1. Seizures and Epilepsy
Dr. Khalid El-Salem
American Board of Neurology
American Board of Clinical Neurophysiology
Assistant Prof of Neurology
JUST
2. Concepts
Seizure: sudden temporary
change in brain function caused
by an abnormal rhythmic
excessive electrical discharge
Epilepsy: a state of recurrent
seizures
3. Epidemiology of Epilepsy
Lifetime risk of developing
epilepsy is 3.2%
10% of population experience
at least one seizure before the
age of 80 years
Higher prevalence at the
extremes of age
4. Seizure Type Versus
Epileptic Syndrome
A seizure type is determined by the
patient’s behavior and EEG pattern
during the ictal event
An epileptic syndrome is defined by
- Seizure type(s)
- Natural history
- EEG (ictal and interictal)
- Response to AEDs
- Etiology
5. Classification of Seizures
Partial seizures
- Simple partial seizures
- Complex partial seizures
Impaired consciousness at outset
Simple partial evolving to lost consciousness
- Partial seizures evolving to general
tonic-clonic seizures (GTCS)
8. Absence Seizure
Simple: abrupt onset and
cessation of motionless stare,
with unresponsiveness and no
post ictal state ( few-30 sec)
Complex:
typical+clonic/myoclonic activity
or automatism
Activated by hyperventilation
10. Complex Partial Seizures
Prodrome: Lethargy
Aura: common
Oral or motor automatism,
alteration of consciousness, head
and eye deviation, contralateral
twitching or clonic movements,
posturing
Rt temporal often hypermobile
Lt temporal often behaviour arrest
11. Frontal lobe seizures
are partial seizures
that can be easily
confused with
psychiatric disease
24. Applications of New AEDs in Epilepsy
Medication Application in Epilepsy
Felbamate Some efficacy in all seizure types
Gabapentin Partial and sec generalized tonic clonic seizures only
Lamotrigine Some efficacy in all seizure types
Levetiracetam Partial and sec generalized tonic clonic seizures
Oxcarbazepine Partial and sec generalized tonic clonic seizures
Tiagabine Partial and sec generalized tonic clonic seizures only
Topiramate Some efficacy in all seizure types
Vigabatrin Infantile spasms, Partial seizures
Zonisamide Some efficacy in all seizure types
36. Therapeutic Drug Monitoring for
Newer AEDs
• Not widely practiced
• No generally accepted target
ranges
• A wide range is associated with
clinical efficacy.
• Considerable overlap in drug
concentrations related to
toxicity and non response.
37. Tentative Target Concentration
Ranges
Medication Range
Felbamate 40-100 mic g/ml
Gabapentin >2 mic g/ml
Lamotrigine 1-4 mic g/ml
Levetiracetam 35-120 mic m/L
Oxcarbazepine 4-12 mic g/ ml
Tiagabine 50-250 nmol/L
Topiramate 2-4 mic g/ml
Vigabatrin 6-278 mic m/L
Zonisamide 10-30 mic g/ml
38. AAN Evidence Based Guidelines
Level A or B Recommendations
Newly Diagnosed Epilepsy
Medication Monotherapy for newly Newly diagnosed absence
diagnosed partial/mixed
Felbamate
Gabapentin Yes No
Lamotrigine Yes Yes
Levetiracetam No No
Oxcarbazepine Yes No
Tiagabine No No
Topiramate Yes No
Vigabatrin
Zonisamide No No
39. AAN Evidence Based Guidelines
Level A or B Recommendations
Refractory Epilepsy
Medication Partial Partial Primary Symptomatic Peds
Add on/adult Monotherapy Generalized Generalized Partial
Felbamate
Gabapentin Yes No No No Yes
Lamotrigine Yes Yes No Yes Yes
Levetiracetam Yes No No No No
Oxcarbazepine Yes Yes No No Yes
Tiagabine Yes No No No No
Topiramate Yes Yes Yes Yes Yes
Vigabatrin
Zonisamide Yes No No No No
40. Conclusions
New AED’s are not more
effective than classical ones
Classical AEDs remain first line
of treatment
Pharmacokinetics and dynamics
are more determinent than
efficacy.