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Diagnosis of epilepsy

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Epilepsy classification
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Diagnosis of epilepsy

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this presentation discusses epileptic seizures
D.D. Of epilepsy
how to Identify type of seizure (seizure semiology) International classification of epileptic seizures.
Investigations aiming at confirmation of the diagnosis & searching for an aetiology of epilepsy
how to Identify epileptic syndrome
International classification of epilepsy & epileptic syndromes

this presentation discusses epileptic seizures
D.D. Of epilepsy
how to Identify type of seizure (seizure semiology) International classification of epileptic seizures.
Investigations aiming at confirmation of the diagnosis & searching for an aetiology of epilepsy
how to Identify epileptic syndrome
International classification of epilepsy & epileptic syndromes

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Diagnosis of epilepsy

  1. 1. Practical Approach To An Epileptic Patient
  2. 2. Amr Hasan, M.D. Associate professor of Neurology - Cairo University
  3. 3. Diagnosis of Epilepsy 3 History taking.. • Physical examination in most cases is relatively unrevealing • History – taking from the patient and observer is the most important step for reaching the diagnosis.
  4. 4. Diagnosis of Epilepsy 4 Axis 1: • Is it epileptic seizure or not?  D.D. Of epilepsy Axis 2: • Identify type of seizure (seizure semiology)  International classification of epileptic seizures. Axis 3: • Investigations aiming at confirmation of the diagnosis & searching for an aetiology Axis 4: • Identify epileptic syndrome  International classification of epilepsy & epileptic syndromes
  5. 5. Diagnosis of Epilepsy 5
  6. 6. AXIS 1: D.D. OF EPILEPSY 6 A) Episodic impairment of consciousness 1. Impaired cerebral perfusion e.g. TIAs 2. Syncope. 3. Metabolic disturbances (e.g.,hypoglycemia). 4. Sudden increase in intracranial pressure. 5. Sleep disorders. 6. Movement disorders. 7. Psychologically – related phenomena.
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  8. 8. Red flags: 8 -Young adult female, low socioeconomic and educational state. -Nontraditional triggers - Events in the waiting room…audience - Longer duration >2min - Historionic behavior, comorbid psych depression - Rapid cognitive recovery - Symptomatizing lengthy dis: fatigue, fibromyalgia - Refractory to AED - High frequency not affected by AED - History of abuse - Pt recalls events during period he was unresponsive
  9. 9. AXIS 1: D.D. OF EPILEPSY 9 B) Drop Attacks • Falling spells without warning signs, without loss of consciousness or post-ictal symptoms. • Identifiable mechanisms OTHER THAN epilepsy include; 1. Brainstem ischemia, or rarely if both ACA arise from the same stenosed ICA. 2. Hydrocephalus.
  10. 10. AXIS 1: D.D. OF EPILEPSY 10 B) Drop Attacks 3. Otolithic catastrophe” of Meniere disease. 4. Cataplexy. 5. orthostatic hypotension. 6. EPS.
  11. 11. AXIS 1: D.D. OF EPILEPSY 11 C) Transient Focal Neurologic Manifestions 1. Migraine with aura. 2. Transient global amnesia. 3. Transient ischemic attacks. 4. Structural intracranial lesions (AVM, chronic subdural hematoma).
  12. 12. AXIS 1: D.D. OF EPILEPSY 12 C) Transient Focal Neurologic Manifestions 5. Metabolic disorders (hyperglycemia “NKHO”, hypoglycemia, hypercalcemia, hyponatremia). 6. Labyrinthine disorders (e.g. Meniere’s and BPV). 7. Paroxysmal abnormal involuntary movements e.g. Paroxysmal dystonia & tics. 8. Psychological.
