englezi epilepsie lobi

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    Cerebral lobe syndromesCerebral lobe syndromes

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    LAYERS OF CORTEX

    1. Molecular: horizontal axons, golgi 2 cells

    2. Ext. Granular: granule cells

    3. Ext. Pyramidal: commisural fibers

    4. Int. Granular: stellate cells, ext. band ofBaillarger

    5. Int. Pyramidal: Largest cells

    6. Multiform Layer

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    LAYERS OF CORTEX

    1 & 2: receive diffuse afferent fibers

    from lower brain to control

    excitability of region

    3: connect two hemispheres and

    ipsilateral cortico-cortico

    association fibers

    4: main sensory afferent input

    (in sensory cortex)

    5: main efferent to brain stem

    and spinal cord(in motor cortex)

    6: efferent fibers to thalamus

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    GGENERAL ANATOMYENERAL ANATOMY Frontal Lobe

    Temporal Lobe

    Parietal Lobe

    Occipital Lobe

    Insula

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    Frontal lobeFrontal lobe

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    Frontal lobeFrontal lobe

    Highest level of brain evolution

    Involved in many functions

    Lesions in different parts lead to different

    syndromes

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    Frontal lobeFrontal lobe

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    Frontal lobe syndromeFrontal lobe syndrome

    Lesions of the motor area lead to motordeficits of the opposite half of the body Irritative lesions jacksonian motor seizures

    Lesions of premotor areas less importantmotor deficit Irritative lesions in premotor areas

    adversive seizures, or supplementarymotor area seizures

    Supplementary motor area seizures:cessation of all activity, tonical contractionsof proximal muscles, repetitions, pallilalia

    Premotory areas lesions: diminishment ofspontaneous movements, delay of voluntaryactions (movements), eventually

    hyopkinesia, akinesia, tremor Forced prehension

    Gait and posture abnormalities; frontal ataxia

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    PPREFRONTAL CORTEXREFRONTAL CORTEX

    Frontal pole Areas 9,10,11

    Plays a role in affective behavior and judgment

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    PPREFRONTAL CORTEXREFRONTAL CORTEX

    Pts with bilateral lesions neglect their appearance,act inappropriately, have no appreciation of social

    norms for conduct. They are uninhibited and highly

    distractable

    Perseveration

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    Frontal lobe syndromeFrontal lobe syndrome

    Prefrontal areas lesions

    Alteration of personality

    Diminishment of spontaneous activity - the patient does not feel the

    need to do anything, is not able to plan the future events, may be

    agitated Attention deficits memory is normal, but the patient doesnt bother to

    use it

    Loss of abstract thinking

    Perseveration

    Afffective changes either apathic, flat, either excessively exuberantand childish; may show lack of inhibition, eventually sexually improper

    actions

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    Frontal lobe syndromeFrontal lobe syndrome

    Prefrontal dorsolateral cortex lesions

    Diminished fluency (verbal & nonverbal),

    reasoning problems, reduction of spontaneous

    responses inhibition, perseveration, attentiondeficits

    Orbitofrontal cortex lesions desinhibition,

    anosmia

    Mezial frontal cortex, anterior cingullary

    cortex lesions apathy, abulia, memory

    impairments

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    Cognitive function testing in frontalCognitive function testing in frontal

    lobe lesionslobe lesions

    MMS does not approach these problems

    Frontal lobe tests:

    go-no go tests patient is told to lift 2 fingers, but theevaluator lifts only 1

    Speech fluency patient is asked to produce as many

    words he can starting with letter Z normally more than 8

    words/ 1 min

    Motor tests for perseveration patient is asked to execute

    series of 3 movements (fist, edge-palm tests Luria)

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    Parietal lobeParietal lobe

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    Parietal lobeParietal lobe

    Anterior somatosensory area,posterior association area

    4th neuron of sensory tracts(3, 1, 2 areas primarysomatosensory cortex

    5, 7, 39, 40 areas somatosensory associationareas; areas 5 and 7 areimportant for stereognosis

    Parietal regions haveappeared when the fingerswere used for more than justmobility (catching, throwing)

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    Parietal lobe syndromesParietal lobe syndromes

    Controlateral hemihypestesia (diminished sensation)

    Astereognosis (5 & 7 areas lesions)

    Sensory epilepsy (paresiae and sometimes paroxisticalpain)

