Management Of Seizure

Management of Seizures with special emphasis on

newer Anti Epileptic Drugs

Speaker Dr. Suneesh.K

Dept. Of Medicine A.I.I.M.S New Delhi

Overview

• Definition and classification• Approach to seizure• Investigations• Treatment of seizure with details of AED• Refractory epilepsy• Status epilepticus• Special situations

Definition Epileptic Seizure

A transient occurrence of signs and or symptoms due to abnormal, excessive or synchronous neuronal activity in the brain

Acute symptomatic seizures

Occur in close temporal proximity with an insult to the brain or during a systemic insult

Epileptic Seizures and Epilepsy: Definitions Proposed by ILAE and IBE, Epilepsia, 46(4):470–472, 2005

Epilepsy

An enduring predisposition to generate epileptic seizures and the

neurobiologic, cognitive, psychological, and social consequences

of this condition

Requires the occurrence of at least 2 epileptic seizure, 24 hr apart

All people with epilepsy have seizures. But all those who have

seizures do not have epilepsy

Definition (Contd…)

Classification

Classification of epileptic seizures and syndromes is continually evolving

ILAE Commission on Classification and Terminology, 2005-2009 updated the classification,

Clinical & Electro-

encephalographic findings

Etiology or Cellular

substrate

2005-2009 Commission ReportEpilepsia 2010;51:676-685

Principal types of seizures

FOCAL SEIZURES

GENARALISED SEIZURES

FOCAL, GENARALISED OR UNCLEAR

Originating within networks limited to one hemisphere.

These may be discretely localized or more widely

distributed

Types of Focal seizures

Focal seizures

Without Dyscognitive features

Motor, sensory, autonomic, psychic symptoms

Evolving to bilateral convulsive seizure

With Dyscognitive features

Originating at some point

within, and rapidly

engaging, bilaterally

distributed networks

Generalized Seizures

Generalized Seizures

GTCS Absence

TonicClonicAtonic

Myoclonic

AtypicalTypical

• Mr. X. 24 year old gentleman was brought to the

casualty after a reported seizure 3 hours back.

According to his brother, who found the patient

on the floor, unresponsive and was throwing

convulsions lasting for less than a minute. The

patient regained consciousness quickly with

slight drowsiness. He has no history of seizures

in the past.

How we will

approach this

case?

What are the

investigations to be

done in casualty?

What imaging is

preferred? Urgent

CT or routine MRI

Should we go for

an EEG?

What is the role of

lumbar puncture

in this patient?

Should we start

AED?

What is the plan

of management?

If we start AED,

will it prevent

epilepsy?

Case scenario..

Is it a seizure ?

Provoked or

unprovokd

Is it a first episode or epilepsy

Focal or generalised

Chance of recurrence

or not

Clinical practice: Initial management of epilepsy. N Engl J Med. 2008;359:166-176

Approach

History..

Seizure mimics

SyncopePsychogenic-

seizures

TIAHypoglycemiaPanic attacks

Delirium tremensBreath holding-

spells

Harrison’s Principles of internal medicine 18th edition, page 3260

Features Syncope Seizure

Occurrence Awake, mostly when upright

Awake/asleep

Premonition (Nausea, sweating, Tunnel vision lightheadedness)

CommonStereotyped transition

Uncommon

Onset Less abrupt Abrupt

Facial appearance Pallor Cyanosis, Frothing at mouth

Jerking of limbs Occasional Frequent

Duration of tonic or clonic movement

Never >15 S 30-60 S

Post ictal recovery Rapid Slow

Post ictal confusion Uncommon Common

Features Psychogenic episode(NES)

Seizure

Age and gender Young, usually females Any age

Precipitating factors Emotional disturbances Lack of sleep, Poor drug compliance

Occurrence in sleep No Yes

Movements Vocalization, pelvic thrusting, bizarre flinging of limbs

Tonic or tonic-clonic jerks

Eyes Can be forcibly closed, Resistance to opening

open

Injuries including tongue bite Infrequent Frequent

Post ictal confusion Unknown Common

EEG / Video EEG/Prolactin Normal Usually abnormal

Side-to-side turning of the head

Asymmetric & large-amplitude

shaking- movements of the limbs

Pelvic thrusting

J Emerg Med. Jan-Feb 1995;13(1):31-5.

