ataxia, WBC decrease, unsteady gait
PB 4-6 20-40 4d Hyperkinesia, inattention, Skin rash
ESX 20 40-120 55h Gastrointestinal disorder, headache , WBC decrease,
CZP 0.01-0.2 20-80 55h Drowsiness, Skin rash, unsteady gait, ataxia, salivate
ACTH 25-40u Hyperfuction of the adrenal cortex
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Update on newer AEDs
drug Dosage mg/kg
Effective blood level ug/ml
T1/2 Side effect
TMP 3-10 20-30h infant 15h
Drowsiness, inattention, slow reaction, lose appetite, weight lose
LTG 5-15 (used with VPA
1-5)
1.1-3.0 20-30h Drowsiness, Skin rash, ataxia, headache, gastric discomfort
GBP 20-50 2-3 5-7 Drowsiness, ataxia, nystagmus, personality and behavioral changes
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2 種 抗 癲 癇 藥 物
3 種 抗 癲 癇 藥 物
試 用 新 藥
7% 難 以 控 制 3% 控 制 良 好
VNS
10% 難 以 控 制 3% 控 制 良 好
10% 難 以 控 制
3% 難 以 控 制 7% 控 制 良 好
10% 手 術 治 療
20% 難 以 控 制 5% 控 制 良 好
25% 難 以 控 制 5% 控 制 良 好
30% 難 以 控 制 70% 控 制 良 好
1 種 抗 癲 癇 藥 物Treatment of epilepsy
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Status epilepticus Status epilepticus is a clinical or electrical
seizure lasting at least 30 minutes, or a series of seizures without complete recovery over the same period of time.
Emergency Treatment ABC(airway, breathing, circulation) Diazepam 0.3-0.5mg/kg ;may repeat in 15-30 minutes Phenytoin 10-20mg/kg Phenobarbital 5-20mg/kg
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Thank you