    Asomatognosia (left hemisphere lesions lead to one sideasomatognosia, anosognosia, anosodiaforia, neglect of leftbody half)

    Right parietal lobe spatial component of activities

    Apraxia loss of the ability to execute or carry out learnedpurposeful movements, despite having the desire and thephysical ability to perform the movements

    Finger agnosia

    Left-right agnosia

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    Parietal lobe syndromesParietal lobe syndromes

    Left parietal lobe symbol and experiences comprehension

    ideomotor (inability to carry out a motor command or a learned gesture,

    for example, "act as if you are brushing your teeth" or "salute")

    limb apraxia when movements of the arms and legs are involved,

    nonverbal-oral or buccofacial (inability to carry out facial movements oncommand, e.g., lick lips, whistle, cough, or wink),

    ideational (inability to create a plan for or idea of a specific movement,

    for example, "pick up this pen and write down your name")

    Inability to use the informations on spatial relations

    Constructive apraxia

    Topographic agnosia

    Prosopagnosia

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    AAPRAXIAPRAXIA

    Apraxia = inability to perform skilled, learned, purposefulmotor acts correctly despite intact motor and sensory

    systems, and normal attention and comprehension

    Ideomotor Apraxia

    Inability to carry out, on verbal command, an activity

    that can be performed spontaneously

    Summary of path activatedwhen pt. asked to move his

    left hand

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    AAPRAXIAPRAXIA

    Ideational Apraxia

    Abnormality in the conception of movement so that

    the the pt. has difficulty sequencing the different

    components of a complex motor task

    Lesion in dominant temporo-parieto-occipital area

    Constructional Apraxia

    Inability of the pt to put together or articulate

    component parts to form a single shape or figure, eg

    assembling blocks to form a design

    Can be seen with either dominant or nondominant

    posterior parietal lesions, although more common

    and severe in nondominant lesions

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    Constructive apraxiaConstructive apraxia

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    Parietal lobe syndromesParietal lobe syndromes

    Speech problems frequentlyassociated with writing problems

    Motor abnormalities (diminishmentof spontaneous movements,unstable hand, syncynesia)

    Balance problems

    Taste problems (area 43)

    Hemianopia

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    Parietal lobeParietal lobe

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    Adaptative

    possibilities of

    parietal lobes

    blind boy readswith the tip of his

    nose

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    Temporal lobeTemporal lobe

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    TTEMPORALEMPORAL LLOBEOBE Two transverse sulci divide into

    Superior Temporal Gyrus

    Middle Temporal Gyrus

    Inferior Temporal Gyrus

    Transverse (Heschls) Gyrus runs anterolaterally oversuperior aspect of first temporal Gyrus

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    Temporal lobeTemporal lobe

    Underneath the lateral sylvian fissure, continues with occipital andparietal lobes

    Primary and associative auditory areas (41, 42), association areas(38, 20, 21, 22);

    Area 38 involved in taste perception

    Areas 41, 42 sound perception and interpretation Limbic system (hypocampal uncus and gyrus, girus cinguli,

    subcalossal areas, olfactory areas) critical role in emotions andaffect

    Optic radiations

    Dominant temporal lobe perception and decoding ofwords/language

    Nondominant temporal lobe perception of intonation, music,conversation

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    Temporal lobe syndromesTemporal lobe syndromes Temporal lobe lesions

    Troubles of hearing, balance, taste, smell, language, sight, memory,dietary comportment, sexual behaviour

    Epilesy with temporal lobe generators reason troubles, halucinations,abnormal behaviour

    Hearing loss area 41 unilateral lesion; bylateral lesions

    cortical deafness; iritative lesions lead to auditory illusions,auditory hallucinations

    Taste and smell problems: olfactory halucinations as part ofepileptic crysis. Destruction of olfactory areas in thehippocampal uncus and hypocampic gyrus lead to anosmia.Olfactory hallucinations may precede seizures (aura)

    Visual damage hemianopia, visual memory impairment

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    AAPHASIAPHASIA

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    WWERNICKES APHASIAERNICKES APHASIA

    Fluent, Receptive

    Normal to supranormal speech output

    Paraphrasia, Substitutions, Neologism,

    Circumlocution

    Empty speech or word-salad

    Cannot comprehend

    Lesion in Wernickes area= posterior part of Superior

    Temporal gyrus (22)