NES

History (Contd..)

Neurology. 2007;69:1996-2007

Transient neurological symptoms

Awakening with a tongue bite or incontinence

Lip masking

Hand automatism

Am Fam Physician. Sep 15 1997;56(4):1113-20

H/O Suspicious

events in past

Exact description

Head or eye deviated?

Incontinence?

Injury?

Total duration

Postictal state?

Questions to

the witnessAuraIctus

Post ictal

Precipitating factorsSleep deprivation

Electrolyte or Metabolic derangements

Acute infection

Drugs

Alcohol

Epileptogenic factors

Prior head trauma

Stroke

Tumor

Infection

Family & Personal-

history

History (Contd..)

Neurology. 2007;69:1996-2007.

Physical and neurological examination

Neuro cutaneous markers

Focal neurological deficit Trauma

Subcutaneous nodules

Optic fundusSystemic illness

Infection

Neurology. 2007;69:1996-2007

Back to Mr.X..• From the story ,

• Did he experienced an aura?

Maybe..had blurry vision..and a

sense of impending change 15-

20 minutes prior to episode

• Trigger? Not identifiable

• Impaired consciousness? Yes

• Got a good description from

witnesses about event, ..Had

jerking movement of the right

UL lasted for less than a

minute

• Loss of continence? No.

• Postictal? Was confused , Not

able explain the exact episode

• Suspicious events in past??

Never that episodes in past

• Medical history: Not

significant

• Family history: Not significant

• Personal history: Smoker, no

illicit drug abuse

• Couldn’t get any relevant

finding from general physical

and systemic examination

With this history, did this gentleman had

a seizure?

Yes, he had a seizure attack!! Because…Focal seizure with

dyscognitive features.

Laboratory studies Routine blood studies Finger stick glucose Lumbar puncture if .. ECG Toxin screening if suspected Pregnancy test in women of childbearing age AED levels ??ABG

ImmunocompromiseSevere headachePersistent fever

Persistently altered mental status

American College of Emergency Physicians. Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency

department with seizures. Ann Emerg Med. May 2004;43(5):605-25

Electroencephalogram

Three types of information: Confirmation of the presence of abnormal electrical

activity Type of seizure disorder, and Location of the seizure focus

Interictal epileptic activity:

Ideal to be done within 24 hr

Video EEG

EEG is not a substitute

for a good clinical

history, but can add to

value of a diagnosis

Lancet. Sep 26 1998;352(9133):1007-11.

Spikes orSharp wavesdischarges

Brain Imaging Mandatory in new onset seizure

MRI is superior to CT

Urgent CT mandatory if

Any focal seizureFND

Recent traumaImmunocompromise

MalignancyPersistently altered

mental statusOn anticoagulation

Am J Emerg Med. Jan 1995;13(1):1-5Indian Epilepsy Society guidelines, (Oct, 2008)

Epilepsy protocol MR imaging

T1 & T2 sequences in a min of 2 orthogonal planes

Contrast enhancement - not necessary in routine cases

If focal seizure or FND, sequences should include 3 Dimensional sequence to allow reformatting in any

orientation.

FLAIR Epilepsia, 38(11):1255-1256, 1997

Single photon emissioncomputed tomography (SPECT)

FDG – PET

If there is no good concordance b/w MRI, EEG & other data

Shows area of hypometabolism -Possible site of seizure onset

Useful for planning the sites of intracranial electrode

Coming back to Mr. X..

• Hemogram –Normal• Metabolic work up and electrolytes-

Normal• ECG-NSR • Urgent NCCT head-Normal• Toxin screening and AED level-Not required• LP-Not required• EEG performed within 24hr – No

epileptogenic discharges.

