group 10 epilepsy) 4b

8/2/2019 Group 10 Epilepsy) 4b

1/29

Mariano Marcos State University

COLLEGE OF HEALTH SCIENCES

Department of Pharmacy

City of Batac

EPILEPSY

(CASE STUDY)

In partial fulfillment of the requirements in Pcare 105

ARELLANO, MENARD B.

BULAN, NIKKO ANGELO M.

DOMINGO, ALFREDO D. JR.

Group X

BPh IV-B


2/29

I. Review of the Anatomy of the System

NERVOUS SYSTEM

Nervous system is the master controlling and communicating system in thebody. Every thought, action, and emotion reflects its activity. Its signaling

devices, or means of communicating with body cells, is electrical impulses, which

are rapid and specific and cause almost immediate responses.

To carry out its normal role, the nervous system has three overlapping

functions. (1) Much like a sentry, its uses its millions of sensory receptors to monitor

changes occurring both inside and outside the body. This changes are called


3/29

stimuli, and the gathered information is called sensory input. (2) Its processes and

interprets the sensory input and decides what should be done at each

momenta process called integration. (3) It then effects a response by

activating muscles or glands (effectors) via motor output.

The nervous system does not work alone to regulate and maintain body

homeostasis; the endocrine system is a second important regulating system.

Whereas the nervous system controls with rapid electrical nerve impulses, the

endocrine system typically brings about its effects in a more leisurely way.

1. Structural Classificationa. Central Nervous System (CNS)

Central nervous system (CNS) consists of the brain and the spinal

cord, which occupy the dorsal body cavity and acts the integrating and

command centers of the nervous system. They interprets incoming sensory

information and issue instruction based on past experience and current

condition.

i. BrainThe adult brains unimpressive appearance gives few hints in its

remarkable abilities. It is about two good fistfuls of pinkish gray tissue,

wrinkled like a walnut and with the texture of cold oatmeal. It weighs a

little over three pounds. Because the brain is the largest and most

complex mass of nervous tissue in the body, it is commonly discussed in

terms of its four major regions.


4/29

Cerebral hemispheres: the paired cerebral hemisphere, collectivelycalled the cerebrum, are the most superior part of the brain and

together are a good deal larger than the other three brain regions

combined. The entire surface cerebral hemispheres exhibits

elevated ridges of tissue called gyri, separated by swallow grooves

called sulci. Each cerebral hemisphere has three basic regions: a

superficial cortex of gray matter, which looks gray in fresh brain

tissue; an internal white matter and the basal nuclei, island of the

gray matter situated deep within the white matter.

Cerebral cortex: speech, memory, logical and emotional response,as well as consciousness, interpretation of sensation, and voluntary

movement, are all function of neurons of the cerebral cortex. The

primary somatic sensory area is located in the parietal lobe

posterior to the central sulcus. The primary motor area, which

allows us to consciously move our skeletal muscle, is anterior to the

central sulcus in the frontal lobe. A specialized cortical area that is

very involved in our ability to speak, Brocas area, is found in the

base in the pre-central gyrus. The speech area is located in the

junction of the temporal, parietal, and occipital lobe.

Cerebral white matter: is composed of fiber tracts carrying impulsesto, from, of within the cortex. One very large fiber tract, the corpus

callosum, connects the cerebral hemisphere. Such fiber tracts

called commisures. The corpus callosum arches above the

structure of the brain stem and allows the cerebral hemisphere to

communicate with one another.

Basal nuclei: although most of the gray matter is in the cerebralcortex, there are several island of gray matter, called the basal

nuclei, or basal ganglia, buried deep within the white matter of the

cerebral hemisphere. The basal nuclei help regulate voluntary

motor activities by modifying instructions sent to the skeletal

muscles by the primary motor cortex.

ii. DiencephalonThe diencephalon, or the interbrain, sits atop the brain stem and is

enclosed by the cerebral hemisphere. The major structures of the

diencephalon are the thalamus, hypothalamus, and epithalamus.


5/29

Thalamus: which enclosed the swallow third ventricle of the brain, isa relay station for the sensory impulses passing upward the sensory

cortex.

Hypothalamus: it is an important autonomic nervous system centerbecause it plays a role in the regulation of body temperature,

water balance and metabolism. The hypothalamus is also center

for many drives and emotions, and as such it is an important part of

the socalled limbic system. The pituitary gland hangs from the

anterior floor of the hypothalamus by a slender stalk. The

mammillary bodies, reflex centers involved in olfaction, bulge from

the floor of the hypothalamus posterior to the pituitary gland.

Epithalamus: forms the roof of the third ventricle. Important partofthe epithalamus are the pineal body and the choroid plexus of the

third ventricle. The choroid plexus, knots of capillaries within each

ventricles, form the cerebrospinal fluid.

iii. Brain StemThe brain stem is about the size of a thumb in diameter and

approximately 3 inches(approximately 7.5 cm) long. Its structure

are the midbrain, pons and medulla oblongata.

Midbrain: the midbrain is relatively small part of the brain stem. Itextends from the mammillary bodies to the pons inferiorly. The

cerebral aqueduct is a tiny canal that travels through the midbrain

and connects the third ventricle of the diencephalon to the fourth

ventricle below. The midbrain is composed primary of two bulging

fiber tracts, the cerebral peduncles, which convey ascending and

descending impulses.

Pons: the pons is the rounded structure that produce just below themidbrain. Pons means bridge and this area of the brain stem is

the mostly fiber tracts.

Medulla oblongata: the medulla oblongata is the most inferior partof the brain stem. It merge into the spinal cord below without any

obvious change in the structure. The medulla also contains many

nuclei that regulate vital visceral activities.


6/29

Reticular formation: extending the entire length of the brain stem isa diffuse mass gray matter. The neurons of the reticular formation

are involved in the motor control of the visceral organs. A special

group of reticular formation neurons, the reticular activating system

(RAS), plays a role in consciousness and the awake/sleep cycles.

