Epilepsy. for students of dentistry

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1 Epilepsy for students of dentistry

2 Epilepsy - definition Chronic neurological disease manifested by repeated non-provoked epileptic seizures Single epileptic seizure reaction of the brain to some type of acute damage with direct and known cause (sleep deprivation, fever, intoxication...)

3 Epileptic seizure Suddenly occuring, short lasting disturbance of consciousness, motor functions, perception, behavior Disturbance of consciousness quantitative or qualitative Abnormal motor phenomena seizures focal, generalized (tonic, clonic, myoclonic) atonia automatic behavior Altered vegetative functions (e.g. mydriasis) Altered behavior, perception, thoughts, speech

4 Epileptic seizure The cause of epileptic seizures is transient disorder of neuronal activity (hyperexcitability, pathological electric activity) affecting the brain to various extent finding on electroencephalography (EEG) Seizures focal and generalized Prevalence in adulthood 1%, children 5% 5% individuals of general population experience one seizure during lifetime

5 Classification of epilepsy According to etiology Idiopatic Symptomatic Cryptogenic According to clinical picture and EEG findings Focal Generalized

6 Classification of epilepsy by etiology Idiopatic epilepsy without evidence of cerebral lesion, genetic predisposition, manifestation in childhood and adolescence Symptomatic epilepsy as a manifestation of another major disease Cryptogenic assumed organic lesion, but not demonstrable by current examination methods

7 Symptomatic epilepsy developmental anomalies vascular cerebral accidents (strokes), arteriovenous malformations traumas tumors (especially of benign type) neurodegenerative diseases intoxication, metabolic disorders, alcohol inflammations hypoxia, anoxia (perinatal, cardiogenic)

8 Classification of epilepsy according to the clinical picture and EEG finding Focal, partial Simple without altered consciousness Complex with altered consciousness (confusion), often with automatism ( psychomotor seizures ) Generalized

9 Generalized epilepsy Affliction of both hemispheres Altered consciousness, amnesia Bilateral symmetrical motor symptoms EEG discharges are often generalized A. Absence B. Myoclonic seizures C. Clonic seizures D. Tonic seizures E. Tonic- clonic seizures F. Atonic seizures

10 Absence Occurs in childhood (4th-12th year of age) Sudden interruption in ongoing activity, absence of consciousness, blank stare, absence of reactions Duration: 5-20 sec High frequency of seizures - status pycnolepticus Good prognosis (80% remission)

11 Absence EEG finding: discharges spike-wave 3 Hz

12 Myoclonic seizures Myoclonus of upper limbs, falls, dropping head Juvenile myoclonic epilepsy (6th chromosome) + GM, occurs after awakening, activation by sleep deprivation and light Myoclonus in neurodegenerative, metabolic diseases

13 Tonic-clonic seizures (grand mal) Loss of consciousness with fall Tonic spasm of limbs, trunk, respiratory muscles (apnoe, cyanosis), eyes rolling back Clonic convulsions, bitting of tongue Vegetative disturbance (tachycardia, mydriasis) Incontinence, hypersalivation Duration cca 2 min Post-paroxysmal phase - sleep, confusional state Risk of injury, aspiration

14 Focal epilepsy Originated from limited, bordered region of cerebral cortex A. Simple (without disturbance of consciousness) 1. motor symptoms (focal motor, motor with progression, adversive) 2. somatosensory or sensitive symptoms (paresthesias, sensory perceptions, vertigo) 3. vegetative symptoms (epigastric problems, sweating, flushing, mydriasis, palpitation) 4. mental symptoms (illusions of deja-vu, deja-entendu, oneiroid states, depersonalization)

15 Focal epilepsy B. Complex (qualitative disturbance of consciousness confusion, obtundation) 1. initiated as simple seizure, consequently disturbance of consciousness 2. initiated by disturbance of consciousness confusion, accompanied by automatisms ( psychomotor seizures ), temporal and frontal lobe C. Secondary generalized partial seizures

