1. Epilepsy – A Modern Day Perspective
Vivek Misra
B.Tech. (Genetic Engg), M.S. (Neuroscience)
Research Associate
The Institute of Neurokrish
Neurological Sciences Consulting Pvt. Ltd
vivek@uberbrain.net
www.UberBrain.net

2. Outline
• Overview of Epilepsy
• Type of Seizures
• Diagnosis and Management
• Psychological Issues
• Social Perspectives

3. What is Epilepsy ?

4. Seizures and Epilepsy
• A fit or seizure represents a transient abnormal electrical
discharge in the brain with or without: alteration in
consciousness, motor (movement) or sensory
(perceptual) symptoms
• Seizures represent underlying brain dysfunction
• Seizures may represent a focal (ex: Tumor) or generalized
(ex: infection) abnormality in electrical brain activity
Seizures  Epilepsy

5. What is Epilepsy?
• A tendency to have recurring unprovoked seizures
• Does not include single or occasional seizures or those
occurring during acute illness (symptomatic seizures)
• Unprovoked seizures occurring on two separate
occasions are required for epilepsy diagnosis
• A cluster of seizures is considered as a single seizure for
the purpose of epilepsy diagnosis

6. How Common Is Epilepsy?
• Most common serious neurological disorder
• Affects 1/200 people worldwide
• Could be as much as 1/100 in developing nations like
India due to increased:
- poor antenatal care and perinatal injury
- infections (tuberculosis & cysticercosis)
- road traffic accidents

7. Who Is At Risk?
• About one half of people affected develop epilepsy
before 15 years of age
• Increasing prevalence in older individuals- probably
due to demographic change and the increasing
prevalence of degenerative cerebrovascular disease
• Slightly higher in males
• Slightly higher in lower socio-economic groups

8. What Causes Epilepsy?
• Causes vary worldwide and with age
• Unknown in two-thirds of cases overall (idiopathic)
• Refractory epilepsy is most often due to
- Hippocampal sclerosis, malformations of cortical
development, small foreign tissue lesions
• Known causes are (secondary)
- Cerebrovascular disease (15%)
- Cerebral tumor (6%)
- Alcohol related (6%)
- Post-traumatic (2%)
- Neuroinfections (tuberculosis & cysticercosis)

9. What Causes Epilepsy ?

10. Contd…

11. Genes and Epilepsy
• Over 200 disorders showing a Mendelian pattern of
inheritance feature epilepsy as a manifestation
• Single gene disorders where epilepsy is the sole or major
manifestation are being discovered but will account only
for a small proportion of cases
• In most forms of epilepsy the inheritance is probably
polygenic (i.e many genes are responsible for the
disorder)

12. Types Of Seizures

14. Epileptic Seizures
• Epileptic seizures are paroxysmal events
• Symptoms:
- Generalized convulsive movements, drop attacks,
transient focal motor or sensory attacks (including facial
and eye movements), psychic experiences, episodic
phenomena in sleep, prolonged confusional states are all
possible
• Several well described types of seizure are recognized and
are usually stereotyped in an individual

15. Mechanisms
• Generalized Seizures:
– Involve much of the cortex bilaterally from the outset and therefore
loss of consciousness.
– Reciprocal cortico-thalamic interaction
• Partial Seizures:
– Begin focally in cortex- may become generalized involving entire cortex
– Local excitation-inhibition imbalance
• Disorder of membrane ion channels: complex changes in brain
receptor, membrane and system levels in most cases
• Pathological, functional imaging and genetics will probably redefine
our understanding and promote rational drug design

16. Simple Partial Seizure
 Awareness Preserved
Memory Preserved
Consciousness Preserved

17. Contd…

18. Complex Partial Seizure
? Awareness Preserved
? Memory Preserved
? Consciousness Preserved
<any one on the above symptoms will be affected>

19. Contd…

20. Generalized Tonic-Clonic Seizures
(Grand Mal Seizure)
Grand mal seizures start with loss of consciousness, a cry,
generalized tonic muscle contraction, and a fall. Autonomic signs
are often present during the tonic phase, including tachycardia,
hypertension, cyanosis, salivation, sweating, and incontinence.