Damage to this area can result in permanent unconsciousness.

iv. CerebellumThe large cauliflower-like cerebellum projects dorsally from under

the occipital lobe of the cerebrum, the cerebellum has two

hemispheres and a convoluted surface. The cerebellum also has

an outer cortex made up gray matter and an inner region of white

matter.

v. Cerebrospinal fluidThe cerebrospinal fluid (CSF) is a watery broth similar in its

makeup to blood plasma, from which is forms. CSF is continually

formed from the blood by the choroid plexuses. Choroid plexuses

are clusters of capillaries hanging from the roof in each of the

brains ventricles. The CSF in and around the brain and cord forms a

watery cushion that protects the fragile nervous tissue from blows

and other trauma.

vi. Spinal CordThe cylindrical spinal cord, which is approximately17 inches (42

cm) long and, is a glistening white continuation of the brain stem. The

spinal cords provides a two-way conduction pathway to and from the

brain, and it is a major reflex center. Enclosed within the vertebral

column, the spinal cord extends from the foramen magnum of the skull to

the first or second lumbar vertebra. Where it ends just below the ribs. In

humans, 31 pairs of spinal nerves arise from the cord and exit from the

vertebral column to serve the body area and close by.

Gray matter of the spinal cord and spinal rootsThe gray matter of the spinal cord looks like a butterfly or a letter Hin cross section. The posterior projections are the dorsal, or

posterior, horns; the two anterior projection are the ventral, or

anterior, horns. The gray matter surrounds the central canal of the

cord which contains CSF.


7/29

White matter of the spinal cordThe white matter of the spinal cord is composed of myelinated

fibers tractssome running to higher center, some traveling from

the brain to the cord, and some conducting impulses from one side

of the spinal cord and other.

b. Peripheral Nervous System (PNS)Peripheral nervous system (PNS), the part of the nervous system

outside the CNS, consists mainly of the nerves that extend from the brain

to the spinal cord. Spinal nerves carry impulses to and from the spinal

cord. Cranial nerves carry impulses to and from the brain. These nerves

serves as communicating lines. They link all parts of the body by carrying

impulses from the sensory receptors to the CNS and from the CNS to the

appropriate glands or muscle.

i. NerveA nerve is a bundle of neuron fibers found outside the CNS. Within a

nerve, neuron fibers, or processes, are wrapped in protective

connective tissue coverings. Each fiber is surrounded by a delicate

connective tissue sheath, an endoneurium. Groups of fibers are bound

by a coarser connective tissue wrapping. The perinurium, to form fiber

bundles, or fascicle. Finally, all the fascicles are bound together by a

tough fibrous sheath, the epineurium, to form the cordlike nerve.

ii. Cranial NerveThe 12 pairs of cranial nerves primarily serves the head and neck.

Only one pair extends the thoracic and abdominal cavities. The

cranial nerves are numbered in order, and in most cases their names

their reveal the most important structures they control.

iii. Spinal Nerves and Nerve PlexusesThe 31 pairs of human spinal nerves are formed by the combination

of the ventral and dorsal roots of the spinal cord. Each spinal nerve

and divides into dorsal and ventral rami, making each spinal nerve

only about inch long. The rami, like the spinal nerves contain bothmotor and sensory fiber.

2. Functional Classificationa. Sensory or Afferent Division

Consists of nerves (composed of nerve fibers) that convey impulses

to the central nervous system from sensory receptors located in various


8/29

parts of the body. Sensory fibers delivering impulses from the skin, skeletal

muscle, and joints are called somatic (soma = body) sensory (afferent)

fibers, whereas those transmitting impulses from the visceral organs are

called visceral sensory fibers, or visceral afferents. These sensory division

keeps the CNS constantly informed of events going on both inside and

outside the body.

b. Motor or Efferent DivisionsMotor or efferent divisions carries impulses from the CNS to effector

organs, the muscle and glands. These impulses activate muscle and

glands; that is, they effect a motor responses.

i. Somatic nervous system allows us to consciously, or voluntarily,control our skeletal muscle. Hence, this subdivision is often referred

to as the voluntary nervous system. However , not all skeletal

muscle activity controlled by this motor division is voluntary.

ii. Autonomic nervous system (ANS) regulates events that areautomatic, or involuntary, such as the activity of smooth and

cardiac muscle and glands. This subdivision, commonly called

involuntary nervous system, itself has two parts, the sympathetic

and parasympathetic, which typically bring about opposite

effects. What one stimulates and other inhibits.

3. Nervous Tissuea. Supporting Cells

Supporting cells in the CNS are lumped together as neuroglia,

literally, nerve glue. Neuroglia includes many types `of cells that

generally support, insulate and protect the delicate neurons. Each of the

different types of neuroglia, also simply called eitherglia orglial cells.

i. Astrocyets: abundant star-shaped cells that account for nearly halfof the neural tissue. Their numerous projections have swollen ends

that cling of neurons, bracing then and anchoring them to their

nutrient supply lines, the blood capillaries. Astrocytes also helpcontrol the environment in the brain by mopping up leaked ions

and recapturing released neurotransmitters.

ii. Microglia: spiderlike phagocytes that dispose of debris, includingdead brain cells and bacteria.


9/29

iii. Ependymal cells: these glial cells line the central cavities of the brainand the spinal cord. The beating their cilia helps to circulate the

cerebrospinal fluid that fills those cavities and forms a protective

cushion around the CNS.

iv. Oligodendrocytes: glial that wrap their flatextensions tightly aroundthe nerve fibers, producing fatty insulating coverings called myelin

sheath.

b. NeuronsNeurons, also called nerve cells, are highly specialized to

transmitted message (nerve impulses) from one part of the body to

another.

i. Cell body is the metabolic center of neuron. Its transparent nucleuscontains a conspicuous nucleolus. The cytoplasm surrounding the

nucleus contains the usual organelles except for centroiles. The

rough ER, called Nissl substance, and neurofibrils (intermediate

filaments that are important in maintaining cell shape) are

particularly abundant in the cell body.

ii. Processes the armlike processes, or fibers vary in length frommicroscopic to 3 to 4 feet. Neuron processes that convey incoming

messages toward the cell body are dendrites, whereas those that

generates nerve impulses and typically conduct them away from

the cell body are axons. Each axon terminal is separated from the

next neuron y a tiny gap called synaptic cleft. Such a functional

junction called a synapse (syn = to clasp or join).

iii. Myelin sheath most long nerve fibers are covered with a whitish,fatty material, which has a waxy appearance. Myelin protects and

insulates the fibers and increase the transmission rate of nerve

impulses. Axons outside the CNS are myelinated by Schwann cells.

