2. History...
3000 yrs ago ......Babylonians wrote
about the symptoms and causes of
epilepsy
caused by demons attacking the person
The word epilepsy is derived from the
Greek word for "attack’’
5. Did you know that:
Epilepsy is not a form of mental illness
Epilepsy can begin at any age from birth to
99+
Epilepsy can & does affect memory and
learning.
NOTHING should be put in the mouth of a
person having a seizure
6. Medication does not stop all seizures .
Epilepsy is not contagious
The tongue cannot be swallowed during a
seizure
Most seizures are not medical emergencies
7. Seizures...
It is a transient occurrence of signs and / or
symptoms resulting from abnormal excessive or
synchronous neuronal activity in the brain
A sudden paroxysmal electrical discharge from the
CNS resulting in involuntary motor, sensory or
autonomic disturbances with or without alteration
in sensorium
8. Epilepsy....
Is a disorder of the brain characterised by an
enduring predisposition to generate seizures
& by the neurological cognitive, psychological
& social consequences.
9. Epileptic syndrome..
Is a disorder that manifests one or more
specific types and a specific age of onset and
a specific prognosis.
11. Provoked vs. Unprovoked
seizures..
Provoked = occurs during the course of acute
illness
Common causes
Febrile seizures
Metabolic events (b. sugar <36mg/dl)
Acute CNS infections
Drug intoxification
Head trauma
12. Incidence
72-80 / 1lak under 9 yrs of age
46-83 / 1lak under 14 yrs of age
Prevalence
Seizure disorders: 360/100,000 (India, Saha
SP 2003).
350/1lak in India
Greater in neonatal period
13. Classification of Epileptic
Seizures.
Partial seizures:
Simple partial (consciousness retained)
Motor
Sensory
Autonomic
Psychic
Complex partial (consciousness impaired)
Simple partial, followed by impaired consciousness
Consciousness impaired at onset
Partial seizures with secondary generalization
15. ILAE classification
Self limited
Focal
Generalised
Continuous
Classification of epilepsy syndromes
•Idiopathic-focal & general
•Familial
•Symptomatic
•reflex
16. Common causes
Infection to the central nervous system
1. Acquired bacterial meningitis
tuberculus meningitis
aseptic
encephalitis
cerebral malaria
2. Intrauterine infections
17. Post infectious or post vaccinal encephalopathy
Pertussis vaccination
Pan encephalitis
Post measles encephalopathy
Chickenpox encephalopathy
Disseminated encephalomyeolopathy
31. Kindling
Process by which brief trans of electrical
stimuli are repeatedly delivered at
appropriate intervals to a susceptible area of
brain.
Prolonged generalised seizure
32. Factors determine focal –
generalised
Excitability of epileptic neurone
The ease with which the electric discharge
can be propagated from focus
Threshold of brain stem for disseminating an
electrical discharge
42. Simple partial seizures with
sensory signs..
Numbness
Tingling
Pricking
Paresthesia/ pain originating in one area
Visual sensations
Motor phenomena – posturing / hypertonia
- Uncommon < 8yrs
43. Complex partial seizures(psychomotor
seizures)
3yrs – adolescence
Characterised by
- Period of altered behaviour
- Amnesia
- Inability to respond to environment
- Impaired consciousness during event
- Drowsiness / sleep
- Confusion & amnesia
44. aura
odd or pleasant odours
Auditory or visual hallucinations
Ill defined feelings (de javu)
Strong feelings of fear and anxiety
In small children
- emission of cry
- attempt to run
45. Patterns of motor behaviour
Stereotypic
May suddenly cease activity , appear dazed
stare into space
Confused & apathetic
Become limp or stiff
automatisms
Post ictal confusion
48. Generalised seizures
Tonic clonic seizures (grandmal )
- Most common
- Occur without warning
Tonic phase clonic phase post ictal phase
49. Tonic phase
10- 20 sec
Eyes roll upward
Immediate loss of consciousness
Stiffness
Contraction of entire body
Arms flexed
Legs, head & neck
flexed
50. May utter a peculiar cry
Apnoeic
Increased salivation
Loss of swallowing reflex
If standing, falls to floor or ground
51. Clonic phase
30 sec
Violent jerking movements
Foams at mouth
Incontinent of urine and faeces
52. Post ictal state
Appears relaxed
Remain semiconscious
May awake in few minutes
Confused for several hours
Poor coordination
Mild impairment in fine motor movements
53. Visual & speech difficulties
Vomit or complain of severe headache
Usually sleeps for several hours
Feels tired
No recollection of event
54. Absence seizures (petit mal/
lapses)
4-12 years of age
common in girls than boys
Ceases at puberty
Brief / no loss of consciousness
