Epilepsy (in Greek ‘to seize’) is a neuropsychiatric condition or brain disorder in which

clusters of nerve cells, or neurons, in the brain sometimes signal abnormally.

Neurons normally generate electrochemical impulses that act on other neurons,

glands, and muscles to produce human thoughts, feelings, and actions.

• In epilepsy, the normal pattern of neuronal activity becomes disturbed, causing strange

sensations, emotions, and behavior, or sometimes convulsions, muscle spasms, and loss

of consciousness.

• During a seizure, neurons may fire as many as 500 times a second, much faster than

normal. In some people, this happens only occasionally; for others, it may happen up to

hundreds of times a day.

Etiological Factors

·        The common causes of seizures in infants and children include:

Congenital malformations

Prenatal injuries or hypoxia

Developmental neurologic disorders

Metabolic defects

Injuries

Infections

• In young adults seizures are commonly caused by

Head trauma

Brain tumors

Infection/high fever

Arteriovenous malformations

• In elderly seizures may be caused by

 Cerebrovascular disease

CNS degenerative diseases

Brain tumors are common causes

Genetic risk increases 2-3 times in individuals with first degree relatives suffering

epilepsy

Head trauma

• Precipitating factors of seizures are

Sleep deprivation

Emotional disturbances/stress

Flickering light like in discos, or after watching TV over many hours

Poor drug compliance

Medical drugs such as Chlorpromazine, Haloperidol are safer but can still cause fits in

high doses

Alcohol and drugs like Amphetamine and Cocaine

Hypoglycemia

Clinical Classification

• Seizures are described and distinguished by clinical pattern as

Partial/Focal Seizures - beginning focally in one area of the brain

Generalized Seizures - They start generalized (bilateral) in the whole brain at the same time

Types of Partial/Focal Seizures

• Simple partial seizures with motoric fits of some part of the body but no loss of

consciousness and frequently with aura

• Complex partial seizures with reduced level of consciousness and frequently with aura

• Partial seizures with secondary generalization. These begin as simple or complex partial

seizures but then spread to the rest of the brain and look like generalized tonic-clonic

seizures with movements and frequently with aura

• An aura represents the initial phase of a focal seizure

Types of Primary Generalized Seizure

• Grand Mal Tonic-Clonic Seizure

Grand mal is a French word meaning the ‘big evil’

The most common seizure during which the person fall to the ground

There is sudden loss of consciousness without aura

Tonic and clonic phase of convulsions

Terminal sleep which lasts for minutes to one hour

Phase of being confused, disoriented and dysphoric

• Absence Seizure

Absence or Petit mal a French word meaning ‘small evil’

Starts suddenly without aura

Lasts for some seconds only

Patient does not fall down

Loss of awareness, patient stares , seems absent minded, stops talking or responding

Regains consciousness suddenly without post-ictal abnormalities and continues his

activities as if nothing happened

• Other Types of Primary Generalized Seizures

Myoclonic seizure

Atonic seizure

Differential Diagnosis

• Pyrexia (fever)

Convulsions occuring in children under 5 years due to high grade fever known as

febrile convulsions

In the majority there is no recurrence

Febrile convulsions are not usually labeled as epilepsy

• Brain tumors and abscesses

Mass occupying lesions (SOL) in the cortex cause seizure either partial or secondary

generalized seizures

Hydrocephalus also lowers seizures threshold

• Vascular problems

Seizures sometimes follow cerebral infarction especially in the elderly

There is a peak in incidence late in life

May present with seizures and occasionally a subarachnoid bleeding

• Alcohol, drugs and drug withdrawal

Chronic alcohol abuse is a common cause of seizures

Occurs either while drinking heavily (rum fit) or during periods of withdrawal

Alcohol-induced hypoglycaemia also provokes epileptiform attacks

Antipsychotics such as phenothiazides and antidepressants (tricyclics) may sometimes

precipitate epileptic seizures

Withdrawal of anticonvulsant drugs especially phenobarbitone and benzodiazepines

may provoke seizures

Many medications can lower seizure threshholds (e.g. efavirenz, bupropion)