.

Mr. X had first episode of an unprovoked seizure

(Focal)

What next?

Acute symptomatic or Provoked

Unprovoked

First episode ??Epilepsy

Treat underlying cause

Start AED

??

Seizure

Trial

3 Month 6 Month 1 Year 2 year 5 year 8 Year

FIRST seizure trial(Italy)

18 28 41 51

MESS Trial(Europe)

26 39 51 52

Chance of recurrence in untreated 1st unprovoked seizure (%)

Recurrence..In MESS Trial Immediate treatment will have a 35–39% chance

of recurrence at 3 and 5 years but with deferred treatment it is 50–

56% risk.

In FIRST Seizure trial the overall risk of seizure recurrence was

50% lower in the treated group compared with the untreated

group at 2 years [RR 0.5 (95% CI: 0.3-0.6)]. Immediate treatment

only reduce seizure recurrences in the next 1-2 years after the 1st

seizure

Treatment of a 1st unprovoked seizure decreases the

risk of relapse in the following 2 yrs, but it does not

affect the probability of long-term remission and will

not prevent epilepsy

(Musicco et al.,1997; Hirtz et al.,2003; Marson et al.,2005)

Epilepsia, 49(Suppl. 1):58–61, 2008

Population-based studies provide a 36% relapse rate at

1 year and 45% relapse rate at 2 years

Epilepsia, 49(Suppl. 1):58–61, 2008

Factors that predict seizure recurrence

Epileptiform discharges on EEG

Abnormal brain imaging

Pre-existing neurological condition

Mental retardation

Abnormal neurological examination

FND or Todd’s palsy

Presenting as status epilepsy

Mental retardation

Positive family history

EEG or Imaging abnormality

High risk jobs

Individual & family do not accept the expected risk of recurrence

Indian Epilepsy Society guidelines, (Oct, 2008)

Treat1st

Unprovokedseizure

if

Treatment significantly reduces the risk of recurrence in the short term

But does not alter the long-term prognosis

Only a case by case approach which balances the pros and cons

Antiepileptic drugs Treatment modalities

Pharmacological Non pharmacological

Old drugs (Before 1993)

Carbamazepine

Clonazepam

Ethosuximide

Phenobarbital

Phenytoin

Primidone

Valproic acid

New drugs (Since 1993) Felbamate

Gabapentin

Lamotrigine

Levetiracetam

Lacosamide

Oxcarbazepine

Pregabalin

Tiagabine

Topiramate

Vigabatrine

Zonisamide

Ezogabine

Rufinamide

Eslicarbazepine

N Engl J Med 2008;359:166-76

Mechanism of Action of AED

Seizure!!! Control

EPSPsNa+ InfluxCa++ CurrentsParoxysmal Depolarization

IPSPsK+ EffluxCl- InfluxPumpsLow pH

Classification based on Mechanism of Action

Na Channel Blockers Ca2+ Current inhibitors

GABA Enhancers Glutamate blockers

Carbonic anhydrase inhibitors

Unknown mechanism

Enhanced Sodium channel inactivation

Na+Na+

Valproate

Carbamazepine

Phenytoin

Lamotrigine

Topiramate

Zonisamide

Activation gate

Inactivation gate

Ca++

Ca++Ethosuximide Valproate

Reduced current through T type Calcium channels

GABA Enhancers

TiagabineGabapentinValproate

BarbiturateBZD

Vigabatrine

Glutamate blockers

MetabotrophicUnder research

AMPA BlockerTopiramate

NMDA BlockersFelbamate

Levetiracetam

AED (Contd..)

Lacosamide

SV2A-binding agentsLevetiracetam

Carbonic anhydrase inhibitors

Acetazolamide

Eslicarbazepine

Retigabine (INN)

Ezogabine (USAN)

Rufinamide

CRMP-2

Neurology. Nov 16 2010;75(20):1817-24

K+ Channel opener

Prolong Na+ Channel inactive

stateWaiting for FDA approval

Talampanel-AMPA Blocker

CarisbamateBrivaracetam

Anal Bioanal Chem. 2010 Jun;397(4):1605-15

A Glimpse of the Future!!