No alteration in muscle tone
May go unrecognised
Abrupt in onset
55. Manifestations:
Brief loss of consciousness
Without aura
5-10 sec
Slight loss of muscle tone
Minor movements
No incontinence
Amnesia
Need reorientation
56. Atonic & akinetic seizures
(drop attacks )
2-5 yrs
Sudden momentary loss of muscle tone &
postural control
Recurrent frequently
Manifestation :
- Loss of tone causing child to fall down
57. Myoclonic seizures
Seizure episodes
Sudden brief contractions of a muscle
No post ictal state
May / not LOC
58. Infantile spasms
Infantile myoclonus / massive spasms /
hypsarrhythmia / salaam episodes / Infantile
myoclonic spasms
6- 8 months of life
Twice common in boys
Numerous without post ictal drowsiness
59. Manifestations
Series of sudden muscular contractons
Head flexed arms extended & legs drawn up
Eyes rolling
Preceded / followed by cry
May / not LOC
Flushing / pallor / cyanosis
60. Jack-knife seizure – sudden dropping forward
of the head & neck with trunk flexed forward
Single momentary shock like contractions
61. Comparison of simple, complex partial
& absence seizure
Clinical features Simple complex Absence
Age of onset Any age Uncommon before
3 yrs
Uncommon before
3 yrs
Freq /day Variable 1- 2 times Multiple
Duration < 30 sec >60 sec <10 sec
Aura May be sole
manifestation
Frequently never
Impaired
consciousness
Never always Always
Automatisms never frequent frequent
63. Video game related epilepsy
Flicker frequency of video games
Type – generalised , simple / complex /
absence
Treatment – abstain from video games
Factors – screen brightness, sleep
deprivation, fatigue, fever, short distance
from screen
64. Epilepsy syndromes
The Major Benign Partial Syndromes
1. Benign Rolandic Epilepsy
- Male preponderance 60%
- Onset 2 - 13 years (peak: 9-10 years)
- Older children- motor & somatosensory
symptoms, usually nocturnal.
65. Younger children- Hemiclonic / GTCS
(especially at night).
Rx: None if seizures are mild and rare.
Most AEDs very effective.
Evolution: Recovery before 15 - 16 years.
67. Initial visual symptoms, often followed by a
hemiclonic seizure or by automatism
Postictal migrainous cephalgia in a quarter of
the cases.
Rx: Most AEDs with control in 60%.
Recovery by end of adolescence.
68. The Major Primary Generalized
Syndromes
Childhood Absence Epilepsy (True Petit Mal
Epilepsy)
Frequency 8%
Genetic predisposition- strong 20%
Female preponderance 75%
Onset 3 - 12 years (peak: 6 - 7 years)
Very frequent simple absences.
69. Rx: VPA or ESM with control in 70 - 80%.
Evolution: Remission- 95%.
- Rare persistence of absences only- 6%.
- GTCS during adolescence or later- 40%.
70. Juvenile Myoclonic Epilepsy (JME)
Frequency 5%
Genetic predisposition- strong >25%
Male = female
Onset: 8-26 years (peak: 16 - 17)
Myoclonus , GTCS often also occur,
occasionally absence.
Rx: VPA with control in 60 - 100%
Evolution: Rarely remits (<10%)
71. Grand Mal on Awakening
(GMA)
Genetic predisposition- strong >10%
Male > female
Onset 6-24 (peak: puberty)
GTS exclusively or predoninantly (90%)
Myoclonic or absence may occur.
Rx: VPA with control in 60 - 100%
Evolution: Rarely remits (<20%)
72. The Major Secondary
Generalized Syndromes
Infantile Spasms (West Syndrome)
Lennox Gastaut Syndrome (LGS)
Frequency 3 - 10%
Genetic predisposition- no
Male preponderance
Onset 1 - 8 years (peak: 3 - 5 years)
73. Poor prognosis in most cases
Tonic, atypical absence, drop attacks, other
generalized or partial seizures.
Rx: VPA,rarely with complete control.
persisting seizures.
74. DIAGNOSTIC EVALUATION
History collection
Physical examination
Laboratory investigations
- Serum glucose & calcium levels
• Lumbar puncture – Ist febrile seizures
protein content – increased
81. Abnormalities.
Slow/ abnormal rhythm-generalised ,localised
or lateralised to one side thus helps to
anatomic lesions
Spikes
Sharp waves
Poly spikes
Slow waves (hypsarrhythmia)
82. Tests consider in the evaluation of
patients with seizures
Type Test Comments
Simple partial
Complex partial
GTC
Absences
MRI
MRI
MRI
None required
Rule out
structural lesions
Rule out
structural lesions
Rule out
structural lesions
83. Management of child with
seizures
Goals:
1. Ensure adequate vitals & oxygenation
2. Terminate seizure activity
3. Prevent seizure recurrence
4. Establish the diagnosis & treat the
underlying
84. steps
Step I – confirm diagnosis
Step II – establish seizure type & syndrome
Step III – evaluate the need for treatment
Step IV – select AED
Step V – start monotherapy (start slow go
slow policy)
Step VI – switch to another monotherapy
add on therapy
85.
