seizures and epilepsy presented by chan hau yee chan wai chung kwok vansie lee kin tong
TRANSCRIPT
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Seizures and Epilepsy
Presented by Chan Hau Yee
Chan Wai ChungKwok VansieLee Kin Tong
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Seizure VS Epilepsy What is the difference?
Seizure: manifestation of paroxysmal involuntary disturban
ce of brain function Abnormality/dysfunction of
Consciousness, motor activity, behaviour, sensory, or autonomic functions
Epilepsy: Recurrent seizures Unrelated to fever or to an acute cerebral insult
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Local Data
The period prevalence rate of epilepsy in 1997 (January to December) is estimated to be 4.5 per 1000 children aged < 19 years
Wong V. Study of seizure and epilepsy in Chinese children in Hong Kong: period prevalence and patterns. J Child Neurol. 2004 Jan;19(1):19-25
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Classification of seizures
Partial seizure (55.4%) Generalized seizure(38.7%) Unclassified Epilepsy syndrome
Fong GC, et al. A prevalence study of epilepsy in Hong Kong. Hong Kong Med J. 2003 Aug;9(4):252-7.
What is the difference between partial and generalised seizures?
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Partial Seizure Simple partial
With motor signs With somatosensory or special symptoms With autonomic symptoms With psychic symptoms
Complex partial Partial seizure with secondary generalisation
How can we differentiate between simple partial and complex partial seizure?
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Simple partial seizure
Complex partial seizure
Consciousness Conscious Impaired
Duration 10-20s 1- 2 minAura + +/-Automatisms - Common
Post-ictal phenomenon
- +
EEG Spikes or sharp waves bilaterally or unilaterally or a multifocal spike pattern
Interictal EEG anterior temporal lobe sharp waves or focal spikes and multifocal spikes (80%)
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Generalized seizure
Absence Myoclonic Clonic Tonic Tonic-clonic atonic
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Status epilepticus
Consciousness does not return in between attacks
Lasts more than 30 mins May be life threatening Terminate the seizure as soon as possible
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Category Localization-related Generalized
Idiopathic (42%) Benign epilepsy of childhood with centrotemporal spikes(benign rolandic epilepsy)Benign occipital epilepsy
Benign familial neonatal convulsionsBenign myoclonic epilepsy in infancyChildhood absence epilepsyJuvenile absence epilepsyJuvenile myoclonic epilepsyEpilepsy with generalized tonic-clonic seizures on awakening
Symptomatic (of underlying structural disease) (40.8%)
Temporal lobeFrontal lobeParietal lobeOccipital lobe
Early myoclonic encephalopathyEarly infantile epileptic encephalopathywith suppression-burst (Ohtahara syndrome)Cortical dysgenesisMetabolic abnormalitiesWest syndromeLennox-Gastaut syndrome
Cryptogenic (16.8%)
Any occurrence of partial seizures without obvious pathology
Epilepsy with myoclonic-astatic seizuresEpilepsy with myoclonic absencesWest syndrome (with unidentified pathology)Lennox-Gastaut syndrome (with unidentified pathology)
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Cont’d (Epilepsy Syndromes)
Special syndromes Febrile convulsions Isolated unprovoked seizures or isolated status epilepticus Seizures occurring only with toxic or metabolic provoking fa
ctors Neonatal seizures of any etiology Epilepsy with continuous spike-wave of slow wave sleep (el
ectrical status epilepticus of sleep) Acquired epileptic aphasia (Landau-Kleffner syndromeModified ILAE Classification of Epilepsy Syndromes
Kwong KL et al .Epidemiology of childhood epilepsy in a cohort of 309 Chinese children. Pediatr Neurol. 2001 Apr
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Video demonstration of seizures
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Simple partial seizure with motor signs
may remain strictly focal or epileptic “march”- Speech:
- speech arrest - occasionally vocalization- partial dysphasia
- Todd’s paralysis
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Simple partial seizure with somatosensory symptoms
1. Pins-and-needles, feeling of numbness, proprioception, spatial perception
2. Visual
3. Auditory
4. Olfactory
5. Gustatory
6. Vertiginous
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13
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Simple partial seizure with psychic symptoms
1. Dysphasia
2. Dysmnesic symptoms • Déjà vu, jamais-vu
3. Cognitive symptoms 4. Affective symptoms 5. Illusions
6. Structured hallucinations
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Simple partial seizurewith autonomic symptoms
