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Epilepsy CME Kisumu 10th February 2015
1. AKH (Kisumu) CME 10.02.15
Dr. Dilraj Singh Sokhi BMedSci(Hons) MBChB(Hons) MRCP(UK)(Neurology)
Honorary Teacher in Adult Clinical Neurology, University of Sheffield (UK)
Visiting Trainee Neurologist and ILAE Epilepsy Teacher, Aga Khan University Hospital
(Nairobi)
2. Outline
Introduction
Causes and risk factors
Classification of seizures
Diagnosis and investigation
Management
Social aspect
Conclude
3. TLOC (“Blackouts”)
Blackouts
Problem with blood circulation
(Syncope)
Primary disturbance
of brain function
Epilepsy Non-epileptic
attacks
Idiopathic generalised
epilepsy
Focal epilepsyUnclassifiable
epilepsy
Non-cardiacCardiac
4. WHO Report 2005; de Boer et al. 2008; Mathers et al. 2008
Africa: 2x incidence + prevalence
3-5x mortality
Kenya:Similar figures (Ngugi 2011, 2012, 2013)
ILAE GCAE “Bridging the Gap: Epilepsy in WHO Africa Region”
Epilepsy – Global Burden
5. Seizure: transient signs and/or symptoms due to abnormal excessive synchronous neuronal activity in the brain.
Epilepsy: enduring predisposition to repeated and unprovoked seizures occurring more than twice in a year.
Kenya:
1-1.2% of 40 million people
National Epilepsy Guidelines
www.epilepsykenya.org
Epilepsy
10. Neurocysticercosis
~1/3 of epilepsy in T.solium-endemic countries
White et al. 1997, 2000; Del Brutto et al. 2005;
Montano et al. 2005; Burneo et al. 2009; Singh et al. 2012
11. Neurocysticercosis Diagnosis
Absolute criteria
CNS Biopsy +ve
Cystic lesions with scolex on neuroimaging
Subretinal parasites by fundoscopic
Major criteria
Highly suggestive lesions on neuroimaging
EITB +ve
Resolution of brain cystic lesions after anti-helminthics
Spontaneous resolution of small single enhancing lesions
Minor criteria
Suggestive lesions on neuroimaging
Suggestive clinical manifestations
Positive CSF Ab or Ag ELISA
Extraneural cysticercosis
Epidemiologic criteria
Individuals in endemic area
Frequent travel to endemic areas
Household contact with T. solium infection
Definitive:
- one absolute OR
- two major + one minor OR
- one epidemiologic
Probable
- one major + two minor OR
- one major + one minor + one
epidemiologic OR
- three minor + one epidemiologic
Del-Brutto et al 2001
16. It’s all in the HISTORY!
Always always always get a collateral history (?video)
Onset
age of first seizure
Association with a particular event, accident, illness, fever?
Is there always fever with the seizures?
Pre-ictal phase
Any precipitating factors?
Are there any prodromal symptoms?
17. History (cont…)
lctal phase – semiology (description of seizure itself)
Is there an aura? What does it consist of?
Does the patient scream?
Where in the body? How does the event start (e.g. turning face)
Does the patient jerk? If so, both arms and legs, or one side?
Are they unconscious? Does the patient fall down?
Does the patient have incontinence of urine or stool?
Does the patient bite the tongue?
Does the patient make irrational or abnormal movements?
Breathing: stertorous/snoring, shallow/deep, hyperventilating?
How long is the ictal phase?
19. History (cont…)
Post-ictal
How long does the convulsion last? (incl. post-ictal phase)
How is the patient's behaviour after the seizure?
Is there any focal sign?
How long is the recovery phase?
Other important details
Time: At what time of the day or night do the seizures occur
(daytime, when sleeping or awakening)?
Frequency: when was the first / last / worst seizure?
How frequent have the seizures been?
Has there been a change in the frequency?
What is the interval between seizures?
20. History (cont…)
Family history
Pregnancy and perinatal history
Developmental history (milestones)
Past Medical History
Medicines or alcohol used?
Social History
21. Examination and Investigations
IT’S ALL IN THE HISTORY!
Examination (BP, temp, neuro)
Video EEG is gold standard
EEG and brain imaging reasonable
ECG is mandatory
Not much room for other investigations except:
FBC, U&E, Mg, Ca, glucose, inflammatory markers
23. Differential Diagnosis of Seizures
Syncope
Psychogenic seizures
Cardiac arrhythmia
Hyperventilation and panic attacks
Night terrors in children
Breath holding spells in children
28. Conversational Analysis for PNES
Feature Epilepsy PNES
Seizure symptoms Volunteered
Detailed
Negation explained
Interviewer-initiated
No detail
“Focussing resistanee“
Formulation work Extensive Little; Head-turn sign
Gaps in consciousness Exact description ‘I don‘t know‘
Metaphors Consistent image of
independently acting
external opponent
Seizure as place or space
person goes to
Catastrophising
Always directly ask about symptoms of hyperventilation
Reuber et al, 2009
30. Prevent injury
Prevent death
when in water, SUDEP
Reduce interruption of daily life (seizure + post-ictal)
Driving regulations in UK
Prolonged seizures (>30 mins) = permanent brain damage
?cure in the longer term
Why Control Epilepsy?
