1. EPILEPSY

2. CREATED BY : SHAIKH NAZMEEN IBRAHIM
UNDER THE GUIDENCE OF
DR. SNEHAL VINYK KALE

3. SR.NO SUBJECT PAGE NO
01 INTRODUCTION OF
EPILEPSY
02 EPIDEMIOLOGY
03 CAUSE OF EPILEPSY
04 CLASSIFICATION
05 PATHOPHYSIOLOGY
06 INVESTIGATION
07 COMMON ERRORS IN
DIAFNOSTING
EPILEPSY
08 MANAGING, DURING
AND ATTACKS
09 MANAGEMENT OF
EPILEPSY

4. CT-SCAN

5. EPIDEMIOLOGY
 5% of children are estimated to experience one and more seizures in
childhood.
 Less than 1% have epilepsy.
 The incidence is highest in pre-school years.
 Interfamilial recurrence of convulsions especially simple febrile
convulsions is common.

6. ETIOLOGY:
1) CRYPTOGENIC:
 The most of cases of epilepsy are cryptogenic in nature.
 Even after CT/MMR and other investigation, we may not be able to find any other lesion.
 It may be minor trauma to the brain which went unnoticed or injury during birth.
2) ACCIDENT:
 Injury to foetus during pregnancy.
 Child birth injury, infants falling from beds, injury on the roads, homicidal injury.
3) HERIDITY:
Certain single gene disorder has been identified and they are
 Benign familial neonatal convulsion
 Tuberous sclerosis
 Progressive myoclonus epilepsy syndrome
 Neurocutaneous syndrome - Xeroderma, pigmentosa, neuro-ichthyosis, sturge, Weber syndrome

7. 4) INFECTIONS:
 Many variety of infections are known to cause epilepsy.
 the commonest were viral, bacterial including tuberculosis or as encephalitis and meningitis.
5)FORCEPS DELIVERY:
 The use of forceps has resulted in brain damage and seizures.
 The use of forceps has been banned and caesarean section has became a standard procedure.
6) CONGENITAL MALFORMATION:
 These anomalies also resulted in patient become mentally retarded.
 The defect may be prenatal, postnatal or perinatal.
7) ALCOHOL AND DRUG ABUSE:
 Alcohol dependence and drug abuse related trauma have become cause of seizures.

8. 8)DRUGS:
The drugs commonly use in day today life are antidepressants, penicillin, insulin
etc, may cause seizures.
9)CANCER AND SURGERY:
Malignant lesions of the brain have a tendency to cause seizures
depending upon the site and type of tumours in frontal and temporal region.
10)MISCALLENEOUS:
 post smallpox and cholera vaccine
 cerebrovascular disease

10. CAUSES OF EPILEPSY
depending upon age of onset at seizures
1) New born and infancy:
• Birth trauma, cerebral anoxia
• Developmental abnormalities
• Metabolic abnormalities
• Infection
2) Childhood:
• Birth trauma
• Infections
• Toxins
• Congenital abnormalities
• Brain tumour, ICH

11. 3) Adolescence (10-12 years):
• Idiopathic
• Infection
• Head injury
• Toxins
• Degenerative

13. CLASSIFICATION
Epilepsy is classified by information of
a) Seizure type- clinical
b) Electroencephalographic data (EEG)
INTERNATIONAL CLASSIFICATION OF EPILEPSY
1) Generalized:
• Tonic clonic
• Tonic
• Clonic
• Absence
• Atonic
• Myoclonic

14. 2) Idiopathic:
• Benign neonatal convulsions
• Childhood absence
• Juvenile absence
• Grandmal seizure on awakening
• Generalised idiopathic
3) Localized:
• Simple partial
i. Motor
ii. Auto tonic
iii. Sensory
iv. Psychic
• Complex partial
i. Simple partial , followed by loss of consciousness
ii. Consciousness impaired at onset
• partial seizures with secondary generalization

15. 4) Syndrome:
• Idiopathic:
i. Benign childhood focal epilepsy
ii. Centro temporal spike
iii. Epilepsy with occipital paroxysms
• Symptomatic:
i. Chronic progressive epilepsy
ii. Epilepsia partialis continua
5) Undetermined syndrome:
• Neonatal seizure
• Severe myoclonic epilepsy of infancy
• Epilepsy with continuous spike waves during slow wave sleep
• Acquired epileptic aphasia

17. 1)GENERALIZED
I. Tonic clonic
• generalized tonic clonic seizures are the most frequent form of childhood epilepsy
• 4 phases
i. Aura
ii. Tonic
iii. Clonic
iv. Postictal phase
i. Aura:
 A transitory premonitory symptom or aura heralds the onset of seizure.
 Aura may be sensory, visceral, motor or autonomic.
 Only one third of patients can describe the aura property.
 It can be in the form of tingling numbness in any part of the body and headache.
 Sometimes there is some minor motor activity in the limbs.
 Patient feels a sensation of obscure smell and flashing of lights and sounds in ear.
 The most common aura experienced by children consist of epigastric discomfort of pain and feeling of
fear

18. II. Tonic phase :
• During this phase skeletal muscle goes into sustained spasm.
• Spasm of the laryngeal muscles force the air out from the lungs through partially closed glottis
resulting in the shrill cry.
• The child becomes unconscious and fall on the ground.
• The face appears pale, pupils are dilated and eyes are rolled either upward or to the side.
• Frothing from mouth may be present.
• Urine or stool may be passed.
• Child may be cyanotic and apnoeic.
• This phase lasts for about 30 seconds.

20. III. Clonic phase:
• It is characterized by rhythmic alteration , contraction and relaxation of muscle group, which persist for
a few minutes.
• In many patients epileptic phase overlaps each other.
• During seizures child may be bite his tongue but rarely vomit.
IV. Postictal phase:
• The child may complain of headache, confusion, perform automatic action of which he has little
recollections later.
• Rarely a child develops a transient paresis, ,ay loose bladder, bowel control or injure himself.
V. Absence attack:
• Simple absence seizure are characterized by a sudden cessation of motor activity or speech with a
blank facial expression.
• Starting abruptly, the peak prevalence is between 6-8 years.
• Even in children, absence seizures are less common than tonic clonic seizures.

22. VI. Myoclonic epilepsies:
• It is characterized by repetitive seizure consisting of brief often symmetric muscular
contractions with loss of body tone and falling for word, which has tendency to cause injuries
to the face and mouth.

23. 2) Localised:
• Partial seizure account for 60% of seizures in childhood.
• Common causes include inflammatory granulomas, atrophic lesions, vascular insults, birth
asphyxia, head trauma and neoplasm.
• In some areas, neurocysticercosis is a common cause.
• Neurocutaneous syndrome , arteriovenous malformations and infarcts are less common cause.

25. 1) Simple partial:
Without loss of consciousness, with motor sensory, autonomic or mixed symptoms.
• The movement are characterized by asynchronous clonic or tonic movements and they tend to involve
the face, neck and extremities.
• Versive seizure consisting of head turning and conjugate eye movement are particularly common in
sps.
• Automatism do not occur.
• The average seizure persists for 10-20 sec.
2) Complex parties:
• With impairment of consciousness and automatisms, psychomotor or limbic system symptoms.
• An aura consisting of vague, unpleasant feelings, epigastric discomfort or fear is present in approx.
1/3rd of children with sps and cps automatisms are a common feature of cps.
• In infants and children occurring in approx. 50-70% cases.
• It is characterized by lip smacking, chewing, swallowing and excessive salivation.
• Autonomic behaviour in older children includes picking and pulling at clothing or bed sheets, rubbing
or caressing objects and walking or running in non directive, repetitive and often fearful fashion.

26. 3) Partial and secondary generalization:
• Spreading of the epileptiform discharge during cps can result in secondary realization with a
tonic-clonic convulsion.
• The average duration of a cps is 1-2 min.
• ECG: anterior temporal lobe sharp waves or focal spikes and multifocal spikes.

