1. Epilepsy
Samantha Harrison MBBS 3

2. What is Epilepsy?
• Etymology: From the greek word Epilepsia. Epi meaning upon and
Lepsis meaning seizure. In ancient times epilepsy was known as the
sacred disease.
• Definition:
• Epilepsy is a disorder of the brain characterized by an enduring
predisposition to epileptic seizures [Fisher et al, 2005]
• WHO: Two or more unprovoked seizures. A chronic
noncommunicable disorder of the brain that affects people of all
ages.
• Epilepsy is a medical condition that produces seizures affecting a
variety of mental and physical functions. It is also called a seizure
disorder. When a person has two or more unprovoked seizures, they
are considered to have epilepsy (Epilepsy Foundation)

3. What is a seizure?
• Etymology: Seiz + ure meaning sudden attack of illness
• Definition
• An epileptic seizure is the transient occurrence of signs or
symptoms due to abnormal electrical activity in the brain [Fisher
et al, 2005]. This manifests itself as a disturbance of
consciousness, behaviour, emotion, motor function, or sensation.
• Seizures happen when clusters of nerve cells in the brain signal
abnormally, which may briefly alter a person's consciousness,
movements or actions.

4. Epilepsy Epidemiology
• 30 million people worldwide are epilepsy sufferers (WHO)
• Prevalence: 4-6 people per 1000; 0.5%
• Epilepsy has been estimated to affect between 260,000 and
416,000 people in England and Wales.
• Incidence: 40-70 new cases per 100000 annually; 0.05% .
Twice as high in developing countries.
• 80% of the world’s epilepsy is found in the developing
countries
• Why?

5. Who is at risk of Epilepsy?
• Neonatal Period
• hypoxic ischemic encephalopathy
• central nervous system (CNS)
infections
• trauma
• congenital CNS abnormalities
• Metabolic diseases
• Late infancy and Early childhood
• febrile seizures (fairly common),
caused by CNS infections and
trauma.
• Childhood
• well-defined epilepsy syndromes
• Adolescence and adulthood
• CNS lesion
• Idiopathic epilepsy (less
comon)stress, trauma, CNS
infections, brain tumors, illicit
drug use and alcohol withdrawal.
• Older adult
• cerebrovascular disease (very
common cause).
• CNS tumors
• head trauma,
• degenerative diseases e.g.
dementia.[15]

6. Epilepsy Classification
• Epilepsy is a symptom – not a diagnosis
• Epilepsies are classified in five ways:
• By their first cause (or etiology).
• By the observable manifestations of the seizures, known as semiology.
• By the location in the brain where the seizures originate.
• As a part of discrete, identifiable medical syndromes.
• By the event that triggers the seizures, such as reading or music
• Or more simply
• Symptomatic – definite lesion as the cause
• Idiopathic – what it says on the tin
• Cryptogenic – not idiopathic but no definite origin, high prevalence
of associated learning disabilities

7. Seizure Types - Definitions
• Simple – no impairment of consciousness
• Complex – impairment of consciousness
• Generalised (primary and secondary): abnormal electrical
activity is over the entire cortex immediately (primary) or
spreads over the entire cortex from a single point (secondary).
• Focal/Partial – Abnormal electrical activity is restricted to a
region of the brain

8. Seizure Types (cont.)
• Absence – seizures characterised by an abrupt, transient loss
or impairment of consciousness (which is not subsequently
remembered)
• Tonic-clonic – type of generalised seizure that involves a tonic
– stiffening phase and a clonic – jerking phase
• Atonic -seizures characterised by abrupt brief loss of muscle
tone. AKA drop seizures
• Jacksonian March – type of simple partial seizure,
characterised by jerking. Spreads from arm > face > leg
(ipsilaterally)
• Tonic seizures characterised by a stiffening of all the muscles
• Febrile seizures characterised by convulsions brought on by a
significant rise in body temperature.

9. Seizure Types

10. • Typical Seizure
• Any precipitating Factors

11. Epilepsy Syndromes
• Epilepsy syndromes are a list of diseases that cause epilepsy
• Epilepsy syndrome as a term – means a syndrome where
recurrent seizures are the predominant feature
• 29 Epilepsy syndromes (ILAE)

12. InternationalClassificationof Epilepsiesand
EpilepticSyndromes
• 1. Localization-related (focal, local, partial) epilepsies
and syndromes
• 1.1. Idiopathic with age-related onset
• A. Benign childhood epilepsy with centrotemporal spikes
• B. Childhood epilepsy with occipital paroxysms
• 1.2. Symptomatic
• A. Chronic progressive epilepsia partialis continua of
childhood
• B. Syndromes characterized by seizures with specific
modes of precipitation
• C. Temporal lobe epilepsies
• D. Frontal lobe epilepsies
• E. Parietal lobe epilepsies
• F. Occipital lobe epilepsies
• 1.3 Crytopgenic

