Download - Problems in the management of epilepsy
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EPILEPSY Medical and surgical
management
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Basic Classification
• Primary
– focal
• simple
• complex partial
– generalized
• Secondary– focal– generalized
• Mis: febrile, alcoholic etc
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Is it epilepsy?
Features suggestive of epilepsy– Suddenness of attack
– Symptoms of recognized seizure type
– An attack during sleep
– Stereotyped attack
– Injury, incontinence, headache and vomiting
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History
• Onset and detail description
• Associated features and modifying factors
• Medical and psychiatric history
• Neurological disorders
• Family history
• Occupation
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Clinical Examination
• Skin and vital signs
• Focal neurological deficit
• Features of raised intracranial pressure
• Systemic examination
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What blood test in epilepsy?
• Complete blood count
• Blood sugar fasting and post pandrial
• Serum creatinin
• S. Calcium and sodium
• SGPT, bilirubin
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EEG in Epilepsy
• To confirm the diagnosis
• To classify the type of seizure
• To locate the focus of discharge
• To find out triggering factors
• To find out associated brain disease
• To monitor anticonvulsant
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When to do Neuroimaging?
• Above 25 years of age
• Focal onset or focal neurological sign
• Features of raised intracranial pressure
• Uncontrolled seizure
• Features of focal lesion in EEG
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CT or MRI
• CT
– Calcification
– Acute hemorrhage
– Emergency
• MRI– Tumor– Old hematoma– AVM– Temporal atrophy– Granuloma
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When to start medication
• Following two seizure within one years
• Following first seizure with
underlying cause
• Employed in dangerous profession
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How to start drug treatment?
• Confirm the diagnosis
• Use single anticonvulsant
• Use proper doses
• Loading dose of certain drug in emergency
• Build up dose of others
• Use minimal effective dose
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What drug to choose?
Focal/GTCS CBZ, PHY, VALPHB,
Absence VAL, EHT, BNZ
Myoclonic VAL, CLN
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Drug level monitoring
• To maintain
minimum dose
• Uncontrolled
epilepsy
• Noncompliance
• Polytherapy
• Drug interaction
• Toxicity
• Hepatic diseases
• Pregnancy
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What is the chance of remission?
• 50% Remission off treatment for 20
years
• 20% Remission on treatment
• 30% Seizure on treatment
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Catamenial epilepsy
• 10-70% of epilepsy in women
• Estrogen induces seizure
• Progesterone falling levels
• Adjust antiepileptic dose
• Estrogen inhibitors (clomifen)
• Progesterone
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Contraceptive in epileptic
• PHY, PHB, CBZ, induces hepatic P450 enzyme and cause contraceptive failure in 6-10%
• Topiramate is weak enzyme induce
• BNZ, LMT, VIG, GPT do no induces P-450
• Estrogen induces seizure
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Pregnancy and Epilepsy
• Choice of drug:– All antiepileptics are teratogenic– Use single drug in low dose– Control GTCS – Use Folic acid 1mg 4-6 week before
pregnancy– Use Vit K before delivery to prevent
bleeding
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Followup in Pregnancy
Weeks Examination 6-10 AED levels (free and total),
serum folate level 15-16 Maternal serum AFP,
amniocentesis,* AED levels 18-19 Ultrasound for neural-tube
defects 22-24 Ultrasound for oral clefts and
heart anomalies 28 AED levels 34-36 AED levels, maternal
vitamin K
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Antiepileptic in breast milk
• Carbamazepine 40% • Ethosuximide 90% • Phenobarbital 36% • Phenytoin 18% • Primidone 70% • Valproic acid 5% • Topiramate,Gabapentin, ??