28. NEONATAL SEIZURES
• Incidence ranges from 1-2% to almost 20% in preterm infants.
• poor myelinations and incomplete dendritic arborisation result in clinical manifestation that are
different from older children.
• neonatal seizure present in decreasing order of frequency as
i. Subtle
ii. Focal clonic
iii. Multifocal clinic
iv. Generalized tonic
v. Myoclonic
• Subtle seizure may manifest as eyelid blinking, fluttering or buccal lingual movement
• There may be pedalling or automatic movement because of subcortical neuronal discharge.
• The common cause are hypoxic ischaemic encephalopathy, sepsis and bacterial meningitis.

29. WEST’S SYNDROME (infantile spasm)
• The onset usually between 3-8 month of life.
• It is characterized by combination of salaam spells
• Brief symmetric contraction of neck, trunk and extremities, mental retardation.
• Common cause of infantile spasm are.
i. Hypoxic ischaemic encephalopathy
ii. Neurocutaneous syndrome
iii. Perinatal infection
iv. Haemorrhage
v. Injury
vi. Metabolic disorder
vii. Localized structural malformations
• Three types of infantile spasm..
i. Flexor
ii. Extensor
iii. Mixed

30. LENNOX-GASTUAT SYNDROME
• Onset is usually in late infancy.
• It is characterized by mixed seizures including myoclonic and atypical absence.
• Generalized tonic clonic or partial seizures with interictal slow spike waves on ECG.
• Prognosis is often unsatisfactory.
• Newer antiepileptic drugs, lamotrigine, to primate and zonisamide are promising.
• The seizures are persistent and frequency of mental retardation and behavioural problems is
approximately 75% of all patients.

31. PATHOPHYSIOLOGY
1) Hereditary theory
• Epilepsy can be familial
• There may be multifactorial / polygenic inheritance
2)Biochemical theory
Na + K + ATPase theory sodium potassium pump (Na+ -k + pump)
• In resting phase the neurons are polarized due to difference in concentration of ion across the cell
membrane, called as polarised state.
• At rest the charge on outside is +ve and inside is when stimulated permeability of cell membrane to
k+ & Na+ ion is changed, this is called depolarisation creating nerve impulse or action potential.
• In repolarisation k+ ion flood out of the neuron and movement of these ions returns the membrane
potential to its resting state.
• As the neurons returns to its original resting state the action of sodium potassium pump (Na+ -k
ATPase) expels Na from the cell in change for k+.

33. In epileptic cortices (brain) level for Na+ k ATPase (enzyme) are
low
Na + leaks into the neuronal cell & k+ remains outside
RMP altered
Electrical discharge
Stimulus (decreased threshold)
Neuronal cell excited
Neuronal firing
Causes seizure

35. TRIGGERING FACTORS:
• Prolonged refractory seizures can lead to brain damage.
• Some patients may develop poor memory due to epilepsy or its treatment.
• Excessive stress worry and anxiety can also precipitate seizure.
• Sometimes , epilepsy may be associated with a metabolic disorder in which case certain food items
may also precipitate seizures.
• Video games due to its flickering light and changing pattern of images can precipitate seizures.
• Certain drugs such as antidepressants antibiotic theophylline may provoke a seizure.
• Most children with well controlled seizures and no additional handicap attend a normal school.
• Extra curricular activity such as swimming, climbing, and crying on road should be avoided.

