Dr.Sanjay Mongia Consultant Neurological & GAMMA KNIFE Surgeon ,

Mumbai , India

Second most common neurological 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

Epilepsy is usually controlled, 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

Development

Education

Driving

Marriage

Life expectancy

Seizures: Transient occurrence 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

Seizures : synchronous, high frequencydischarge of neurons from cortical orsubcortical centres Non-epileptic seizures : result of extreme metabolic disturbance, eg- sedative/hypnotic drug withdrawal- meningitis, CVA- renal failure- fever (children)

Epileptic seizures - primary disorder ofrecurrent seizures without a reversiblemetabolic cause (about 1% population)• Causes of this hyperexcitability :- genetic (autosomal dominant genes)- congenital defects- severe head injury- ischemic injury, tumour

Loss of consciousness Fall, cry Muscular rigidity (tonic) Rhythmic jerking (clonic) Respiration inhibited Tongue bite/

incontinence/ injury can occur Usually lasts 1-3 minutes Postictal confusion

Infarct

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

Single seizure : May or may not treat depending on likelihood of recurrence

Epilepsy : – Antiepileptic drugs – Surgery – Vagus nerve stimulation

Goal - no seizures, 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

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

Gabapentin (Neurontin) Lamotrigine (Lamictal) Topiramate (Topamax) Tiagabine (Gabitril) Levetiracetam (Keppra) Oxcarbazepine (Trileptal) Zonisamide (Zonegran) Felbamate (Felbatol)

Type of seizure/epileptic syndrome Potential side effects Frequency of dosing Comorbid conditions Drug interactions Age, gender Cost of drug

Side effects and drug 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

Epilepsy that is resistant 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

Another group of patients 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

Referral to an epileptologist

Video-EEG telemetry

Structural Imaging – MRI scan

Functional Imaging – SPECT/PET scan

Neuropsychology assessment

If suitable for surgery – then referral to an epilepsy neurosurgeon.

Shrunken Hippocampus

Hippocampal atrophy and T2 signal change ,specificty for mesial temporal sclerosis, >95% good prognostic feature correlates with low risk of memory deficits Volumetric measurements of hippocampus

Curative Temporal lobectomy Lesion removal “Non-lesional” resection Hemispherectomy Corpus callosotomy Vagal Nerve Stimulator Gamma knife Treatment