86. Treatment of a newly diagnosed case of
epilepsy
Newly diagnosed case
Ist monotherarpy seizure therapy
IInd monotherapy/ combination therapy seizure
free
Intractable epilepsy
Combination therapy ketogenic diet , VNS
87. Choice of AED
Seizure First line second line
partial CBZ, PHT, SVA , PB OXC, LTG, TPM
2nd gen GTCS SVA, ESM, CZP,
CLB
LTG , TPM , LEV
GTCS SVA, CBZ, PHT, PB TPM, LTG, OXC,
LEV
Absence SVA, CZP, CLB LTG , TPM , LEV
Myoclonic SVA LTG , TPM , LEV
Atonic / tonic SVA CBZ, CLB , NTZ,
LTG, TPM
mixed SVA
88.
89.
90. ILAE GUIDELINE FOR DRUG
LEVEL MONITORING
Check compliance once or twice YEARLY
Suspect toxicity after each AED change
DURATION:
Withdrawal – if seizure free for 2 YEARS
Gradually over 6-12 wks
91. Ketogenic diet
A very strict diet that involves fluid restriction,
high fat and low carbohydrate + protein
intake.
The goal: alter the body’s fuel source from
glucose to fat.
The basis of the diet – fasting
The encounter with a faith healer
97. Types of surgery
1. Resection
Removal of the area causing the seizures
2. Disconnection
Corpus callosotomy
Multiple subpial transections
3.Hemispherectomy
99. Nursing management
Seizure precautions
Relieving anxiety
Managing treatment
Providing family support & education
100. Febrile seizures
Occurrence of seizure activity in
neurologically healthy infants & children
between 6 months & 5 yrs of age associated
with fever >38c without evidence of
intracranial infection & with no history of prior
afebrile seizures
101. Common in 18- 22 months
Provoked seizures
Causes:
- Infections of middle ear
- URTI
- Urinary tract & GI infections
102. Types
Simple febrile seizures:
- 85%
- Generalised seizures
- Lasting less than 15 min
- No post ictal neurologic abnormalities
103. Complex febrile seizures
- Recurrent within 24 hrs
Febrile status
- A seizure with duration of 30 min
- Without regaining consciousness interictally
104. Risk factors
Age <18 months
Family history
Shorter duration
Recurrence
75% within 1 yr
Risk of subsequent epilepsy – 2- 2.5 %
106. Management
During the seizure
- Manage as for any other acute seizure
- Should hospitalise
o Lethargy
o Complex features
o Unclear follow up
107.
108. Long term management
Primary goal – to prevent recurrences
Antipyretics – to reduce fever
INTERMITTENT PROPHYLAXIS
Diazepam – 0.3 – 0.5 mg/ kg orally / rectally
clobazem - 1mg /kg / day
109. Continuous prophylaxis
Indications :
- Recurrent complex seizures
- Abnormal neurodevelopment
- Positive family history
Sodium valproate is preferred
110. Status epilepticus
A seizure that persists for a sufficient length
of time / is repeated frequently enough that
recovery between attacks does not occur
Early status established status
Epilepticus Epilepticus
111. A condition characterised by an epileptic
seizure that is sufficiently prolonged or
repeated at sufficiently brief intervals so as to
produce an unvarying and enduring epileptic
condition
(dictionary of epilepsy )
113. Classification
Generalised status epilepticus
Partial status epilepticus
Refractory status epilepticus
Super refractory status epilepticus
115. Refractory status epilepticus
Persistent seizure beyond 120 min
Despite of therapy with benzodiazepine,
phenytoin, phenobarbitone or valproate
Treatment :
- Midazolam
- Thiopentone
- Magnesium
- Ketogenic diet
116.
117. Intractable epilepsy
It is defined as an at least one seizure every
2 months for the first 5 years of treatment &
subsequently as at least one seizure per year
with failure of at least 3 Ist line AEDs
Rx: surgery
Ketogenic diet
VNS
118. Misconceptions about
childhood epilepsy
Children with epilepsy are brain injured
Has mental handicaps
Only SE will harm child's brain
An EEG will determine if child has epilepsy
Abnormal EEG -↑ AED dose
119. Child has twitches of legs & arms while
asleep. Are these seizures ?
Blood level AED ↑ - change the dose ?
AED – only way of treatment
Surgery – after a attempting all AED
Life will never be the same
120. Nursing diagnosis
Risk for injury related to CNS dysfunction &
inability to control self secondary to the type of
seizure.
Risk for aspiration & ineffective breathing
pattern related to impaired motor activity, LOC.
Risk for injury related to impaired
consciousness & automatisms
121. Anxiety / fear related to child having life
threatening seizure activity
Ineffective tissue perfusion
Interrupted family processes
Self esteem disturbances