This part of the Schwann cell, external to the myelin sheath, is

called the neurilemma. Because the myelin sheath is formed bymany individual Schwann cells, it has gaps, or indentations called

nodes of Ranvier at regular intervals.


10/29

Definition of Disease

Seizure

Seizure is the physical findings or changes in behavior that occur after an

episode of abnormal electrical activity in the brain.

The term "seizure" is often used interchangeably with "convulsion."Convulsions are when a person's body shakes rapidly and uncontrollably. During

convulsions, the person's muscles contract and relax repeatedly. There are many

different types of seizures. Some have mild symptoms and no body shaking.

Types of seizure

1. Generalized SeizureThere are six types of generalized seizures. The most common and

dramatic, and therefore the most well known, is the generalized

convulsion, also called the grand-mal seizure. In this type of seizure, the

patient loses consciousness and usually collapses. The loss of

consciousness is followed by generalized body stiffening (called the

"tonic" phase of the seizure) for 30 to 60 seconds, then by violent jerking

(the "clonic" phase) for 30 to 60 seconds, after which the patient goes into

a deep sleep (the "postictal" or after-seizure phase). During grand-mal

seizures, injuries and accidents may occur, such as tongue biting and

urinary incontinence.

Absence seizures cause a short loss of consciousness (just a fewseconds) with few or no symptoms. The patient, most often a child,

typically interrupts an activity and stares blankly. These seizures

begin and end abruptly and may occur several times a day.

Patients are usually not aware that they are having a seizure,

except that they may be aware of "losing time."

Myoclonic seizures consist of sporadic jerks, usually on both sides ofthe body. Patients sometimes describe the jerks as brief electrical

shocks. When violent, these seizures may result in dropping or

involuntarily throwing objects.

Clonic seizures are repetitive, rhythmic jerks that involve both sidesof the body at the same time.

Tonic seizures are characterized by stiffening of the muscles.


11/29

Atonic seizures consist of a sudden and general loss of muscletone, particularly in the arms and legs, which often results in a fall.

2. Partial SeizuresPartial seizures are divided into simple, complex and those that

evolve into secondary generalized seizures. The difference between

simple and complex seizures is that during simple partial seizures, patients

retain awareness; during complex partial seizures, they lose awareness.

Simple partial seizures are further subdivided into four categoriesaccording to the nature of their symptoms: motor, autonomic,

sensory, or psychological. Motor symptoms include movements

such as jerking and stiffening. Sensory symptoms caused by seizures

involve unusual sensations affecting any of the five senses (vision,

hearing, smell, taste, or touch). When simple partial seizures causesensory symptoms only (and not motor symptoms), they are called

"auras."

Complex partial seizures, by definition, include impairment ofawareness. Patients seem to be "out of touch," "out of it," or "staring

into space" during these seizures. There may also be some

"complex" symptoms called automatisms. Automatisms consist of

involuntary but coordinated movements that tend to be

purposeless and repetitive. Common automatisms include lip

smacking, chewing, fidgeting, and walking.

II. EtiologyEpilepsy is a chronic disorder surrounded by many myths and

misconceptions. Recent advances in the understanding and treatment of

epilepsy have improved societal attitudes toward this condition, but the

diagnosis still represents the social stigma for many patients. A seizure is an

abnormal, paroxysmal electrical discharge from the cerebral cortex, and

epilepsy is defined as recurrent, stereotypic seizures. Seizures are seen clinically

as alteration of sensation, behavior, movement, perception, or consciousness.Symptoms are related to the area of cortex involved.

Any condition that causes cerebral irritation or alters the biochemical

environment of the brain can result in seizures. The risk of having an isolated

seizure during ones lifetime is thought to be about 10%. Seizure can occur inas a

result of a wide range of metabolic derangement that affect the nervous


12/29

system; if the underlying condition is corrected, the condition do not recur. These

episodic seizures are not the same as epilepsy.

An estimated 2 million people in the United States have epilepsy, and

approximately 125,000 new cases are diagnosed each year. Thirty percent of

newly diagnosed patients are under 18 years old of age. The prevalence of

epilepsy in persons over 65 years of age is 1%. When no identifiable cause for

epilepsy can be found, the seizure considered idiopathic; idiopathic epilepsy

accounts for 70% of all cases. Genetics clearly plays a role in a some forms of

epilepsy. The remaining 30% of cases are related to a known cases, such as

structure lesions in the central nervous system. Risk factors for developing in

adulthood include lesions within the central nervous system, meningitis or

encephalitis, cerebral tumors and stroke. Initial seizures in children are often

fever, anoxia, cerebral plasy, perinatal problems, congenital central nervous

system defects, mental retardation, febrile conditions, family history of epilepsy,

head trauma, central nervous system infections, central nervous system tumors,

cerebrovascular disease, alcohol or drug abuse, metabolic disturbances,

exposure to toxins and degenerative disease.

III. PathophysiologyA seizure can be caused by any process thats disrupts the cell

membrane stability of neurons. A seizure starts when a tiny cluster of the brain

cells begin to emit rapid, repetitive, highly synchronized electrical discharge. The

discharge may remain localized or rapidly spread to involved the entire brain.

The point at which the cell membrane becomes destabilized and uncontrollable

electrical discharge begins its known as seizure threshold. Some people have

lower seizure thresholds than others and are therefore more prone to seizures.

In 1981 the International League Against Epilepsy proposed a revised

classification of seizure. The major categorize are partial (focal) and generalized

seizures. Further subdivisions within the categories are based on the persons

clinical behavior during the ictal and interictal times. Ictal refers to the time

during a seizure. Interictal refers to the time between seizure activity. Postictal

refers to the time immediately after a seizure as a patient recovers.

Partial seizures do not always affect consciousness. Simple partial seizures

have less motor, sensory, and consciousness involvement because they arelimited to a smaller area of the brain. The wider the area of cerebral cortex

affected, the more clinical symptoms are seen. With simple partial seizures a

patient may experience uncontrolled movement of an extremity or a portion of

the face. He or she is able to interact with others during the seizure and

remembers the event afterwards. Complex partial seizures affect consciousness.

Patients may recall an aura, a warning sensation can occurs before the seizure,


13/29

and often exhibits automatism, such as lip smacking, chewing , rubbing or

picking at clothes. The behaviors are not voluntary because consciousness is

impaired. Some complex partial seizures spread to a large areas of the cortex

and become generalized tonic-clonic seizures, but these are different from true

tonic-clonic seizures, in which the initial seizure behavior is generalized.

Generalized seizures impair consciousness from the start. Absence seizures

do not include motor signs and may last less than 1 minute. These seizure are

often seen in children and may initially be thought of as day dreaming. There is

no postictal state, and absence seizure can occur many times a day.

Toni-clonic seizures have a tonic phase, during which the muscles

become rigid, and then a clonic phase, which involves rhythmic muscle jerking.

As a muscle of the trunk and diaphragm become rigid, the air moving past the

vocal creates a cry. Once the diaphragm is constructed, the patients is unable

to breath. If the seizure lasts long enough, the patient may become cyanotic.

Bladder and bowel muscles are also affected, and the patient may experience

incontinence.

Other generalized seizure include myoclonic and atonic types. Myoclonic

seizures cause one or several muscle jerk, often causing the patient to fall. Atonic

seizures cause a brief loss of tone in one or more muscle, causing the patient to

drop things or fall. They cause only a brief loss of consciousness and no postictal

state. The patient is able to get up right away unless he/she is injured in the fall. A

seizure is not generally fatal but creates a risk for injury from falls and other

environmental problems.

Postictal state represents periods of recovery from the seizure. The brain

must recover from the intense burst of electrical activity. The length of the

postictal period varies from patient to patient. Patient may have some degree of

confusion, lethargy, or an inability to follow commands or speak clearly during

this period. In cases the patient may experience Todds paralysis, which is

prolonged weakness involving one or more extremities. Although not permanent,

the paralysis may persist beyond the postictal period of confusion or fatigue.

Status epilepticus is an episode of seizure activity lasting at least 30

minutes, or repeated seizures without full recovery between each seizure.

Seizures cause a marked increase in cerebral metabolic activity and demands.

Oxygen consumption typically increases by 60 % and cerebral blood flow by as

much as 250%. These demands may outpace the delivery of oxygen andnutrients from the cerebral blood flow, and prolonged seizures can lead to

cellular exhaustion and destruction and even death if not effectively interrupted.


14/29

IV. Clinical Features/Signs and SymptomsThe two categories of seizures are generalized and partial.

a. Generalized SeizuresGeneralized seizures are caused by abnormal electrical impulses in the

brain and typically occur with no warning. There are six types of generalized

seizures.

Tonic-clonic (grand-mal) Seizure This seizure causes you to lose consciousnessand often collapse. Your body becomes stiff during what's called the "tonic"

phase. During the "clonic" phase, muscle contractions cause your body to jerk.

Your jaws clamp shut and you may bite your tongue. Your bladder may contract

and cause you to urinate. After one to two minutes, you fall into a deep sleep.

Absence (petit mal) Seizuure During these brief episodes, you lose awarenessand stare blankly. Usually, there are no other symptoms. They tend to begin and

end suddenly and last for about 10 seconds, although they can last as long as 20

seconds. These seizures may occur several times a day.

Myoclonic Seizure These very brief seizures cause your body to jerk, as ifshocked by electricity, for a second or two. The jerks can range from a single

muscle jerking to involvement of the entire body.

Clonic Seizure This seizure cause rhythmic jerking motions of the arms and legs,sometimes on both sides of your body.

Tonic Seizure Tonic seizures cause your muscles to suddenly stiffen, sometimesfor as long as 20 seconds. If you're standing, you'll typically fall.

Akinetic or Atonic Seizure This seizure causes your muscles to relax or losestrength, particularly in the arms and legs. Although you usually remain

conscious, it can cause you to suddenly fall and frequently causes injuries, such

as facial cuts. These seizures also are called "drop attacks."

b. Partial SeizuresPartial seizures, also known as local or focal seizures, are caused by

abnormal electrical activity in a specific, smaller part of the brain. The part of the

brain causing the seizure is called the seizure focus. Partial seizures are divided

into simple and complex seizures.


15/29

Some partial seizures evolve into generalized ones and are called

secondarily generalized seizures.

Simple Partial Seizure During these seizures, you remain conscious althoughsome people can't speak or move until the seizure is over. Uncontrolled

movements, such as jerking or stiffening, can occur throughout your body. You

also may experience emotions such as fear or rage or even joy; and odd

sensations, such as ringing sounds or strange smells. In addition, you may

experience peculiar memories such as a feeling of "deja-vu." Typically, these

seizures last less than two minutes.

Complex Partial Seizure During these seizures, you are not fully conscious andmay appear to be in a dreamlike state. Typically, they start with a blank stare.

You may involuntarily chew, walk, fidget, or perform other repetitive movements

or simple actions, but actions are typically unorganized or confused. These

seizures typically last between 30 seconds and two minutes.

Secondarily Generalized Seizure These seizures begin as a partial seizure anddevelop into generalized ones as the electrical abnormality spreads throughout

the brain. When the seizure begins, you may be fully conscious but then lose

consciousness and experience convulsions as it develops.

