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Epilepsy
Epilepsy is a neurological disorder affecting around 1% of the population worldwide. It is characterized by recurrent seizures which are brief episodes of abnormal electrical activity in the brain. Approximately 30% of epilepsy patients do not achieve seizure control with antiepileptic medications alone. For these medically refractory cases, epilepsy surgery may be considered to remove the specific area of the brain responsible for generating seizures. The goal of both medication and surgery is to reduce or eliminate seizures while minimizing side effects from treatment.
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Epilepsy
- 1. Dr.Sanjay Mongia Consultant Neurological & GAMMA KNIFE Surgeon , Mumbai , India
- 2. Second most commonneurological disorder – Prevalence: ~1% (2.5 million) – Incidence: 125,000-180,000 new cases per year – Total annual epilepsy-associated costs: $12.5 billion • Occurs at all ages
- 3. Epilepsy is usuallycontrolled, but not cured, with medication, although surgery may be considered in difficult cases. About 50 million people worldwide have epilepsy at any one time. Epilepsy is usually controlled, but current estimates indicate that 20 - 30% of patients with epilepsy are refractory to all forms of medical therapy These medically intractable patients are candidates for surgical treatment in an attempt to achieve better seizure control
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- 6. Seizures: Transientoccurrence of clinical symptoms due to abnormal neuronal behavior – Convulsions: Seizures with prominent body movement – Non-convulsive seizures: Seizures with minimal or no body Movement Epilepsy : Brain disorder with an enduring predisposition to generate epileptic seizures Epilepsy syndromes : Groups of epileptic patterns of varying cause but similar course and response to treatment
- 7. Seizures :synchronous, high frequency discharge of neurons from cortical or subcortical centres Non-epileptic seizures : result of extreme metabolic disturbance, eg - sedative/hypnotic drug withdrawal - meningitis, CVA - renal failure - fever (children)
- 8. Epileptic seizures - primary disorder of recurrent seizures without a reversible metabolic cause (about 1% population) • Causes of this hyperexcitability : - genetic (autosomal dominant genes) - congenital defects - severe head injury - ischemic injury, tumour
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- 10. Loss of consciousnessFall, cry Muscular rigidity (tonic) Rhythmic jerking (clonic) Respiration inhibited Tongue bite/ incontinence/ injury can occur Usually lasts 1-3 minutes Postictal confusion
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- 12. History – Patient – Eyewitness Physical/neuro exam EEG – Photic stimulation – Hyperventilation – Sleep deprivation Imaging – CT scan – MRI Special studies – Ictal SPECT – PET Video-EEG monitoring – Diagnostic – Presurgical
- 13. Single seizure : May or may not treat depending on likelihood of recurrence Epilepsy : – Antiepileptic drugs – Surgery – Vagus nerve stimulation
- 14. Goal - noseizures, but ↓ drug side effects (60-80% patients obtain good seizure control) Diagnosis - drug selection (for seizure type) Clinical evaluation - drug trial period Plasma drug levels - narrow therapeutic range – monitor Compliance difficult - chronic disorder Withdrawing medication - weeks -> months
- 15. Phenytoin (Dilantin): oral,IV, fosphenytoin Carbamazepine (Tegretol): oral Valproic acid (Depakote): oral, IV Phenobarbital (Luminal): oral, IV Primidone (Mysoline): oral Ethosuximide (Zarontin): oral Benzodiazepines: Diazepam, lorazepam, clonazepam (CZP) - oral, IV, rectal
- 16. Gabapentin (Neurontin) Lamotrigine(Lamictal) Topiramate (Topamax) Tiagabine (Gabitril) Levetiracetam (Keppra) Oxcarbazepine (Trileptal) Zonisamide (Zonegran) Felbamate (Felbatol)
- 17. Type of seizure/epilepticsyndrome Potential side effects Frequency of dosing Comorbid conditions Drug interactions Age, gender Cost of drug
- 18. Side effects anddrug interactions Drowsiness, confusion, ataxia, diplopia Most are metabolised in the liver, & induce liver enzymes -> ↑ metabolism of other drugs, including oral contraceptives Some are teratogenic (eg cleft palate), but seizures present risk for fetus Monotherapy is preferred, but 2 or more drugs may be used
- 19. Epilepsy that isresistant to medication (often 2 years duration and 2 drug trials) Epilepsy originating in a single area in the Brain. Area able to be removed without causing a new neurological problem
- 20. Another group ofpatients who might benefit are those whose seizures may be relatively well controlled but who have certain characteristic presentations or lesions that strongly suggest surgical intervention might be curative. Clinical data suggests that continued medical therapy after failure to control seizures with aggressive trials of antiepileptic drugs (AEDs) is not optimal treatment of certain
- 21. Referral to anepileptologist Video-EEG telemetry Structural Imaging – MRI scan Functional Imaging – SPECT/PET scan Neuropsychology assessment If suitable for surgery – then referral to an epilepsy neurosurgeon.
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- 23. Hippocampal atrophy andT2 signal change ,specificty for mesial temporal sclerosis, >95% good prognostic feature correlates with low risk of memory deficits Volumetric measurements of hippocampus
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- 25. Curative Temporal lobectomyLesion removal “ Non-lesional” resection Hemispherectomy Corpus callosotomy Vagal Nerve Stimulator Gamma knife Treatment
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