21. Absence Seizures
(Petit Mal)
Sudden & brief cessation in activity with rapid return
to normality, may be frequent, 3Hz spike and wave

22. Contd…
• Atypical Absence Seizures
– Atypical absence seizures differ from typical absence seizures because motor
symptoms are more prominent and sometimes have a focal preponderance.
– Children with atypical absence seizures tend to have multifocal or generalized
cerebral pathology, clinically associated with a lag in attaining normal
developmental milestones.
• Myoclonic Seizures
• Myoclonus is also a nonspecific term that describes brief nonepileptic muscle
jerks. They may involve a body segment or be generalized, may be single or
repetitive, and may be spontaneous or provoked by sensory stimulation
(reflex) or limb action.
• Myoclonic seizures also may occur in children with a variety of epileptic
syndromes such as the Lennox–Gastaut syndrome, infantile spasms (West
syndrome), and early myoclonic encephalopathy. Myoclonus also may be a
part of CNS storage diseases. In the adult population, it is classic finding for
spongiform encephalopathy (Creutzfeldt–Jakob disease).

23. Contd…
• Status Epilepticus
– Usually occurs in a person with history of seizures
– Repeated seizures lasting 30 minutes or longer without recovery of
consciousness
– Usually due to AED withdrawal (non-compliance), acute infections or
metabolic states
– GTC status is a medical emergency
– Complex partial and absence status present with impaired awareness
• Automatisms:
– Semi-purposeful or release phenomena, occur in both absences and
complex partial;
– lip smacking, swallowing, fidgeting with hands, complex behaviors

24. Absence Seizure
http://youtu.be/fmIkxJs635o

25. Partial Complex Seizure
http://youtu.be/Qli6cZdLnG0

26. Myoclonic Jerks
http://youtu.be/_QGF9sTx2DI

27. Generalized Tonic Clonic Seizure
http://youtu.be/hciaAeYLJSw

28. Diagnosis and Management

29. Diagnosis
• Almost always clinical: a detailed history and an
eyewitness account are essential
• Information about:
- The circumstances of the episode
- Patterns of occurrence
- Preceding symptoms- localizing or diagnostic
- Timing, pattern, tempo and evolution of symptoms
- Reported behaviors- before, during and after
- Investigations are seldom necessary for making
diagnosis: but are helpful in terms of management

30. Differential Diagnosis
• Syncope
vasovagal, micturition,
postural, vascular, respiratory,
cardiac
• Cardiac Disorders
arrhythmias, aortic or mitral
stenosis, cardio-myopathies,
myxoma..
• Metabolic/ Endocrine
hypoglycemia,
phaeochromocytoma,
porphyria, carcinoid syndrome
• Neurological
TIA, cataplexy-narcolepsy,
basilar migraine, III ventricle
cyst, Meniere’s disease,
episodic ataxias, movement
and sleep disorders
• Psychogenic
hyperventilation, panic attacks,
non-epileptic attack disorder,
episodic dyscontrol syndrome,
malingering, Munchausen

31. Pharmaco-Therapy
• The management of epilepsy has been transformed, with
more than 24 agents available for use in the United
States and even more options elsewhere in the world.
• Although there are a considerable number of choices of
AEDs for the management of both the first seizure and
chronic epilepsy, there is a paucity of comparative
effectiveness data to offer evidence-based
recommendations of which drug should be best used in a
given clinical scenario.

32. Newer Anti-Epileptic Drugs

33. Antiepileptic Drugs Currently Approved by FDA

34. Contd…
Much work is needed to answer vital common clinical questions
regarding AEDs, such as:
1. Which drug should be used (first-generation or a new
agent)?
2. Are there certain agents that should be tried before surgery?
3. Can a certain combination of medications yield better
seizure control than a single agent?
4. Are the trial designs used to approve new AEDs clinically
meaningful?
Joseph et.al, Mayo Clin Proc. 2012

35. Surgical Treatments For Epilepsy
• Surgical treatment may be an option for individuals whose
seizures are unresponsive to medical therapy or those who
cannot take medications because of significant adverse effects
or quality-of-life issues.
• In a randomized controlled study of patients with refractory
temporal lobe epilepsy, patients that underwent temporal
lobectomy were more likely to be seizure free than the
patients randomized to AED therapy.
• Many aspects of cortical mapping and function were derived
from work related to surgery for epileptic activity.

36. Contd…

37. Contd…
• Corpus Callosotomy
– Occasionally, surgical division of this important inter-hemispheric
connector is helpful for controlling seizures
that spread quickly from one side to the other.
• Functional Hemispherectomy
• Functional isolation of specific cerebral regions within each
hemisphere is possible by dividing the fiber connections
between frontal, temporal, and parietal lobes while
avoiding large resection of cortex and sparing the deeper
nuclei and structures such as the basal ganglia.

38. Deep Brain Stimulation
• Deep brain stimulation (DBS) therapy can be used for people
who have epilepsy that is difficult to treat, or who cannot
have surgery to separate or remove the part of the brain that
causes seizures to happen. It involves implanting electrodes
into specific areas of the brain
• The electrodes are connected to a neuro-stimulator, a battery
powered device that sends electrical impulses to the brain.
• DBS therapy aims to control excess electrical activity in the
brain using regular electrical impulses to reduce the
frequency and severity of seizures.