V. Clinical EvaluationThe developing brain is particularly susceptible to seizures. Diffuse central

nervous system pathology or injury in early infancy, when the brain is mostvulnerable, may lead to catastrophic epilepsies such as Ohtahara's epilepticencephalopathy and early myoclonic epileptic encephalopathy. Theseepileptic encephalopathies are difficult to treat and have poor prognoses. Asthe brain undergoes programmed synaptogenesis, apoptosis, and myelination,the epilepsy phenotypes and electroencephalography (EEG) findings change,producing age-dependent epileptic encephalopathies. Specifically, as theygrow older, 40% to 60% of infants with infantile spasms and a concomitanthypsarrhythmia on EEG will develop Lennox-Gastaut syndrome with tonic andatonic seizures, associated with a synchronous, generalized 1.5- to 2-Hz spike andslow wave discharges on EEG. In the context of age-dependent epilepticencephalopathies, as an epilepsy syndrome is evolving, it is often difficult toaccurately diagnose the specific epilepsy syndrome in a young child whopresents with seizures. It is the clinical evolution of the seizure types and the EEGthat helps the clinician make an accurate diagnosis. As more is known about theunderlying pathophysiology for the various epilepsy syndromes, not only theclinical picture and EEG but also a genetic blood test will be used to accuratelydiagnose a specific epilepsy syndrome. A case in point would be severemyoclonic epilepsy of infancy (classically known as Dravet syndrome) and


16/29

severe myoclonic epilepsy of infancy-borderland/ borderline, which areassociated with specific mutations in the sodium ion channel gene SCN1A.

VI. ComplicationsHaving a seizure at certain times can lead to circumstances that are

dangerous to yourself or others.

y Hypoxic brain damage and mental retardation may follow repeated seizures.y Depression and anxiety may develop.y Falling. If you fall during a seizure, you can injure your head or break a bone.y Drowning. If you have epilepsy, you're 13 times more likely to drown while

swimming or bathing than is the rest of the population because of the possibility

of having a seizure while in the water.

y Car accidents. A seizure that causes either loss of awareness or control can bedangerous if you're driving a car or operating other equipment. Many states

have driver's-licensing restrictions related to your ability to control seizures and

impose a minimum amount of time that you've been seizure-free ranging from

three months to two years before you're allowed to drive.

y Pregnancy complications. Seizures during pregnancy pose dangers to bothmother and baby, and certain anti-epileptic medications increase the risk of

birth defects. If you have epilepsy and you're considering becoming pregnant,

talk to your doctor as you plan your pregnancy. Most women with epilepsy can

become pregnant and have a healthy baby. You'll need to be carefully

monitored throughout pregnancy, and medications may need to be adjusted.

It's very important that you work with your doctor to plan your pregnancy.

y Emotional health issues. People with epilepsy are more prone to havepsychological problems, especially depression, anxiety and, in extreme cases,

suicide. This could be due to difficulties dealing with the condition itself as well as

medication side effects.

Other life-threatening complications from epilepsy are uncommon, but do

occur.y Status epilepticus. This condition occurs if you're in a state of continuous seizure

activity lasting more than five minutes, or you have frequent recurrent seizures

without regaining full consciousness in between them. People with status

epilepticus have an increased risk of permanent brain damage and death.


17/29

y Sudden unexplained death in epilepsy (SUDEP). People with poorly controlledepilepsy also have a small risk of sudden unexplained death. Overall, less than 1

in 1,000 people with epilepsy die of SUDEP, but it's more common among people

whose seizures aren't controlled by treatment. The risk of SUDEP is particularly

elevated when generalized tonic-clonic seizures are frequent, and the risk over a

one-year period could be as high as approximately 1 in a hundred people.

VII. Treatment and MonitoringDrug Therapy

General Classification

Sodium channel blocking agents

Have the capacity to block sustained high frequency repetitive firing (SRF) of

action potentials. This is accomplished by reducing the amplitude of sodium

dependent action potentials through an enhancement of steady state

inactivation.

1. Phenytoin (Dilantin)A valuable for the treatment of generalized tonic clonic seizure and for

the treatment of partial seizures with complex symptoms.

MOA:

Blockade of Sodium channels (use dependent) and inhibition ofgeneration of high frequency repetitive action potentials.

At high concentration reduction in calcium influx responsible forinhibition of secretory processes: release of hormones (ADH, insulin)

and neurotransmitters (NE, 5HT). Promotes uptake of dopamine

and inhibits MAO activity.

Alters sodium, potassium, calcium conductance, membranepotentials and concentrations of amino acids and

neurotransmitters.

Drug interacts with membrane lipids and this promotes stabilizationof membrane.

Pharmacokinetics:

Absorption:- Absorption is slow but usually complete, primarily in the duodenum.

- On IM injection absorption poor.


18/29

- Fosphenytoin (more soluble prodrug phosphate ester).

Distribution:- Highly bound (about 90%) to plasma proteins, primarily albumin.

Metabolism and excretion:- Half life 12 36(24) hours with mild therapy and steady state is

reached in 5 6 days but with higher levels, it may take 4 6 weeks

with half life reaching to 60 hour.

- Metabolized in l iver to parahydroxyphenyl derivative.

- Excreted as glucuronide in bile and urine.

Adverse effects:

Acute effects:- Nystagmus

- Diplopia reduce dose.

- Ataxia

- Lethargy, sedation at higher concentration.

Chronic effects:- GIT disturbances nausea, vomiting, epigastric pain, anorexia.

- Gingival hyperplasia.

- Coarsened facial features

- Hirsutism, acne

- Megaloblastic anemia

- Hemorrhagic disease of new born: hypoprothrombinemia and

hemorrhage in new borns of mothers.

- Use during pregnancy teratogenic: may produce fetal

hydantoin syndrome (hypoplastic phalanges, cleft palate, hare lip,

microcephaly)

- Peripheral neuropathy depressed tendon reflexes

- Endocrine effects:

Osteomalacia with hypocalemia due to altered vitamin Dand K metabolism.