CerebellarPhenytoin

CarbamazepineValproic acidLamotrigine

EthosuximideGabapentinLacosamideRufinamide

Psychomotor slowingLanguage problems

TopiramateTiagabine

Mood changesFelbamate

LevetiracetamZonisamide


Adverse effects

Cardiac conductionLacosamideRufinamide

HepatotoxicityValproate

BenzodiapineFelbamate

BM SuppressionCarbamazepineEthosuximideLevetiracitam

ValproateFelbamate

Skin rashLamotriginePhenytoin

CarbamazepinePhenobarbitone

PhenytoinGum hyperplasia

LNEHirsutism

Osteomalacia

CBZHyponatremia

VPAIncrease NH3Weight gain

TopiramateRenal stones Weight lossGlaucoma


Liver and renal disease

Avoid VPA, PB and BZD

OXC,LEV and GBP are safe

Phenytoin, Lamotrigine and Valproate are safer


Enzyme Inducers decrease All AED level except Gabapentin and

LevetiracetamValproate increase blood level of

LEV and PB

INH increase PHT and CBZINH and Rifampicin increase

Carbamazepine levelRifampicin reduces Phenytoin and

valproate level

Drug Interactions


AED selection-First line

CBZOx-CBZ

PhenytoinLamotrigine

ValproateLamotrigineTopramate

ValproateEthosuximide


Focal

Atypical absence

MyoclonicAtonic

Typical absence

Generalised onset

Tonic-Clonic


Lancet 2007; 369: 1016–26

Newer AEDs:

How good??

Valproate -more effective than lamotrigine and topiramate

Lamotrigine had twice the failure rate because of inadequate seizure control

Topiramate -similar in efficacy but had a higher failure rate than valproate due to side effects

Valproate should remain the drug of 1st choice for generalised and unclassified epilepsies

Older drugs are still used as 1st line therapy

No evidence that new drugs are more effective

But side effect and drug interactions low

Comparative trials are not necessarily the last word

Decision must be individualized for each patient

Follow-up and monitoring

CBC, LFT & RFT before Starting

treatment and every 3-6 month

Ca2+,ALP and Vit-D every year

First follow-up within 2-4 weeks

Subsequent

follow-ups every 3-6 months

Seizure diary

RoutineMonitoring not recommended

Suspected AED toxicity Managing drug

interactions

Liver or renal disease and pregnancy

Routine laboratory tests

Follow-up AED level monitoring


Therapeutic range (In micro gm/mL)

Phenytoin 10-20CBZ 6-12

VPA 50-125 Phenobarbital 10-40

When to stop AED?

Withdraw AED if seizure-free period of 2-3 yr

Should discuss the risk and benefits

Withdraw gradually over 3-6 months

Withdraw one drug at a time


Prolonged AED RX after 2 years, without seizures, does not guarantee lifelong seizure freedom

Using life-table analysis, the cumulative probability of remaining seizure-free after RX discontinuation is 39–74% at 1st year and 35–57% at 2nd year

The relapse rate is highest in the 1st 12 months (Mainly 6 months)

J Neural Transm (2011) 118:187–191

A

B

C

DIndian Epilepsy Society guidelines, (Oct, 2008)

Accuracy of

Diagnosis

Best drug

Compliance

Dose

Treatment failure

Refractory Epilepsy

Epilepsy not controlled by 2 or more appropriate AEDs

used in their optimal dosage or

Adults (16 years or above) who continue to have seizures

even after 2 years of treatment

20–30% of patients with epilepsy

Surgery should be considered early; not as last resort


Medically intractable epilepsy

No lesion seen on epilepsy protocol MRI:Substrate negative

Lesion seen on epilepsy protocol MRI:Substrate positive

Standard investigations: EEG, MRI, VEEG

Patient not a suitable candidate for curative/palliative surgery

Advance investigations: SPECT, PET, fMRI

EPILEPSY SURGERY Evaluate for Vagal nerve stimulation

(VNS)

+ve-ve

-ve

Non-pharmacological options

Lifestyle Modifications

• Adequate sleep

• Avoidance of alcohol,

stimulants, etc.

