Epilepsy

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Epilepsy

• Morgan Feely
• Consultant Physician
• Target Meeting
• Tong, November 2006

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Epilepsy

• A person is said to have epilepsy when they
  have exhibited a tendency to have recurring
  seizures
• It is not a single disease
• Manifest by underlying brain dysfunction from
  many known or unknown causes
• Single seizures should not be diagnosed as
  epilepsy
• A patient could be said to have one of the
  epilepsies as there are a number of seizure
  types and causes.

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Epidemiology

• Bimodal incidence
• 440,000 active cases in UK
• Typical practice 15 patients per 2000

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Age-specific incidence of treated epilepsy per
100,000 persons(Source Wallace, Shorvon,
Tallis The Lancet, 1998 Dec 1926352
(9145)1952-3)
Incidence/100,000
Age
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The epilepsies

• Generalised epilepsies
• (mostly idiopathic)
• tonic-clonic (T-C)
• and/or absences
• and/or myoclonic seizures

• Location related
• epilepsies
• (mostly symptomatic)
• partial seizures
• partial /- secondary (T-C) generalisation

Over 200 epilepsy syndromes described - mostly of
relevance to young people
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Seizures across the ages
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Making the diagnosis 1
History History and / or Eye witness or
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First tonic-clonic seizure in an adult

• Clinical scenario
• You are asked to see a patient who collapsed and
  appeared to have a fit within the last few days
  and is now back to normal
• What are the key issues?
• Seizure versus (convulsive) syncope
• Provocation (late nights and alcohol, drugs) ?
• Is there any evidence of previous unrecognised
  seizures
• What is the patients occupation / driving
  status?

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Differences between seizures and syncope
Seizures Syncope
Any posture (e.g. in bed at night) Blue lips during attack Stiffness and tonic-clonic movements coincide with loss of consciousness and often last for several minutes Patient is rigid as falls to ground Urinary incontinence common Disorientated or headache afterwards Tongue biting and serious injuries are common Seizures arising from secondary generalisation may be preceded by an aura or recognisable partial seizure Occurs standing (or sitting if elderly) Pale and clammy Brief jerking movements may occur after loss of consciousness Patient loses tone then falls to ground Urinary incontinence can occur Quick recovery Tongue biting rarely serious injuries occur in 5 of cases Often preceded by feeling warm and light headed
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Case 1

• 18 year old female law student attends your
  surgery after
• suffering a blackout following breakfast. Her
  housemate
• had said to her she had a grand mal convulsion.
• Seizure versus syncope
• features to support syncope or convulsive
  syncopeWITNESS / TELEPHONE
• Provocation
• Studying for exams, started drinking at
  university, no illicit drugs
• Is there any evidence of previous unrecognised
  seizures
• Since the age of 16 occasionally daydreams,
  jerks in the morning, cup of tea
• What is the patients occupation / driving status
• Student, drives a car, NB. OCP

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Diagnosis JME
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Case 2

• 42 year old businessman attends surgery following
  a
• generalised seizure. On record he has a heavy
  alcohol
• consumption (gt50 units per week), but has
  recently cut
• down.
• Seizure versus syncope
• No clear witness account, any eye witnesses?
• Provocation
• Alcohol (ab)use and cut down
• Is there any evidence of previous unrecognised
  seizures
• Has had a fit before after binge drinking
• What is the patients occupation / driving status
• Driver. DVLA issues. Provoked seizure?

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Case 3

• 42 year old businessman attends surgery with his
  wife who
• is concerned he is behaving oddly at times,
  repeatedly
• saying things over and over. On record he has a
  heavy
• alcohol consumption (gt50 units per week)
• Seizure versus syncope
• History from wife Golf-traps! Golf-traps! ,
  detached complex partial seizure(s)
• Provocation
• Alcohol use, but not in keeping with focal
  seizure
• Is there any evidence of previous unrecognised
  seizures
• No
• What is the patients occupation / driving status
• Driver. Urgent investigations

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Diagnosis Glioblastoma
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Case 4

• A 69 year old male attends with seven attacks of
  speech
• disturbance lasting 3 minutes over the last 4
  months. He
• has been investigated previously for TIA /
  stroke.
• Seizure versus syncope
• No evidence of syncope. Recurrent stereotypical
  focal neurology. Clean stroke tests.
• Provocation
• No evidence. Not situational. Without warning.
• Is there evidence of unrecognised seizures?
• No
• What is the patients occupation / driving
  status?
• Driver. DVLA issues

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Case 5

• You are asked to see a 73 year old lady in her
  RH. She had a
• previous Left hemi-paresis. The staff think that
  she has had
• another stroke.
• Seizure versus syncope?
• Speak to RH witness. Vacant at onset with
  jerking movements of left upper limb.
• Provocation
• Recently started antidepressant for low mood,
  recent UTI and antibiotics
• Is their evidence of unrecognised seizures?
• RH staff say she occasionally switches off and
  stares into space. Recurrent strokes
• Occupation / driving status
• Less relevant, lifestyle issues. Avoid
  unnecessary tests?

