1. Epilepsy
Dr. Kalpana Malla
MD Pediatrics
Manipal Teaching Hospital
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2. Epilepsy
Definition:-
Two or more unprovoked seizures (unrelated
to fever or an acute cerebral insult) occurring
at an interval greater than 24 hrs apart
 Exceptions –Multiple seizure within 24 hrs
Episodes of status epilepticus
** F. convulsion & neonatal seizures are excluded
Incidence of epilepsy 3%

3. Aetiology of Epilepsy
• Idiopathic 67.6%
• Specific etiology - Identifiable in only 30% cases
• Congenital……….20%
– HIE
– Congenital brain anomalies
• Infection …………4.0%
• Trauma………… 4.7%
• Vascular …………1.5%
• Neoplastic……….1.5%
• Degenerative…….0.7%

4. ILAE- Epileptic seizures
• Partial seizures:
1. Simple partial (consciousness retained) –
Motor, sensory, Autonomic, psychic
2.Complex partial (consciousness impaired)
*simple P followed by impaired
conscious
*Consciousness impaired at onset
3. Partial seizures with secondary
generalization

5. ( ILAE): using both clinical data and EEG
II. Generalized seizures
A. Absence seizures (petit mal)
B. Clonic seizures
C. Tonic seizures
D. Tonic-clonic seizures
E. Atonic seizures
F. Myoclonic seizures
I. Infantile spasms
III. Unclassified seizures which, due to inadequate data or
classification

6. ILAE epilepsy & Epileptic syndromes
1. Localised - Simple Partial S
Complex Partial S
Syndromes:-
a) Idiopathic age related -Benign
childhood focal epilepsy with
centrotemporal spikes (rolandic E)
b) Symptomatic- chronic progressive E
Epilepsia partalis continua

7. ILAE epilepsy & Epileptic syndromes
2. Generalized – Same
Syndromes :
A) Idiopathic age related – childhood
absence,
juvenile absence
B) Cryptogenic -West syndrome (infantile
spasms)
- Lennox-Gastaut
Syndrome
- Myoclonic seizures

8. Simple Partial seizures
• Motor activity is the most common
symptom
• Tend to involve the face, neck, extremities
• Automatism do not occur, some c/o Aura
• Persists -10-20 sec
• Remain conscious can verbalize
• No postictal phase
• EEG-spikes or sharp waves uni or bilaterally
or multifocal spikes

9. Complex partial S
• Aura may be +
• Brief blank stare or sudden cessation/ pause
in activity
• Period of altered consciousness may be brief
& infrequent
• Automatisms are common 50-75%-
• In infancy -lip smacking, chewing, swallowing
,excessive salivation (alimentary
Automatisms)

10. Complex partial S
• In older children-semipurposeful
uncoordinated and unplanned
gestures-picking & pulling at
clothing or bed sheets, rubbing
objects, walking or running in
nondirective , repetitive , fearful
fashion
• Secondary generalization may be +
• Duration 1-2 min

11. Generalized seizures
1.Absence S (petit-mal),simple, typical :-
-Sudden cessation of motor activity with
blank facial expression & flickering of
the eyelids
- Seizures are subtle - first clue to absence S
is often unexplained "daydreaming" and a
decline in school performance recognized
by a teacher

12. Absence S (petit-mal),simple, typical
- Common age - 4 to 8 yrs or early adolescence,
- Prevalent in girls
- Incidence 15 to 20% of children
- No aura, no postictal state
- Duration 30 sec
- Countless seizures in
a day

13. Generalized seizures
Absence S (petit-
mal),simple, typical……..
- Body tone normal but head may fall
slightly forward
-Automatism frequently present
-EEG-3/sec spike and generalized wave
discharge

14. Atypical Absence Seizures
• Longer duration
• Seizure is accompanied by more obvious motor
signs consisting of myoclonic movements of face,
fingers and extremities, focal or lateralizing features
• Mental retardation may be present
• Less responsive to anticonvulsants
• The EEG - shows a generalized, slow spike-and-wave
pattern with a frequency of =2- 2.5cycles/sec

15. 2.Generalized tonic – clonic grand –mal)
Aura – Due to partial onset of seizure
, lasts sec –min eg olfactory
hallucination, epigastric
discomfort, deja-vu, jerking of one
limb
Tonic phase -rapid discharging of motor cortex cells
cause tonic contraction of muscles throughout the
body - skeletal muscle undergoes sustained spasm

16. Tonic phase….
• Skeletal muscle undergoes sustained spasm
- Laryngeal muscles ,muscles of expiration - forces air
out of the lungs through a partially closed glottis -
produce "ictal cry." (shrill cry)
- Respirations are impaired, secretions pool in the
oropharynx, and cyanosis develops
- Muscle rigidity: more in antigravity muscles
uprolling of eyes or deviated to sides

