SlideShare une entreprise Scribd logo
1  sur  41
DR.SRIRAMA.ANJANEYULU
                MD;DM
         NEUROLOGIST
               GUNTUR
Terminology

 “Treatment nonresponder”
 “Refractory”
 “Intractable”
 “Drug resistant”
CONSEQUENCES OF RE
 Bodily injuries - hospitalization.
 Shortened life spans-risk of sudden unexpected death.
 Significant neuropsychological, psychiatric, and social
  impairments.
 Limited employment, reduce marriage rates, and
  decrease quality of life.
PROGNOSTIC GROUPS IN EPILEPSY
 (1) Spontaneous remission (20–30%) - benign epilepsy
 with centrotemporal spikes or childhood absences.

 (2) Remission on AEDs (20–30%) - most focal epilepsy
 and myoclonic juvenile epilepsy syndromes;.

 (3) Persistent seizures under AEDs (30–40%) .
DEFINITION
 (1) Absence of response to 2 AEDs tolerated at
  reasonable doses.

 (2) Minimum frequency of seizures (e.g. 1 seizure per
  month) to be considered refractory or the duration of
  minimum remission (e.g. 6– 12 months) to be qualified
  as non refractory.

 (3) Duration of 1 year to 1 decade of non controlled
  epilepsy.
EPIDEMIOLOGY
 (i) No unifying definition of RE.
 (ii) Same pt might be refractory at one time, but treatment
  responsive at another.
 (iii) Response to medication is assessed without a
  pretreatment baseline, as most pts are treated rapidly after
  diagnosis.
  It is unclear whether or not so-called refractory pts have
  had a substantial response to treatment.
 (iv) There is evidence from trials that pts defined as
  refractory will respond readily, although not completely to
  therapy.
EPI…………
 Epilepsy - prevalence ~ 5/1000
 Incidence ~ 50/100,000/year.
 Assuming that 20% of patients with active epilepsy
  would be resistant to AED treatment
 One bn population of India,
 There would be about one mn people with medically
  refractory epilepsy.
Refractory epilepsy
Refractory epilepsy
Refractory epilepsy
PREDICTING REFRACTORINESS
 Type of syndrome.
 Etiology.
 13% of all patients with IGE , and no case with
  idiopathic partial epilepsy, were refractory.
 78% of patients with symptomatic generalized
  epilepsy and 49% of patients with symptomatic partial
  epilepsy were not in remission.
 Younger age.
 High sz frequency.
 Presentation with SE.
 Abnormal NE.
 Mixed seizure types with dev.delay.
 Multiple sz types prior to treatment and after
  treatment.
 Quantity of interictal spikes.
 Human factors-
 Wrong drug,
 Dose,
 Frequency,
 Compliance.


 Environmental –trauma ,drug exposure.


 Genetic -
Mechanisms of Refractoriness
 Drug transporter hypothesis
 Target hypothesis
 Intrinsic disease severity
REFRACTRORINESS
 Drug fails to reach the neuronal target
  (pharmacokinetic hypothesis).
 Drug fails to act at the neuronal target
  (pharmacodynamic hypothesis).
 Seizure phenotype and history of seizures determine
  the “level of refractoriness” (the inherent disease
  severity hypothesis).
Refractory epilepsy
 Pathobiosis- process whereby malfunctioning cells are
 allowed to survive in an otherwise hostile
 environment; this phenomenon would in turn
 promote survival of defective glia.
Refractory epilepsy
Refractory epilepsy
Diagnosis of Refractory Epilepsy
Exclude false refractoriness related to -
 Nonepileptic seizures. (20%)
 Inadequate AEDs.
 Noncompliance .
 Seizure-precipitating factors.
Confirm refractoriness
 Inadequate control of seizures despite at least 2
  potentially effective AEDs (mono- or polytherapy)
  taken in tolerable doses.
 Occurrence of an average of one sz per month for 18
  months or more.
 Not more than 3 month sz free hiatus during this
  period of 18 months.
AED FOR RE
FIRST LINE DRUGS
 Partial epilepsies-CBZ
 Generalized epilepsies-VPA