36. INVESTIGATIONS
• EEG: paroxysmal discharge
• Computerised tomography
• SPECT scanning
• Position Emission Tomography’
• Routine investigation of blood / urine / stool , other serum tests.
eg: serum prolactin is the main serum test for epilepsy.
 Avoidance of certain factors will reduce frequency of seizures
• Fever
• Alcohol, sedatives
• Medications, insulin, is ionized, chloroquine, aminophylline, lignocaine, antidepressants,
neuroleptic
• Photosensitive
• Fatigue

37.  COMMON ERRORS IN DIAGNOSING EPULEPSY
• A wrong label of epilepsy may be given to 20-30% children reporting to epilepsy clinics.
• A variety of paroxysmal disorder, which minimic seizures should be excluded.
• These includes..
i. Syncope
ii. Breath holding spells
iii. Acute psychiatric states
iv. Migraine variants
v. Abnormal movements disorder
vi. Paroxysmal disturbance of sleep
vii. Narcolepsy
viii. Hysteria
• Careful history & EEG are useful to these conditions.
• Treatment should be deferred until the diagnosis becomes obvious on follow-up of natural
course of diseases.

38.  MANAGING, DURING & ATTACK
• The relatives & onlookers should not crowd.
• Convulsions seizures are always of short duration.
• Patient should be made to lie down and place on one side, neck and jaw should be gently hyperextended to
enhance breathing.
• Tight clothing should be loosened, jewellery around neck should be loosened.
• Do not force anything into the mouth.
• As soon as patient regains consciousness he should be comported and reassured.
 MANAGEMENT OF EPILEPSY
• Epilepsy management includes drugs, psychosocial and lifestyle management
• Epilepsy management for a period 1-4 year.

39.  DRUG THERAPY
• The first line anti epileptic drug (AED) include phenytoin, phenobarbital, sodium valproate and
carbamazepine commonly used drug.
• Age, sex, economic factors and seizure type determine choice of AED
 TONIC-CLONIC SEIZURES
• Carbamazepine is an effective drug for partial and generalized tonic clonic seizure
• It has advantage of very few side-effect
• Phenobarbital is the drug of choice in the first year of life.
• Almost 20%develop hyperactive behaviour and learning disabilities after first year of life.

40.  COMPLEX PARTIAL SEIZURE:
• The drug of choice is carbamazepine, 10-30 mg/kg/day in 2-3 doses.
• It has a positive psychotropic effects.
• Slow release preparations may have advantages
• Newer drugs and surgery should be restricted for selected patients.
 ABSENCE SEIZURES:
• Effective against include ethosuximide, benzodiazepines, sodium valproate lamotrigine.
 MYOCLONIC & ATONIC SEIZURES:
• Sodium valproate, levetiracetam, benzodiazepines such as clonazepam, nitrazepam or clobazam
may be used.
 INFANTILE SPASM:
• In west syndrome, intramuscular ACTH 40-60 unit/day may be given, 4-6 weeks and them tapered
off.

42.  NEWER ANTIEPILEPTIC DRUG:
• Lamotrigine and topiramate have wide spectrum and are useful adjunct after primary failure in
partial and generalized epilepsies
• Familiarization of drug use and side-effects is essential.
• Oxcarbazepine may be useful for partial epilepsies, and vigabatrin for infants.
 VAGAL NERVE STIMULATION:
Shows useful adjunctive therapy for patients refractory to other therapies.
 SURGICAL TREATMENT
• Severe disabling medically resistant case of epilepsy may be treated surgically after a careful
selection and work up
eg: resection of corpus callosum, parts of temporal lobe.
• Surgical treatment should be increasing used by identification of anatomic lesions to cure
epilepsy.

43.  DURATION OF THERAPY & PROGRESS:
• Drug withdrawal should be attempted slowly over 3-6 months, usually after 1-2 years in the
absence of attack and 2yr seizures free period in tonic clonic seizures.
• Treatment has to be continued life long in juvenile myoclonic epilepsy.
• It is difficult to control seizures in children with neurodevelopment handicaps and post traumatic
epilepsy.
• CBC & LFT to be checked after every mouth initial 3 months of starting treatment.
 SOCIAL ASPECT:
• One should encourage full participation in educational and extracurricular activities.
• Competitive sports, which may endanger the child’s life should be avoided.
 COUNSELLING THE PARENTS:
About diagnosis, accurate information about duration of disorder, side effects medicines,
genetic implications, first aid measures, avoid once of swimming and driving etc.