17. Tonic phase….
• Contraction of the jaw muscles - biting of the tongue.
• Lasts 10-30 sec

18. Generalized tonic – clonic grand –mal)
Clonic phase- 1-5 min
- Gradually slowing discharge of cortical
cells, rhythmic clonic contractions
alternating with relaxation of muscle
groups
- Marked enhancement of sympathetic tone - increases
in heart rate, blood pressure, pupil dilated, Loss of
sphincter control

19. Postictal phase
• Characterized by :
- Semicomatose- Unresponsiveness - deep sleep
for 30min to 2hrs
• Muscular flaccidity, loss of corneal reflex
• Extensor plantar responses
• Loss of sphincter control -incontinence , tongue biting
• Lasts 30 min – 2 hrs

20. Generalized tonic – clonic grand –mal)
Post-ictal – 30 min – 2 hrs
Deep unconsciousness, flaccid
limbs, loss
of corneal reflexes, extensor plantar
responses, Excessive salivation cause stridorous
breathing and partial airway obstruction
- Patients gradually regain consciousness
• Bi-frontal headache, confusion, aching
muscles ,sometimes automatic
behavior, occasional violence (2-
21/2hours)

21. Postictal confusion
• Bifrontal headache
• Confusion
• Aching muscles
• Sometimes automatic behavior
• Occasinal violence
• Lasts - 2-2 ½ hours

22. GTCS - Precipitated by
- Infections
- Excessive fatique
- Emotional stress
- Various drugs -theophylline, anti-
psychotropic drugs, cipro, benzodiazepines,
amphetamine, cocaine, alcohol, flumazenil
- Forgetting to take anticonvulsants

23. The EEG
During the tonic phase - shows a
- progressive increase in generalized low-voltage fast
activity, followed by generalized high-amplitude,
polyspike discharges
During clonic phase - the high-amplitude activity is typically
interrupted by slow waves to create a spike-and-wave
pattern
The postictal EEG - shows diffuse slowing that gradually recovers as
the patient awakens

24. 3.Myoclonic epilepsies of childhood
• Repetitive seizures with brief ,symmetric
muscular contractions with loss of body tone
and falling or slumping forward
• Subgroups:
A. Benign myoclonus of infancy
-confined to neck, trunk, extremities
- EEG normal
- Good prognosis - improves by age
2yrs
- No medications needed

25. B. Typical myoclonic epilepsy of early childhood
-Normal birth history, normal
milestones
-starts at 6 mo -4 yrs peak age-2 ½ yrs
-Family history + in 1/3rd cases
-EEG- fast spike waves
-50% seizure free few yrs after
treatment
-Learning language problem, emotional,
behavioral disorder
- MR may occur in some

26. C. Complex myoclonic epilepsies
• Begin-1st yr of life,
• Starts as generalized seizure associated
with URTI
• Presents as status epilepticus-poor
prognosis
• 1/3rd have delayed development,
• H/o birth asphyxia ,microcephaly
• No family h/o epilepsy
• EEG- interictal slow spike waves
• Refractory to anticonvulsants

27. D. Juvenile myoclonic epilepsy (janz syndrome)
• Begin at age 12-16 yrs
• Initially hair combing, tooth brushing
become difficult
• Few yrs later with myoclonus have GTC
seizure
• EEG –abnormal
• Responds to valproate required
lifelong

28. E. Progressive myoclonic epilepsies
• Neurologic abnormalities-cerebellar &
extrapyramidal signs ++
• Mental deterioration is characteristic
feature
• Genetic disorder –grave prognosis
• EEG-abnormal
• Valproic acid + clonazepam is effective

29. 4.Infantile spasms
• 4-8 mo of life
• Brief symmetrical contractions of
neck, trunk, extremities-sudden
dropping of head & flexion of arms
- ‘Salaam fit’
• EEG-Hypsarrhythmic pattern –
diffuse high voltage slow spike and
chaotic activity

30. 4.Infantile spasms
• Types –
• Flexor spasms
• Extensor spasms-least common
• Mixed infantile spasms-most
common
• More tendency when drowsy or
immediately on awaking

31. 4.Infantile spasms
Two groups
1. Crytogenic
-10-20% cases
- Normal birth history
- Normal development
- Neurologic exam, CT,MRI head-
normal
- No risk factors

32. 4.Infantile spasms
2. Symtomatic-
- 80-90% Related to several factors:-
Antenatal-HIE, cong infections, inborn
errors of metabolism, neurocutaneous
syndromes, Cong anomalies of brain
Post natal–CNS infections, head
Trauma,HIE
-80-90% -MR

33. Lennox –Gastaut Syndrome
• Onset –late infancy or childhood
• Mixed seizure- myoclonic, atypical absence
,generalized tonic-clonic, partial
• Prognosis unsatisfactory
• Triad-
1.Atypical absences, axial tonic seizures, drop
attacks
2. Typical EEG pattern - Slow spike and waves
on awake EEG & 10Hz bursts during sleep
3.Psychomotor retardation