ADD ON DRUGS
 Partial-PHB,CLB;/LEV,TPM
 Generalized-ZNS,LEV,LTG

 VPA+TPM=hyper ammonaemia
 LEV+ZNS=SZ++++.
Refractory epilepsy
Refractory epilepsy
Refractory epilepsy
Refractory epilepsy
Approaches to the
treatment of refractory epilepsy
 Continue on present course and accept a 5%per year
  remission rate.
 Try to develop a blockbuster magic bullet that cures
  everyone.
 Attempt to target drug therapy for each individual
  patient.
EPILEPTIC SURGERY
Refractory epilepsy
Refractory epilepsy
Refractory epilepsy
Types of surgical procedures for medically refractory
epilepsy
Ideal candidates for anterior temporal lobectomy with
amygdalohippocamectomy
Classification of postoperative seizure outcome (modified
Engel classification)
Predictors of seizure outcome following epilepsy surgery
 KD-chronic ketosis,GABA synthesis
  increase,hyperpolarize neurons and glia.
 VNS
Treatments under Investigation
 Polymers
 Electrical brain stimulation
 Prediction of seizures
POLYMERS
 Polymers containing AEDs - 2- to 3-mm microspheres ,
    placed near the epileptogenic zone.
   (1) new AEDs could be used which do not cross the BBB or
    show systemic toxicity.
   (2) useful when the epileptogenic zone is near eloquent
    cortex.
   (3) prevent noncompliance .
   Implanting wafers impregnated with chemotherapeutic
    agents into the resection cavity results in prolongation of
    survival without an increased incidence of adverse events .
   Studies in animals have been promising as the application
    of polymers containing phenytoin to the epileptogenic
    zone in mice has reduced epileptogenic indexes .
ELECTRICAL STIMULATION
 Still not accepted as a routine treatment for epilepsy-
  no consensus regarding the better region to stimulate
  and in what type of seizure it is most effective.
 The epileptogenic zone and the centromedian or
  anterior nuclei of the thalamus seem to be the most
  effective targets for electrical stimulation .
 The efficacy similar to vagal nerve stimulation which
  has a lower risk and less comorbidity .
FUTURE…..
 Seizure detector coupled with a trigger AED infusion
  pump has been developed with success in the mouse .
 Research has also been done in predicting seizures .
 Device may predict seizures and automatically
  administer AEDs to prevent them from occurring.
Thank you

Contenu connexe

Tendances

Withdrawal of anti epileptic drugs
Withdrawal of anti epileptic drugsWithdrawal of anti epileptic drugs
Withdrawal of anti epileptic drugsPramod Krishnan
 
Autoimmune encephalitis
Autoimmune encephalitisAutoimmune encephalitis
Autoimmune encephalitisNeurologyKota
 
Neuromyelitis optica spectrum disorders
Neuromyelitis optica spectrum disordersNeuromyelitis optica spectrum disorders
Neuromyelitis optica spectrum disordersNeurologyKota
 
Autoimmune Encephalitis
Autoimmune EncephalitisAutoimmune Encephalitis
Autoimmune EncephalitisNeha Rai
 
Advances in myasthenia gravis
Advances in myasthenia gravisAdvances in myasthenia gravis
Advances in myasthenia gravisNeurologyKota
 
Epileptic encephalopathies during infancy
Epileptic encephalopathies during infancyEpileptic encephalopathies during infancy
Epileptic encephalopathies during infancyDr. Arghya Deb
 
Chronic inflammatory demyelinating Polyradiculoneuropathy
Chronic inflammatory demyelinating Polyradiculoneuropathy Chronic inflammatory demyelinating Polyradiculoneuropathy
Chronic inflammatory demyelinating Polyradiculoneuropathy Ajay Kumar
 
Autoimmune encephalitis ppt
Autoimmune encephalitis pptAutoimmune encephalitis ppt
Autoimmune encephalitis pptSachin Adukia
 
Epileptic encephalopathies
Epileptic encephalopathiesEpileptic encephalopathies
Epileptic encephalopathiesSachin Adukia
 
Variants of AIDP & CIDP.pptx
Variants of AIDP & CIDP.pptxVariants of AIDP & CIDP.pptx
Variants of AIDP & CIDP.pptxNeurologyKota
 
Neuropsychiatric Systemic Lupus Erythematosus
Neuropsychiatric Systemic Lupus Erythematosus Neuropsychiatric Systemic Lupus Erythematosus
Neuropsychiatric Systemic Lupus Erythematosus Ade Wijaya
 
Generalised periodic epileptiform discharges
Generalised periodic epileptiform dischargesGeneralised periodic epileptiform discharges
Generalised periodic epileptiform dischargesPramod Krishnan
 
Plasma pharesis in neurological disorders
Plasma pharesis in neurological disorders Plasma pharesis in neurological disorders
Plasma pharesis in neurological disorders NeurologyKota
 
Reversible dementia and delirium
Reversible dementia and deliriumReversible dementia and delirium
Reversible dementia and deliriumUdayan Majumder
 
