4. Past
• Oldest record SakikKu -babilonian medcal text
1067 B.C
• Aurvedic description as “Apasmara” 400 B.C
• “epilambanein”
to be overwhelmed by surprise
• Falling sickness
• Demonic possession
4
5. Past
• “its cause lies in the brain”
• 1920- Human EEG (Hans Berger)
5
9. Basics
SEIZURE PSEUDO
SEIZURE
SYNCOPE
• Sudden
• Unconscious
• Cyanosis
• Injury
• Sec to mints
• Hand on face
• Post ictal
confusion
• EEG,CPK,
Prolactin
• Gradual
• Conscious
• Thrusting
• Mins to hr
• Eye opening
• Pupil- Normal
• Psycho social
• Suggestive
• Light
headedness
• Standing
• Preventive-
lying
• Brief- lost
consciousness
9
10. Current scenario
• 60 million people worldwide
• 85% people-inadequate/not at all
• Specialist care:
LIC- 56%, HIC-89%
• AEDs: Govt priority, high cost , PB
10
11. Current scenario
• Age: any age (childhood, old age)
• Prevalence:
Single episode - 5%
Repeated- 0.5 to 2.5%
Our country- 2%
Developing country- 5 times higher
11
13. Cause
• Family history
5 to 10% of all epilepsies
Usually- 10 GTCS, Febrile convulsion,
Absence, Juvenile myoclonic epilepsy
• Primary generalized- 75% idiopathic
• Partial & 20 generalized- definite cause
75% adult
13
14. Cause
Neonates
<1 month
Infants
< 12 years
Adolescents
12-18 years
Young adult
18-35 years
Older
>35 years
Perinatal
hypoxia and
ischemia
ICH
Ca++ , Glucose
Bilirubin
Water
intoxication
Inborn error of
metabolism
Trauma
Febrile
seizures
CNS infection
Trauma
Developmental
disorder
Inborn error of
metabolism
Trauma
CNS infection
AVM
Infection
Congenital
defect
Tumors
Trauma
CNS infection
Brain tumor
AVM
Drugs and
alcohol
Drugs and
alcohol
Trauma
Tumor
CVD
Degenerative
CNS infection
14
33. Diagnostic approach
• CLINICAL EXAM
General survey
Vital signs
Cyanosis, Jaundice
Tongue bite mark
Systemic exam
Neurological, CVS, HBS, Resp System
33
34. Diagnostic approach
• LAB INQUIRY
Hematology
Biochemistry
Serology
CSF, Hormone, ECG
Imaging
• Late in onset
• Partial / 2o
generalized
• Refractory to drug
• Focal neuro deficit
• Status epilepticus
• Suspected ICSOL
• EEG shows focal
seizure
MRI/CT brain
Indication
34
35. Diagnostic approach
• LAB ENQUIRY
EEG
Type of epilepsy
Drug choice
Advanced lab test
Sphenoidal intra operative oval and
telemetric EEG
Ambulatory EEG, Videotelemetry
PET, SPET
35
42. Management
• AEDs-
Single drug , Low dose, Compliance
Switching
3rd drug prior combination
Two drugs at a time
Resistant to drug- metabolic/structural
42
43. Type First line Second line Third line
Partial / Secondary
GTCS
Carbamazepine Lamotrigine
Na Valproate
Topiramaate
Tigabine
Gabapentin
Clobazam
Phenytoin
Primidone
Phenobarbital
Oxcarbazepine
Levetiracetam
Vigabatrin
Acetazoalmide
Primary GTCS Na Valproate Lamotrigine
Topiramate
Carbamazepine
Phenytoin
Gabapentin
Primidone
Phenobarbital
Tigabine
Acetazolamide
Absence Ethosuximide Na Valproate Lamotirizine
Clonazepam
Acetazolamide
Myoclonic Na Valproate Clonazepam Piracetam
Lamotrizine
Phenobarbital
43
50. Interphase
• Psychiatric disorders in epilepsy
50% patient with epilepsy.
Ictal, peri-ictal , inter ictal (depression)
• Treatment related psychiatric problem
Depression, psychosis etc
AEDs (PB, Vigabatrin etc)
“Forced normalization”
50
51. Summary
51
History, Exam,
Exclusion D/D
History of
Epilepsy
Adequacy
Sub therapeutic
Level
Increase the dose
Therapeutic
Level
Max dose,
Alternative drug
Lab features
(biochemistry
hematology)
Positive Treat the cause
No History of
epilepsy
Lab features
(Biochemistry,
Hematology)
Positive Further work up Drug
Normal Imaging
Treat cause Drug
Idiopathic Drug
52. References
• Davidson’s principal & practice of Medicine, 21st edition, elsevier publisher,
2012
• Harrison’s Principales of internal medicine, 18th edition.
• Lecture Notes-Prof AKM Anwarullah
• Epilepsia, 44(suppl 6): 12-143. 2003, Blackwell publishing Inc, ILAE
• History of epilepsy 1909-2009: The ILAE century
• Recognition of psychogenic non epileptic seizure: acurable neurophobia, S S
O Sallivan et al, Journal of Neurosurg Psychiatry, 2013, 84: 228-231
• Why do some brain seize? Molecular ,cellular and network mechanism,
Andrew Trevelyan, Jphysiol(editorial)591.4(2013) 751-752
• The treatment gap in epilepsy, A Neliga, J W Sander, Epileptology 1 (2013)
28-30
52
53. “The sadness will last forever”
(Vincent van Gogh)
53
Wheat field with crows (1890)