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Seizure & Epilepsy
Ersifa Fatimah, dr.
PPDS-1 Neurologi FK UNAIR – RS Dr Soetomo
Surabaya, 2013
Chapter #1:
Diagnosis
1st-thing First
Chief complaint
“Seizure”
Non-
seizure
Seizure
Pseudo /
Non-epileptic
True / Epileptic
Non-epilepsy Epilepsy
Hints
Non-seizure Seizure: gejala menghebat, paroxysmal
Epileptic/True-seizure
listrik, sinkron, ritmis
EEG (+)
Non-epileptic/ Pseudo-seizure
Epilepsi:
Unprovoked
Non-Epilepsi
Systemic Disturbances
• Metabolic, Endocrine
• Syncope
Neurologic Disturbances
• Migraine, Vertigo
• Cerebrovascular disorder
• Sleep disorder
• Myoclonus
• Movement disorder
Psychiatric Disturbance
• PNES
• Episodic dyscontrol
• Discociative disorder
• Panic disorder
• OCD
• Psychoses
Engel & Pedley,
Epilepsy: A Comprehensive Textbook,
2nd Ed, 2008
Disorders That
Can Be Confused
with Epilepsy
4Ersifa's
ATTACK FEATURE PSYCHOGENIC SEIZURE EPILEPTIC SEIZURE
Stereotypy of attack May be variable Usually stereotypical
Duration May be prolonged Brief
Diurnal variation Daytime Nocturnal or daytime
Injury Rare Can occur with tonic-
clonic seizures
Tongue biting Rare Can occur with tonic-
clonic seizures
Ictal eye closure Common Rare (eyes generally open)
Urinary incontinence Rare Frequent
Motor activity Prolonged, uncoordinated; pelvic
thrusting
Automatisms or coordinated tonic-
clonic activity
Prolonged loss of muscle tone Common Rare
Postictal confusion Rare Common
Postictal crying Common Rare
Relation to medication changes Unrelated Usually related
Triggers Emotional disturbances No
Interictal EEG findings Normal Frequently abnormal
Reproduction of attack by
suggestion
Sometimes No
Ictal EEG findings Normal Abnormal
Presence of secondary gain Common Uncommon
Psychiatric disturbances Common Uncommon
Bradley: Neurology in Clinical Practice, 5th ed
5Ersifa's
Epileptic Seizure
• Manifestasi klinik
– tiba-tiba
– sementara
– perubahan perilaku
stereotipik
– gangguan kesadaran /
motorik / sensorik/
otonomik/ psikik
• Aktivitas listrik otak
abnormal-berlebihan
sekelompok neuron
Epilepsi
• Bangkitan epileptik
• Berulang
• Selang >24 jam
• Tanpa provokasi
Pedoman Tatalaksana Epilepsi, PERDOSSI, 2012
Status
Epileptikus
• Kejang > 30 menit
(mulai terapi: 5
menit)
• Kejang >= 2x,
diantara kejang px
tidak sadar
Pedoman Tatalaksana Epilepsi, PERDOSSI, 2012
Sindrom Epilepsi
• Tipe bangkitan
• Etiologi
• Anatomi
• Faktor presipitasi
• Usia onset
• Severitas
• Kronisitas
• Siklus diurnal / sikardian
• Prognosis
• Klasifikasi sindrom ILAE 1989
Serial Seizure:
Diantara 2 kejang px sadar
5 Axes of Epilepsy Diagnosis
1. Ictal
phenomenology
2. Seizure type
3. Syndrome
4. Etiology
5. Impairment
Ictal Phenomenology
pre - durante - post
Kondisi saat bangkitan Duduk, berdiri, berbaring, tidur berkemih
Gejala awitan Aura, gerakan/ sensasi awal
Apa yg tampak selama bangkitan Bentuk bangkitan, lidah tergigit, inkontinensia,
deviasi mata, pucat, berkeringat
Kondisi setelah kejadian Bingung, terjaga, nyeri kepala, tidur, gaduh
gelisah, Todd’s
Faktor pencetus Alkohol, kurang tidur, hormonal, dll
Pola bangkitan lain/perubahan
Pedoman Tatalaksana Epilepsi, PERDOSSI, 2012
Adams & Victor’s
Principles in Neurology,
8th ed, 2005
Seizure Type
ILAE 1981
Bradley, Neurology in Clinical practice, 2010
Adams & Victor’s Principles in Neurology, 8th ed, 2005
Syndrome
ILAE 1989
(Bradley, Neurology in Clinical Practice, 2010)
Etiologi
Idiopatik
Lesi struktural otak (-)
Defisit neurologik (-)
Predisposisi genetik
Berkaitan dengan usia
Kriptogenik
(dianggap) simtomatik
Penyebab belum diketahui
Klinis ~ ensefalopati difus
~Sindrom epilepsi
Simtomatik
Kelainan/ lesi struktural otak
Causa: “CEMENTED”
Pedoman Tatalaksana Epilepsi, PERDOSSI, 2012
Adams & Victor’s
Principles in Neurology,
8th ed, 2005
Adams & Victor’s Principles in Neurology, 8th ed, 2005
“Unprovoked” vs “Symptomatic Epilepsy”
Kapan
“Acute symptomatic seizure”
menjadi
“Epilepsi”
?