Childhood demyelinating syndromes
Childhood demyelinating syndromesChildhood demyelinating syndromes
Childhood demyelinating syndromesAmr Hassan
 
Autoimmune encephalitis current concepts
Autoimmune encephalitis current conceptsAutoimmune encephalitis current concepts
Autoimmune encephalitis current conceptsNeurologyKota
 
Vagal Nerve stimulation
Vagal Nerve stimulationVagal Nerve stimulation
Vagal Nerve stimulationAmr Hassan
 

Tendances (20)

Withdrawal of anti epileptic drugs
Withdrawal of anti epileptic drugsWithdrawal of anti epileptic drugs
Withdrawal of anti epileptic drugs
 
Autoimmune encephalitis
Autoimmune encephalitisAutoimmune encephalitis
Autoimmune encephalitis
 
Neuromyelitis optica spectrum disorders
Neuromyelitis optica spectrum disordersNeuromyelitis optica spectrum disorders
Neuromyelitis optica spectrum disorders
 
Autoimmune Encephalitis
Autoimmune EncephalitisAutoimmune Encephalitis
Autoimmune Encephalitis
 
Advances in myasthenia gravis
Advances in myasthenia gravisAdvances in myasthenia gravis
Advances in myasthenia gravis
 
Epileptic encephalopathies during infancy
Epileptic encephalopathies during infancyEpileptic encephalopathies during infancy
Epileptic encephalopathies during infancy
 
Chronic inflammatory demyelinating Polyradiculoneuropathy
Chronic inflammatory demyelinating Polyradiculoneuropathy Chronic inflammatory demyelinating Polyradiculoneuropathy
Chronic inflammatory demyelinating Polyradiculoneuropathy
 
Drug Resistant Epilepsy
Drug Resistant EpilepsyDrug Resistant Epilepsy
Drug Resistant Epilepsy
 
Autoimmune encephalitis
Autoimmune encephalitisAutoimmune encephalitis
Autoimmune encephalitis
 
Autoimmune encephalitis ppt
Autoimmune encephalitis pptAutoimmune encephalitis ppt
Autoimmune encephalitis ppt
 
Epileptic encephalopathies
Epileptic encephalopathiesEpileptic encephalopathies
Epileptic encephalopathies
 
Variants of AIDP & CIDP.pptx
Variants of AIDP & CIDP.pptxVariants of AIDP & CIDP.pptx
Variants of AIDP & CIDP.pptx
 
Neuropsychiatric Systemic Lupus Erythematosus
Neuropsychiatric Systemic Lupus Erythematosus Neuropsychiatric Systemic Lupus Erythematosus
Neuropsychiatric Systemic Lupus Erythematosus
 
Final ppt epilepsy
Final ppt epilepsyFinal ppt epilepsy
Final ppt epilepsy
 
Generalised periodic epileptiform discharges
Generalised periodic epileptiform dischargesGeneralised periodic epileptiform discharges
Generalised periodic epileptiform discharges
 
Plasma pharesis in neurological disorders
Plasma pharesis in neurological disorders Plasma pharesis in neurological disorders
Plasma pharesis in neurological disorders
 
Reversible dementia and delirium
Reversible dementia and deliriumReversible dementia and delirium
Reversible dementia and delirium
 
Childhood demyelinating syndromes
Childhood demyelinating syndromesChildhood demyelinating syndromes
Childhood demyelinating syndromes
 
Autoimmune encephalitis current concepts
Autoimmune encephalitis current conceptsAutoimmune encephalitis current concepts
Autoimmune encephalitis current concepts
 
Vagal Nerve stimulation
Vagal Nerve stimulationVagal Nerve stimulation
Vagal Nerve stimulation
 

En vedette

Epilepsia. Aspectos prácticos
Epilepsia. Aspectos prácticosEpilepsia. Aspectos prácticos
Epilepsia. Aspectos prácticosgemma mas sese
 
Management of epilepsy in this millennium–recent perspectives in intrtactable...
Management of epilepsy in this millennium–recent perspectives in intrtactable...Management of epilepsy in this millennium–recent perspectives in intrtactable...
Management of epilepsy in this millennium–recent perspectives in intrtactable...webzforu
 
Why Use A Paintable Refractory Coating? -- The Benefits of ZYP Coatings
Why Use A Paintable Refractory Coating?  -- The Benefits of ZYP Coatings Why Use A Paintable Refractory Coating?  -- The Benefits of ZYP Coatings
Why Use A Paintable Refractory Coating? -- The Benefits of ZYP Coatings ZYP Coatings, Inc.
 