  13. 13. AXIS 1: D.D. OF EPILEPSY 13 D) Non-Epileptic Paroxysmal Attacks in Pediatric Age Group • Breath-holding attacks: • Cyanotic spells • Pallid spells “reflex anoxic seizures” • Movement disorders: • Benign non-epileptic myoclonus of early infancy Paroxysmal choreoathetosis • Shuddering attacks, • hyperekplexia, paroxysmal torticollis and tics
  14. 14. Diagnosis of Epilepsy 14 Axis 1: • Is it epileptic seizure or not?  D.D. Of epilepsy Axis 2: • Identify type of seizure (seizure semiology)  International classification of epileptic seizures. Axis 3: • Investigations aiming at confirmation of the diagnosis & searching for an aetiology Axis 4: • Identify epileptic syndrome  International classification of epilepsy & epileptic syndromes Axis 1: • Is it epileptic seizure or not?  D.D. Of epilepsy
  15. 15. Diagnosis of Epilepsy 15
  16. 16. International Classification of Epilepsies 16 I. Partial (focal, local) seizures A. Simple partial seizures (consciousness not impaired) 1. With motor signs 2. With sensory symptoms 3. With autonomic symptoms or signs 4. With psychic symptoms
  17. 17. International Classification of Epilepsies 17 I. Partial (focal, local) seizures B. Complex partial seizures (temporal lobe or psychomotor seizures; consciousness impaired) 1. Simple partial onset, followed by impairment of consciousness a. With simple partial features (A.1-A.4), followed by impaired consciousness b. With automatisms 2. With impairment of consciousness at onset a. With impairment of consciousness only b. With automatisms
  18. 18. International Classification of Epilepsies 18 I. Partial (focal, local) seizures C. Partial seizures evolving to secondarily generalized seizures (tonic-clonic, tonic or clonic) 1. Simple partial seizures (A) evolving to generalized seizures 2. Complex partial seizures (B) evolving to generalized seizures 3. Simple partial seizures evolving to complex partial seizures, evolving to generalized seizures
  19. 19. International Classification of Epilepsies 19 II. Generalized seizures (convulsive or nonconvulsive) 1. Simple partial seizures (A) evolving to generalized seizures 2. Complex partial seizures (B) evolving to generalized seizures 3. Simple partial seizures evolving to complex partial seizures, evolving to generalized seizures III. Unclassified epileptic seizures (caused by incomplete data)
  20. 20. AXIS 2: IDENTIFY TYPE OF SEIZURE TYPES OF SEIZURES 20 I. Partial (focal, local) seizures A. Simple partial seizures • Are caused by focal cortical discharge that results in seizure phenomenon appropriate to the function of the discharging area of the brain without impairment of consciousness • SPS may consist of motor , sensory, autonomic or psychic symptoms and signs
  21. 21. AXIS 2: IDENTIFY TYPE OF SEIZURE TYPES OF SEIZURES 21 I. Partial (focal, local) seizures • The symptoms are, at least initially, always strictly contralateral to the hemispheric focus and may represent the expression of excitatory (positive—irritative) phenomena, inhibitory (negative—suppressive or paralytic) phenomena, or a combination of the two. A. Simple partial seizures 1. Simple partial seizures with motor signs:
  22. 22. AXIS 2: IDENTIFY TYPE OF SEIZURE TYPES OF SEIZURES 22 I. Partial (focal, local) seizures • The simplest form of simple partial seizure with motor signs is clonus, which consists of rhythmic alternating contraction and relaxation of muscle groups controlled by the precentral gyrus A. Simple partial seizures 1. Simple partial seizures with motor signs:
  23. 23. AXIS 2: IDENTIFY TYPE OF SEIZURE TYPES OF SEIZURES 23 I. Partial (focal, local) seizures • The episodes may be self-limited (clonic focal seizure), recurrent (focal motor status epilepticus), or continuous (epilepsia partialis continua). • Spread of the discharge along contiguous areas of the precentral gyrus gives rise to the characteristic march of spreading involvement of muscle groups in jacksonian seizures. A. Simple partial seizures 1. Simple partial seizures with motor signs:
  24. 24. AXIS 2: IDENTIFY TYPE OF SEIZURE TYPES OF SEIZURES 24 I. Partial (focal, local) seizures • Somatosensory seizures are usually described as"numbness," "tingling," "pins and needles," or "like a weak electric shock" and may arise from the postcentral (most often) or precentral areas. A. Simple partial seizures 2. Simple partial seizures with sensory symptoms:
  25. 25. AXIS 2: IDENTIFY TYPE OF SEIZURE TYPES OF SEIZURES 25 I. Partial (focal, local) seizures • The focal discharge may spread to the adjacent sensory cortex, producing a jacksonian march of sensory phenomena. • The focal discharge also may spread to the adjacent motor cortex, producing motor symptoms. A. Simple partial seizures 2. Simple partial seizures with sensory symptoms:
  26. 26. AXIS 2: IDENTIFY TYPE OF SEIZURE TYPES OF SEIZURES 26 I. Partial (focal, local) seizures • The focal discharge may spread to the adjacent sensory cortex, producing a jacksonian march of sensory phenomena. • The focal discharge also may spread to the adjacent motor cortex, producing motor symptoms. A. Simple partial seizures 3. Simple partial seizures with autonomic symptoms or signs:
  27. 27. AXIS 2: IDENTIFY TYPE OF SEIZURE TYPES OF SEIZURES 27 I. Partial (focal, local) seizures • Autonomic symptoms accompanying simple partial seizures may consist of epigastric sensations, flushing or pallor, sweating, pupil dilation, diaphoresis, piloerection, nausea, vomiting, borborygmi, or incontinence. A. Simple partial seizures 3. Simple partial seizures with autonomic symptoms or signs:
  28. 28. AXIS 2: IDENTIFY TYPE OF SEIZURE TYPES OF SEIZURES 28 I. Partial (focal, local) seizures • Psychic symptoms of simple partial seizures may include dysphasia, dysmnesia, cognitive symptoms, affective symptoms, illusions, or structured hallucinations. • Dysphasic symptoms may take the form of speech arrest, vocalization, or palilalia (involuntary repetition of a syllable or phrase). A. Simple partial seizures 4. Simple partial seizures with psychic symptoms.
  29. 29. AXIS 2: IDENTIFY TYPE OF SEIZURE TYPES OF SEIZURES 29 I. Partial (focal, local) seizures • Dysmnesic symptoms, distortions of memory, may take the form of a temporal disorientation, a dreamy state, a flashback, the sensation that an experience has occurred before (deja vu, if, visual; deja entendu, if auditory), or the sensation that a familiar sensation is new (jamais vu, if visual; jamais entendu, if auditory). • Occasionally, a patient may experience a rapid recollection of episodes from the past (panoramic vision). A. Simple partial seizures 4. Simple partial seizures with psychic symptoms.
  30. 30. AXIS 2: IDENTIFY TYPE OF SEIZURE TYPES OF SEIZURES 30 I. Partial (focal, local) seizures • The central feature of CPSs is impairment of consciousness, which is defined as the inability to respond normally to exogenous stimuli by virtue of altered awareness or responsiveness. B. Complex Partial Seizures (Psychomotor or Temporal Lobe Seizures)
  31. 31. AXIS 2: IDENTIFY TYPE OF SEIZURE TYPES OF SEIZURES 31 I. Partial (focal, local) seizures • Responsiveness refers to the ability of the patient to carry out simple commands or willed movement. • Awareness refers to the patient's contact with events during the period in question and its recall. B. Complex Partial Seizures (Psychomotor or Temporal Lobe Seizures)
  32. 32. AXIS 2: IDENTIFY TYPE OF SEIZURE TYPES OF SEIZURES 32 I. Partial (focal, local) seizures • The period of impairment of consciousness may or may not be preceded by symptoms or signs of a simple partial seizure. B. Complex Partial Seizures (Psychomotor or Temporal Lobe Seizures)
  33. 33. AXIS 2: IDENTIFY TYPE OF SEIZURE TYPES OF SEIZURES 33 I. Partial (focal, local) seizures • Other manifestations may appear during the period of impaired consciousness, or automatisms (i.e., nonreflex actions performed "automatically," without conscious volition, and for which the patient has no recollection. B. Complex Partial Seizures (Psychomotor or Temporal Lobe Seizures)
  34. 34. AXIS 2: IDENTIFY TYPE OF SEIZURE TYPES OF SEIZURES 34 II. Generalized seizures • Absence seizures consist of sudden onset and cessation of impaired responsiveness, accompanied by a unique 3-Hz spike and wave EEG pattern. 1. Absence Seizures:
  35. 35. AXIS 2: IDENTIFY TYPE OF SEIZURE TYPES OF SEIZURES 35 II. Generalized seizures •No aura is present, and little or no postictal symptomatology occurs. • The majority of absence seizures last 10 seconds or less and may be accompanied by mild clonic components, atonic or tonic components, automatisms, or autonomic components. 1. Absence (Petit Mal) Seizures:
  36. 36. AXIS 2: IDENTIFY TYPE OF SEIZURE TYPES OF SEIZURES 36 II. Generalized seizures • Absence seizures usually first manifest between the ages of 5 and 12 years and often stop spontaneously in the teens. 1. Absence Seizures:
  37. 37. AXIS 2: IDENTIFY TYPE OF SEIZURE TYPES OF SEIZURES 37 II. Generalized seizures •Myoclonic seizures consist of brief, sudden muscle contractions that may be generalized or localized, symmetric or asymmetric, synchronous or asynchronous. • No loss of consciousness is usually detectable 2. Myoclonic Seizures:
  38. 38. AXIS 2: IDENTIFY TYPE OF SEIZURE TYPES OF SEIZURES 38 II. Generalized seizures •Tonic seizures consist of a sudden increase in muscle tone in the axial or extremity muscles, or both, producing a number of characteristic postures. •Consciousness is usually partially or completely lost 3. Tonic Seizures
  39. 39. AXIS 2: IDENTIFY TYPE OF SEIZURE TYPES OF SEIZURES 39 II. Generalized seizures •Prominent autonomic phenomena occur. •Postictal alteration of consciousness is usually brief, but it may last several minutes. •Tonic seizures are relatively rare and usually begin between 1 and 7 years of age 3. Tonic Seizures
  40. 40. AXIS 2: IDENTIFY TYPE OF SEIZURE TYPES OF SEIZURES 40 II. Generalized seizures •Atonic seizures consist of sudden loss of muscle tone. •The loss of muscle tone may be confined to a group of muscles, such as the neck, resulting in a head drop. •Alternatively, atonic seizures may involve all trunk muscles, leading to a fall to the ground . 4. Atonic Seizures
  41. 41. AXIS 2: IDENTIFY TYPE OF SEIZURE TYPES OF SEIZURES 41 II. Generalized seizures •Clonic seizures occur almost exclusively in early childhood. •The attack begins with loss or impairment of consciousness associated with sudden hypotonia or a brief, generalized tonic spasm. •This is followed by 1 minute to several minutes of bilateral jerks, which are often asymmetric and may appear predominately in one limb 5. Clonic Seizures
  42. 42. AXIS 2: IDENTIFY TYPE OF SEIZURE TYPES OF SEIZURES 42 II. Generalized seizures •During the attack, the amplitude, frequency, and spatial distribution of these jerks may vary greatly from moment to moment. •In other children, particularly those aged 1 to 3 years, the jerks remain bilateral and synchronous throughout the attack. •Postictally, recovery may be rapid, or a prolonged period of confusion or coma may ensue. 5. Clonic Seizures
  43. 43. AXIS 2: IDENTIFY TYPE OF SEIZURE TYPES OF SEIZURES 43 II. Generalized seizures • Before the tonic phase of a tonic-clonic seizure, bilateral jerks of the extremities or focal seizure activity may occur. • The onset of the seizure is marked by loss of consciousness and increased muscle tone (tonic phase), which usually results in a rigid, flexed posture at first, and then a rigid, extended posture. 6. Tonic-Clonic (Grand Mal) Seizures
  44. 44. AXIS 2: IDENTIFY TYPE OF SEIZURE TYPES OF SEIZURES 44 II. Generalized seizures • This is followed by bilateral rhythmic jerks that become further apart (clonic phase). • Prominent autonomic phenomena are observable during the tonic and clonic phases. Incontinence may occur. • The patient awakens by passing through stages of coma, confusional state and drowsiness 6. Tonic-Clonic (Grand Mal) Seizures
  45. 45. Diagnosis of Epilepsy 45 Axis 1: • Is it epileptic seizure or not?  D.D. Of epilepsy Axis 2: • Identify type of seizure (seizure semiology)  International classification of epileptic seizures. Axis 3: • Investigations aiming at confirmation of the diagnosis & searching for an aetiology Axis 4: • Identify epileptic syndrome  International classification of epilepsy & epileptic syndromes Axis 1: • Is it epileptic seizure or not?  D.D. Of epilepsy Axis 2: • Identify type of seizure (seizure semiology)  International classification of epileptic seizures.