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Making the diagnosis 2
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Making the diagnosis 3
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Management
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Management
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Starting AED treatment in newly diagnosed
epilepsy

• AIMS
• Prevention of seizures
• Minimal side effects
• Optimise QOL

• PRINCIPALS
• Appropriate drug for patients seizure(s)
• Appropriate drug for individual patient
• Through trial and error

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Antiepileptic drug development

More
AEDS
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Levetiracetam
Oxcarbazepine
Tiagabine
Fosphenytoin
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Topiramate
Gabapentin
Felbamate
Lamotrigine
Zonisamide
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Vigabatrin
Sodium valproate
Carbamazepine
Benzodiazepines
Ethosuximide
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Primidone
Phenobarbital
Bromide
Phenytoin
0
1840
1860
1880
1900
1920
1940
1960
1980
2000
Year
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Choice of drug

• Seizure type
• Women of childbearing age
• Pregnancy
• Breastfeeding
• Children
• Elderly
• Learning disability

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Treatment options by seizure type
GENERALISED-ONSET SEIZURES
PARTIAL-ONSET SEIZURES Absence myoclonic tonic
/ atonic primary T-C simple
complex-partial secondary
generalisation Ethosuxamide CARBAMAZEP
INE Phenytoin Vigabatrin Gaba
pentin Oxcarbazepine VALPROATE
LAMOTRIGINE Levetiracetam Topiramat
e Phenobarbital Benzodiazepines

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Initial (first line) treatment

• Drugs for generalised seizures
• Valproate (Epilim Chrono)
• Lamotrigine
• Topiramate

• Drugs for partial seizures (/-
• secondary generalisation)
• Carbemazepine (Tegretol Retard)
• Lamotrigine
• Valproate (Epilim Chrono)
• Levetiracetam
• Topiramate

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Sodium valproate (Epilim Chrono)

• Useful for location related and generalised
  epilepsy
• Can be brought up to therapeutic dose quickly
• Low(er) doses tolerated and possibly drug of
  choice for elderly patients

• Can cause tiredness, tremor, weight gain,
  alopecia
• Teratogenic (spina bifida)

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Carbamazepine (Tegratol)

• Good drug for partial seizures in young(er)
  adults
• Needs gradual build up to a therapeutic dose
• Enzyme-inducer, therefore interactions/oestoporisi
  s
• Most specialists use MR (Tegretol Retard)

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Lamotrigine (Lamictal)

• Broad spectrum
• Good tolerability as monotherapy
• Well tolerated by the elderly
• Synergistic effect with sodium valproate
• Least teratogenic

• Needs to build up slowly (months) to reduce AEs
• Rash common, sometimes severe and associated with
  Steven-Johnsons syndrome
• Blood dyscrasias

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Newer second line agents - Levetiracetam (Keppra)

• Relatively new but appears well tolerated and
  efficacious
• Monotherapy licence
• Licensed for partial seizures /- secondary
  generalisation (may be effective in other seizure
  types)
• Can be started at close to therapeutic range

• Sedation common, though tends to resolve
• Long-term experience still lacking

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Newer second line agents - Topiramate

• Potent anticonvulsant activity
• Useful for most forms of epilepsy

• Often not tolerated due to side effects
  confusion, word-finding difficulties, weight loss
• Needs slow induction

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When to start treatment

• What is the cause?
• What is the risk of recurrence?
• First Vs second seizure?
• What does the patient / carer think?

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Poor control

• Concurrent pro-convulsant drugs Alcohol
• prescription
• Lifestyle Sleep
• Stress
• Concordance / compliance Why?
• ADR
• other drugs
• Social aspects

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Treatment errors

• Incorrect / incomplete detection of seizure(s)
  resulting in inappropriate drug choice.
• Appropriate drug for the seizure(s), but not the
  patient.
• Wrong dose (high or low)
• Seizures are controlled, but intolerance / SE are
  a problem.
• The occurrence of a progressive neurological
  condition

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Prognosis

• 70 80 prolonged remission
• Poor control Structural lesion
• EEG abnormality
• Associated neuropsychiatric disorder
• More than one drug ?
• SUDEP

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AED withdrawal

• Seizure free (remission) gt 3 (2?) years
• Overall risk of recurrence is 40
• Most relapses occur within the first year off
  treatment
• Factors increasing relapse syndrome, structural
  abnormality, severe epilepsy before remission,
  age.
• Discussion risk versus continued therapy
• DVLA 6 month suspension
• Leisure pursuits
• Contraception / pregnancy etc

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Service Level

• Primary Care
• GMS
• Referral First seizure
• Poor control
• Special cases
• AED withdrawal
• Follow-up if stable
• Re-refer

• Secondary care
• Establish diagnosis
• initiate treatment
• Follow up
• Difficult control
• Tertiary referral
• Neuro-oncology
• Obstetrics
• Elderly

Epilepsy Nurse specialists
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