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Seizures and Epilepsy
Seizures and Epilepsy
Objectives
Define seizures and epilepsy
Classification of seizures and epilepsy
Evaluation/diagnosis of seizures
Treatment of epilepsy
Anticonvulsant medication
Medical Devices and surgery
SEIZURE
result of sudden, usually brief, excessive
electrical discharges in a group of brain
cells (neurons)
can occur in different parts of the brain
depending on where in the brain this
occurs, the person will experience
different symptoms
EPILEPSY
A tendency to have
recurrent seizures
1% by age 20
3% by age 75
Epilepsy
1%
Disorder
characterized by
recurrent,
unprovoked
seizures
Incidence of Epilepsy
per 100,000
250
200
150
100
50
0
0
12
20
30
40
50
60
70
Age (Years)
Hauser et al., 1993
85
Terminology
Old
Recent Past
Focal Motor
Simple Partial
Focal
Psychomotor
Temporal Lobe
Complex Partial
Grand Mal
Tonic Clonic
Generalized
Petit Mal
Absence
Generalized
Classification of Seizures
Focal seizures
Generalized seizures
Without
Absence seizures
Typical vs Atypical
Tonic-clonic seizures
impaired
consciousness or
responsiveness
With motor or autonomic
components
Involving subjective
sensory or psychic
phenomena (aura)
With
impaired
consciousness or
responsiveness
Evolving to a bilateral
convulsive seizure
Myoclonic
seizures
Tonic seizures
Clonic seizures
Atonic seizures
Epilepsy Types
(past classification)
Idiopathic
(Primary)
Onset in childhood or
young adult
Probably genetic
Favorable prognosis
Normal brain
Symptomatic
(Secondary)
Multiple etiologies
Variable response
Variable prognosis
Brain pathology
Distinctive Constellations
i.e. Mesial Temporal Lobe Epilepsy with
Malformations
Post-Traumatic Epilepsy
(Dizziness)
Automatisms-less frequent
Post-ictal confusion may be prolonged
May present with altered mental status,
confusion, or memory disturbance
Ramsey, Rowen & Pryor, 2004
Labs
Chemistry Panel, Consider Lumbar Puncture
Electroencephalography
Stat if patient not returning to baseline
Imaging
MRI with gad (usually not urgent)
CLINICAL SZ
EVENT
Goals of Therapy
Seizures
Side
Effects
Pharmacotherapy
Up to 70% of newly diagnosed children
and adults can be successfully treated
Ascend monotherapy to maximum
tolerated dose (regardless of serum
levels!)
3-letter abbreviation
Brand names
Phenobarbital
PHB
Luminal
Phenytoin
PHT
Primidone
PMD
Mysoline
Ethosuximide
ESX
Zarontin
Carbamazepine
CBZ
Valproate
VPA
Felbamate
FBM
Felbatol
Gabapentin
GBP
Neurontin
Lamotrigine
LTG
Lamictal
Tiagabine
TGB
Gabatril
Topiramate
TPM
Topamax
Levetiracetam
LEV
Keppra, Keppra XR
Oxcarbazepine
OXC
Trileptal
Zonisamide
ZNS
Zonegran
Pregabalin
PGB
Lyrica
Lacosamide
LCM
Vimpat
Vigabitrin
VGB
Sabril
Historical Perspective:
Phenobarbital
Tablet/
Capsule
IV
IM
1912
Sprinkle
Capsule
Chewable
Suspension/
Syrup/Elixir
+
Phenytoin
1938
Primidone
1954
Ethosuximide
1960
Carbamazepine
1974
Valproate
1978
Felbamate
1993
1993
Gabapentin
1993
1993
Lamotrigine
1994
Fosphenytoin
1995
1996
Levetiracetam
1999
Oxcarbazepine
2000
Zonisamide
2000
Pregabalin
2004
Lacosamide
2009
Vigabitrin
2009
1995
1995
2000
2000
1997
1996
2000
1997
1978
2002
1998
1996
Topiramate
ExtendedRelease
1996
1999
2008
2009
2000
2009
PB
1900
1920
PHT
1940
CBZ
1960
VPA
1980
FOS
LTG ZNS
LEV
GBP
OCBZ
FBM
?
2000
2nd
Generation
exception: CBZ-Absence
Incomplete Efficacy
Unfavorable Kinetics
Narrow Therapeutic Range
Adverse CNS Effects
Drug Interactions
Hepatic Metabolism-1st
Generation AEDs
Inducers
Phenobarbital
Phenytoin
Carbamazepine
Inhibitor
Valproate
Refer
to Neurology or Epilepsy
Center for Expertise
Generalized
Tonic
Myoclonic
*?Myoclonic **?Absence
Atonic Absence
ESX
Drowsiness
Incoordination
Dizziness
Cognitive impairment
Osteoporosis CYP450
Inducers + VPA
Hyponatremia CBZ and
OXC
Rash LTG, CBZ, PHB, DPH
Hyperammonemia VPA
Encephalopathy TGB and
VPA
Peripheral Neuropathy PB,
PHT and CBZ
Closed angle glaucoma
TPM, ZNG
~40%
Second Drug
~20%
Third Drug
<10%
Addl Drugs
<5%
>20% Refractory!
appropriate?
Does the seizure onset allow for surgical
options?
Magnetoencephalography (MEG)
PET
Wada
Neuropsychological testing
Multi-Modality Evaluation
Epilepsy Surgery
Emerging Treatments
Deep
thalamus (ANT)
Continuous cyclic stimulation similar to VNS
Did not receive FDA approval in US
Responsive
Neurostimulation
refractory
New concerns: drug interactions, side effects
Establishment of VA Epilepsy
Centers of Excellence
Response in 2008 to Section 404
(Epilepsy Centers) of Veterans Mental
Health and Other Care Improvements
Act of 2008 (PL110-387)
Requirements of PL110-387
ECoE Site
ECoE & Polytrauma
NORTHEAST REGIONAL
CENTERS
NORTHWEST REGIONAL
CENTERS
SOUTHEAST REGIONAL
CENTERS
SOUTHWEST REGIONAL
CENTERS
Regions
Facilities
Station
Contact Information
*Claude Wasterlain
West LA VA
691
(310) 268-3595
Richard A Hrachovy
Houston
580
Karen Parko
San Francisco
662
Larry E. Davis
Albuquerque
501
* Aatif Husain
Durham
Durham VAMC
558
Enrique Carazanas
Miami
Miami VAHCS
546
J. Chris Sackellares
Gainesville
Malcolm R
150
(352) 376-1611
Alfred Frontera
Tampa
J. A. Haley
673
* Paul Rutecki
Madison
648
(608) 256-1901
Stephen Holloway
Minneapolis
Minneapolis VAMC
607
Martin Salinsky
Portland
Portland VAMC
618
(503) 494-5682
William Spain
Seattle
Puget Sound
663
(206) 764-2021
*Alan Krumholz
Baltimore
VA Maryland HCS
512
(410) 605-7000
Huned Patwa
West Haven
VA Connecticut HCS
689
Alan Towne
Richmond
652
(804) 675-5127
Southeast Centers
Northwest Centers
Northeast Centers
ECOE Goals
Delivery the highest quality care to
veterans with epilepsy
Establish network for regional epilepsy
care
Promote outreach and educational
efforts
Provide an efficient and cost-effective
mechanism of care delivery
Resources
www.epilepsy.va.gov
www.epilepsyfoundation.org
www.epilepsy.com
www.cureepilepsy.org
www.ninds.nih.gov/disorders/epilepsy