Antiepileptics
AntiepilepticsAntiepileptics
AntiepilepticsAmit Kumar
 
Increasing refractory lining life and energy saving in furnace operations.
Increasing refractory lining life and energy saving in furnace operations.Increasing refractory lining life and energy saving in furnace operations.
Increasing refractory lining life and energy saving in furnace operations.Srikar Shenoy
 
Epilepsy syndromes
Epilepsy syndromesEpilepsy syndromes
Epilepsy syndromessabiiiiii
 
A guideline for discontinuing antiepileptic drugs in seizure-free patients – ...
A guideline for discontinuing antiepileptic drugs in seizure-free patients – ...A guideline for discontinuing antiepileptic drugs in seizure-free patients – ...
A guideline for discontinuing antiepileptic drugs in seizure-free patients – ...Dr. Rafael Higashi
 
Gujarat Petroleum, Chemical and Petrochemical Investment Region (PCPIR)
Gujarat Petroleum, Chemical and Petrochemical Investment Region (PCPIR)Gujarat Petroleum, Chemical and Petrochemical Investment Region (PCPIR)
Gujarat Petroleum, Chemical and Petrochemical Investment Region (PCPIR)Outlook Menia
 
Petrochemical hub of india gujarat
Petrochemical hub of india gujaratPetrochemical hub of india gujarat
Petrochemical hub of india gujaratKalahub
 
Presentation on Panic Disorder
Presentation on Panic Disorder Presentation on Panic Disorder
Presentation on Panic Disorder SACAP
 
classification of refractories and commonly used refractory bricks
classification of refractories and commonly used refractory bricksclassification of refractories and commonly used refractory bricks
classification of refractories and commonly used refractory brickssunrise refractory
 
Refractory Materials
Refractory MaterialsRefractory Materials
Refractory MaterialsRahul Mitra
 
Refractories-A Short Description
Refractories-A Short Description  Refractories-A Short Description
Refractories-A Short Description Dhruv Dattani
 
Refractories and its types www.chemicallibrary.blogspot.com
Refractories and its types www.chemicallibrary.blogspot.comRefractories and its types www.chemicallibrary.blogspot.com
Refractories and its types www.chemicallibrary.blogspot.comFARRUKH SHEHZAD
 
Panic disorder
Panic disorderPanic disorder
Panic disorderjat66200
 
Panic Disorder
Panic DisorderPanic Disorder
Panic Disorderjsnaza01
 

En vedette (20)

Epilepsia. Aspectos prácticos
Epilepsia. Aspectos prácticosEpilepsia. Aspectos prácticos
Epilepsia. Aspectos prácticos
 
Management of epilepsy in this millennium–recent perspectives in intrtactable...
Management of epilepsy in this millennium–recent perspectives in intrtactable...Management of epilepsy in this millennium–recent perspectives in intrtactable...
Management of epilepsy in this millennium–recent perspectives in intrtactable...
 
Why Use A Paintable Refractory Coating? -- The Benefits of ZYP Coatings
Why Use A Paintable Refractory Coating?  -- The Benefits of ZYP Coatings Why Use A Paintable Refractory Coating?  -- The Benefits of ZYP Coatings
Why Use A Paintable Refractory Coating? -- The Benefits of ZYP Coatings
 
Antiepileptics
AntiepilepticsAntiepileptics
Antiepileptics
 
Increasing refractory lining life and energy saving in furnace operations.
Increasing refractory lining life and energy saving in furnace operations.Increasing refractory lining life and energy saving in furnace operations.
Increasing refractory lining life and energy saving in furnace operations.
 
Epilepsy syndromes
Epilepsy syndromesEpilepsy syndromes
Epilepsy syndromes
 
A guideline for discontinuing antiepileptic drugs in seizure-free patients – ...
A guideline for discontinuing antiepileptic drugs in seizure-free patients – ...A guideline for discontinuing antiepileptic drugs in seizure-free patients – ...
A guideline for discontinuing antiepileptic drugs in seizure-free patients – ...
 
