1. EPILPSY
“7”
Presented By:
Dr. Raed Ahmed
MBChB , FIBMS
Neurologist
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2. Introduction
 Terms seizure and epilepsy are not synonymous
 Epilepsy : chronic brain disorder of various aetiologies
characterized by two or more unprovoked seizures
 Seizure : a paroxysmal event due to abnormal excessive or
synchronous neuronal activity in the brain.
 Convulsion : abnormal movement associated with epileptic
event

3. ‘Sacred illness’
• ‘Sacred illness’: 600 BC
• A seizure (from the Latin sacire , “to take possession of ”)
• Hippocrates 400 BC: It is thus with regard to the disease called
sacred: it appears to me to be in no way more divine nor more
sacred than other diseases [...].
The brain is the cause of this affliction [...].
Alexander the Great Julius Caesar Napoleon

4. Epidemiology
• Epilepsy is common
• Prevalence of epilepsy: 0.5-1%
• Incidence of epilepsy: 40 - 70/100,000/year
• Lifetime risk of having a single seizure is 5%. , with
the highest incidence occurring in early childhood
and late adulthood.
• Its prevalence is 5 times higher in developing than
developed (0.5%) countries, and the incidence is
doubled.
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5. Pathophysiological classification of
seizures
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• Balance between excitation and inhibition,
• Inhibitory (GABA) acting on ion channels to
enhance chloride inflow and reduce the chances of
action potential formation.
• Excitatory amino acids (glutamate and aspartate)
allow influx of sodium and calcium, producing the
opposite effect.
• Seizures result from an imbalance between this
excitation and Inhibition predisposing to recurrent
action potentials.

6. Seizures VS Epilepsy
 Non-epilepsy
 Drug-related
 metabolic
 Toxic
 Febrile
 Cardiovascular
 Poison
 Pseudo-seizures
 Epilepsy
(recurrent)
Idiopathic Symptomatic
(primary) (secondary)

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9. Clinical presentations of epilepsy
• Loss of awareness
• Generalized convulsive movements
• Drop attacks
• Transient focal motor attacks
• Transient focal sensory attacks
• Facial muscle and eye movements
• Psychic experiences
• Aggressive or vocal outbursts
• Episodic phenomena in sleep
• Prolonged confusional or fugue states
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11. The International League Against Epilepsy (ILAE)
Classification of Seizure Type
I. Partial (focal, local) seizures
A. Simple partial seizures
• 1. With motor signs
• 2. With somatosensory or special sensory symptoms
• 3. With autonomic symptoms or signs
• 4. With psychic symptoms
B. Complex partial seizures
• 1. Simple partial onset followed by impairment of
consciousness
• 2. With impairment of consciousness at onset
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12. ILAE
C. Partial seizures evolving to secondarily generalized
seizures (tonic–clonic, tonic, or clonic)
• 1. Simple partial seizures evolving to generalized
seizures
• 2. Complex partial seizures evolving to generalized
seizures
• 3. Simple partial seizures evolving to complex partial
seizures evolving to generalized seizures
II. Generalized seizures (convulsive and non-convulsive)
• A. Absence seizures (typical , atypical )
• B. Myoclonic seizures
• C. Clonic seizures
• D. Tonic seizures
• E. Tonic–clonic seizures F. Atonic seizures
III. Unclassified epileptic seizures 12

13. Simple partial seizures
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14. Simple partial seizures
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15. Complex partial seizures
 A common seizure type in adulthood
 Origin is most often in the temporal lobe
 Temporal >> frontal > parietal or occipital
 Can be introduced by a simplex partial
psychosensory seizure:
 olfactory hallucination
 déjà vu (familiarity), jamais vu (unfamiliarity)
 feeling of alienation
 Loss of consciousness: stare, ‘going blank’
 Automatisms:involuntary complex motor activity
during impaired consciousness .
 Examples are gum chewing, nose wiping,
drinking from cup, lip smacking .
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16. Generalised tonic-clonic seizure
(grand mal)
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17. Absence (previously ‘petit mal’)
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 Age of onset: 3-10 years
 Occurs in genetic (idiopathic)
 Seizure types: absence; often in
clusters; …hyperventilation
 Cognitive dysfunction with a
sudden onset and end, lasting 5-
10 seconds
 Stare, expressionless face; arrest
of ongoing activity; generally no
motor phenomena
 No neurological or mental
alterations
 EEG: generalised 3 Hz spike and
wave activity
 Good response to treatment

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19. Myoclonic seizure
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 Sudden, quick, arrhythmic
muscle contraction, twitch of a
limb; no loss of consciousness
 EEG: generalised polyspike and
wave activity
 Occurs in genetic (idiopathic)
epilepsies
 Not only an epileptic
phenomenon- it can be the sign
of diffuse encephalopathies

20. Juvenile myoclonic epilepsy
 Most common form of idiopathic
generalised epilepsy
 Family history positive in 40%
 Age of onset: 15-18 years
 Seizure types:
 myoclonic
 generalised tonic-clonic
 absence
 EEG: generalised 3-4 Hz spike
and wave, polyspike and wave,
hyperventillation and
fotostimulation are provoking
 Good response to treatment, but
needs life-long treatment