Vomiting Pallor Flushing Sweating Piloerection Pupil dilatation Borborygmi Incontinence
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18
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Complex partial seizures
Primary involvement of only one hemisphere (but often bilateral involvement in the course of seizure)
Impaired consciousness (gradually increasing)
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Partial Seizures with Secondary Generalization Onset: Spontaneous Description of Seizure
Simple partialTakes his left hand in his right to prevent it
from shakingTurn to the right, left arm starts jerkingCoarse jerking of arms, stretching of back,
tonic contraction of face, open mouthJerks predominant in left arm and eye, eye
blinking, head and eyes to the left
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Partial Seizures with Secondary Generalization
Secondary generalizationGeneralized jerks in face, arms and legsLeft arm bent, right arm stretched
Relaxation and Postictal sleep
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Absence Seizures
Onset: provoked by hyperventilation Description of Seizure
Stop hyperventilation Slight loss of tone in neck muscles 2 eye blinks about 1 second apart Regains awareness 1.5 second before paroxysm stops
The duration of impaired consciousness is often shorter than the duration of spike and wave discharge series. It starts later and ends earlier.
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Absence Seizures with atonic components
Onset: Spontaneous Description of Seizure
Head drop
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Atonic Seizure vs Atonic Absence
Atonic Seizure: general loss of tone often resulting in a sudden fall
Atonic Absence: loss of tone is often restricted to the head that gradually goes down
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Absence Seizure with tonic component
Onset: Spontaneous Description of Seizure
Upward movement of the eyeballs for 15 seconds Immediate regain of consciousness
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Tonic Seizure vs Tonic Absence
Tonic Seizure: tonic seizure affects the whole body resulting in bending forward with abduction of the arms and reddening of the face, sometimes a loss of balance
Tonic Seizure: Head is mainly affected, often with retropulsion of the head and upward deviation of the eyes
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Myoclonic seizure
Single or multiple, sudden, brief, shock-like jerky contraction
Generalized / face & trunk / one or more extremities / individual muscles or group of muscle
Around hr of going to sleep / awake from sleep Myoclonic jerks can also be seen in: - spinal cord diseas - dyssynergia cerebellaris myoclonica - subcortical segmental myoclonus
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Clonic seizure
Tonic seizure with periodic interruptions (shaking)
The diagnosis is rare When a generalized seizure occasionally lack
a tonic component / as a co-existing event in other type of seizure
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Myoclonic seizure jerky contraction of mus
cles Regarded as an isolate
d event Considered as a separ
ate epilepsy type
Clonic seizure tonic seizure with per
iodic interruption (shaking)
rarely as a diagnosis usu get involved in othe
r type of seizure (eg. Absence seizure with mild clonic components)
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Tonic seizure
Rigid, violent muscular contraction, fixing the body & limbs in strained position
Usu deviation of eyes and head Colour of face distorted: unchangedpaleflushed
ultimately livid(black & blue; as spasm of respiratory muscle)
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Tonic-clonic seizure Most common type of generalized seizure Also known as ‘grand mal’ Tonic phase (~10sec): - falls - stridor, cry or moan, cyanosis - incontinence Clonic phase (~1-2mins): Postictal phase: - muscles relax - remain unconscious - go into deep sleep
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Atonic seizure
Sudden reduction in muscle tone ‘drop attack’ Prolonged atonic attacks:
progressive drop in a rhythmic, successive relaxation manner
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Causes of seizures
Epileptic Idiopathic( ~70%) Congenital dysgenesis or
malformation Cerebral trauma Space occupying lesion Neurogenerative disorder Syndrome
Non-epileptic Infection: fever, meningiti
s, encephalitis, sepsis Metabolic: acidosis, hypo
glycaemia Drugs, toxins Trauma
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Approach to a patient with seizure attack
History of present illness Review of systems Important relevant aspects
Perinatal Development Past medical Drug Social Family Diet
What would you ask in a patient with epilepsy?
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Physical exam General Neurological Other systems when indicated (e.g. trauma, fever)
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Investigations of Convulsion
Depends on the clinical presentation and history CBC LFT, RFT, blood glucose level, ABG Infection screen Toxicology screen EEG CT, MRI
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EEG indicated when epilepsy
is suspected
CT/MRI Late onset of seizure Partial seizure Interictal neurological sig
ns Progression of seizure d
espite good complicance
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Medical Treatment
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Anti-epileptic drug (AED)Seizure Type Drug recommended
Partial Carbamazepine
Valproate
Phenytoin
Tonic-clonic Valproate
Carbamazepine
Phenytoin
Phenobarbital
Absence, Atonic, Myoclonic Valproate
Clonazepam
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Drug complication
Carbamazepin Drowsiness; visual disturbance; aplastic anemia; SLE
Valproate Drowsiness; Transient hair loss; GIT disturbance; pancreatitis; hepatitis; thrombocytopenia
Phenytoin Gingival hyperplasia; hirsutism; Steven-Johnson syndrome; SLE
Phenobarbital Sedation; Reduced cognition; Hyperactivity; Steven-Johnson Syndrome;
Clonazepam Ataxia; Lethargy
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Principle of medical treatment
Start if seizure becomes recurrent Monotherapy preferred
- decrease drug interaction & toxicity
- increase compliance
- decrease cost
- 50% of children have satisfactory control
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Treatment- Pharmacological Aim: fit free Common agents
Sodium valporate Phenytoin Phenobarbitone Carbamazepine
Most of them have known side effects and monotherapy is preferred for the sake of side effects
Withdrawal of drug therapy can be considered in a patient with no relapse of seizure for 3 or more years; it should be withdrawn slowly
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Treatment: Diet
Ketogenic Diet For recalcitrant seizures Complex myoclonic epilepsy with associated tonic-clo
nic convulsions Restricts the quantity of carbohydrate and protein
(most calories provided as fat) Mechanism of action unknown ? Anticonvulsant effect secondary to elevated lev
els of beta-hydroxybutyrate and acetoacetate resulting from the ketosis
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Surgical Treatments Considered for children with
intractable seizures unresponsive to anticonvulsants
Well-defined focus of epileptogenic activity + identical structural lesion on CT/MRI
Options Lobectomy and cortical resection Hemispherectomy Corpus Callosotomy Multiple Sub-pial Transection Vagal nerve stimulation
Vagal nerve stimulation
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Education and support
Good compliance is very important May disturb the child’s school life Management during fits Side effects of the anticonvulsants Avoid known provoking factors
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References Fong GC, Mak W, Cheng TS, Chan KH, Fong JK, Ho SL. A prevalence study of e
pilepsy in Hong Kong. Hong Kong Med J. 2003 Aug;9(4):252-7. Kwong KL, Chak WK, Wong SN, So KT.Epidemiology of childhood epilepsy in
a cohort of 309 Chinese children. Pediatr Neurol. 2001 Apr;24(4):276-82 Leung GK, Fan YW, Fong KY. Temporal lobe resection for intractable epilepsy:
review of 11 cases. Hong Kong Med J. 1999 Dec;5(4):329-336 Wong V. Study of seizure and epilepsy in Chinese children in Hong Kong: peri
od prevalence and patterns. J Child Neurol. 2004 Jan;19(1):19-25 Modified ILAE Classification of Epilepsy Syndromes Nelson’s Textbook of Pediatrics Ch. 602 Video Atlas of epileptic seizures - Classical examples, International League a
gainst epilepsy
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Special Thanks to Prof. V. Wong