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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.

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3.2 million patients in the U.S.

180,000 new cases each year.

16 billion dollars per year.

Functional Areas of the Brain

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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

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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.”

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Partial & Generalized Seizure

Generalized Seizures

Tonic-clonic

Absence

Myoclonic

Atonic

Clonic

Tonic

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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

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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.

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VIDEO-EEG Monitoring.

Reason for Video-EEG Monitoring

Seizure vs. Pseudo seizure

Type of seizure – best medication

Degree of seizure control

Presurgical work up.

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Primary Gen. Epilepsy

Temporal Lobe Epilepsy

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Frontal Lobe Epilepsy

Non – Epileptic Seizures

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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.

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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.

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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.

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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

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Right Mesial Temporal Sclerosis[MTS].

Hippocampal atrophy

Enlarged temporal horn of lateral ventricle.

MRI - TLE

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MRI Brain – Right M.T.S.

MTS - Hippocampus

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M.R. MICROSCOPY – [9.4 Tesla]

14 yrs. Old male with left sided sensory seizures.

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PET-M.E.S.

WADA TEST.

Angiogram

SODIUM AMYTAL

Right ICA

Left ICA

Test for lateralization:

- Speech.

- Memory.

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fMRI

Intracranial Recording

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Treatment of Epilepsy

Anti epileptic medications – AED’s.

Epilepsy Surgery – resective

Vagal Nerve Stimulator

Deep Brain Stimulator

RNS

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Antiepileptic Medications

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First Canabis Drug Approved for Epilepsy

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Temporal Lobectomy for M.T.L.E.

Vagal Nerve Stimulator

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Deep Brain Stimulation

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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.

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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.

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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

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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