Inhibition of release of ADH secretion

Inhibition of insulin secretion Hypersensitivity or idiosyncratic effects:

- Skin rashes, fever, and rarely Steven Johnson syndrome,

exfoliative lesion, SLE and fatal hepatic necrosis.

- Hematological reactions: neutropenia and leucopenia,

thrombocytopenia, and rarely red cell aplasia, agranulocytosis

- Lymphadenopathy resembling Hodgkins disease


19/29

Drug interaction:

- Cimitidine, Chloramphenicol, Disulfiram, Sulthiamine, and

Isoniazid.

- Carbamazepine

- Oral contraceptives, oral anticoagulants

2. Carbamazepine (Tegretol)It become a major drug in the treatment of seizure disorders. An effective

agent for the treatment of partial seizures,generalized tonic-clonic seizures

and bipolar.

MOA:

Blocks Na+ channels, inhibits high frequency repetitive firing ofneurons.

It acts presynaptically to decrease synaptic transmission. Inhibits intake and release of NE, potentiate post synaptic GABA

action.

Pharmacokinetics:

Slowly but completely absorbed orally (poor water solubility).Available only for oral administration.

75% bound to plasma proteins. Metabolized by oxidation to an active metabolite (10-11

epoxide). Further metabolism is by conjugation to inactive

metabolites.

Initial half-life is 36 hours but decreases on chronic administrationto 20 hours due to enzyme induction.

Adverse effects:

Dose related:-CNS: diplopia is first symptom of over dose and then ataxia,

unsteadiness, and drowsiness appear at the higher concentration.

-GIT: mild GI upset vomiting, diarrhea.

-Other: water retention and hyponatremia can occur in elderly asitenhances ADH action.

Idiosyncratic reaction:-Erythematous rashes.

-blood dyscrasias: fatal aplastic anemia and agranulocytosis; mild

persistent leucopenia .


20/29

-Hepatic dysfunction.

Teratogenicity:-fetal malformation (neural tube defects) and its combination with

valporate double teratogenecity.

Drug interactions:

- Can induce its own metabolism (autoinduction)

- Can induce enzymes that metabolize phenytoin, primidone,

Phenobarbital,valproic acid, clonazepam, and ethosuximide, and

other drugs the patient may be taking.

- Erythromycin and Troleandomycin (macrolide antibiotic)

- Cimetidine, Propoxyphene and INH

3. Oxcarbazepine (Trileptal)Chemically and pharmacologically related to carbamazepine, but has much

less capacity to induced drug metabolizing enzymes.

4. Lamotrigine (Lamictal)Has a broad spectrum of action and is effective in generalized and

partial epilepsies.

MOA:

Acts on Na+ channels, suppresses sustained rapid firing of neurons(voltage and use dependent inactivation of Na+ channels).

Also acts on voltage activated Ca+ channels effective inabsence seizures.

Also inhibits release of excitatory amino acids- glutamate.Pharmacokinetics:

absorption from the GIT is almost complete; peak plasma levelsachieved in about 2 to 5 hours.

Plasma half-life after a single dose = 24 hours; metabolized primarilyby glucoronidation.

Adverse Effect:

Concentration dependent-dizziness, headache, diplopia, vertigo, sedation, ataxia.

-nausea, vomiting.

Idiosyncracy or hypersensitivity reaction:


21/29

-rash, Stevens-johnsons syndrome, toxic epidermal necrolysis,

sometimes life threatening dermatitis in pediatric patients.

-flulike syndrome: patient should report immediately if flu like

symptoms or rash appears.

. TOPIRAMATE (Topamax)Substitute monosaccharide, structurally different from other antiepileptics.

It is a broad spectrum antiepileptic.Most useful in patients with generalized tonic-

clonic seizures and those with partial complex seizures.

MOA:

Blockade of voltage dependent Na+ Channel- blocks repetitivefiring of neurons.

Potentiation of inhibitory GABA responses. Impairement of glutamate receptor activity, blocking AMPA-

kainate subtype (s)of glutamate receptors.

Weak inhibitor of carbonic anhydrase.ADVERS EFFECT:

Somnolence, fatigue, dizziness, ataxia, cognitive slowing, weightloss.

Acute myopia and glaucoma- stop. Urolithiasis Teratogenic

6. ZONIZAMIDE (Zonegran)Effective in partial complex and generalized tonic-clonic seizure. Also

appears to be beneficial in certain myoclonic seizure. Half-life is about 60 hours;

requires about 2 weeks achieve steady-state levels.

ADVERSE EFFECT:

Cerebellovestibular S/E similar to most AEDs sharing its mechanismof action.

Increase incidence of kidney stone.7. VALPROIC ACID (Depakene)

SODIUM VALPROATE (Depakote)

Highly effective against absence seizures and myoclonic seizures. Can be

used alone or in combination with other drugs for the treatment generalized

tonic-clonic epilepsy and for partial seizures with complex symptoms. Well

absorbed the GIT and highly bound to 90% plasma protein.


22/29

MOA:

Blockade of voltage activated Na+ channels Blockade of NMDA receptor mediated excitation. Increase in GABA content of brain by:

- Stimulating the activity of GABA synthetase enzyme, glutamic

acid decarboxylase (GAD) enzyme responsible for GABA synthesis.

- Inhibits GABA transpoter GATI

- At high concentration: inhibit 2 enzyme systems that inactivate

GABA namely GABA transaminase and succinic semialdehyde

dehydrogenase.

Enhancement of postsynaptic action of GABA Blockade of low threshold (T) Ca + channels. Decrease in aspartate levels. At high concentration increase in K+ ion permeability leading to

hyperpolarization.

ADVERSE EFFECTS:

Concentration dependent- GIT nausea, vomiting, abdominal pain, heartburn

- CNS: sedation, uncommon, may occur when given with

phenobarbitone. Fine tremor at high level.