Beghi et al, Recommendation for a definition of acute symptomatic seizure. Epilepsia,51(4):671–675,2010
Beleza P
Acute Symptomatic Seizures
A Clinically Oriented Review
The Neurologist Volume 18, Number 3, May 2012
General rules
Seizure in the setting of two causes where one cause would
classify the seizure as acute symptomatic
If a person has preexisting epilepsy, a seizure that meets criteria
for acute symptomatic will still be so classified.
Cerebrovascular disease, cerebral hypoxia Within 7 days onset
TBI, intracranial surgery Within 7 days onset
CNS infections Beyond 7 days, ~ clinical & lab findings
Multipe sclerosis Within 7 days of relapse
Metabolic Blood sample within 24 h of seizure
Alcohol Within 7-48 h of last drink
Beghi et al, Recommendation for a definition of acute symptomatic seizure. Epilepsia,51(4):671–675,2010
Beghi et al,
Recommendation for a definition of
acute symptomatic seizure.
Epilepsia,51(4):671–675,2010
“Kenapa saya kejang,
sedangkan kamu tidak kejang?”
Beghi et al, Recommendation for a definition of acute symptomatic seizure. Epilepsia,51(4):671–675,2010
Impairment
Classification: WHO ICDH-2
Anamnesis Kejang
Gejala sebelum, selama, sesudah bangkitan
Riwayat penyakit saat ini yang mungkin menjadi penyebab
Usia onset, durasi, frekuensi, interval terpanjang
Riwayat epilepsi dalam keluarga
Riwayat keluarga dengan penyakit neurologik lain/ psikiatrik/ sistemik
Riwayat saat dalam kandungan/ kelahiran/ tumbuh kembang
Riwayat bangkitan neonatal/ kejang demam
Riwayat trauma kepala/ infeksi SSP, dll
Pedoman Tatalaksana Epilepsi, PERDOSSI, 2012
Pemeriksaan Fisik
• Umum
• Neurologik
Pemeriksaan Penunjang
EEG
• CT-scan
• MRI
• PET, SPECT, MRS
Neuroimaging
• Hb, WBC, Hct, Plt, HDT
• Na, K, Ca, Mg
• Glu
• RFT
• LFT
• (LP)
• (Toksikologi)
• Kadar OAE
Laboratoris
Pedoman Tatalaksana Epilepsi, PERDOSSI, 2012
Seizure & Epilepsy
At a Glance
Chapter #1.5:
Patofisiologi
Hipotesis
Secondary epileptogenesis
Kindling
Gangguan Membran Neuron
Kalium
Natrium
Perubahan
permeabilitas
&
potensial
membranNormal
Intrasel
Buku Ajar Ilmu Penyakit Saraf, FK Unair, 2011
Imbalance!
Inhibisi Eksitasi
Buku Ajar Ilmu Penyakit Saraf, FK Unair, 2011
Disfungsi Sel Glia
• Mengatur fungsi konsentrasi ion Kalium
ekstrasel di sekitar neuron & terminal
presinaps
Buku Ajar Ilmu Penyakit Saraf, FK Unair, 2011
..to be continued.