Lamotrigine
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What drug in systemic disease
Liver disease
• Gabapantine
• Phynobarbitone
• Phenytoin
• Benzodiazepine
Renal disease
• Phenytoin
• Phynobarbione
• Benzodiazepine
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Febrile seizure
• No seizure for single febrile seizure
• Diazepam orally for recurrent febrile
seizure
• Valproate or phenobarb for recurrent
febrile seizure
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Good prognostic signs• Granuloma• Early posttraumatic epilepsy• Mild infrequent seizure• Secondary systemic or toxic
seizure• Benign rolandic epilepsy• Primary generalized epilepsy• Absence seizure• Early treatment
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Bad prognostic signs
• Diffuse cerebral disease
• Late posttraumatic epilepsy
• Multiple seizure types
• Complex partial seizure
• Long untreated seizure
• History of Status in the past
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When to stop treatment
• Primary generalized seizure with normal
EEG for 2-3 seizure free years
• Taper slowly
• Severe brain damaged needs life long
treatment
• Short course following medical disorder
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Intractable seizures
• 20-30% of epilepsy
• Poor compliance
• Inadequate drug doses
• Improper choice of drug
• Inappropriate combination of drugs
• Misdiagnosis of seizure or seizure type
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New antiepileptic drugs
1. Clobazam
2. Gabapantin
3. Lamotrigine
4. Topiramate
5. Vigabatrin
6. Falbamate
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Clobazam
• Benzodiazepine, anxiolytic
• Weak antiepileptic
• For add on therapy
• Less side effect
• Can be used in children with primay and febrile seizure
• Dose: 0.1-0.5mg/Kg/dayBD
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Gabapantine
• First pass metabolism
• No interaction
• Drug level monitoring not required
• Can be use in high doses
• Renal and hepatic failure and transplant patient
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Lamotrigine
• Broad spectrum antiepileptic
• Skin rash common, no other significant toxicity
• Can be used in all age as primary and secondary drug
• Dose: 0.5-10mg/kg in two divided dose
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Topiramate
• GABArgic
• Efficacy: Partial seizure
• Side effects: fatigue, nervousness, difficulty with concentration, tremor, weight loss, renal stone
• Dose: 50-400mg in two divided doses
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Status epilepticus causes
Drug withdrawal 25
Alcohol withdraw 25
Cerebrovascular: 22
Metabolic: 10
Systemic infection 12
Trauma 15
Drug toxicity 15
CNS infection 12
Tumor 8
Congenital lesion 8
Prior Epilepsy 33
Idiopathic 30
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Status epilepticus management
• ABCD
• Blood: Electrolytes, CBC, Calcium, Magnesium, BUN, Liver function Anticonvulsant level, Alcohol, Toxicology screen
• If hypoglycemia suspected, give 50% glucose
• Give Thiamine 100 mg iv
• Lorazepam 0.1 mg/kg iv
• Phenytoin 20 mg/kg iv, 50 mg/min
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Status management cont.
If seizure persists:
• Phenobarbital 20 mg/kg iv at 50 to 100 mg/min
• Review lab result and correct any abnormality
• CT/MRI: bleed, infection, AV malformations, neoplasm
• Lumbar puncture: if CNS infection suspected
• Blood cultures: Sepsis
For refractory seizure:• Intubation, EEG
monitoring and Pentobarbital 5-15 mg/kg loading over 3 minutes, 0.5 to 5 mg/kg/hr drip or
• Midazolam (Versed) 0.15-0.20 mg/kg loading, then 0.06-1.1 mg/kg/hr drip
• Propofol 1-2 mg/kg loading, then 3-10 mg/kg/h
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Surgical Procedures
• Resection of epileptic focus
– cortical resection
– temporal lobectomy
– Amygdylohippocampectomy
• Corpus callosotomy
• Hemispherictomy
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Resection of epileptic focus
• Partial seizures
– Temporal origin
– extratemporal origin
• Generalized seizure with identifiable
resectable focus
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Corpus callosotomy
• Atonic seizures– frequent episodes– frequent falls and injury– 70% reduction with callosotomy
• Infantile hemiplegic syndrome
• some patients with generalized seizures with epsilateral focus
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Evaluation:
• MRI– hippocampal
asymmetry
– temporal lobe abnormality
• CT– interictal CT: may
show enhancement with contrast, slow uptake
• PET– hypometabolism
lateralized to side of temoral lobe focus in 70% of patients
• WADA test– localizes dominant
hemisphere– Amytal
• Video EEG monitoring• Invasive EEG
monitoring
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Corpus callosotomy
• leave Ant commissur
• usuallt anterior 2/3
• may produce post op decresed
verbalization
• usually resolves in few days
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Temporal lobectomy
• 80% pt have focus in anterior temporal lobe
• most of the pathology in mesial temporal lobe
• Limit of resection:– dominant 4.5 cms– non dominant 6-7 cms
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Epilepsy surgery :Outcome
• 2 years post op– 50% seizure free– 80% more than 50% reduction in
frequency
• Dominant temporal lobectomy without intraoperative monitoring– 6% mild dysphasia– major deficit; < 2%