Panic disorder
Panic disorderPanic disorder
Panic disorder
 
Gujarat Petroleum, Chemical and Petrochemical Investment Region (PCPIR)
Gujarat Petroleum, Chemical and Petrochemical Investment Region (PCPIR)Gujarat Petroleum, Chemical and Petrochemical Investment Region (PCPIR)
Gujarat Petroleum, Chemical and Petrochemical Investment Region (PCPIR)
 
Petrochemical hub of india gujarat
Petrochemical hub of india gujaratPetrochemical hub of india gujarat
Petrochemical hub of india gujarat
 
Presentation on Panic Disorder
Presentation on Panic Disorder Presentation on Panic Disorder
Presentation on Panic Disorder
 
classification of refractories and commonly used refractory bricks
classification of refractories and commonly used refractory bricksclassification of refractories and commonly used refractory bricks
classification of refractories and commonly used refractory bricks
 
Refractory Materials
Refractory MaterialsRefractory Materials
Refractory Materials
 
Refractories-A Short Description
Refractories-A Short Description  Refractories-A Short Description
Refractories-A Short Description
 
Refractories and its types www.chemicallibrary.blogspot.com
Refractories and its types www.chemicallibrary.blogspot.comRefractories and its types www.chemicallibrary.blogspot.com
Refractories and its types www.chemicallibrary.blogspot.com
 
Panic disorders
Panic disordersPanic disorders
Panic disorders
 
Panic disorder
Panic disorderPanic disorder
Panic disorder
 
Panic disorder
Panic disorder Panic disorder
Panic disorder
 
Refractories
RefractoriesRefractories
Refractories
 
Panic Disorder
Panic DisorderPanic Disorder
Panic Disorder
 

Similaire à Refractory epilepsy

Which patients of epilepsy require early neurosurgical referral
Which patients of epilepsy require early neurosurgical referral Which patients of epilepsy require early neurosurgical referral
Which patients of epilepsy require early neurosurgical referral Dr. Arghya Deb
 
SEIZURE DISORDER MEDICAL AND SURGICAL MANAGEMENT
SEIZURE DISORDER MEDICAL AND SURGICAL MANAGEMENTSEIZURE DISORDER MEDICAL AND SURGICAL MANAGEMENT
SEIZURE DISORDER MEDICAL AND SURGICAL MANAGEMENTKush Bhagat
 
Study of anticonvulsant activity of quinidine in albino rats using pentylenet...
Study of anticonvulsant activity of quinidine in albino rats using pentylenet...Study of anticonvulsant activity of quinidine in albino rats using pentylenet...
Study of anticonvulsant activity of quinidine in albino rats using pentylenet...iosrjce
 
presurgical evaluation of epilepsy
presurgical evaluation of epilepsypresurgical evaluation of epilepsy
presurgical evaluation of epilepsySrirama Anjaneyulu
 
status epilepticus presentation
status epilepticus presentation status epilepticus presentation
status epilepticus presentation Manideep Malaka
 
recent seminar topic for m.pharm
recent seminar topic for m.pharmrecent seminar topic for m.pharm
recent seminar topic for m.pharmnilesh1208
 
Pregnancy in a young girl with Myasthenia Gravis.
Pregnancy in a young girl with Myasthenia Gravis.Pregnancy in a young girl with Myasthenia Gravis.
Pregnancy in a young girl with Myasthenia Gravis.Anita Aggarwal
 
Refractory epilepsy in children
Refractory epilepsy in children Refractory epilepsy in children
Refractory epilepsy in children Khaled Saad
 
NEW GUIDELINES FOR Status epilepticus
NEW GUIDELINES FOR Status epilepticus NEW GUIDELINES FOR Status epilepticus
NEW GUIDELINES FOR Status epilepticus njdfmudhol
 
About epilepsy - The Matty Fund
About epilepsy - The Matty FundAbout epilepsy - The Matty Fund
About epilepsy - The Matty FundMattyFund
 
Resistant urticaria tutorial ppt.
Resistant urticaria tutorial ppt.Resistant urticaria tutorial ppt.
Resistant urticaria tutorial ppt.Dr Daulatram Dhaked
 
Neuroinflammatory msnmonmda resident lecture2020canonico
Neuroinflammatory msnmonmda resident lecture2020canonicoNeuroinflammatory msnmonmda resident lecture2020canonico
Neuroinflammatory msnmonmda resident lecture2020canonicoMonique Canonico
 
Qavi ppt epileptic syndromes of neonate and infancy (2)
Qavi ppt epileptic syndromes of neonate and infancy (2)Qavi ppt epileptic syndromes of neonate and infancy (2)
Qavi ppt epileptic syndromes of neonate and infancy (2)qavi786
 

Similaire à Refractory epilepsy (20)

Management of epilepsy
Management of epilepsyManagement of epilepsy
Management of epilepsy
 
Which patients of epilepsy require early neurosurgical referral
Which patients of epilepsy require early neurosurgical referral Which patients of epilepsy require early neurosurgical referral
Which patients of epilepsy require early neurosurgical referral
 
SEIZURE DISORDER MEDICAL AND SURGICAL MANAGEMENT
SEIZURE DISORDER MEDICAL AND SURGICAL MANAGEMENTSEIZURE DISORDER MEDICAL AND SURGICAL MANAGEMENT
SEIZURE DISORDER MEDICAL AND SURGICAL MANAGEMENT
 
Study of anticonvulsant activity of quinidine in albino rats using pentylenet...
Study of anticonvulsant activity of quinidine in albino rats using pentylenet...Study of anticonvulsant activity of quinidine in albino rats using pentylenet...
Study of anticonvulsant activity of quinidine in albino rats using pentylenet...
 
Epileptogenesis
EpileptogenesisEpileptogenesis
Epileptogenesis
 
presurgical evaluation of epilepsy
presurgical evaluation of epilepsypresurgical evaluation of epilepsy
presurgical evaluation of epilepsy
 
status epilepticus presentation
status epilepticus presentation status epilepticus presentation
status epilepticus presentation
 
recent seminar topic for m.pharm
recent seminar topic for m.pharmrecent seminar topic for m.pharm
recent seminar topic for m.pharm
 
Pregnancy in a young girl with Myasthenia Gravis.
Pregnancy in a young girl with Myasthenia Gravis.Pregnancy in a young girl with Myasthenia Gravis.
Pregnancy in a young girl with Myasthenia Gravis.
 
Ref.epilepsy final
Ref.epilepsy finalRef.epilepsy final
Ref.epilepsy final
 
Refractory epilepsy in children
Refractory epilepsy in children Refractory epilepsy in children
Refractory epilepsy in children
 
Epilepsy
EpilepsyEpilepsy
Epilepsy
 
NEW GUIDELINES FOR Status epilepticus
NEW GUIDELINES FOR Status epilepticus NEW GUIDELINES FOR Status epilepticus
NEW GUIDELINES FOR Status epilepticus
 
About epilepsy - The Matty Fund
About epilepsy - The Matty FundAbout epilepsy - The Matty Fund
About epilepsy - The Matty Fund
 
Resistant urticaria tutorial ppt.
Resistant urticaria tutorial ppt.Resistant urticaria tutorial ppt.
Resistant urticaria tutorial ppt.
 
1st seizure ppt
1st seizure ppt1st seizure ppt
1st seizure ppt
 
Epilepsy Lecture.pdf
Epilepsy Lecture.pdfEpilepsy Lecture.pdf
Epilepsy Lecture.pdf
 
Neuroinflammatory msnmonmda resident lecture2020canonico
Neuroinflammatory msnmonmda resident lecture2020canonicoNeuroinflammatory msnmonmda resident lecture2020canonico
Neuroinflammatory msnmonmda resident lecture2020canonico
 
Qavi ppt epileptic syndromes of neonate and infancy (2)
Qavi ppt epileptic syndromes of neonate and infancy (2)Qavi ppt epileptic syndromes of neonate and infancy (2)
Qavi ppt epileptic syndromes of neonate and infancy (2)
 
1176830.pptx
1176830.pptx1176830.pptx
1176830.pptx
 

Plus de Srirama Anjaneyulu (20)

Refractory pediatric epilepsy ,Management
Refractory pediatric epilepsy ,ManagementRefractory pediatric epilepsy ,Management
Refractory pediatric epilepsy ,Management
 
Vertigo
VertigoVertigo
Vertigo
 
Epileptic encephalopathy -EEG
Epileptic encephalopathy -EEGEpileptic encephalopathy -EEG
Epileptic encephalopathy -EEG
 
Thalamic lesions Radiology diagnose your self
Thalamic lesions Radiology diagnose your selfThalamic lesions Radiology diagnose your self
Thalamic lesions Radiology diagnose your self
 
HEADACHE
HEADACHE HEADACHE
HEADACHE
 
Treatment of epilepsy
Treatment of epilepsyTreatment of epilepsy
Treatment of epilepsy
 
EMBRYOLOGY OF BRAIN,NEW
EMBRYOLOGY OF BRAIN,NEWEMBRYOLOGY OF BRAIN,NEW
EMBRYOLOGY OF BRAIN,NEW
 
Stroke in children
Stroke in children Stroke in children
Stroke in children
 
Radiology of ventricles
Radiology of ventriclesRadiology of ventricles
Radiology of ventricles
 