  46. 46. Diagnosis of Epilepsy 46
  47. 47. AXIS 3: INVESTIGATIONS Labs 47 Should be tailored according to the case; • Drug screen • Electrolytes • KFT • LFT • CSF examination • Lactic acid
  48. 48. AXIS 3: INVESTIGATIONS EEG 48 Conventional Electroencephalography • Used in establishing the diagnosis and focality of an epileptic disorder • Normal EEG doesnot exclude presence of epilepsy thus the yield of EEG can be increased by Sleep deprivation(< 4 h sleep ) • Invasive techniques are used in some cases which include: • Sphenoidal leads, • Subdural • Epidural electrodes • Depth electrodes.
  49. 49. AXIS 3: INVESTIGATIONS EEG 49 Multiple Electroencephalography (EEG) exams • Records interictal and ictal events, sometimes with sleep deprivation or other activation techniques may help in bringing out the abnormality. EEG monitoring with video (video-EEG) • Used widely in the evaluation of epileptic fits , exclusion of non-epileptic attacks and to define the electro-clinical characteristics of the seizures.
  50. 50. AXIS 3: INVESTIGATIONS NEUROIMAGING 50 A) MRI • MRI Has become necessary in delineating anatomic abnormalities that may be the etiology of the seizure focus such as: • Focal cerebral pathologies e.g. neoplastic lesions ,infarction, vascular malformations.
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  54. 54. AXIS 3: INVESTIGATIONS NEUROIMAGING 57 A) MRI • Diffuse cerebral pathologies e.g. cytoarchitectural lesions, such as neuronal heterotopias, gyral anomalies, and other abnormalities.
  55. 55. AXIS 3: INVESTIGATIONS NEUROIMAGING 58 B) Functional Neuroimaging • When anatomical imaging fails to identify a lesion, positron emission tomography (PET) and single photon emission tomography (SPECT) are used. • PET measures regional cerebral metabolism and blood flow. It has been quite successful in identifying the focus as an area of hypometabolism between attacks.
  56. 56. AXIS 3: INVESTIGATIONS NEUROIMAGING 59 B) Functional Neuroimaging • SPECT demonstrates regional cerebral blood flow, which is linked to cerebral metabolism and can therefore be used to identify the epileptic focus and can be used to study both ictal and inter-ictal states.
  57. 57. AXIS 3: INVESTIGATIONS NEUROIMAGING 60 C) Others 1. Proton MRS 2. Magnetoencephalograpy/magnetic source imaging • However, PET ,SPECT ,Proton MRS & Magnetoencephalograpy/magnetic source imaging should be only done when surgical resection is planned
  58. 58. Diagnosis of Epilepsy 61 Axis 1: • Is it epileptic seizure or not?  D.D. Of epilepsy Axis 2: • Identify type of seizure (seizure semiology)  International classification of epileptic seizures. Axis 3: • Investigations aiming at confirmation of the diagnosis & searching for an aetiology Axis 4: • Identify epileptic syndrome  International classification of epilepsy & epileptic syndromes Axis 1: • Is it epileptic seizure or not?  D.D. Of epilepsy Axis 2: • Identify type of seizure (seizure semiology)  International classification of epileptic seizures. Axis 3: • Investigations aiming at confirmation of the diagnosis & searching for an aetiology
  59. 59. Diagnosis of Epilepsy 62
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  61. 61. AXIS 4: IDENTIFY EPILEPTIC SYNDROME EPILEPTIC SYNDROMES 64 EPILEPTIC SYNDROME IS DEFINED BY 1. Type or types of seizure e.g. Absence ,GTC. 2. Age of seizure onset 3. Aetiology 4. Degree of neurologic and intellectual deficit 5. Clinical evolution of the epilepsy 6. EEG pattern 7. Neuroimaging abnormality
  62. 62. Important epileptic syndromes 65
  63. 63. AXIS 4: IDENTIFY EPILEPTIC SYNDROME EPILEPTIC SYNDROMES 66 I. LOCALIZATION RELATED (IDIOPATHIC) Benign epilepsy of childhood with centrotemporal spikes • The syndrome is termed "rolandic" epilepsy because of the characteristic features of partial seizures involving the region around the lower portion of the central gyrus of Rolando.