16 Focal epilepsy Frontal epilepsy Absence of perception (pseudoabsence), confusion Complex motor manifestation automatic (orofacial) hypermotor seizures Interrupted speech, vocalizations, cry, wheezing, swallowing, salivation Mimic expression of fear, terror Temporal epilepsy Pseudoabsence, confusion, aggressivity Automatic behavior, orofacial automatisms Hallucinations, illusions of deja-vu, depersonalization Vegetative symptoms (gastric and cardiac)

17 Status epilepticus Prolonged seizure or accumulation of seizures (>30min) From therapeutic point of view: every seizure lasting more than min should be managed as status! Convulsive and non-convulsive status Consequences of convulsive status: vegetative disturbances, cerebral hypoxia, metabolic disruption, hyperpyrexia Mortality 8-32%, first 2 hours are crucial for prognosis

18 Examination in epilepsy Electroencephalography (EEG) Long-term video EEG monitoring Imaging techniques of CNS acute CT of the brain, MRI of the brain in every patient with epilepsy to detect event. structural lesion In some cases SPECT (single-photon emission computed tomography), PET, metabolic tests In case of 1. seizure: inflammation markers, biochemical tests (ions, glycemia), ECG

19 EEG recording of electric activity of the brain Focal or generalized epileptiform discharges epileptiform discharges: sharp waves and spikes, complexes of sharp-slow-wave, spike- slow wave

20 EEG There is often negative EEG finding in periods between seizures (40%) Contrary, cca 1% of healthy population has epileptiform finding on EEG Activation methods: hyperventilation, photostimulation, sleep deprivation

21 Differential diagnosis of epilepsy Cardiogenic syncope Tetany Migraines Cerebral vascular accidents (transitory) Psychogenic seizures- pseudo-seizures, conversion (unaware) or simulated Narcolepsy Sleep disorders pavor nocturnus, somnambulism

22 Treatment of epilepsy: pharmacotherapy Antiepileptic drugs: 1. generation: phenobarbital, phenytoin, primidon, etosuximid 2. generation: carbamazepine, valproate, benzodiazepines 3. generation: lamotrigine, levetiracetam, topiramate, gabapentin

23 Treatment of epilepsy: pharmacotherapy Generalized seizures: valproate, lamotrigine, levetiracetam, topiramate Focal seizures: carbamazepine, valproate, lamotrigine, topiramate, levetiracetam Necessary controls of blood cell count, liver enzymes valproate, carbamazepine

24 Treatment of epilepsy: pharmacotherapy Antiepileptic drugs do not cure epilepsy, but they reduce the risk of occurence of seizures There should be an effort to treat by monotherapy with minimal dosage The treatment is initiated after the 2nd seizure. In focal seizures - sometimes after the 1st seizure Duration of treatment: 2 years. If 2 years without seizure are achieved, it is possible to gradually discontinue the medication

25 Treatment of epilepsy : regimen measures Driving is prohibited it can be allowed again after 1 year without seizures No consumption of alcohol, beware of sleep deprivation and photostimulation Prohibition of shift work, working in high altitudes, with rotating machines or working with high voltage. Patients may not have firearm or diving license.

26 Treatment of epilepsy: epilepsy surgery Pharmacoresistence no satisfactory compensation of seizures with use of 2 antiepileptic drugs, in sufficient dosage during 2 years Indicated especially: in temporal epilepsy, in secondary epilepsy with structural lesion, in case of detected epileptic focus

27 Treatment of epileptic seizure and status epilepticus Diazepam mg i.v. or per rectum Status epilepticus (arbitrarily: when duration is more than 30 min, but practically: every seizure should be treated as status after 10 minutes!) Phenytoin 20mg/kg slowly i.v. or valproate15-20 mg/kg i.v. if no effect Barbiturate narcosis (thiopental) or propofol, midazolam.

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