• Stress reduction — specific

techniques

• Adequate diet

Ketogenic diet

• Low carbohydrate, low protein, high

fat after fasting to initiate ketosis

• Anti-seizure effect of ketosis, acidosis

• ? Role of leptin release

• Main experience with children,

especially with multiple seizure types

• Long-term effects unknown

Approved in 1997 by FDA

Indicated for

Refractory partial onset seizures

Either not good candidates or

unwilling for surgery

Intermittent programmed electrical stimulation of left Vagus nerve

50% reduction of seizures can be expected in up to 30–40% of

patients

Vagal nerve stimulation

Back to Mr. X..• What are the future plans?

– Advise to stop driving– But he is the only earning member in family !!!– Start AED (After discussing with relatives-

adverse effects…)– Phenytoin ,Carbamazepine or Lamotrigine??

Consider cost also!!– Repeat EEG after 2 weeks → Then after 2 month– MRI brain with epilepsy protocol– Ensure adequate follow-up, compliance & avoid

triggers of seizure

Start with lowest possible dose!!

CBZ 100 mg BDPhenytoin 300 mg ODLamotrigine 25 mg ODValproate 200 mg BD

Levetiracetam 250 mg BD

Monotherapy is

the rule!!

Convulsive status epilepticus (CSE)

Continuous convulsive seizures lasting more than 5 minutes or 2 or

more seizures during which patient does not return to baseline

consciousness

Nonconvulsive status epilepticus (NCSE)

Change in mental status from baseline for at least 30 minutes a/w ictal

changes on EEGIndian Epilepsy Society guidelines, (Oct, 2008)

Status epilepticus

Lancet Neurol 2011; 10: 922–30

Management of Status Epilepticus

Non-pharmacological optionsResective surgery

Ketogenic dietVagal nerve stimulationRepetitive transcranial magnetic stimulation

ECTMild hypothermia

SuperRefractory

SE

Special situations..

Monotherapy and lowest possible dose

Supplement with folate at 4 mg/d & genetic counseling

Check AED level monthly

Maternal sAFP levels and USG at 19-20 wks

Oral Vitamin K (20 mg/day) in last 2 weeks

Give 1mg of vitamin K (i/m) for the infant

Rule out eclampsia in status epilepticus

Seizure Disorders in Pregnancy

The management of epilepsy in pregnancy. BJOG 116:758, 2009

Seizure disorders in pregnancy

The management of epilepsy in pregnancy. BJOG 116:758, 2009

Seizure frequency unchanged in 50%, Increase

in 30% & Decrease in 20%

5-6% congenital defects in babies

Valproate-Maximum!

Risk increases with number of medications

Monotherapy as far as possible

Newer drugs??

In utero exposure to Valproate, as compared with other

commonly used AED, is associated with an increased risk of

impaired cognitive function at 3 yr of age. This finding supports

a recommendation that valproate not be used as a 1st drug in

women of childbearing potential.

The NEAD Study

AEDs and ART

Epilepsia, 53(1):207–214, 2012

With Phenytoin--↑Dose of Ritonavir & Lopinavir

With Valproate--↓ Dose of Zidovudine

With Ritonavir / Atazanavir--↑Dose of Lamotrigine

Avoid enzyme inducing AED with PI/NNRTI

Take home message…

Establish the diagnosis of epilepsy before starting

treatment

The choice of AED should be based on seizure type,

affordability and availability of AEDs

Initiate treatment with monotherapy. Use polytherapy

with caution when monotherapy is not successful

The principle, “start low and go slow” should be

followed for AED dosages

Take home message…

Maintain seizure diary, ensure regular

follow up and AED compliance

Conventional AEDs are generally as

effective as newer AEDs and should be the

first line of treatment in most cases

Consider AED withdrawal after 2 years of

seizure-free interval

Thank you..