13. InternationalClassificationof Epilepsiesand
EpilepticSyndromes
• 2. Generalized epilepsies and syndromes
• 2.1. Idiopathic, with age-related onset
(listed in order of age)
• A. Benign neonatal familial convulsions
• B. Benign neonatal convulsions
• C. Benign myoclonic epilepsy in infancy
• D. Childhood absence epilepsy
(pyknolepsy)
• E. Juvenile absence epilepsy
• F. Juvenile myoclonic epilepsy (impulsive
petit mal)
• G. Epilepsy with grand mal seizures on
awakening
• H. Other generalized idiopathic epilepsies
not defined above
• I. Epilepsies with seizures precipitated by
specific modes of activation2.2.
Idiopathic and/or symptomatic (listed in
order of age)
• A. West syndrome (infantile spasms)
• B. Lennox-Gastaut syndrome
• C. Epilepsy with myoclonic-astatic
seizures
• D. Epilepsy with myoclonic absences
• 2.3. Symptomatic
• A. Nonspecific etiology
• a. Early myoclonic encephalopathy
• b. Early infantile epileptic encephalopathy
with suppression burst
• c. Other symptomatic generalized
epilepsies not defined above
• B. Specific etiology
• a. Epileptic seizures may complicate many
disease states

14. InternationalClassificationof Epilepsiesand
EpilepticSyndromes
• 3. Epilepsies and syndromes undetermined as to whether they are
focal or generalized
• 3.1. With both generalized and focal seizures
• A. Neonatal seizures
• B. Severe myoclonic epilepsy in infancy
• C. Epilepsy with continuous spike waves during slow-wave sleep
• D. Acquired epileptic aphasia (Landau-Kleffner syndrome)
• E. Other undetermined epilepsies not defined above
• 3.2. Without unequivocal generalized or focal features
• 4. Special syndromes
• 4.1. Situation-related seizures
• A. Febrile convulsions
• B. Isolated, apparently unprovoked epileptic events
• C. Seizures related to other identifiable situations such as stress,
hormonal changes, drugs, alcohol, or sleep deprivation

15. Reflex epilepsy
• Epilepsy always triggered by a specific stimulus
• Music
• Photosensitive epilepsy
• Reading

16. Precipitating factors
• Emotional stress
• Sleep deprivation
• Sleep itself
• Heat stress
• Alcohol
• Febrile illness
• Menstrual Cycle.
• Catamenial epilepsy is the term denoting seizures linked to the
menstrual cycle

17. What happens during the Ictal
phase?
• Dependent on the seizure
• Faecal/urinary incontinence
• Tongue biting – lateral vs anterior
• Observer – collateral history – jerking
• Loss of consciousness

18. What happens post-ictally?
• Confusion
• Extreme fatigue
• Memory Loss
• Drowsiness
• Nausea
• Headache/migraine
• psychosis
• Poor attention and concentration
• Depression
• Todd’s paresis
• Post ictal bliss

19. Temporal Lobe Epilepsy
• Automatisms common
• Lip smacking
• Fiddling with hands
• Secondary generalised seizures
• MRI shows hippocampal sclerosis

20. Status Epilepticus
• Definition: Epileptic seizure that lasts for over 30 minutes
• Can be life threatening

21. Psychogenic Seizures
• More common in women
• More common in people with personality disorders
• Commonly a history of physical or sexual abuse as a child
• Can also suffer epileptic attacks as well as psychogenic non-
epileptic psychogenic attacks

22. Pathophysiology of Epilepsy
• PET Scanning has shown that areas of the brain that induce
seixures are less active than other areas of the brain between
seizures (is the brain suppressing the overactive region?)
• PET scanning also revealed abnormal receptor functioning in
these regions with reduced GABAa density.

23. Complications of Epilepsy
• The risk of premature death in people with epilepsy is two to
three times higher than it is for the general population.
• Driving Restrictions – must have had no awake seizures for 6
months or only had sleep seizures for the previous three years
to retain licence in a first seizure scenario. Recurrent sseizure
profile revoke licence – 12 months seizure free

24. Differential Diagnoses
• Psychogenic Cause
• Malingering
• Narcolepsy
• Syncope
• Other paroxysmal sleep and movement disorders

25. Taking a History of a seizure
• What you want to know?
• Are these really epileptic seizures?
• How you are going to find out?
• Ask the right questions
• Did anything bring on the attack?
• Before the attack was there any lightheadedness or blurring/fogging of vision?
• Did anyone else comment that you had become pale?
• Did this happen during or following exercise?
• Did you make an abnormal noise at the start of the attack?
• How did you fall? Stiff vs Floppy
• Did you hurt yourself when you fell?
• Tongue Biting – Lateral vs Anterior
• Faecal incontinence
• How long was the attack?
• Were you able to recognise where you were, who you were with after the attack?
If so how long did this take to resolve?
• Were you lethargic for hours after the attack?

26. Investigating Epilepsy
• Examination
• ECG
• EEG
• Video of a seizure
• MRI
• Blood Tests: Calcium, LFTs, drug and alcohol screen

27. EEG
• Electroencephalogram

28. Treatment of epilepsy
• Carbamazepine – focal
• Valproate – generalised
• Cepra – both
• Lamotrigine
• Carbamazepine metabolism slowed by clarithromycin

29. Treatments
• Surgery
• Vagal stimulation
• Deep brain stimulation
• Transcranial magnetic stimulation
• Ketogenic diet
• Surgery to disconnect rather than remove brain areas

30. Is Epilepsy Curable?
• Controllable but not curable. Sometimes surgery can be a
curable treatment.
• 20-40% of patients have AED resistant epilepsy