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    AAPHASIAPHASIATYPE FLUENCY COMPREHESION REPETITION

    BROCAS - + -

    TRANSCORTICAL + - -

    MOTOR

    GLOBAL - - -

    WERNICKES + - -

    TRANSCORTICAL + - +

    SENSORY

    CONDUCTION + + -

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    Temporal lobe syndromesTemporal lobe syndromes

    Memory impairment Recent memory in billateral inferior

    hypocampic lesions

    Short term memory bilateral lesionsof mamillary bodiesAfectarea memorieipentru cuvinte

    Long time memory mamillothalamicor cortical bilateral lesions

    Storage of new memories andcomprehension of those elements isperformed by the Papez circuit(hypocampus, mammilary bodies,thalamus, girus cinguli)

    Sexual and feeding behaviour

    Temporal lobe epilepsy EEG

    Simple or complex psychosensorialhalucinations, aphasia, olfactory orauditory halucinations

    Recall and recognition impairment dj vu, deja pense, jamais vu

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    Papez circuitPapez circuit James Papez in 1937

    One of the major pathways of the limbic system

    Chiefly involved in the cortical control of emotion.

    Role in storing memory.

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    KKLUVERLUVER-- BBUCYUCY SYNDROMESYNDROME

    Heinrich Kluver, Paul Bucy,1939

    Bilateral temporallobectomy

    Blunted Affect with Apathy Psychic Blindness or visual

    agnosia with inability todistinguish between friendsand strangers

    Hypermetamorphosis =hypersensitivity tominute/fine visual stimuli

    Hyperorality

    Bulemia or unusual dietaryhabits

    Hypersexulaitity

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    Occipital lobeOccipital lobe

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    Occipital lobeOccipital lobe

    Small part of dorsolateral part of the hemispheres

    Visual function Visual perception

    Recognition in relation to spatial and temporal parameters

    17, 18, 19 Brodmann areas

    17th area

    Near the calcarine sulcus

    Reception center for visual information (colour, shape, size, movement, light,transparency)

    18th area (parastriate) and 19th area (peristriate) association cortex

    Disorders of the occipital lobe can be the result of distruction (defficit) orirritation, and symptoms may be uni- or bylateral

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    PPRIMARY VISUAL CORTEXRIMARY VISUAL CORTEX

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    Occipital lobe syndromesOccipital lobe syndromes

    Irritative pathology: Visual hallucinations simple (elementary) or complex, with sensory

    and cognitive aspects

    Elementary hallucinations:stars, flashes, colours, lights, geometric figures

    Complex hallucinations: objects, persons, animals of normal or abnormalsize; patients may perceive those object as unreal, or believe that they are

    real Visual illusions (metamorphopsia) objects have abnormal visual

    properties: shape, size, colours

    Images may be related to previous experiences

    Mycropsia, macropsia, megalopsia, moving objects

    Abnormal colours (erithropsia), lack of colour (acromatopsia), reversesight, poliopia (one object appears in multiple instances), monoculardiplopia,

    Loss of spatial sight, reappariton of images after the source has ceased toexist in the visual fields, false orientation of objects in space

    Occipital lobe epilepsy elementary visual hallucinations, mobile/fixedin the visual fields

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    PPRIMARY VISUAL CORTEXRIMARY VISUAL CORTEX

    Occipital lobe syndromes Lesions produce visual field defect in

    contralateral visual field

    e.g. lesion of inferior calcrine cortex = contralateralquadrantanopsia

    Lesions of the whole visual cortex in onehemishpere result in a loss of vision in thecontralateral visual field

    If lesion is vascular (eg occlusion of PCA)

    results in macular sparing because macula areareceives collateral blood supply from the MCA

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    Occipital lobe syndromesOccipital lobe syndromes

    Deficit syndromesDeficit syndromes

    Colour agnosia loss of correctperception of colours, impossibility ofcolour naming and identification

    Cortical blindness Both primary visual areas are damaged

    Patient cannot interpret visual information,and acts as in the case of a peripheralblindness

    Some patients try to act as if they were seeing Anton syndrome (associates parietal lesionsand sensory neglect)

