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Praha & EU: Investujeme do vaší budoucnosti Evropský sociální fond

Epilepsy Evžen Nešpor

Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


Defining the problem • Epilepsy is defined as a repeated occurrence of unprovoked epileptic seizures. • Epileptic seizure is an intermittent derangement of the nervous system due to sudden excessive activity of cerebral neurons Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


Prevalence • 1% of adult population suffers from epilepsy • 5% of all population has had at least one seizure in their lifetime • Prevalence has a U-shaped dependency on age . • Prevalence in developing counties is higher Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277




Diagnosis • Positive proof is necessary. The diagnosis has many non-medical consequences • Usual diagnostic pitfalls: Syncope and psychogenic non epileptic seizures • Diagnostic tools: History, EEG, MRI, EEG-video monitoring



Diff.diagnosis between EP Syncope • Syncope

• Epilepsy

• Warning symptoms • Tonic convulsion can occur • Consciousness is regained immediately • No biting of the tongue

• Sometimes aura • Tonic-clonic convulsions, generalised • Consciousness regained slowly • Tongue often bitten



Bitten tongue



Non-epileptic psychogenic seizures • They differ from conscious malingering • They are considered to be an expression of very deep personal conflict. Traumatic experience in childhood is common • Diagnosis should be done promptly



Non-epileptic seizures • History often non-specific • Every intractable epilepsy must be suspected • Usual features: do not occur without witnesses, bizarre motor manifestations, do not react to treatment • Can often be diagnosed by video monitoring only Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


Classification of seizures • Generalised • Generalised tonicclonic ( Grand mal) • Absences (Petit mal) • Tonic • Clonic

• Partial • Simple • Complex



Generalised seizures • Absences • Typically age dependent • EEG always positive • Never cause deterioration • Good reaction to treatment

• GTCS (generalised tonic-clonic seizure) • Starts with a fall , often „cri epileptique“ • Generalised convulsions, cyanosis • Consciousness regained after a period of confusion Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


Partial seizures • Simplex partial seizure • No loss of consciousness • Different clinical manifestations • Memory not impaired

• Complex partial seizure • Consciousness is clouded, behaviour is automatic, often oral automatisms • The seizures are not remembered



EEG picture of an absence



Status epilepticus • • • • •

Convulsive status Non-convulsive status Absence status Complex partial status Focal motor status- Kozevnikov´s syndrome



Convulsive status • One of the most important emergencies in neurology • Urgent and qualified treatment is necessary • Induction of barbiturate coma with EEG monitoring



Non-convulsive status • Complex partial status: If complex partial seizure is protracted, behaviour can resemble „normal behaviour“ and can be very complicated • It can last for hours, even for a day



Aetiology • Besides clearly inherited or clearly acquired cases many others are mixed • First a treatable cause ( e.g. tumour) must be excluded. MRI is the standard • Therapy is mostly independent on aetiology, if the need for an operation is not indicated. Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277




Most common causes of EP • • • • • • •

Tumours Inflammatory diseases Traumas Intoxications A-V malformations CVA varia - dysplasias, tuberous sclerosis etc. Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


Guidelines for therapy • Monotherapy is preferred • Combination may be necessary in case of monotherapy failure • The medicine should be chosen according to type of seizure, age, gender etc.



Antiepileptic drugs • Phenobarbital 1912 • Phenytoin 1938 • Primidon 1952 • Ethosuccimid 60 • Carbamazepin63 • Clonazepam 74 • Valproic acid 74

• • • • • • • •

Clobazam 82 Vigabatrin 1989 Lamotrigine 1991 Gabapentin 1993 Topiramate Tiagabin Levetiracetam Pregabalin Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


Surgical treatment • • • •

Lesionectomy Topectomy corpus calosum section subpial resection



Thank you for your attention


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