21. • Epileptic Syndromes: grouping of similar epileptic
patterns according to sz type, EEG, age of onset, familial
episodes, prognosis, other clinical signs.
• Electroclinical epilepsy syndromes ….
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22. Temporal lobe epilepsy
 Most common epilepsy in adulthood;
can be heralded by a few seizures in
childhood, but typical age of onset is
20-22 years
 Seizure types:
 olfactory hallucination (simplex
partial)
 psychosensory seizures (simplex
partial)
 complex partial
 generalised tonic-clonic
 Febrile convulsions in childhood
 Hippocampal sclerosis
 Often refractory to therapy
 Surgical treatment eliminates
seizures in 80%-90% of refractory
cases

23. West syndrome
 Age of onset: 3-5 months
 Seizure types: infantile spasms
 Causes: inborn metabolic, storage
diseases, perinatal hipoxic brain damage
 Cryptogenic in 40-50%
 Neurological symptoms, mental
retardation; bad prognosis; can transform
into Lennox-Gastaut syndrome
 EEG: hypsarrhythmia

24. Lennox-Gastaut syndrome
 Age of onset: 1-8 years
 3-10 of childhood epilepsy
 Seizure types: atonic, axial tonic,
myoclonic, atypical absence, tonic-
clonic
 30%of WS syndrome will have
LGS
 Causes: same as in West
syndrome; can develop from West
syndrome
 Neurological symptoms, mental
retardation
 Unfavourable prognosis, refractory
to treatment

25. Diagnosis / differential diagnosis
Is it an epileptic
seizure? ?
Yes No
1. Seizure type?
2. Acute symptomatic
seizure or epilepsy?
Epilepsy
Idiopathic or
symptomatic?
Acute symptomatic seizure
Cause?
Symptomatic epilepsy
Cause?
Syncope?
TIA?
Psychogenic?

26. Diagram shows the common causes of
“blackouts”
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27. DISORDERS RESEMBLING SEIZURES
• Syncope
• Cardiac disorders
• Migraine
• Transient ischemic attack
• Hypoglycemia
• Movement disorders
• Psychogenic nonepileptic seizures
• Malingering
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28. Syncope
• Syncope is the most common cause of episodes of loss of
awareness.
• Simple faints or vasovagal syncopal attacks can usually be
related to identifiable precipitants.
Hyperventilation blackouts
• young and female; anxious , difficulty in ‘getting her breath’,
distal limb paraesthesiae and/or tetany are mentioned, need
reassurance and rebreathing into a paper bag.
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29. Cardiac syncope
• Potentially serious and often treatable.
• Caused by a sudden drop in cardiac output
• May be provoked by exertion in those with severe
aortic stenosis, ischaemia or hypertrophic obstructive
cardiomyopathy, or
• Without warning in patients with cardiac arrhythmia
(e.g. Stokes–Adams attack).
• Often prodromal features as palpitations, chest pain,
shortness of breath or other features of cardiovascular
insufficiency.
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31. Migraine
• A common cause of episodic visual phenomena
• Evolution is usually gradual, over several minutes,
with fortification spectra and associated
photophobia, nausea and headache.
• Epileptic phenomena are usually much shorter,
evolving over seconds & visual hallucinations are
more commonly of coloured blobs rather than
jagged lines.
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32. Transient cerebral ischaemia
• TIAs usually present with negative phenomena
• TIAs are not usually stereotyped or repeated with the
frequency of epileptic seizures
• Usually associated features to suggest vascular disease.
Vertebrobasilar ischaemia
• Typically, the attacks occur in the elderly, with evidence of
vascular disease
• Attacks may be precipitated by head turning or neck extension
• Sudden onset, with features of brainstem ischaemia such as
diplopia, vertigo and bilateral facial and limb sensory and
motor deficits.
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33. Hypoglycaemia
• Hypoglycaemic attacks esp. in patients with treated
diabetes mellitus.
• Causes attacks of loss of consciousness, sometimes
with a convulsion.
• Often warning, with hunger, malaise, shaking and
sweating.
• Prompt recovery occurs with i.v. (or oral) glucose, or
household sugar.
Hypocalcaemia
• may be accompanied by a grand mal fit as seizure
threshold is lowered.
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34. Other neurological disorders
Movement disorders
• Paroxysmal choreoathetosis may cause drop attacks if
there is lower limb involvement
• Tics
Cataplexy
• Cataplexy usually occurs in association with narcolepsy,
although it may be the presenting clinical feature.
• There is no loss of consciousness with attacks.
• Attacks may be precipitated by emotion, especially
laughter. 34

35. Psychogenic nonepileptic seizures
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36. Diagnostic steps
 History ( 70% of Dx)
 EEG
 Negative EEG does not exclude epilepsy
 Positive EEG without clinical signs does not prove epilepsy
 EEG after sleep deprivation or during sleep
 Long-term EEG / video monitoring
 CT, MRI
Epilepsy is a clinical diagnosis.

37. EEG Abnormalities
• During a seizure the EEG is almost invariably abnormal
• Background abnormalities
-Significant asymmetries and/or degree of slowing
inappropriate for clinical state
•Transient abnormalities associated with seizures
-Spikes (< 70 m sec)
-Sharp waves (~70 – 200 msec)
-Spike-wave complexes
•May be focal, lateralized or generalized

38. Indications for brain imaging in epilepsy (either
CT or MRI)
 Epilepsy starting after the age of 16 yrs
 Seizures having focal features clinically
 EEG showing a focal seizure source
 Control of seizures difficult or deteriorating
 Video of Epilepsy