  64. 64. AXIS 4: IDENTIFY EPILEPTIC SYNDROME EPILEPTIC SYNDROMES 67 I. LOCALIZATION RELATED (IDIOPATHIC) Benign epilepsy of childhood with centrotemporal spikes • Common characteristic features includes :Unilateral somatosensory involvement, mostly of the tongue (occasionally of the inner cheeks, lips, gums, or even a single tooth) ,Speech arrest ,Preservation of consciousness in most cases ,Pooling of saliva &Tonic or tonic-clonic spread to face.
  65. 65. AXIS 4: IDENTIFY EPILEPTIC SYNDROME EPILEPTIC SYNDROMES 68 I. LOCALIZATION RELATED (IDIOPATHIC) Benign epilepsy of childhood with centrotemporal spikes • The typical interictal EEG shows centrotemporal spikes or SW, which are either unifocal or bifocal. • Carbamazepine is often the first medication to be tried, and seizures usually are well controlled. • Excellent prognosis.
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  68. 68. AXIS 4: IDENTIFY EPILEPTIC SYNDROME EPILEPTIC SYNDROMES 71 I. LOCALIZATION RELATED (IDIOPATHIC) Childhood epilepsy with occipital paroxysms: • Early onset type : • Young childern 5 ys • Ictal vomiting , deviation of the eye ,impairment of the consciousness sometimes progress into GTCs • Two thirds of seizures occur during sleep
  69. 69. AXIS 4: IDENTIFY EPILEPTIC SYNDROME EPILEPTIC SYNDROMES 72 I. LOCALIZATION RELATED (IDIOPATHIC) Childhood epilepsy with occipital paroxysms: • Late onset (Gastaut) type : • Older childern 9 ys • Formed visual hallucinations or amaurosis followed by hemiclonic convulsions with post-ictal migrain • EEG: occipital spikes • Excellent prognosis
  70. 70. AXIS 4: IDENTIFY EPILEPTIC SYNDROME EPILEPTIC SYNDROMES 73 II. GENERALIZED(IDIOPATHIC): Childhood absence epilepsy • Seizure semiology: • Absence:Typical absence • High frequency hundreds / day • + Myoclonus • + GTCS • 3-12 years • EEG changes: 3-Hz spike and wave • Treatment : VPA, EXM • Favorable outcome( long term remission)
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  74. 74. AXIS 4: IDENTIFY EPILEPTIC SYNDROME EPILEPTIC SYNDROMES 77 II. GENERALIZED(IDIOPATHIC): Juvenile myoclonic epilepsy • Genetic disorder • Females>Males • Age 8-26 Y, but 79% mostly12-18 Y • Symmetric myoclonus (upper limbs) • GTCs: common • Absence (associated or independently) • Photosensitivity • EEG : polyspike and spike wave(rapid) • Respond to medical ttt: VPA,LEV
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  81. 81. AXIS 4: IDENTIFY EPILEPTIC SYNDROME EPILEPTIC SYNDROMES 85 II. GENERALIZED (CRYPTOGENIC): West syndrome (infantile spasms): • Triad of : 1. Seizures 2. Psychomotor retardation or regression 3. Specific EEG changes : hypsarrythmia. • 1st year of life • Related to prenatal ,natal or postnatal insult
  82. 82. AXIS 4: IDENTIFY EPILEPTIC SYNDROME EPILEPTIC SYNDROMES 86 II. GENERALIZED (CRYPTOGENIC): West syndrome (infantile spasms): • Seizures 1. Flexor spasms 2. Extensor spasms 3. Mixed flexor & extensor spasms • Resistant to treatment • Poor prognosis
  83. 83. AXIS 4: IDENTIFY EPILEPTIC SYNDROME EPILEPTIC SYNDROMES 87 II. GENERALIZED (CRYPTOGENIC): Lennox Gastaut syndrome • Mixed seizure disorder: • (Tonic, TC, Myoclonic, Atypical absence & drop attacks ) • Mental retradation • EEG:  Slow spike & wave  Sharp & slow wave complex  Slow abnormal background • Treatment : commonly need Polytherapy • Poor prognosis & cure rarely achieved
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  85. 85. 89 CHANGE YOUR OLD CONCEPTS
  86. 86. 90 CHANGE YOUR OLD CONCEPTS
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  88. 88. 92 CHANGE YOUR OLD CONCEPTS
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  91. 91. THANK YOU

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