34. Management
• 1st seizure:
Blood sugar, electrolytes,calcium,
EEG,
CT,MRI,CSF-when indicated
** Normal-Negative family history-No
treatment ,only close observation
**Abnormal-treat underlying cause/AED if
necessary
**Normal except EEG abnormal-Idiopathic
Epilepsy-treatment

35. Did the child had seizure ?
NO YES
SEIZURE MIMICS INITIAL RECURENT
SEIZURE SIEZURE
Drug compliance
RBS , electrolyte,
Improper drug
EEG?, CT?, CSF?
Metabolic
icSol
Degenerative CNS
Drug interaction
ABNORMAL NORMAL NORMAL
SYMPTOMATIC SIEZURE EXCEPT EEG
Isolated 1st sizure IDIOPATHIC
TREAT underlying cause No family history EPILEPSY
AED if necessary No TREATMENT
Close observation

36. NORMAL EXCEPT EEG
IDIOPATHIC EPILEPSY
Classify seizure type
Good control Poor control
Regular follow up Hospitalize
AED drug levels EEG , video monitoring
Monitor toxicity Readjust drugs
EEG CT, MRI, FREQUENT
FOLLOW UPS

37. When To Initiate AED Therapy
(1) An abnormal neurologic examination
(2) Seizures presenting as status epilepticus
(3) Postictal Todd's paralysis
(4) A strong family history of seizures
(5) An abnormal EEG
• Antiepileptic drug therapy should be started in any
patient with recurrent seizures of unknown etiology

38. Selection Of AED
• Carbamazepine, phenytoin, or lamotrigine is
currently the initial drug of choice for partial
seizures, including those that secondarily generalize
• Valproic acid is currently - best initial choice for
primarily generalized, tonic-clonic seizures.
• Lamotrigine, followed by carbamazepine and
phenytoin, are suitable alternatives.

39. • Valproic acid is effective in - absence,
myoclonic, and atonic seizures - drug of
choice for generalized epilepsy syndromes
having mixed seizure types

40. Treatment
1.Establish diagnosis
2. Decide about need for AED
3. Choice of most suitable drug-age, type
of seizure, economic condition of
patient
4.Proper F/U
**Go for monotherapy
**start with small dose & gradually
increase to maintenance dose over few
weeks

41. AED Choice Based on S. Type
Seizure First choice Others
type
Partial S CBZ Phenytoin, Valproic acid,
Phenobarbital,
Tonic- Valproic acid Topiramate, Phenobarbital,
clonic Lamotrigine, Zonisamide,
Felbamate,phenytoin
,carbamazepine
Atonic Valproic acid Topiramate, Lamotrigine,
Zonisamide,Felbamate

42. AED Choice Based on S. Type
Seizure First choice Others
type
Childhood Ethosuximide Lamotrigine,valproic acid,
Absence Zonisamide, clonazepam
epilepsy felbamate
Juvenile Valproic acid Lamotrigine, topiramate, zonisamide
Absence
Epilepsy
Infantile ACTH, Topiramate, Zonisamide
spasm Vigabatrin ,prednisolone,valproic acid

43. AED Choice Based on S. Type
Seizure First choice Others
type
Partial S CBZ Phenytoin, Valproic acid,
Phenobarbital,
Tonic- Valproic acid Topiramate, Phenobarbital,
clonic Lamotrigine, Zonisamide,
Felbamate,phenytoin
,carbamazepine
Atonic Valproic acid Topiramate, Lamotrigine,
Zonisamide,Felbamate

44. AED Choice Based on Epilepsy Type
Epilepsy First-choice Others
type
Juvenile Valproic acid Lamotrigine, topiramate,
Myoclonic zonisamide, felbamate
Epilepsy ,phenobarbitone,clonazepam
Benign Rolandic Carbamazepine Gabapentine,topiramate,lamo
Epilepsy trigine,valproic
acid,phenytoin
Lennox- Valproic acid Topiramate,lamotrigine,
Gastaut zonisamide,
felbamate,clonazepam

45. Adjunctive T when S poorly controlled
• Gabapentine, clobazam, lamotrigine, to
piramate, vigabatrin
• Surgical Rx-Resection of corpus
callosum, focal resection of parts of
cerebral cortex involved as epileptic foci

46. WHEN TO DISCONTINUE THERAPY
Duration: should be invidualized as there is no
unanimity in literature
(1) Complete medical control of seizures for 1 to 5
years
(2) In children seizures that are easily controlled and
have no underlying structural lesions, no MR, no
neurological deficits need 2-3 yrs seizure free
course
(3) Normal EEG

47. Thank you
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