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Epilepsy- phases of seizure, symptoms, diagnosis, medical management, drugs

PHASES OF SEIZURE

  • Prodromal phase –signs or activity which precede a seizure.
  • The aural phase – a sensory warning
  • The ictal phase – full seizure
  • Post ictal phase – period of recovery after the seizure

Sign and symptoms

CEREBRAL HEMISPHERE LOBE DESCRIPTION  
Frontal lobe epilepsy  

 

 

 

  • Many overlapping syndromes with frequent brief attacks
  • Simple complex seizure
  • Focal motor seizure
  • Tonic and postural sign and symptoms with preserved consciousness: frequent fall
  • Complex partial seizures
  • Complex motor activity, vocalization and gestural automatisms
Mesial temporal lobe epilepsy 
  • Most common cause is hippocampal sclerosis
  • Mostly complex partial seizures withautomatisms and psychic symptoms
  • Preceded by aurain 50- 95% patient. Epigastric discomfort is common in aura
  • Seizure may include
  • Staring
  • Oral or manual automatism
  • Olfactory and auditory illusion or hallucination
  • Unilateral dystonic posturing
Parietal lobe epilepsy
  • usually simple complex and secondarily generalized seizures
  • >75% have somatosensory auras
  • May have distorted body image, visual and auditory hallucination
  • Usually proceed to impaired consciousness and contralateral motor activity
Occipital lobe epilepsy
  • May have visual auras
  • Elemental visual hallucination
  • Eye blinking, nystagmus, head deviation, tonic and clonic eye movement
  • Visual phenomena usually contralateral to side of the seizure
  • Often progress to complex partial seizure or secondary generalized seizures depending on pathway stimulated

Epilepsy Differential Diagnosis

The following should be considered in the differential diagnosis of epilepsy

  • Syncope attacks (when pt. is standing; results from global reduction of cerebral blood flow; prodromal pallor, nausea, sweating; jerks)
  • Cardiac arrythmias (e.g. Adams-Stokes attacks). Prolonged arrest of cardiac rate will progressively lead to loss of consciousness –jerks
  • Migraine (the slow evolution of focal hemisensory or hemimotor symptomas in complicated migraine contrasts with more rapid “spread“of such manifestation in SPS. Basilar migraine may lead to loss of consciousness
  • Hypoglycemia – seizures or intermittent behavioral disturbances may occur.
  • Narcolepsy – inappropriate sudden sleep episodes
  • Panic attacks
  • PSEUDOSEIZURES – psychosomatic and personality disorders

DIAGNOSTIC STUDIES

  • History and physical examination

*        Birth and developmental history
*        Significant illness and injuries
*        Family history
*        Febrile seizures
*        Comprehensive neurologic assessment

  • Seizure history

–        Precipitating factors

–     Antecedent events

–     Seizure description(including onset,duration,frequency,postictal state)

  • Diagnostic studies
    • CBC (Complete Blood Count), urinalysis, electrolytes, creatinine, fasting blood glucose
    • Lumbar puncture for CSF analysis
    • CT,MRI, PET scan
    • Electroencephalography (EEG)

           MANAGEMENT

Antiseizure drugs

First Generation   Second Generation   Unconventional  
  • Carbamazepine (Tegretol)
  • Clonazepam (Klonopin)
  • Clorazepate (Tranxene)
  • Ethosuximide (Zarontin)
  • Phenobarbital
  • Phenytoin (Dilantin)
  • Primidone (Mysoline)
  • Valproic acid (Depakote)

 

  • Felbamate (Felbatol)
  • Gabapentin (Neurontin)
  • Lamotrigine (Lamictal)
  • Levetiracetam (Keppra)
  • Oxcarbazepine (Trileptal) Pregabalin (Lyrica)
  • Tiagabine (Gabitril)
  • Topiramate (Topamax)
  • Zonisamide (Zonegran
  • Adrenocorticotropic hormone (ACTH )
  • Acetazolamide (Diamox)
  • Amantadine (Symmetrel)
  • Bromides
  • Clomiphene (Clomid)
  • Ethotoin (Peganone)
  • Mephenytoin (Mesantoin)
  • Mephobarbital (Mebaral)
  • Methsuximide (Celontin)
  • Trimethadione (Tridione)

 

Antiepileptic drugs and related seizures types

 

Drugs Primary generalized tonic- clonic   Partial ( simple, complex and secondary generalized seizures
First line drugs  Valproic acidlamotrigine

 

LamotrigineValproic acid

Carbamazepine (Tegretol

Phenobarbital

 

Alternative drugs  Primidone (Mysoline)Carbamazepine (Tegretol

Phenobarbital

Felbamate

 

TopiramateTiagabine

Primidone

Zonisamide

Gabapentin

 

Absence Seizures   Atypical absence, myoclonic and atonic Seizures
First line drugs EthosuximideValproic acid

 

Valproic acid 
Alternative drugs MethsuximaideLamotrigine

clonazepam

 

Lamotrigineclonazepam

felbamate

 

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