• Encephalitis and inflammatory conditions

Seizures occur frequently as presenting features of

Viral encephalitis

Central nervous HIV manifestations

Toxoplasmosis

Cytomegalovirus

Bacterial and viral meningitis

Neurosyphilis

CNS cysticercosis (due to calcification by taenia solium cysticerci in the brain)

Cryptococcus meningitis

Cerebral malaria

• Metabolic abnormalities

Seizures are seen with

hypocalcaemia

 Acute hypoxia

Uraemia

Hepatocellular failure

Hypo or hypernatremia

Hypoglycemia

• Degenerative brain disorders

Seizures can occur in dementia like in alzheimer’s disease

• Psychogenic

Seizures which are mimicking epilepsy may occur in hysteria and other dissociative

disorders

• Pueperal

Spontaneous paroxysmal muscular contractions and relaxation in postpartum woman

may mimic epilepsy.

• Eclampsia

Seizures may occur in third trimester pregnancy with hypertension and

glomerulonephritis.

Investigations

Investigations Done in Primary Health Care Facilities

• Blood slides for malaria parasites

• FBP (HB is necessary)

• Urinalysis (albumin is necessary)

• Sputum for AFB

• Serological test of HIV after counseling

• Blood sugar

Investigations Done in Hospitals (in Addition to those Done in Primary Health Care

Levels)

• Renal (Kidney) function test (serum creatinine or urea)

• Liver function test (serum bilirubin, transaminases)

• VDRL (serological test for syphilis)

• Serum electrolytes (Na+ K+ Ca2+ )

• Chest X-ray

• Lumbar puncture (CSF sugar, protein, gram stain, and ZN stain, Indian Ink stain)

Investigations Done in a Consultant Hospitals (in Addition to those Done in Other

Hospitals)

• Brain scan

• Electroencephalogram EEG

• Electrocardiogram

Treatment

Generalized Tonic-Clonic Seizures

• Prevent person from hurting himself or herself

Place something soft under the head

Loosen tight clothing

Clear area for sharp or hard objects

• Do not force any objects into patient's mouth

• Do not restrain patient's movements

• Turn patient on his or her side to allow saliva to drain from mouth

• Stay with the patient until seizure ends naturally

• Do not pour liquids into patient's mouth or offer any food, drink or medication until

she/he is fully awake

• Give artificial respiration if patient does not resume breathing after seizure

• Provide area for patient to rest until fully awakened accompanied by responsible person

• Be reassuring and supportive when consciousness returns

• Convulsive seizure (due to epilepsy) is not usually a medical emergency but presence of

any of the following signs indicate the need for immediate medical attention

Seizure lasting longer than 10 minutes or occurrence of second seizure

Difficulty in rousing at 20-minute intervals

Complaints of difficulty with vision

Vomiting

Persistent headache after a rest period

Unconsciousness

Unequal size pupils or excessively dilated

Other co-morbid conditions (like abnormal breathing, frothing, unusual smell from

the mouth like rotten fish smell)

Pharmacotherapy

• This includes beliefs considering the traditional and customs of a particular society in the

community, some may be superstitious i.e. spirit possession, curse, contagious and

sometimes the beliefs of mistrust of hospital treatment.

• First treatment starts with education concerning epilepsy to the community.

• Since epilepsy is not cured completely but can be controlled, treatment must be

continuous and interchangeable.

Principles of Treating Epilepsy

• Treat underlying cause

• Control the seizures with Phenobarbital

• Initial dose of Phenobarbital for children is 3 - 4 mg/kg once daily or in 2 divided doses,

increase to 8 mg/kg/day if necessary

• In adults – in acute seizures, dilute the injection in 1ml of water for injection, give

10mg/kg at a rate of not more than 100mg/minute (maximum total dose is 1g).