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    Balints syndrome

    Bylateral lesions of occipital lobes

    Optic Ataxia, Ocular Apraxia

    Inability to direct eyes to a certain point in

    visual fileld despite intact vision and eye

    movements

    Seen with Bilateral Parieto-Occipitallesions

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    AGNOSIAAGNOSIA

    Agnosia = the inability to recognize perceived sensory informaton

    Often modality specifiv: visual, auditory or tactile

    Visual Agnosias

    Visual Object Agnosia= inability to recognize visually presented objects Prosopagnosia= inability to recognize faces

    Visual color agnosia= inability to recognize colors

    Simultanagnosia= inability to recognize the whole

    Auditory Agnosias Auditory Verbal Agnosia= inability to recognize spoken language

    Auditory Sound Agnosia= inabiltiy to recognize non-verbal sounds Sensory Amusia= inability to recognize music

    Tactile Agnosias Astereognosia= inability to judge form of object by touch

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    EpilepsyEpilepsy

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    DefinitionDefinition

    Epilepsy: A group of recurrent disorders of

    cerebral function characterized by both seizures

    and convulsions.

    Convulsion: Sudden attack of involuntary muscularcontractions and relaxations.

    Seizure: Abnormal central nervous system electrical

    activity.

    Sezures are generated by abnormal

    synchronous electrical brain activity

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    EtiologyEtiology

    Idiopathic genetic conditions

    Acquired:

    Trauma Brain tumors

    Stroke

    Infections

    Degenerative diseases

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    Ion channelsIon channels

    Proteins that are organised into small pores in the

    cell membrane

    They allow selective passage of ions (Na, Ca, K,

    Cl), with an important contribution in maintaining themembrane potential and in forming the trans

    membranare electric flow.

    Intercelular signals, transmembrane transport, pH

    and cell volume

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    Calcium channelCalcium channel

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    Natrium channelNatrium channel

    Na channel

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    Potassium channelPotassium channel

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    ClassificationClassification

    Partial (focal) Simple

    Motor

    Sensitive Vegetative

    Psichical

    Complex Secondary generalized

    Generalized Tonic

    Atonic

    Clonic Tonic-clonic

    Mioclonic

    Absenceunclassifiable

    International Classification of SeizuresInternational Classification of Seizures (ILAE, Epilepsia 1981)(ILAE, Epilepsia 1981)

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    Epileptogenesis

    The abnormal

    discharge originates

    usually in a definite

    area

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    InvestigatiiInvestigatii

    Electroencefalogrphy spectral analysis Cerebral Computed Tomography (CT)

    MRI

    Functional imagistics techniques: PET

    fMRI

    SPECT Magnetoencephalography

    video EEG monitoring

    S l EEG D t A i itiS l EEG D t A i iti

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    Scalp EEG Data AcquisitionScalp EEG Data Acquisition

    1010 second EEGs: Seizure Evolutionsecond EEGs: Seizure Evolution

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    1010--second EEGs: Seizure Evolutionsecond EEGs: Seizure EvolutionNormal Pre-Seizure

    Seizure Post-Seizure

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    EEG- normal

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    --

    Spike-wave complexes

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    fMRIfMRI

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    PETPET

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    MagnetoMagneto--

    encefalographyencefalography

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    TYPES OF SEIZURESTYPES OF SEIZURES

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    Generalized SeizuresGeneralized Seizures

    Grand Mal

    Absence

    Tonic seizures Atonic seizures

    Mioclonic seizures

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    Generalized SeizuresGeneralized Seizures

    Excessive electrical activity in both

    cerebral hemispheres.

    Usually originates in the thalamus or

    brainstem.

    Affects the whole body.

    Loss of consciousness is common.

    G li d S iG li d S i

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    Generalized SeizuresGeneralized Seizures Myoclonic: Brief shock-like muscle jerks generalized or

    restricted to part of one extremity.

    Atonic: Sudden loss of muscle tone.

    Tonic Seizures: sudden stiffening of the body, arms, or

    legs

    Clonic Seizures: rhythmic jerking movements of the

    arms and legs without a tonic component

    Tonic-clonic (grand mal): Tonic phase followed by clonic phase

    https://reader009.{domain}/reader009/html5/0526/5b08503b8ee61/5b08506c48dba.jpg

    G li d S iG li d S i

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    Generalized SeizuresGeneralized Seizures

    Absence (petit mal): Person appears to blankout - Daydreaming Simple Absence (primarily effects consciousness only)

    Complex Absence

    Atypical Absence (Includes physical symptoms like eye blinking orlip movements)

    Status Epilepticus: A seizure lasting longer than

    30 min, or 3 seizures without a normal period inbetween

    May be fatal

    Emergency intervention required

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    Grand Mal epilepsyGrand Mal epilepsy

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    AbsencesAbsences

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    Partial (focal) SeizuresPartial (focal) Seizures

    Excessive electrical activity in one

    cerebral hemisphere. -Affects only part of

    the body.

