![Page 1: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/1.jpg)
11/4/2019
1
Epilepsy Update
Sanjay P. Singh, M.D.Director – CHI Health-Creighton University Epilepsy Center,
Chairman & Professor,Department of Neurology,
Creighton University School of Medicine.
EPILEPSY
Seizures – Abnormal electrical discharge in the brain leading to a change in behavior.
Epilepsy – chronic disorder with spontaneous seizures.
![Page 2: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/2.jpg)
11/4/2019
2
3.2 million patients in the U.S.
180,000 new cases each year.
16 billion dollars per year.
Functional Areas of the Brain
![Page 3: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/3.jpg)
11/4/2019
3
International Classification of Epilepsy
I. Partial (focal, local) seizures
A. Simple partial seizures (consciousness is not impaired)
1. With motor symptoms 2. With somatosensory1 or special sensory symptoms 3. With autonomic symptoms 4. With psychic symptoms
B. Complex partial seizures (with impairment of consciousness) 1. Beginning as simple partial seizures and progressing to impairment of
consciousness a. With no other features b. With features as in I.A.1 - 4 c. With automatisms4 2. With impairment of consciousness at the start a. With no other features b. With features as in I.A.1 - 4 c. With automatisms
C. Partial seizures evolving to secondarily generalised seizures
1. Simple partial seizures evolving to generalised seizures 2. Complex partial seizures evolving to generalised seizures 3. Simple partial seizures evolving to complex partial seizures to generalised
seizures.
II. Generalised seizures (convulsive or non-convulsive)
A. Absence seizures1. Absence seizures2. Atypical absence seizures
B. Myoclonic seizures
C. Clonic seizures
D. Tonic seizures
E. Tonic-clonic seizures
F. Atonic seizures
III. Unclassified epileptic seizures
![Page 4: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/4.jpg)
11/4/2019
4
Old Definition
Epilepsy was defined conceptually in 2005 -as a disorder of the brain characterized by an enduring predisposition to generate epileptic seizures. This definition is usually practically applied as having two unprovoked seizures >24 h apart.
New Definition
Epilepsy be considered to be a disease of the brain defined by any of the following conditions:
(1) At least two unprovoked (or reflex) seizures occurring >24 h apart;
(2) one unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years;
(3) diagnosis of an epilepsy syndrome.
Epilepsy – ‘Resolved’
Epilepsy is considered to be resolved for individuals who either had an age dependent epilepsy syndrome but are now past the applicable age or who have remained seizure-free for the last 10 years and off antiseizure medicines for at least the last 5 years.
“Resolved” is not necessarily identical to the conventional view of “remission or “cure.”
![Page 5: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/5.jpg)
11/4/2019
5
Partial & Generalized Seizure
Generalized Seizures
Tonic-clonic
Absence
Myoclonic
Atonic
Clonic
Tonic
![Page 6: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/6.jpg)
11/4/2019
6
Absence Epilepsy
Generalized epilepsy syndrome
Stare and cease normal activity – few seconds
EEG – 3Hz spike and wave
Williams et al. 1953. – Electrodes in thalamus.
Occurs in specific age groups.
NREM sleep breaks in for a few seconds !!!!
Complex Partial Seizures
Frontal
Temporal
Parietal
Occipital
![Page 7: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/7.jpg)
11/4/2019
7
Epilepsy Incidence: 1935 – 1984
Hauser WA, et al. Epilepsia. 1993;34:453-468.
Inci
den
ce (
per
100
,000
Per
son
-Yea
rs)
Age (y)
Male
Female
Total
Creighton Epilepsy Program Work up.
Phase-1: - Video-EEG monitoring
- MRI Brain – structure of brain
- PET – metabolism of brain
- SPECT – perfusion of brain
- Neuropsychological testing.
Phase-2: WADA TEST.
Phase-3: Intracranial monitoring
Phase-4: Epilepsy Surgery or other
treatment options.
![Page 8: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/8.jpg)
11/4/2019
8
VIDEO-EEG Monitoring.
Reason for Video-EEG Monitoring
Seizure vs. Pseudo seizure
Type of seizure – best medication
Degree of seizure control
Presurgical work up.
![Page 9: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/9.jpg)
11/4/2019
9
Primary Gen. Epilepsy
Temporal Lobe Epilepsy
![Page 10: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/10.jpg)
11/4/2019
10
Frontal Lobe Epilepsy
Non – Epileptic Seizures
![Page 11: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/11.jpg)
11/4/2019
11
EEG Recording
Routine Scalp EEG
Video-Scalp EEG Monitoring
Intracranial EEG.
EEG reading – “Pattern Recognition”
EEG
Alpha – 8-13 Hz
Beta - >13 Hz
Theta – 4-7 Hz.
Delta – 1-3 Hz.
![Page 12: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/12.jpg)
11/4/2019
12
10-20 System of Electrode Placement
EpileptiformElectroencephalographic Patterns
Epileptiform discharges are distinct paroxysmal EEG waveforms that have a high degree of association with seizures.
The common types of epileptiform discharges are spikes, sharp waves, and spike-and-wave discharges.
![Page 13: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/13.jpg)
11/4/2019
13
Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms. Spike-and-wave discharges consist of a spike followed by a slow wave.
EpileptiformElectroencephalographic Patterns
The interictal discharges seen in routine EEG tracings usually occur singly or sporadically. Spikes, sharps or spike & wave.
In contrast, a seizure (ictal)-related discharge usually consists of repetitive or rhythmic activity that has an abrupt onset and end and that usually is associated with the clinical manifestations of a seizure.