Maintenance dose is 60-200mg per day.

A volunteer will read the following case study and questions. You will be given time to

discuss the answers to the questions. Note down your responses on the worksheet. Be

prepared to share responses in a discussion with the large group.

Definition and Management of Status Epilepticus

Definition

• Status Epilepticus exist when a series of seizures occurs without the patient regaining

awareness between attacks over a period of 30 minutes.

• Most often this refers to recurrent tonic clonic seizure.

• It is a life threatening condition and therefore a medical emergency.

• Status epileptics may be precipitated by abrupt withdrawal of anticonvulsant drugs or the

presence of major structural lesion in the brain or acute metabolic disturbance

Management

• Give immediate care as it appeared in the first aid for seizure notes

General Measures

• Secure intravenous access

• Draw blood for

Glucose

Urea and electrolytes including calcium and magnesium

Liver function and

Sample for future analysis (e.g. drug misuse)

• Give diazepam 10mg IV or rectally repeat once only after 15 minutes

• Monitor vital signs

• If seizure still continues after 30 minutes give Phenobarbital I.V. 10mg/kg at

100mls/minute and refer immediately

Drug Management for Epilepsy

Principles of Treating Epilepsy

• Treat underlying cause

• Control the seizures with Phenobarbital

• Initial dose for children is 3 to 4 mg/kg once daily or in 2 divided doses, increase to 8

mg/kg/day if necessary

• In adults – in acute seizures, dilute the injection in 1ml of water for injection, give

10mg/kg at a rate of not more than 100mg/minute (maximum total dose is 1g).

Maintenance dose is 60-200mg per day.

Figure 2: Phenobarbital Dosage by Age

Age 0 to 2 months 1 years to 5 years 5 years to 15

years Adult

Weight 4kg 8kg to 15 kg

15kg to 35kg

Initial dose

30mg tablet

½ tab x2 1 ½ tab x2 3 tab

50mg tablet 1 tab x2 2 tab

100mg tablet 1 tab 1 tab

Source: Cumming, 2008

Carbamezapine (Tegretol)

Child

• Initially 5mg/kg once daily or in 2 divided doses then increase every 2 weeks up to 10 to

20 mg/kg/day in 2 to 4 divided doses

Adult

• Initially 100-200mg once daily or in 2 divided doses then increase by 100-200mg

increments every 2 weeks up to 800-1200mg per day in 2 to 4 divided doses

• Potential side effects include

Dizziness

Diplopia

Aplastic anemia (rare but potentially fatal). Therefore, need to make sure that CBC

and liver functions are monitored on this medication.

Phenytoin (Epanutin)

Child

• 5 - 8mg/kg/day in 2 to 3 divided doses (max. 300mg)

Adult

• 3-4mg/kg/day or 150-300mg once or twice daily before meals, increase gradually as

necessary in 2 to 3 divided doses

• Usual adult dosing is 200-500mg (max 60mg per day)

• Side effects of medication include

GIT disturbances

Nervousness

Weight loss

Insomnia

Unsteadiness

Hirsutism and excessive motor activity in the adolescents

Haematological disorders

Megaloblastic anaemia

Leucopaenia

Thrombocytopaenia

Agranulocytosis

Aplastic anaemia

Lymphadenopathy (occasionally)

Gingival hyperplasia

Coarse faeces

Acne (especially in adolescents)

Nystagmus in combination with diplopia and ataxia

• Lethargy, confusion and irritability (these are usually severe)

• Usually check blood levels- therapeutic levels are 10-20 ug/mL (40-80 umol/L)

• There are also drug-drug interactions between phenytoin and the protease inhibitors (in the management of HIV)       

 

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Davidson, S (2006). Principles and practice of medicine 20th Ed.  Churchill: Livingstone.

Kumar & Clark (2003) Textbook of clinical medicine. Churchill: Livingstone.

Douglas Model (2006): Making sense of Clinical Examination of the Adult patient. 1st Ed. Hodder Arnold

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