EEG artifacts
EEG  artifactsEEG  artifacts
EEG artifacts
 
Prion diseases ---kuru
Prion diseases ---kuru Prion diseases ---kuru
Prion diseases ---kuru
 
Neurology of heat stroke
Neurology of heat strokeNeurology of heat stroke
Neurology of heat stroke
 
Stroke in malignancy
Stroke in malignancyStroke in malignancy
Stroke in malignancy
 
CAROTID ARTERY STENOSIS
CAROTID ARTERY STENOSISCAROTID ARTERY STENOSIS
CAROTID ARTERY STENOSIS
 
heat stroke
heat strokeheat stroke
heat stroke
 
Brain death
Brain deathBrain death
Brain death
 
PROGRESSIVE MYOCLONIC EPILEPSY
PROGRESSIVE MYOCLONIC EPILEPSYPROGRESSIVE MYOCLONIC EPILEPSY
PROGRESSIVE MYOCLONIC EPILEPSY
 
CEREBRAL VENOUS THROMBOSIS
CEREBRAL VENOUS THROMBOSISCEREBRAL VENOUS THROMBOSIS
CEREBRAL VENOUS THROMBOSIS
 
Stroke imaging
Stroke imagingStroke imaging
Stroke imaging
 
Primary headache
Primary headachePrimary headache
Primary headache
 

Dernier

The Importance of Mental Health: Why is Mental Health Important?
The Importance of Mental Health: Why is Mental Health Important?The Importance of Mental Health: Why is Mental Health Important?
The Importance of Mental Health: Why is Mental Health Important?Ryan Addison
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Vaikunthan Rajaratnam
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsMedicoseAcademics
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...Sujoy Dasgupta
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptPradnya Wadekar
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfHongBiThi1
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Peter Embi
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .Mohamed Rizk Khodair
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxkomalt2001
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu Medical University
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.kishan singh tomar
 
BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE Mamatha Lakka
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets barmohitRahangdale
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxNaveenkumar267201
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...Shubhanshu Gaurav
 
Physiotherapy Management of Rheumatoid Arthritis
Physiotherapy Management of Rheumatoid ArthritisPhysiotherapy Management of Rheumatoid Arthritis
Physiotherapy Management of Rheumatoid ArthritisNilofarRasheed1
 
Pregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdfPregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdfMedicoseAcademics
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionkrishnareddy157915
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyZurück zum Ursprung
 

Dernier (20)

The Importance of Mental Health: Why is Mental Health Important?
The Importance of Mental Health: Why is Mental Health Important?The Importance of Mental Health: Why is Mental Health Important?
The Importance of Mental Health: Why is Mental Health Important?
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functions
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologyppt
 
Cone beam CT: concepts and applications.pptx
Cone beam CT: concepts and applications.pptxCone beam CT: concepts and applications.pptx
Cone beam CT: concepts and applications.pptx
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptx
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.
 
BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets bar
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
 
Physiotherapy Management of Rheumatoid Arthritis
Physiotherapy Management of Rheumatoid ArthritisPhysiotherapy Management of Rheumatoid Arthritis
Physiotherapy Management of Rheumatoid Arthritis
 
Pregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdfPregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdf
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung function
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturally
 