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Seizures & Epilepsy, chapt. #1: Diagnosis, at a glance, for beginners

  • 1. Seizure & Epilepsy Ersifa Fatimah, dr. PPDS-1 Neurologi FK UNAIR – RS Dr Soetomo Surabaya, 2013 Chapter #1: Diagnosis
  • 2. 1st-thing First Chief complaint “Seizure” Non- seizure Seizure Pseudo / Non-epileptic True / Epileptic Non-epilepsy Epilepsy
  • 3. Hints Non-seizure Seizure: gejala menghebat, paroxysmal Epileptic/True-seizure listrik, sinkron, ritmis EEG (+) Non-epileptic/ Pseudo-seizure Epilepsi: Unprovoked Non-Epilepsi
  • 4. Systemic Disturbances • Metabolic, Endocrine • Syncope Neurologic Disturbances • Migraine, Vertigo • Cerebrovascular disorder • Sleep disorder • Myoclonus • Movement disorder Psychiatric Disturbance • PNES • Episodic dyscontrol • Discociative disorder • Panic disorder • OCD • Psychoses Engel & Pedley, Epilepsy: A Comprehensive Textbook, 2nd Ed, 2008 Disorders That Can Be Confused with Epilepsy 4Ersifa's
  • 5. ATTACK FEATURE PSYCHOGENIC SEIZURE EPILEPTIC SEIZURE Stereotypy of attack May be variable Usually stereotypical Duration May be prolonged Brief Diurnal variation Daytime Nocturnal or daytime Injury Rare Can occur with tonic- clonic seizures Tongue biting Rare Can occur with tonic- clonic seizures Ictal eye closure Common Rare (eyes generally open) Urinary incontinence Rare Frequent Motor activity Prolonged, uncoordinated; pelvic thrusting Automatisms or coordinated tonic- clonic activity Prolonged loss of muscle tone Common Rare Postictal confusion Rare Common Postictal crying Common Rare Relation to medication changes Unrelated Usually related Triggers Emotional disturbances No Interictal EEG findings Normal Frequently abnormal Reproduction of attack by suggestion Sometimes No Ictal EEG findings Normal Abnormal Presence of secondary gain Common Uncommon Psychiatric disturbances Common Uncommon Bradley: Neurology in Clinical Practice, 5th ed 5Ersifa's
  • 6. Epileptic Seizure • Manifestasi klinik – tiba-tiba – sementara – perubahan perilaku stereotipik – gangguan kesadaran / motorik / sensorik/ otonomik/ psikik • Aktivitas listrik otak abnormal-berlebihan sekelompok neuron Epilepsi • Bangkitan epileptik • Berulang • Selang >24 jam • Tanpa provokasi Pedoman Tatalaksana Epilepsi, PERDOSSI, 2012
  • 7. Status Epileptikus • Kejang > 30 menit (mulai terapi: 5 menit) • Kejang >= 2x, diantara kejang px tidak sadar Pedoman Tatalaksana Epilepsi, PERDOSSI, 2012 Sindrom Epilepsi • Tipe bangkitan • Etiologi • Anatomi • Faktor presipitasi • Usia onset • Severitas • Kronisitas • Siklus diurnal / sikardian • Prognosis • Klasifikasi sindrom ILAE 1989 Serial Seizure: Diantara 2 kejang px sadar
  • 8. 5 Axes of Epilepsy Diagnosis 1. Ictal phenomenology 2. Seizure type 3. Syndrome 4. Etiology 5. Impairment
  • 9. Ictal Phenomenology pre - durante - post Kondisi saat bangkitan Duduk, berdiri, berbaring, tidur berkemih Gejala awitan Aura, gerakan/ sensasi awal Apa yg tampak selama bangkitan Bentuk bangkitan, lidah tergigit, inkontinensia, deviasi mata, pucat, berkeringat Kondisi setelah kejadian Bingung, terjaga, nyeri kepala, tidur, gaduh gelisah, Todd’s Faktor pencetus Alkohol, kurang tidur, hormonal, dll Pola bangkitan lain/perubahan Pedoman Tatalaksana Epilepsi, PERDOSSI, 2012
  • 10. Adams & Victor’s Principles in Neurology, 8th ed, 2005
  • 11. Seizure Type ILAE 1981 Bradley, Neurology in Clinical practice, 2010
  • 12. Adams & Victor’s Principles in Neurology, 8th ed, 2005
  • 13. Syndrome ILAE 1989 (Bradley, Neurology in Clinical Practice, 2010)
  • 14. Etiologi Idiopatik Lesi struktural otak (-) Defisit neurologik (-) Predisposisi genetik Berkaitan dengan usia Kriptogenik (dianggap) simtomatik Penyebab belum diketahui Klinis ~ ensefalopati difus ~Sindrom epilepsi Simtomatik Kelainan/ lesi struktural otak Causa: “CEMENTED” Pedoman Tatalaksana Epilepsi, PERDOSSI, 2012
  • 15. Adams & Victor’s Principles in Neurology, 8th ed, 2005
  • 16. Adams & Victor’s Principles in Neurology, 8th ed, 2005
  • 17. “Unprovoked” vs “Symptomatic Epilepsy” Kapan “Acute symptomatic seizure” menjadi “Epilepsi” ?