    Simple Partial: Person may experience a

    range of strange or unusual sensations.

    Motor

    Sensory

    Autonomic

    Key feature: preservation of consciousness.

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    Partial (focal) SeizuresPartial (focal) Seizures

    Complex Partial:

    Loss of awareness at seizure onset. Person

    seems dazed or confused and exhibits

    meaningless behaviors.

    Typically originate in frontal or temporal lobes(e.g. Temporal lobe epilepsy)

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    Motor partial seizuresMotor partial seizures

    Motor (Jacksonian) seizures Oculo-cefalogiric seizures

    Adversive seizures

    Supplementary motor area seizures Tonic seizures

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    Sensory partial seizuresSensory partial seizures

    Jacksonian sensory seizures

    Visual

    Auditive Vestibulary

    Olfactive & gustative

    Vegetative

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    Partial complex seizuresPartial complex seizures

    Association areas are involved:

    Partial loss of awareness

    Dream state, Dj vu,

    Jamais vu

    Anger, fear, joy crisis

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    Partial motor & sensory seizuresPartial motor & sensory seizures

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    Complex partial seizuresComplex partial seizures

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    Drugs

    Cetogenic diet

    Surgery

    Vagal stimulation

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    Treatment principlesTreatment principles

    Monotherapy

    Politherapy

    Titration

    Treatment cessation

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    Absence seizuresAbsence seizures

    Etosuximide

    Oxazolidindione

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    Drugs that work in seizures otherDrugs that work in seizures other

    than absencethan absence

    Phenobarbital

    Phenitoin

    Carbamazepine

    Primidone

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    Drugs efficient in all types ofDrugs efficient in all types of

    seizuresseizures

    Sodium valproate

    Clonazepam

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    Status epilepticusStatus epilepticus

    Prolonged seizure or seizures without

    remission periods between

    Parenteral treatment:Clonazepam

    Diazepam

    Phenitoin

    A ti il ti ffiA ti il ti ffiA ti il ti ffiA ti il ti ffi

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    Antiepileptics: efficacy rangeAntiepileptics: efficacy rangeAntiepileptics: efficacy rangeAntiepileptics: efficacy rangeLarge range of efficacy Narrow range

    *Based on preliminary evidence*Based on preliminary evidence

    Sodium valproate

    Levetiracetam

    Phenobarbital

    Benzodiazepines

    Topiramate

    Lamotrigine

    Zonisamide*

    Phenytoin

    Carbamazepine

    Ethosuximide Gabapentin

    Oxcarbazepine

    Tiagabine

    Pregabalin

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    Modern AntiepilepticsModern Antiepileptics

    Topiramate

    Vigabatrin

    Oxcarbazepine Lamotrigine

    Clobazam

    Gabapentin

    Pregabalin

    Tiagabine Levetiracetam

    Zonisamide

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    ff

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    Adverse efectsAdverse efects

    Gingival hyperplasia

    Hirsutism/ Transient hair loss

    Vitamine/folate deficiency Polycystic ovary syndrome and menstrual

    disturbances

    Bone loss

    SS

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    SurgerySurgery

    Resection of epileptic abnormal

    discharge source

    Lobectomiy

    Hemispherectomy

    Calosotomy

    V l ti l tiV l ti l ti

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    Vagal stimulationVagal stimulation

    Electrodes are

    attached to the vagus

    nerve

    Intermittent

    stimulation

    Indication in treatment

    resistent epilepsy

    S i l iS i l i

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    Special issuesSpecial issues

    Driving

    Extreme/risky sports

    Special professions

    Pregnancy and breast feeding

    eop e w ep epsy aveeop e w ep epsy ave

    ll d i ll d i

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    Lord Byron

    excelled in every area.excelled in every area.

    Margaux

    Hemingway

    Gustave Flaubert

    Jeanne d'Arc

    Hermann von

    Helmholtz

    Alfred Nobel

    Sokrates

    G. Julius

    Caesar

    NapoleonBonaparte