Continuous video & synchronized EEG recording for

more than 24 hrs.

Documentation of at least 3 or more events

In case of diagnostic uncertainty (e.g. focal seizure of

frontal lobe origin) & if surgical treatment is

considered

Differential diagnosis of type of seizure

Video EEG (VEEG)

FLAIR

Certain lesions such as focal cortical dysplasia

FLAIR increases conspicuity of lesions

Should be part of a standard MRI protocol

Magnetic Resonance Spectroscopy

Reductions in

NAA/(Cho + Cr) ratio in

Temporal lobe epilepsy

Correlate with presence

of hippocampal sclerosis

and correctly lateralize

side of seizure onset in

97% of patients

Diffusion tensor imaging - tractography

Visualise white-matter tracts including connections of eloquent areas

Reduce the risks of surgery

SPECT (Contd..)

Identification of a possible epileptic focus, when structural imaging is unremarkable

Assessment of suitability for epilepsy surgery

SISCOS – subtraction ictal SPECT co-registered with SPECT

SISCOM – subtraction ictal SPECT co-registered with MRI

Pharmacological

Surgery Lifestyle modification

Ketogenic diet

Vagal nerve stimulation

Non-Pharmacological

Treatment modalities


100 mg thiamine IV and

50 mL of 50% dextrose iv if hypoglycemic,

0.1 mg/kg IV Lorazepam (<2 mg/min)

If seizures persist, may repeat initial dose of

Lorazepam once

If no IV access, consider rectal Diazepam 10

to 20 mg

If seizures persist, may repeat initial dose of

Diazepam once

6-10 Min

Dose (in mg/kg)!!!

Lorazepam 0.1

Diazepam 0.15

Midazolam 0.2

Clonazepam 0.015

Beware of sedation,

respiratory depression, and

hypotension

11-30 Min

Phenytoin iv 20 mg/kg by slow push (50

mg/min) or fosphenytoin (150 mg PE/min)

If seizures persist, give additional iv

fosphenytoin or phenytoin to a maximum

total dose of 30 mg/kg

Try to correct metabolic abnormalities if

any

Alternatives to phenytoin are Valproate,

Or Levetiracetam

Beware of cardiac depression and arrhythmia, hypotension,

parasthesias, and pruritis

Valproate 20-30 mg/kg

Levetiracetam 20-30 mg/kg

Rate 500 mg/min

Not FDA

approvd for SE

Established SE


31-60 Min

Midazolam

Propofol

Barbiturates

Intubate the patient

Shift to ICU


EarlyRefractory

SE

Try other general anesthetics

Isoflurane

Desflurane

Ketamine

Lidocaine

Verapamil

Still seizure persists


LateRefractory

SE

What the literature says..?

Which Antiepileptic Drugs Work Best??

High oral efficacy without seizure aggravation

Good tolerability

No or minimal drug interactions

Once or twice daily dosing

Low cost and high cost effectiveness

Pharmacogenetics??

Choosing an Antiepileptic Drug Assess airway, apply o2 & pulse oximetry

Cardiac and hemodynamic monitoring

Venipuncture with 2 large-gauge

intravenous catheters

Stat blood work:

ABG, and antiepileptic drug levels if

appropriate

Treat hypothermia

Check finger-stick glucose

Begin normal saline drip

Etiology

Exacerbation of a pre-existing seizure disorder

Initial manifestation of a seizure disorder

Insult other than a seizure disorder

Change in medication

Toxic , Metabolic or Structural cortical damage

Functional Operations

Division of pathways of spread• Corpus callosotomy

Division of epileptogenic neuronal aggregate

• Multiple subpial transections

Seizures in elderly

Seizures in the Elderly

Clinical history and examination Cardiac evaluation is mandatory ‘Start low and go slow 1st episode of unprovoked seizure: Better to treat (First Seizure Trial) Potential drug interactions!!