  • 18. Beghi et al, Recommendation for a definition of acute symptomatic seizure. Epilepsia,51(4):671–675,2010
  • 19. Beleza P Acute Symptomatic Seizures A Clinically Oriented Review The Neurologist Volume 18, Number 3, May 2012
  • 20. General rules Seizure in the setting of two causes where one cause would classify the seizure as acute symptomatic If a person has preexisting epilepsy, a seizure that meets criteria for acute symptomatic will still be so classified. Cerebrovascular disease, cerebral hypoxia Within 7 days onset TBI, intracranial surgery Within 7 days onset CNS infections Beyond 7 days, ~ clinical & lab findings Multipe sclerosis Within 7 days of relapse Metabolic Blood sample within 24 h of seizure Alcohol Within 7-48 h of last drink Beghi et al, Recommendation for a definition of acute symptomatic seizure. Epilepsia,51(4):671–675,2010
  • 21. Beghi et al, Recommendation for a definition of acute symptomatic seizure. Epilepsia,51(4):671–675,2010
  • 22. “Kenapa saya kejang, sedangkan kamu tidak kejang?” Beghi et al, Recommendation for a definition of acute symptomatic seizure. Epilepsia,51(4):671–675,2010
  • 24. Anamnesis Kejang Gejala sebelum, selama, sesudah bangkitan Riwayat penyakit saat ini yang mungkin menjadi penyebab Usia onset, durasi, frekuensi, interval terpanjang Riwayat epilepsi dalam keluarga Riwayat keluarga dengan penyakit neurologik lain/ psikiatrik/ sistemik Riwayat saat dalam kandungan/ kelahiran/ tumbuh kembang Riwayat bangkitan neonatal/ kejang demam Riwayat trauma kepala/ infeksi SSP, dll Pedoman Tatalaksana Epilepsi, PERDOSSI, 2012
  • 26. Pemeriksaan Penunjang EEG • CT-scan • MRI • PET, SPECT, MRS Neuroimaging • Hb, WBC, Hct, Plt, HDT • Na, K, Ca, Mg • Glu • RFT • LFT • (LP) • (Toksikologi) • Kadar OAE Laboratoris Pedoman Tatalaksana Epilepsi, PERDOSSI, 2012
  • 27. Seizure & Epilepsy At a Glance Chapter #1.5: Patofisiologi
  • 30. Imbalance! Inhibisi Eksitasi Buku Ajar Ilmu Penyakit Saraf, FK Unair, 2011
  • 31. Disfungsi Sel Glia • Mengatur fungsi konsentrasi ion Kalium ekstrasel di sekitar neuron & terminal presinaps Buku Ajar Ilmu Penyakit Saraf, FK Unair, 2011

Notas do Editor

  1. Tdkharusselalumasukkedlmsindromtertentu
  2. http://jnnp.bmj.com/content/70/suppl_2/ii3/F4.large.jpg
  3. http://jnnp.bmj.com/content/70/suppl_2/ii3/F1.large.jpg
  4. http://emergency-cases.com/index.php/2011/08/10/approach-to-first-seizure-in-adults-causes-and-management/