- Others:

Alopecia, thinning and curling of hair Peripheral edema. Weight gain, increased appetite.

Idiosyncratic reactions- Fatal hepatic failure

- Hepatotoxicity

- Rashes and thrombocytopenia

Teratogenic (neural tube defects)DRUG INTERACTIONS

- Phenobarbital, Phenytoin

Drugs that Primarily Enhance the Action of GABA

Benzodiazepines

Used in the treatment of absence, myoclonic, and atonic seizures and in

the emergency treatment of status epilepticus.


23/29

MOA

To enhance inhibition through their action with the GABA receptorat the benzodiazepines binding sites.

Additional action: blocking voltage-dependent sodium channels.This effect is not seen at a usual does but is likely a factor in their use in

status epilepticus.

Benzodiazepines used in seizure disorder

1. ClonazepamThe first benzodiazepines approved in the U.S. specially for the treatment

of convulsion disorders. Unfortunately, sedation and tolerance tend to limit its

usefulness. Drooling and hypersalivation may be troublesome in infants and in

children.

2. LorazepamThe benzodiazepines of choice for the emergency treatment of status

epilepticus, serial seizures and prolong seizures and for the prophylaxis of febrile

seizures. The IV route is preferable for emergency treatment.

3. Clorazepate DipotassiumAs an adjunct in the treatment of partial complex seizures; useful

especially in patients with high seizure frequencies and psychic disturbances.

Adverse effects

Drowsiness, dizziness and lethargy-some tolerance develops onchronic use.

Lac of concentrations, irritability, temper and other behavioralabnormalities in children.

Dose dependent motor disturbance: ataxia, hypotonia, dysarthria. Salivation and increase respiratory secretions. Tolerance develops to therapeutics effects in 6 months or so.

4. Tiagabine (Gabitril)An analog of GABA and a derivative of nipecotic acid, lipohilic. Primarily

used in the treatment of partial complex seizures.

MOA

Blocks the reuptake of GABA into neurons and glia, therebyresulting in higher levels of GABA in the synaptic cleft


24/29

Adverse Effects

Dizziness, somnolence, nervousness, nausea and confusion.. Vigabatrin (Sabril)

Gamma vinyl GABA derivative. Primary indication in the treatment of

partial seizures.

MOA

A relatively specific irreversible inhibitor of GABA-transaminase(GABA-T)

Adverse Effects

Drowsiness, dizziness, weight gain. Agitation, confusion, and psychosis. Irreversible visual fields defects.

6. Phenobarbital and PrimidoneConsidered as alternative treatment of partial seizures and for generalized

tonic-clonic epilepsy (they are judge to be less effective than carbamazepine

and phenytoin).

MOA

GABA facilitator, GABA-mimeticit acts on GABA receptor andenhances chloride conductance, causes potentiation of synaptic

inhibition at the therapeutic concentration.

Antiglutamate-blocks excitatory responses of glutamate. At higher concentration: Na+ and L, N type calcium channels.

Pharmacokinetics

Well absorbed, 50% bound to plasma protein has a long half-life(100 hours, longer in neonate), 75% metabolized in liver by

oxidation and conjugation with glucoronide, some (25%) excreted

unchanged in urine, which is the pH dependent.

Steady state concentration are reach in 2-3 weeks, a single dailydose is effective.

It is powerful enzyme inducer.Adverse Effects

Sedation tolerance occurs on chronic use. Nystagmus, ataxia-at high doses.


25/29

Long-term use diminution of intelligence, impairment of learningthe memory, impaired school performance, behavioral

abnormalities, depression, and mental confusion in elderly.

Megaloblastic anemia and osteomalacia on prolong use. Hemorrhagic disease of new born Hypersensitivity reactions: rashes, exfoliative dermatitis,

hypoprothrombinemia.

Agents That Block T calcium Channels

1. Ethosuximide (Zarontin)Used in the treatment of absence epilepsy.

MOA

Reduces the low-threshold calcium current (LTCC) or T(transient) current. These current underlie the 3-Hz spike wave

discharges that are characteristics of absence epilepsy.

Adverse Effects

Dose related effects:-GI irritation, nausea, vomiting, anorexia

-CNS: lethargy, fatigue, sometimes lethargy dizziness, mood

changes, agitation, headache, drowsiness, and inability to

concentrate.

Idiosyncratic reactions:-Rare, rashes, SJ syndromes

-Blood dyscrasias- eosinophilia, lecopenia, pancytopenia.

Noncategorized

1. GabapentineEffective in both types of epilepsy-generalized and partial seizures. As an

analgesic for neuropathic pain-post herpetic neuralgia. It also for

migraine and bipolar disorder.

MOA

Is a highly lipid soluble, amino acid related to GABA, effectiveagainst partial seizures.

Alter GABA metabolism- its nonsynaptic release or its reuptakeby GABA transporter

Also binds to Ca++ channels.Adverse Effects

Sedation, ataxia, headache and tremor.


26/29

y Other Therapeutic MeasuresFor some patients, surgery may be recommended to prevent seizures or to

implant devices that deliver medications or stimulators to emit electrical

impulses. Your neurologist will explain the procedure as well as possible risks.

Focal Resections The removal of a small area of the brain where seizuresoriginate. This procedure often results in complete seizure control.

Disconnection Procedures, which disrupt abnormal electrical activity that occursin the brain and triggers epileptic seizures. Two types of disconnection operationsare:

o Corpus callostomy, which stop atonic and tonic seizures.o Multiple subpial transections, which are performed when seizures are

caused by parts of the brain that can't be removed.

Focal Resections These procedures are the most common operations fortreating epilepsy and provide the best chance for patients to gain completeseizure control. They involve the removal of a small area of the brain whereseizures originate. New brain monitoring techniques allow doctors to betterpinpoint brain tissue causing seizures. Types of resections include:

o Temporal lobectomy, where a portion of the temporal lobe is removed tocontrol seizures.

o Lobar resection, where a portion of a seizure-producing lobe frontal,parietal or occipital lobe is removed, if it can be done withoutdamaging vital functions.

o Hemispherectomy, where one sphere of the brain is removed or disabled.The remaining half of the brain takes over many of the functions of thehalf that was removed. This procedure is used to treat severe conditionsthat have not responded to other treatments.