31. Treatment – First Aid
Move patient away from fire, traffic or water
Take away any objects that could harm the patient
Loosen tight clothes, remove glasses
Put wooden stick into the mouth to prevent injury
Put something soft under the head
Turn patient on his or her left side, so that saliva and
mucus can run out of the mouth
Try to stop the jerking, or restrain the movements.
Remain with patient until regains consciousness
Give them something to drink during the seizure
Put them in the recovery position at the end
32. Treatment – First Aid
Move patient away from fire, traffic or water
Take away any objects that could harm the patient
Loosen tight clothes, remove glasses
Put wooden stick into the mouth to prevent injury
Put something soft under the head
Turn patient on his or her left side, so that saliva and
mucus can run out of the mouth
Try to stop the jerking, or restrain the movements.
Remain with patient until regains consciousness
Give them something to drink during the seizure
Put them in the recovery position at the end
33. Treatment - Considerations
Confirmed diagnosis of active epilepsy:
≥ 2 unprovoked seizures > 24 hours apart in a year
Rarely can start after single seizure. Evidence needed:
relevant neurological deficit
abnormal EEG: epileptiform activity or focal slowing
patient, after adequate counselling, desires treatment
Counsel patients – precipitating factors, adherence,
social impact, safety, side effects etc
Also consider: - gender and age
- Other meds esp cART
- Other PMH
34. Treatment (1)
Initiation of treatment
Start with one drug and small dose
Gradually adjust dosage at two weeks intervals until:
- complete seizure control
- maximum pharmacologically tolerated dose is reached
If no seizure control, add second drug and consider
gradually reducing or maintaining the initial drug
The aim of treatment is to achieve the lowest maintenance
dose which provides complete seizure control.
Gradual introduction of AED can produce therapeutic
effects but with fewer side-effects.
Severe "intoxication" side-effects at the beginning of the
treatment indicate too rapid or too large dose increases.
35. Treatment (2)
Maintenance
Ideally, only one drug should be used.
If the first drug has only produced a partial response, then a
second drug can be added gradually taking into
consideration drug interactions.
The aim should be to have a maximum of two drugs.
If the two drugs fail, then consult the next level.
Partnership between patient and provider is
important to ensure that the patient
understands the importance of adhering to
treatment.
36. Treatment (3)
Follow up and monitoring
Holistic approach with partnership of patient, family and
care providers enhances patient's insight and compliance.
Drug monitoring should be done by measuring serum levels
in cases where there is difficulty in management.
Compliance is the key to successful seizure control, and
counselling the patient is the most critical factor.
37. Treatment (3)
When to withdraw drugs
If the patient has been seizure-free for 2-3 years (depends)
Prior to drug withdrawal, consider:
- Focal seizures are often very difficult to control
especially hippocampus and other temporal
lobe areas. Relapse rate is high. ? Carry on
indefinitely
- IGE generalised seizures have best remission rates
- Perisistently abnormal EEG vs. seizures controlled
- Patient views: may opt to remain on medications
despite achieving prolonged remission.
5-10% chance getting another seizure anyway.
Counselling is very important to alert them of the chance of
38. Treatment (4)
How to withdraw treatment
Done in a very gradual manner
at the lowest dosages
over three to six months.
In case of poly-therapy, each drug should be withdrawn
separately one after the other.
39. Treatment Choices
First Line
Phenobarbitone
Phenytoin
Carbamezapine
Sodium Valproate
Rescue medication
Second Line
Clonazepam, Clobazam, Lorazepam, Lamotrigine, Gabapentin, Pregabalin,
Ethosuximide, Methsuximide, Esclimezapine, Oxcarbazapine, Topiramate,
Levetiracetam, Peramapanel, Tiagabine, Vigabatrin, etc etc
REFER TO GUIDELINES
FOR RATIONALE OF
CHOICES, DOSES,
REGIMES ETC
41. Other (Social) Aspects
Drugs have to be taken for many years, possibly a life-time.
Sudden discontinuation of the drugs may result in recurrence of the
seizures or in life-threatening status epilepticus.
It may take days few weeks before drugs have any effect.
Combination with herbal treatment might be dangerous as interaction
between the drugs and the herbs unpredictable.
Not contagious and anyone can touch the person while they are having
a seizure (e.g. to remove them from the danger of fire or water) or in
between the seizures.
Child of normal intelligence should be placed in normal school.
Over-protection not helpful in a child's upbringing, but reasonable
precautions should be taken
Epilepsy should be talked about with family, school, work etc
Epilepsy is NOT a reason for not marrying or have a family.
42. Summary
3 main causes of TLOC; important to differentiate
Clinical features of these 3 main types
Its all in the history! (and the video…)
(some) Role of investigations: ECG always, EEG, CT/MRI
Treatment options; status epilepticus
Counselling patients and families/caretakers is key on all
aspects of their disease.
44. ILAE PNES TF Global Survey
We will collect Pan-African, including Kenyan, data this year
Has been approved by local ethics board!
www.TinyURL.com/pneskenya