Refractory epilepsy

  • 1. DR.SRIRAMA.ANJANEYULU MD;DM NEUROLOGIST GUNTUR
  • 2. Terminology  “Treatment nonresponder”  “Refractory”  “Intractable”  “Drug resistant”
  • 3. CONSEQUENCES OF RE  Bodily injuries - hospitalization.  Shortened life spans-risk of sudden unexpected death.  Significant neuropsychological, psychiatric, and social impairments.  Limited employment, reduce marriage rates, and decrease quality of life.
  • 4. PROGNOSTIC GROUPS IN EPILEPSY  (1) Spontaneous remission (20–30%) - benign epilepsy with centrotemporal spikes or childhood absences.  (2) Remission on AEDs (20–30%) - most focal epilepsy and myoclonic juvenile epilepsy syndromes;.  (3) Persistent seizures under AEDs (30–40%) .
  • 5. DEFINITION  (1) Absence of response to 2 AEDs tolerated at reasonable doses.  (2) Minimum frequency of seizures (e.g. 1 seizure per month) to be considered refractory or the duration of minimum remission (e.g. 6– 12 months) to be qualified as non refractory.  (3) Duration of 1 year to 1 decade of non controlled epilepsy.
  • 6. EPIDEMIOLOGY  (i) No unifying definition of RE.  (ii) Same pt might be refractory at one time, but treatment responsive at another.  (iii) Response to medication is assessed without a pretreatment baseline, as most pts are treated rapidly after diagnosis. It is unclear whether or not so-called refractory pts have had a substantial response to treatment.  (iv) There is evidence from trials that pts defined as refractory will respond readily, although not completely to therapy.
  • 7. EPI…………  Epilepsy - prevalence ~ 5/1000  Incidence ~ 50/100,000/year.  Assuming that 20% of patients with active epilepsy would be resistant to AED treatment  One bn population of India,  There would be about one mn people with medically refractory epilepsy.
  • 11. PREDICTING REFRACTORINESS  Type of syndrome.  Etiology.  13% of all patients with IGE , and no case with idiopathic partial epilepsy, were refractory.  78% of patients with symptomatic generalized epilepsy and 49% of patients with symptomatic partial epilepsy were not in remission.
  • 12.  Younger age.  High sz frequency.  Presentation with SE.  Abnormal NE.  Mixed seizure types with dev.delay.  Multiple sz types prior to treatment and after treatment.  Quantity of interictal spikes.
  • 13.  Human factors-  Wrong drug,  Dose,  Frequency,  Compliance.  Environmental –trauma ,drug exposure.  Genetic -
  • 14. Mechanisms of Refractoriness  Drug transporter hypothesis  Target hypothesis  Intrinsic disease severity
  • 15. REFRACTRORINESS  Drug fails to reach the neuronal target (pharmacokinetic hypothesis).  Drug fails to act at the neuronal target (pharmacodynamic hypothesis).  Seizure phenotype and history of seizures determine the “level of refractoriness” (the inherent disease severity hypothesis).
  • 17.  Pathobiosis- process whereby malfunctioning cells are allowed to survive in an otherwise hostile environment; this phenomenon would in turn promote survival of defective glia.
  • 20. Diagnosis of Refractory Epilepsy Exclude false refractoriness related to -  Nonepileptic seizures. (20%)  Inadequate AEDs.  Noncompliance .  Seizure-precipitating factors.
  • 21. Confirm refractoriness  Inadequate control of seizures despite at least 2 potentially effective AEDs (mono- or polytherapy) taken in tolerable doses.  Occurrence of an average of one sz per month for 18 months or more.  Not more than 3 month sz free hiatus during this period of 18 months.
  • 22. AED FOR RE FIRST LINE DRUGS  Partial epilepsies-CBZ  Generalized epilepsies-VPA ADD ON DRUGS  Partial-PHB,CLB;/LEV,TPM  Generalized-ZNS,LEV,LTG  VPA+TPM=hyper ammonaemia  LEV+ZNS=SZ++++.
  • 27. Approaches to the treatment of refractory epilepsy  Continue on present course and accept a 5%per year remission rate.  Try to develop a blockbuster magic bullet that cures everyone.  Attempt to target drug therapy for each individual patient.
  • 32. Types of surgical procedures for medically refractory epilepsy
  • 33. Ideal candidates for anterior temporal lobectomy with amygdalohippocamectomy
  • 34. Classification of postoperative seizure outcome (modified Engel classification)
  • 35. Predictors of seizure outcome following epilepsy surgery
  • 36.  KD-chronic ketosis,GABA synthesis increase,hyperpolarize neurons and glia.  VNS
  • 37. Treatments under Investigation  Polymers  Electrical brain stimulation  Prediction of seizures
  • 38. POLYMERS  Polymers containing AEDs - 2- to 3-mm microspheres , placed near the epileptogenic zone.  (1) new AEDs could be used which do not cross the BBB or show systemic toxicity.  (2) useful when the epileptogenic zone is near eloquent cortex.  (3) prevent noncompliance .  Implanting wafers impregnated with chemotherapeutic agents into the resection cavity results in prolongation of survival without an increased incidence of adverse events .  Studies in animals have been promising as the application of polymers containing phenytoin to the epileptogenic zone in mice has reduced epileptogenic indexes .
  • 39. ELECTRICAL STIMULATION  Still not accepted as a routine treatment for epilepsy- no consensus regarding the better region to stimulate and in what type of seizure it is most effective.  The epileptogenic zone and the centromedian or anterior nuclei of the thalamus seem to be the most effective targets for electrical stimulation .  The efficacy similar to vagal nerve stimulation which has a lower risk and less comorbidity .
  • 40. FUTURE…..  Seizure detector coupled with a trigger AED infusion pump has been developed with success in the mouse .  Research has also been done in predicting seizures .  Device may predict seizures and automatically administer AEDs to prevent them from occurring.