WHAT IS EPILEPSY?

Professor (Dr.) Ennapadam S. KrishnamoorthyFounder & Director

Neurokrish & Trimed

Adjunct Professor: Public Health Foundation of India

Seizures and Epilepsy• A fit or seizure represents a transient abnormal electrical discharge in the brain with or without: alteration in consciousness, motor (movement) or sensory (perceptual) symptoms

• Seizures represent a focal (ex: Tumor) or generalized (ex: infection) abnormality in electrical brain activity

• Seizures represent underlying brain dysfunction

Seizures≠Epilepsy

What is Epilepsy?• A tendency to have recurring unprovoked seizures

• Does not include single or occasional seizures or those occurring during acute illness (symptomatic seizures)

• Unprovoked seizures occurring on two separate occasions are required for epilepsy diagnosis

• A cluster of seizures is considered as a single seizure for the purpose of epilepsy diagnosis

How common is epilepsy?

• Most common serious neurological disease• Affects 1/200 people worldwide• Could be as much as 1/100 in developing nations like India due to increased:- poor antenatal care and perinatal injury- infections (tuberculosis & cysticercosis)- road traffic accidents

Who is at risk?

• About one half of people affected develop epilepsy before 15 years of age

• Increasing prevalence in older individuals- probably due to demographic change and the increasing prevalence of degenerative cerebrovascular disease

• Slightly higher in males• Slightly higher in lower socio-economic groups

What causes epilepsy?

• Causes vary worldwide and with age• Unknown in two-thirds of cases overall• Known causes are

- Cerebrovascular disease (15%)

- Cerebral tumor (6%)

- Alcohol related (6%)

- Post-traumatic (2%)

- Neuroinfections (tuberculosis & cysticercosis)• Refractory epilepsy is most often due to

- Hippocampal sclerosis, malformations of cortical development, small foreign tissue lesions

Hippocampal Sclerosis

Brain Infections

Genes and Epilepsy

• Over 200 disorders showing a Mendelian pattern of inheritance feature epilepsy as a manifestation

• Single gene disorders where epilepsy is the sole or major manifestation are being discovered but will account only for a small proportion of cases (10%)

• In most forms of epilepsy the inheritance is probably polygenic (i.e. many genes are responsible for the disorder)

Mechanisms• Generalized Seizures: Reciprocal cortico-thalamic interaction

• Partial Seizures: Local excitation-inhibition imbalance

• Disorder of membrane ion channels: complex changes in brain receptor, membrane and system levels in most cases

• Pathological, functional imaging and genetics will probably redefine our understanding and promote rational drug design

Epileptic Seizures

• Epileptic seizures are paroxysmal events• Symptoms:- Generalized convulsive movements, drop attacks, transient focal motor or sensory attacks (including facial and eye movements), psychic experiences, episodic phenomena in sleep, prolonged confusional states are all possible

• Several well described types of seizure are recognized and are usually stereotyped in an individual

Diagnosis• Almost always clinical: a detailed history and an eyewitness account are essential

• Information about:- The circumstances of the episode- Patterns of occurrence- Preceding symptoms- localizing or diagnostic- Timing, pattern, tempo and evolution of symptoms- Reported behaviors- before, during and after- Investigations are seldom necessary for making diagnosis: but are helpful in terms of management

Differential Diagnosis• Syncope

vasovagal, micturition, postural, vascular, respiratory, cardiac

• Cardiac Disordersarrhythmias, aortic or mitral stenosis, cardio-myopathies, myxoma..

• Metabolic/ Endocrinehypoglycemia, phaeochromocytoma, porphyria, carcinoid syndrome

• NeurologicalTIA, cataplexy-narcolepsy, basilar migraine, III ventricle cyst, Meniere’s disease, episodic ataxias, movement and sleep disorders

• Psychogenichyperventilation, panic attacks, non-epileptic attack disorder, episodic dyscontrol syndrome, malingering, Munchausen

Type of Seizure

• Partial: Begin focally in cortex- may become generalized involving entire cortex

• Generalized: Involve much of the cortex bilaterally from the outset and therefore loss of consciousness- - Generalized tonic clonic seizures: cry, loc, fall, spasm, cyanosis, Generalized tonic clonic seizures: cry, loc, fall, spasm, cyanosis, noisy breathing, jerking, tongue bite, incontinencenoisy breathing, jerking, tongue bite, incontinence- Absences: sudden & brief cessation in activity with rapid return - Absences: sudden & brief cessation in activity with rapid return to normality, may be frequent, 3Hz spike and waveto normality, may be frequent, 3Hz spike and wave- Partial Seizures: simple (preserved consciousness) vs. complex - Partial Seizures: simple (preserved consciousness) vs. complex (impaired consciousness); temporal (taste, smell, epigastric (impaired consciousness); temporal (taste, smell, epigastric sensations, autonomic, fear, déjà vu, jamais vu); frontal (brief with sensations, autonomic, fear, déjà vu, jamais vu); frontal (brief with rapid recovery, bizarre, version of eyes, bilateral limb movement, rapid recovery, bizarre, version of eyes, bilateral limb movement, posturing); parietal (sensory, pain); occipital (colored visual posturing); parietal (sensory, pain); occipital (colored visual phenomena, visual loss)phenomena, visual loss)

• Automatisms: Automatisms: semi-purposeful or release phenomena, occur in semi-purposeful or release phenomena, occur in both absences and complex partial; lip smacking, swallowing, both absences and complex partial; lip smacking, swallowing, fidgeting with hands, complex behaviorsfidgeting with hands, complex behaviors

Status Epilepticus

• Usually occurs in a person with history of seizures

• Repeated seizures lasting 30 minutes or longer without recovery of consciousness

• Usually due to AED withdrawal (non-compliance), acute infections or metabolic states

• GTC status is a medical emergency• Complex partial and absence status present with impaired awareness

Issues in Caring for the person with epilepsy

• Investigations, Medical Treatment, Non-Medical Therapies, Counseling and Support

• Learning, Behavior, Education, Employment, Marriage, Pregnancy, Driving, Safety in Home, Safety in the Work Place, Social Stigma

• Awareness and Empowerment

Thank you for your attention & interest