![Page 14: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/14.jpg)
11/4/2019
14
Right Temporal Spike
3 Hz spike & wave.
The frequency of the spike-wave complexes is usually 4 Hz at the onset of the absence seizures and may slow to 2.5 Hz at the end of a seizure
![Page 15: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/15.jpg)
11/4/2019
15
Right Mesial Temporal Sclerosis[MTS].
Hippocampal atrophy
Enlarged temporal horn of lateral ventricle.
MRI - TLE
![Page 16: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/16.jpg)
11/4/2019
16
MRI Brain – Right M.T.S.
MTS - Hippocampus
![Page 17: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/17.jpg)
11/4/2019
17
M.R. MICROSCOPY – [9.4 Tesla]
14 yrs. Old male with left sided sensory seizures.
![Page 18: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/18.jpg)
11/4/2019
18
![Page 19: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/19.jpg)
11/4/2019
19
PET-M.E.S.
WADA TEST.
Angiogram
SODIUM AMYTAL
Right ICA
Left ICA
Test for lateralization:
- Speech.
- Memory.
![Page 20: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/20.jpg)
11/4/2019
20
fMRI
Intracranial Recording
![Page 21: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/21.jpg)
11/4/2019
21
Treatment of Epilepsy
Anti epileptic medications – AED’s.
Epilepsy Surgery – resective
Vagal Nerve Stimulator
Deep Brain Stimulator
RNS
![Page 22: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/22.jpg)
11/4/2019
22
Antiepileptic Medications
![Page 23: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/23.jpg)
11/4/2019
23
First Canabis Drug Approved for Epilepsy
![Page 24: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/24.jpg)
11/4/2019
24
Temporal Lobectomy for M.T.L.E.
Vagal Nerve Stimulator
![Page 25: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/25.jpg)
11/4/2019
25
Deep Brain Stimulation
![Page 26: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/26.jpg)
11/4/2019
26
RNS System
First Seizure - ? Risk of seizure recurrence
in patients with normal EEG, normal MRI & exam – 24%
Risk of seizure recurrence in patients with either an abnormal EEG or MRI/Exam – 48%
Risk of seizure recurrence in patients with an abnormal MRI/exam and an abnormal EEG – 65%
Risk of recurrence – 35%
Berg et al – Neurology, 1991 Hauser et al – NEJM, 1998
Tx reduces risk of recurrence but does not influence disease course.
F.S.T.G. – Neurology, 1993.
Discuss the options with the patient.
Tx is no longer automatic.
![Page 27: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/27.jpg)
11/4/2019
27
STATUS EPILEPTICUS. [SE].
~ Operational Definition: “Seizure lasting
>30 mins. or a series of seizures lasting a
total of >30 mins. without full recovery
to baseline.”
~ Incidence: 60,000 to 195,000 cases per
year in the U.S.
Commission on Epidemiology and Prognosis of the ILAE - Epilepsia 1993.
Dodson et al - JAMA 1993.
Delorenzo et al - Neurology 1996.
Status Epilepticus
EFA definition >30 minutes of continuous seizure activity
>2 sequential seizures without full recovery of consciousness for >30 minutes
Proposed operational definition Persistent seizure activity for >5 minutes after a
witnessed seizure Lowenstein et al.1999.
EFA Working Group on Status Epilepticus. JAMA. 1993;270;:854-859.
![Page 28: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/28.jpg)
11/4/2019
28
Treatment of Status Epilepticus.
~Airway, Breathing,
Circulation
~Hypertension - will correct
with SE Tx.
~ Admit to ICU.
~ If intubation & NMJ
blockade is required
use short acting agentsi.e.. Vecuronium.
~ Thiamine & Glucose Adults - 50ml 50% glucose.
Pediatric - 2ml/kg of 25%
glucose.
~ 2 i/v lines.
~ Blood Draw: -CBC, CHEMISTRY,
LFT’s, Tox Screen,
AED levels, Glucose.
~ Treat Hyperthermia
S.E. Treatment ~ Ativan 0.1mg/kg at the rate of 2mg/min.
Maximum of 8mg. Treiman et al - NEJM, 1998.
~ Dilantin 20mg/kg, max rate of 50mg/min.
or Fosphenytoin 20mg/kg of PE, 150mg/min
~ Dilantin 5mg/kg additional dose.
~ ‘Phenobarb’ - Intubate.20mg/kg, rate of
100mg/min.
~ VA Study - Only 5% of patients who failed Ativan & Dilantin responded to Phenobarb. Other options like I/V
Midazolam & I/V Propofol are available specially in the ICU setting
![Page 29: Singh epilepsy-Neurology2019 - Compatibility Mode...11/4/2019 13 Spikes are potentials with a short duration (less than 70 ms); sharp waves usually have a duration of 70 to 200 ms](https://reader033.vdocument.in/reader033/viewer/2022041607/5e353b5e62f33046913b6f00/html5/thumbnails/29.jpg)
11/4/2019
29
Status Epilepticus:Treatment Guidance
Lowenstein DH, et al. N Engl J Med. 1998;338:970-976.
Lorazepam0.1 mg/kg IV at 2 mg/min
Phenytoin (20 mg/kg IV at 50 mg/min) orFosphenytoin (20 mg/kg PE IV at 150 mg/min)
Phenytoin or fosphenytoinadditional 5-10 mg/kg or 5-10 mg/kg PE
Phenobarbital20 mg/kg IV at 50-75 mg/min
Phenobarbitaladditional 5-10 mg/kg
Anesthesia withMidazolam or propofol
Status Epilepticus