Adherence

Frailty and medical comorbidities

Social isolation & Withdrawal

Depression


Epilepsia 43(4), 365–385 (2002)

Lancet Neurol. 2(8), 473–481 (2003)

xamination

0-5 Min

Brief medical and neurological examination

2011; 10: 922–30

Management of Status Epilepticus

Epilepsy Syndromes

Mesial Temporal Lobe Epilepsy Syndrome

Multiple seizure types EEG showing slow (<3 Hz) spike-and-

wave dischargesImpaired cognitive

function

Generalized seizure disorder

Early adolescenceBilateral

myoclonic jerks

Lennox-Gastautx Syndrome

Juvenile Myoclonic Epilepsy

History of febrile seizuresFamily history of epilepsy

Early onsetAura

Behavioral arrestUnilateral or bilateral

anterior temporal spikes on EEG

Lamotrigine

Sodium valproate

Topiramate

Levetiracetam

ValproateLamotrigineTopiramateFelbamate

ZonisamideRufinamide

GabapentinTopiramate

Lamotrigine, Levetiracetam, Oxcarbazepine

Pregabalin LacosamideVigabatrineEzogabine

Temporal lobectomy

Vagus nerve stimulation (VNS)

Head injuryPhenytoin

7 days

Only in severe trauma

StrokeCortical and hemorrhagic

A single seizure may

not be treated

Lamotrigine Gabapentin

Neurocystic-ercosis

AED at least 6 monthsRepeat

imaging at on 6th m

CVSTAED is

recommended for 1year

after 1st episode

Alcohol related

seizuresAED should be continued for 6-12 m

EEG advised

Common provoked seizures


AEDs and ATT

INH and Rifampicin increase Carbamazepine level

Rifampicin reduces Phenytoin and valproate level

Avoid Phenytoin with ATT

AEDs and ATT


LamotrigineCBZ

Ox-CBZPhenytoin

Levetiracetam

TopiramateZonisamide

Valproic acidTiagabine

GabapentinLacosamide

PhenobarbitalFelbamate

ValproateEthosuximide

AED selection-Alternatives

ClonazepamFelbamate


Focal

Atypical absence

MyoclonicAtonic

Typical absence

Generalised onset

Tonic-Clonic

Zonisamide

Phenytoin

Carbamazepine

Felbamate

Topiramate

LamotrigineClonazepam


Definition

Seizure occur due

an acute brain

insult

Structural7days

Metabolic(24 hr)


Management of Common provoked seizures

Other special issues in women

Catamenial epilepsy

Contraception

Breast feeding

Natural progestins or i/m medroxy progesterone

Enzyme inducers decrease efficacy of OCP

No evidence of long term harm on child

Medical

Medical

Non Medical

Non Medical

Factors to consider when deciding whether or not to treat a first unprovoked seizure

Medical Treatment effect on risk of

seizure recurrence

Adverse events A/W AED

Non-medical

Driving and employment

Financial considerations

Social relationships

Newer AEDs – how good? Levetiracetam and carbamazepine produced equivalent

seizure freedom rates in newly diagnosed epilepsy Neurology. 2007;68:402-408.

Lamotrigine and carbamazepine were equally effective, but

lamotrigine was better tolerated.

Epilepsy Res. 1996;23:149-155

New onset geriatric epilepsy-Carbamazepine had the highest seizure-free rates, comparing Gabapentin or Lamotrigine

Neurology. 2005;64:1868-1873

Head to head trials.. Older drugs are still used as 1st line therapy

No evidence that new drugs are more effective

Comparative trials are not necessarily the last word

Decision must be individualized for each patient

"If an epilepsy demon falls many times upon

him on a given day, he seven times punishes him

and possesses him, his life will be spared. If he

falls upon him eight times, his life may not be

spared."Babylonian treatise on epilepsy: Med Hist. Apr 1990;34(2):185-98.

Health & Medicine

Management Of Seizure