39. Contd…
Trials show that for some people their seizures become much
less frequent, for others it may reduce their seizures a little, and
for others it has no effect.

40. Psychological Issues

41. On Diagnosis
• Grief
• Fears for Safety
• Doubts about ability to cope with the situation – no
control over life.
• Resentment from family – disruption to their own lives
• Guilt – is it their fault?
• Isolation
• Insecurity in patients affecting self worth & confidence.

42. Anxiety
• Fear of having a seizure
• Stigmatizing condition
• Determination to conceal the condition
Reciprocal Relationship
Higher the Anxiety - Higher the Seizure - Higher the Anxiety.

43. Depression
• Reaction to acquiring label of epilepsy
• Reaction to social/family problems
• Ability to function effectively in work place as well as a
family supporter.
• Prodromal/ictal experience

44. Aggression
• Response to constraint by others
• Loss of freedom/independence

45. Psychosis
• Due to lesions in the brain
• Prolonged high dosage of medication.

46. Psychological Impact
• Low Self Esteem
• Inferiority Complex
• Isolation

47. Minimizing Psychological Impact
• Relaxation Exercise
• Cognitive Behavior Therapy
• Family Support
• Supportive Counseling - Reassurance

48. Social Perspective

49. Education
• Lowered Expectation From Teachers & Parents
• Attitude To Learning
• Acceptance Of Failure
• Actual Loss Of Schooling/Classes
• School/Teacher Avoiding Responsibility

50. Employment
• Restrictions/Options Available
• Overprotection Of Family – Not Sending ToWork
• Employer Avoiding Responsibility

51. Marriage
• Finding understanding partners/family due to social
stigma – especially for women
• Unemployment
• Misconception as mental illness

52. Divorce
• Concealing the Condition
• Economic Condition
• Misconception as mental illness
• Fear of offspring acquiring seizures

53. Marriages and Indian Law
• Until December 1999, India was the only country in the world
with "an absurd law on epilepsy and marriage."
• Marriages under the above mentioned acts could be
solemnized "if at the time of marriage neither party suffers
from recurrent attacks of insanity or epilepsy.“
• It took a struggle of 12 years for the Indian Epilepsy
Association to have the word ‘epilepsy’ deleted from this law.
• Seizure no longer a condition to claim for divorce.

54. Stigma
• Knowledge, Attitude And Practice Studies
• Studies done in India reveal that knowledge of epilepsy
among the Indian population is high or comparable to
western countries.
• However, attitudes towards epilepsy are more negative.
These attitudes have a significant correlation with level of
education and occupation, i.e. lower education is
associated with higher discrimination.

55. Krishnamoorthy ES, Misra V, Sankar S, Anand A
TS Srinivasan Institute of Neurosciences
VHS Multi-Specialty Hospital & Research Institute
ILAE Annual Congress 2013, Montreal, CA

56. Mobility - Driving
• Dependence on public transport/family members –
restrictions in driving.
• Overprotection from family
• Restriction in employment

57. Develop a Management Plan
Clinical Guidelines for the Management of Epilepsy in Adult with Intellectual
Disability 2001
• Both the medical and psychological impact of epilepsy are
assessed adequately, and reviewed;
• Carers and staff working with Individual should receive
training in epilepsy and its management, and on the impact it
has on peoples live;
• Training should also be provided on methods of behavioral
observation and seizure reporting;

58. Contd…
• Carers should also be trained in any necessary emergency
procedures, such as the rectal administration of medication and
resuscitation, and clear policies should be provided for these on an
individual basis;
• Care plans should be ensure consistency in the support offered to
people with intellectual disability and epilepsy. For example, the
same individual should accompany the person with epilepsy to
clinic appointment
• Accurate records should be kept, using diaries or equivalent and
those working with the person with epilepsy should be familiar
with use.

59. Social Issues - Mitigation
Developing and Designing Information Services on Epilepsy &
Services
• Public Education – Remove Misconceptions
• Societal Support
• Self Help Groups
• Government Support for Networking

60. What Epilepsy is Not ?

61. Epilepsy is Not
• A Curse
• Witchcraft
• Contagious
• Mental Illness
• Something to be feared or Rejected
• A supernatural gift or blessing

62. Possession: Jesus Driving out an Unclean Spirit. 1700. Artist Unknown

64. For more info !!
http://www.neurokrish.com/epicare
--
http://www.epilepsy.com
--
http://www.epilepsysociety.org.uk

65. 65
Thank You