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EPILEPSY & SEIZURE DISORDERS

ETIOLOGY

EPIDEMIOLOGY

PATHOPHYSIOLOGY OF EPILEPSY

CLASSIFICATION OF SEIZURES

GENERALIZED SEIZURES •

Generalized Tonic-Clonic Seizures (Grand Mal)  –

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Prodrome : apathetic, depressed, irritable, abdominal pain/cramps, throbbing headache, constipation, diarrhea, etc Flexion of trunk, mouth & eyelids opening, upward deviation of eye, erms elevated and abducted, elbows semifelxed, hands pronated

Tonic phase(10-20s): stiff body, piercing cry, pupils dilated, unresponsive to light, bladder empty

GENERALIZED SEIZURES  –

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Clonic Phase : tremors, violent flexor spasm in rhytmic salvos agitate the entire body Terminal phase : all movements ended, deep coma, pupils contract to light, breathing quiet or stertorous. Wake up  confused and bewildered, don’t remember anything, pulsatile headache, sleepy

GENERALIZED SEIZURES •

Absence, Petit Mal Seizures  –

Coming without warning

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Sudden interruption of conciousness

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10%  motionless. Minor automatism : lipsmacking, chewing, fumbling movement of fingers May continue complex acts (walking, riding bike)

After 2-10s  reestablish full contact, resume preseizure activity Hyperventilation  provoke seizure

GENERALIZED SEIZURES •

Absence Variants  –

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Less complete loss of conciousness, prominent myoclonus

Lennox-Gastaut Syndrome : atonic, astatic seizures, succeded by motor, tonic-clonic, partial seizure

GENERALIZED SEIZURES •

Myoclonic Seizures  –

Brusque, brief, muscular contraction

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May affect part muscle, or entire muscle

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Benign, respond well to medication

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Dissemniated myoclonus  suspicion of some other diseases

Juvenile Myoclonic Epilepsy : most common form of generalized epilepsy in older children and young adults

PARTIAL OR FOCAL SEIZURES •

Simplex Partial Seizures  –

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Seizures begin in a focal area and do not impair awareness

Complex Partial Seizures  –

Seizures with focal onset and impair awareness

EPILEPSY SYNDROMES

DIAGNOSIS •

History  –

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Most important, diagnosis can be made by history alone

Patient or witness describes the condition

Physical Examination  –

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Rarely benefits in diagnosis

Used to diagnose meningitis, or other underlying etiology of seizures

DIAGNOSIS •

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Laboratory Test  –

Reveal underlying metabolic etiology

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Hyponatremia, hypocalcemia, lactic acidosis

Radiographic Imaging  –

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MRI and CT to find structural abnormalities

Electroencephalography (EEG)

EEG

TREATMENT •

Drugs

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Vagus nerve stimulation

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Surgery

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Ketogenic diet

Drugs •

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The mainstay of epilepsy treatment: medical therapy ( AEDs). AED treatment is usually begun after 2 seizures that are not symptomatic or provoked. Goal: monotherapy – control of seizures using a single drug.

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Increase the dosage of a single drug until either sizure control is achieved or adverse effects become intolerable. If the latter occurs, the dose is lowered and a second drug added if necessary. If seizure control is achieved  taper the 1st drug  leaving the 2nd as monotherapy.

TREATMENT •

Antiepileptic drugs for adults

TREATMENT •

Antiepileptic drugs for children

TREATMENT •

Drugs combination

Vagus nerve stimulation •

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Effective in the treatment of partial seizures. The device is implanted subcutaneosuly in the chest and stimulates the left vagus nerve through programmed electrical impulses delivered through leads places in the neck.

Surgery •

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Patients refractory to medical management may be treated with epilepsy surgery. The most common surgical procedure is resection of the epileptogenic area. For seizure of medical temporal lobe origin, the rate of seizure freedom following resective surgery may be as high as 90%.

Ketogenic diet •

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The diet is used mainly in children between the ages of 1 and 10 years. The regimen is initiated during hospitalization by starvation for a day or two in order to induce ketosis, followed by a diet in which 80 to 90 % of the calories are derived from fat.  –

Traditional approach ketosis diet •

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Fat : carbohydrate and protein = 4 : 1

MCT based ketosis diet

STATUS EPILEPTICUS •

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Recurrent generalized convulsions at a frequency that precludes regaining of consciousness in the interval between seizures Prolonged convulsive status >30 minutes Emergencies : Rising temperature, acidosis, hypotension, renal failure, epileptic encephalopathy, neurogenic pulmonary edema  hypertensive encephalopathy

STATUS EPILEPTICUS •

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Etiologies : all fundamentals of seizure Mostly associated with viral or paraneopastic encephalitis, old traumatic injury, epilepsy with idiopathic mental retardation

APPROACH TO TREATMENT OF STATUS EPILEPTICUS

APPROACH TO TREATMENT OF STATUS EPILEPTICUS