Gamma Knife Radiosurgery This procedure delivers a finely focused, high doseof radiation to remove tissue without damaging surrounding tissue. Some types ofseizures, such as gelastic seizures which are accompanied by brief, sudden bursts

of emotion, can be treated with this technology. Doctors at UCSF MedicalCenter are involved in research using the Gamma Knife to treat temporal lobeepilepsy.

Vagus nerve stimulation This procedure involves minor surgery and is arelatively new treatment that helps prevent or lessen the severity of seizures. Anelectrical stimulator is implanted that sends regular electrical pulses through thevagus nerve to the brain to reduce the onset or frequency of seizes.


27/29

VIII. Patient Casey Patient Information

Name: BUDOY Address: Brgy.1,Juan Solsona, Ilocos Norte Hospital Number: 01-13-79 Sex: Male Age: 16 years old Place of birth: Manila Date of Birth: September 17,1986 Civil Status: Single Religion: Roman Catholic Educational Attainment: Day care Graduate Date of admission to the hospital: December 8, 2011 (12:15 AM)

y Chief-ComplaintFive hours prior to admission: two times of watery stool, five times of

vomiting of previous ingested food and abdominal pain.

y History of Present IllnessBudoy is positive in epilepsy and maintain in Phenobarbital and

positive in cerebral pulsy. At the age of 10 he has a cerebral hypoxia and

started taking Phenobarbital up to the present. Epilepsy mostly attack

every month 7-8 times usually at night.

y Past Medical HistoryBudoy was describe as yellow baby at the age of 7 days old. At

the age of 10, budoy has a cerebral hypoxia and started a cough and

fever with associated vomiting at the age of 12.

y Social HistoryBudoy drink 7-8 cup of coffee everyday. He started drinking coffee

when he was 14 years old. He eats a lot of vegetable and fish as his

primary meal. For the past 6 years, he takes tiki-tiki as vitamins when he

was a child. He started to walk at the age of 7 and started to talk at the

age of 10. He loves listening music as loud as he wanted and play with his

childhood neighbors as his recreational activity. He doesnt smoke and

drink beverages, in fact he doesnt have any vices except drinking coffee

everyday. He is an undergraduate in elementary and he lives with his

auntie and cousins in a simple house.


28/29

y Family HistoryBudoys mother is a lady guard and still alive at the age of 39 and lives

in Ilo-ilo. Together with her mother, Budoys father is still alive at the age of

57 and lives with his wife in Ilo-ilo. Budoy has 3 sisters and they live with their

parents in ilo-ilo. Budoy is the eldest among his siblings. He was adopted by

his auntie since he was 7 month old and migrated in Barngay 1 Juan,

Solsona, Ilocos Norte where he was raised by his relatives. His grandmother

was diagnosed of epilepsy before. Budoy was diagnosed with epilepsy in

his 7 day old and he was a yellow baby when he was born.

IX. Medication HistoryBudoy has an allergies or adverse effects on the different kinds of

antibacterial drugs. He had started taking Phenobarbital that is mixed with water

at the age of 7 days old when the patient was diagnosed with simple partial

seizure. At the age of 10 years old 10/12/05 he was admitted to a hospital and

on that time he was already diagnosed with status epilecticus. His first dose

medication in the hospital was at 11:40AM on 10/12/05. Phenytoin 45 mg was

injected to Budoy as a Loading dose then 60mg IV of 12 as maintenance dose

to start 8 from the loading dose. At 7:15PM Budoy has a temperature of 38.5C

and for that case he was injected with Paracetamol 250mg IV. On the 10/15/05

Budoy was given a Phenytoin 100mg Oral Dose and Phenobarbital 60mg tab.

After 3 days, the Phenytoin was discontinued and Phenobarbital was taken by

Budoy as maintenance until at the present. According to his auntie the last time

she took a prescription drug was on the last week of December 2011 wherein the

last attack of seizure occurs to Budoy. He has not taken any alternative drug.

X. Review of SystemsWatery stool, vomiting and abdominal pain.

XI. Physical ExaminationBudoy is well developed. He is 49 kg in weight 56 in height. His vital signs

include a blood pressure of 110/80 mm Hg. All the data of physical examination

of Budoy is within the normal limits.

XII. Laboratory Diagnostic Test ResultsThe result of HGB hemoglobin is 131 g/L, HCT hematocrit 0.39, RBC (RedBlood Cells) 4.66, MCV 77.9, MCH 28.1, MCHC 36.1, WBC (White Blood Cells) 10.80

with 0.31% neutropilia, 0.07% lymphocytes and 0.02% monocytes. The platelet

count is 248 and none has found in fecalycis.


29/29

XIII. Patient Problem List Problem #1

Sedation is the major side effect of Phenobarbital.

Problem #2Long-term use of Phenobarbital can diminution the intelligence of

the patient, impairment of learning the memory, impaired school

performance, behavioral abnormalities, depression, and mental confusion

in elderly.

Problem #3Cooled temperature can cause lethargy to the patient.

Problem#4Coffee addiction. Counsel regarding the interaction of coffee and

Phenobarbital.

Problem#5Special child.

XIV. ProgressThere is a progress on Budoys Loss in Bowel Movement and stop in

vomiting. The blood pressure and temperature is in the normal state.

XV. Other InformationFor the plans of additional diagnostic procedures and therapeutic

interventions, and plans of follow up after hospitalization, Budoy will still

continue the maintenance medication of Phenobarbital but for some cases

that will occur, paracetamol/acetaminophen must not be taken with

Phenobarbital because barbiturates may increase the hepatotoxic potential of

acetaminophen and decrease therapeutic effects. Budoy must also lessen his

drinking of coffee.

group 10 epilepsy) 4b

Documents