skhalora95@gmail.com

Epilepsy

A seizure or epileptic attack is the consequence of a paroxysmal uncontrolled discharge of neuron within the central nervous system.

The clinical manifestations range from a major motor convulsion to a brief period of lack of awareness.

INCIDENCE:-

  • 5% of the population suffer a single seizure.
  • 0.5% of the population have recurrent seizures.
    • 10% -well controlled with drugs with few seizures and prolonged remissions.
    • 30%- epilepsy at least partially resistant to drug treatment.

CAUSES:-

Possible causes include-

  • Traumatic brain injury.
  • Scarring on the brain after a brain injury ( post traumatic epilepsy)
  • Serious illness or very high fever
  • Stroke
  • Other vascular disease
  • Lack of oxygen to the brain
  • Brain tumour or cyst
  • Dementia or Alzheimer’s disease
  • Maternal drug use , prenatal injury,brain malformation or lack of oxygen at birth
  • Infectious disease such as AIDS and meningitis
  • Genetic or development disorder or neurological diseases
  • Hereditary plays a main role in some type of epilepsy.

CLASSIFICATION OF SEIZURE TYPE:-

A) PARTIAL SEIZURE:– (affect just one part of brain)

1)According to severity:-

  • Tonic/clonic attacks

2) Site of onset :-

a) Frontal lobe seizure:– there are a number of seizure types:-

  • Jacksonian motor seizures:-
    • Consist of march of involuntary movement from one muscle group to the next.
    • Movementis clonic shaking and usually beings in- hand or face.
  • Advesive seizures:-
    • The patient’s eyes and head turn away from the site of the facal origin.
  • Supplementary motor area seizure:-
    • More complicated stereotyped movements often arising from sleep.Ex.-cycling movement

b) Parietal lobe seizure:- this arise in the sensory cortex ( parietal lobe)

c) Temporal lobe seizures:-

  • These attacks are characterized by a complex aura ( initial symptoms) often with some impairment of consciousness.

d) Occipital lobe seizure:-

Uncommon typically there is an elementary visual hallucination.

B) GENERALISED SEIZURE:- (affect the whole brain)

  • Absences (induced by hyperventilation)
  • Absence status
  • Myoclonic seizures
  • Tonic seizures
  • Atonic seizures
  • Tonic / clonic seizures

SYMPTOMS:-

1.Partial seizure:-

a) Frontal lobe seizure:

  • involuntary movement from one muscle group to the next.
  • Movement is clonic or tonic
  • Todd’s paralysis-after a motor for some hours before return of function occurs.
  • Loss of consciousness.

b) Partial lobe seizure:-

  • Paraesthesia or tingling in an extremity or on the face sometimes.
  • Limb appears weak without involuntary movement.

c) Temporal lobe seizure:-

  • Visceral disturbance-
    • Gustatory(taste)
    • Olfactory (smell) hallucinations
    • Lip smacking
    • Epigastric fullness
    • Choking sensation
    • Nausea
    • Pallor
    • Papillary changes(dilation)
  • Memory disturbance:-Something has happened before-
    • Feeling of unfamiliarity
    • Depersonalisation
    • Derealisation
    • Flashbacks
    • Formed visual or auditory hallucinations
  • Motor disturbance:-
    • Fumbling movement
    • Rubbing
    • Chewing
    • Semi-purposeful limb movement
  • Affective disturbance:-
    • Displeasure
    • Pleasure
    • Depression
    • Fear
  • Confusion and headache after an attack are common.

d) Occipital lobe seizure

  • visual hallucination

f) Tonic/clonic attack – loss of consciousness falls to the ground.

  • Tonic phase (10sec)
    • Eyes open- elbow flexed
    • Arms pronated- legs extended
    • Teeth clenched-pupils dilated
    • Breathe-cyanosis
    • Bowel/bladder control may be lost at the end of this phase.
  • Clonic phase(1-2)
    • Tremor gives way to violent generalized shaking.
    • Eyes roll backward and forwards.
    • Tongue may be bitten
    • Tachycardia develops
    • Breathing recommence

B) Generalized seizure:-

  • Absence seizures( petit mal seizures)- This type of seizures may also cause-
    • Repetitive movement like lip smacking or blinking .
    • Usually a short loss of awareness.
  • Myoclonic seizures – spontaneous quick twitching of the arms and legs.
  • Tonic seizures – muscle stiffness with immediate loss of consciousness.
  • Atonic seizures- loss of muscle contraction and can make you fall down suddenly.

EPILEPSY CLASSIFICATION

A) Idiopathic :-

  • primarily genetic with generalized seizure.
  • sometimes grouped as more specific syndromes.
  • 10-20% of cases.

B) Symptomatic:-partial onset seizures associated with structural lesion such as –

  • Tumour
  • Cortical dysplasia
  • Infection
  • Head injury or trauma
  • 30-40% of cases.

C) Cryptogenic :-

  • partial onset seizure for which no cause has been found.
  • 50% of patients.

INVESTIGATION:-

  • CT scan
  • MRI
  • EEG
  • ECG
  • Advanced investigations
    • Positron emission tomography(PET)
    • Single photon emission computerized tomography (SPECT)

TREATMENT:-

Basic principles:-

Anticonvulsant (Antiepileptic drug therapy):-

  • Treatment aim to prevent seizures without side effect though this is not always achieved.
  • Sugery is an option in a small number on non-responsers.

Anti-epileptic ( anticovulsant, antiseizure drug):-

  • Idiopathic generalized epilepsy-
    • Sodium valproat
    • Lamotrigine
    • Topiramate
    • Levetiracetam
    • Phenytoin
  • Partial (focal) epilepsy:-
    • Lamotrigine
    • Carbamazepine
    • Sodium valproate
    • Phenobarbitone
    • Levetiracetam
    • Topiramate
    • Tiagabine
    • Zohisamide
    • Oxcarbazepine
    • Gabapentine
    • Pregabalin
    • Lacosamide

Ketogenic diet:-

  • More than half of people who don’t respond to medication, benefits from this high fat low carbohydrate diet.

Life style issues:-

  • Generally there should be as few restrictions as possible ( see driving regulation).
  • patient should be made aware of potential triggers to avoid-sleep deprivation, excess alcohol, and where relevant flashing lights. (thought most patient are not photosensitive)

Sensible precaution:- showering rather than taking a bath . Avoiding heights should be suggested.

SURGICAL TREATMENT:-

Operation is contraindicated in patient with severe mental retardation or with an underlying psychiatric problem.

Operative technique:-

  • Extra-temporal cortical resection
  • Anterior temporal lobectomy
  • Corpus callosal section
  • Selective amygydalo-hippocampectomy
  • Hemispherectomy / hemispherotomy :-

Vagal nerve stimulation(VNS):-

  • Involves periodic stimulation of the left vagal nerve by an implanted stimulator.
  • VNS appears to reduce neuronal excitability but the exact mechanishm remains obscure.
  • About 30% of patients show a 50% seizure reduction within two years.

EXERCISE AND SEIZURES:-

  • Most patient with epilepsy do not need physiotherapy, but some do have limited mobility and other disorder.
  • To enhance the mobility and co-ordination.
  • Weight bearing stimulus through the feet-encourage extension and counteract flexion.

The patient and their parents should be educated about the nature of illness and condition.

  • Overall fitness and felling of well being have been shown to help reduce seizures frequency.

People feel better and may improve their seizure control with regular exercise.

%d bloggers like this: