Epilepsy the spontaneous cessation of the disease Affects 1 to 2% - - PDF document

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Adult Epilepsy Update

• J. Layne Moore, MD, MPH

Associate Professor Department of Neurology and Pharmacy Director, Division of Epilepsy The Ohio State University

Epilepsy

• Affects 1 to 2% of US Population
• Chronic Condition
• Multiple Drug Therapies
• Issues

Patients

• Compliance
• Drug Interactions
• Education
• Social and Behavioral

Used by permission Health Press Oxford

Annual Incidence

“the spontaneous cessation of the disease is an event too rare to be reasonably anticipated in any give case.” Gowers 1881

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Refractory Epilepsy

• What is refractory epilepsy?

Uncontrolled with multiple medications Intolerable side-effects to achieve control

• How to fight back?

Newly Diagnosed (n=470) Seizure-free 47% (n=222) Uncontrolled 53% (n=248) Seizure-free 13% (n=61) Uncontrolled 40% (n=187) Seizure-free 4% (n=18) Uncontrolled 36% (n=169)

Kwan & Brodie NEJM 2000

1st drug 2nd drug 3rd drug

Which patients respond?

• Early response in key
• Response to the 1st drug

11% response to 2nd drug if 1st was ineffective 41% for SE 55% idiosyncratic reaction

Kwan and Brodie

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Seeking a Cause

• For most persons with epilepsy or

seizures no cause is found

• People without a clear cause have the

best prognosis.

Risk Ratios for Selected Causes

1 29 4 1.5 20 7.3 2 16 10 5 10 15 20 25 30 35 Baseline Severe HI Moderate HI Mild HI Stroke HTN LVH Aseptic Meningitis Encephalitis Alzheimers Risk Ratio

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Diagnostic Pitfalls

• Is the diagnosis correct?
• Does the patient have epilepsy?
• Syncope

Often prominent autonomic symptoms

• Seizure
• An “aura” is a seizure

symptoms may be positive, negative, or mixed

• pSychogenic spell

Almost anything goes

• other Stuff

cataplexy migraine TIA

Our Differential Diagnoses Seizure or Spell Evaluation

• Careful history hopefully with collateral

history Past Medical History

• Risk factors
• Neurological examination
• EEG
• Neuroimaging

Seizure Evaluation

• EEG

Awake and asleep increase sensitivity Looking for evidence of epilepsy * Less than 2% of normal people have epileptiform discharges

• Evidence of focal-onset vs.

generalized-onset seizure

• This will dictate our choice of AEDs

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• Awake
• Stage I
• Stage II
• Stage III
• Stage IV
• REM

Most Interictals Seizures

Sleep Stages

Seizure Evaluation

• Neuroimaging

MRI with thin coronal cuts through hippocampus CT scan is only indicated if:

• Patient has contraindications to MRI
• It is emergent to look for a bleed or

mass effect

MTS

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Strategies for Management

• f Epilepsy
• Medication

Partial Generalized

• Resective Surgery
• Vagal Nerve Stimulator
• Ketogenic Diet/ Atkins Diet
• Stimulators

Antiepileptic Drug (AED) Therapy

Long-Term Management Strategies for Epilepsy

1900 1920 1940 1960 1980 2000

PB PHT CBZ VPA FBM GBP LTG FOS TPM TGB

PGB

1st Generation 2nd Generation OCBZ LVT ZNS

• Dilantin (Phenytoin) PHT
• Phenobarbital
• Tegretol, Carbatrol (Carbamazepine) CBZ
• Depakote, Depakene (Valproic Acid) VPA

Bones loss

• Aging population, post-menopausal

women Hormonal birth control failure (except VPA)

• And may decrease the levels of other AEDs

High protein binding displacing drugs like coumadin and synthroid

Older Drugs

• Neurontin (Gabapentin)
• Felbatol (Felbamate)
• Lamictal (Lamotrigine)
• Topamaz (Topiramate)
• Gabitril (Tiagabine)

No enzyme induction Low protein binding Less interference with other drugs

2nd Generation Drugs

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3rd Generation Drugs

• Trileptal (Oxcarbazepine)
• Zonegran (Zonisamide)
• Keppra (Leviteracitam)
• Lyrica (Pregabalin)

Little interaction with other drugs Renal excretion

Kwan & Brodie NEJM 2000

Newly Diagnosed (n=470) Seizure-free 47% (n=222) Uncontrolled 53% (n=248) Seizure-free 13% (n=61) Uncontrolled 40% (n=187) Seizure-free 4% (n=18) Uncontrolled 36% (n=169)

3rd drug 2nd drug 1st drug

The End

Pediatric Epilepsy

Jorge Vidaurre M.D.

Director Epilepsy Center Nationwide Children’s Hospital- OSU

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Epilepsy

• Convulsive disorders are among the

most frequently occurring neurological condition in children

Incidence

• Incidence of seizures is higher in

childhood, especially the first year of life (100/100,000) and in older patients

Epilepsy: Incidence/100,000

200 150 100 50 20 40 60 80 100 Age

Hauser, Epilepsia 33:1992

181,000 new Cases Per year

Causes of Childhood- Acquired Epilepsy

Trauma Tumors Prematurity Poison Metabolic Disturbances Birth injury

45%-55%

Fever

45%-55%

Infection Genetic or idiopathic

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Definitions

• Seizure: Clinical manifestation of an

abnormal, excessive activity of a set of cortical neurons

• Epilepsy: Chronic brain disorder of

various etiologies characterized by recurrent, unprovoked seizures

• Epilepsy syndromes: Grouping of similar

patients according to seizure type EEG, age

• f onset, familial episodes, prognosis, and
• ther clinical signs

Was the Event a Seizure?

• Syncope
• Breath-holding spells
• Movement disorders (tics)
• Sleep disorders (parasomnias, night

terrors, sleep walking)

• Day dreaming, inattentiveness &

distractibility

• Self stimulatory behavior
• Gastroesophageal reflux
• Psychogenic

Non-epileptic paroxysmal events in childhood

Breath Holding Event Video

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Seizure Classification

• Partial seizures: originating in a focal area
• f the brain.

Simple: Do not impair consciousness Complex: Impairment of consciousness

• Generalized seizures

Absences, clonic, tonic, tonic-clonic, atonic and myoclonic

Benign Partial Epilepsies of Childhood

Benign Rolandic Epilepsy (BRE)

• One of the most frequent syndromes,
• ccurring in up to 24% of all epileptic

seizures in children between ages 5 and 14

• Age of presentation: 3- 13 year
• Remission rate almost 100% at age 16.
• Seizures are usually infrequent.

Benign Rolandic Epilepsy (BRE)

• Seizures usually occur during sleep
• Partial sensorimotor: hemi facial

twitching, drooling, arrest of speech, numbness of tongue, lips.

• GTC in 20-30% of cases

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BRE Video

Idiopathic Generalized Epilepsies

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Childhood Absence Epilepsy (Pyknolepsy, Petit Mal Epilepsy)

• “Very frequent (several to many per day)

absence seizures”

• Brief in duration (usually 5-30 seconds)
• Sudden behavioral arrest, with staring and

quick return to normal baseline activities

• “Otherwise normal child”

Childhood Absence Epilepsy (Pyknolepsy, Petit Mal Epilepsy)

• Often precipitated by

hyperventilation

• An EEG demonstrating “bilateral,

synchronous spike-waves, usually 3 HZ, on a normal background activity”

Absence Video

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Commonly used Medications

• Ethosuxamide
• Valproic acid
• Lamotrigine
• Age of onset: 8-24 years. Peak between

12-18 years

• The characteristic seizure type is

“myoclonus”, usually affecting shoulders

• GTC seizures appear usually more than

3 years after myoclonus.

• Absences occur in up to 30% of patients.

Juvenile Myoclonic Epilepsy(JME) Juvenile Myoclonic Epilepsy(JME)

• Seizures are precipitated by sleep

deprivation, alcohol, stress.

• Photosensitivity
• Intelligence remain normal

Myoclonus video Child during sleep

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Photic Induced Seizure

Medications used for JME

• Broad spectrum medications:
• Valproic Acid
• Lamotrigine
• Topiramate
• Levetiracetam
• Medications that can worsen seizures:
• Phenytoin, carbamazepine

Symptomatic Generalized Epilepsies

• Infantile spasms
• Lennox Gastaut syndrome
• Age of onset: 4-6 months
• Types: flexor (Jackknife, salaam attacks) ,

extensor or mixed.

• Usually occur in cluster, during awakening
• r falling sleep
• Usual EEG shows hypsarrhythmia
• interictaly. Most frequent ictal

manifestation: ”electrodecremental response”

Infantile Spasms

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• Infantile spasms
• Hypsarrhythmia
• Mental retardation

West Syndrome

Hypsarrhythmia-Wakefulness

Hypsarrhythmia Sleep

Ictal Event: IS