Epilepsy is a symptom which indicates that there is some problem in the physiology of brain.
So, if a person presents with seizures a detailed work up should be done. It begins with detailed history.
Broadly epilepsy is classified as:
GTCS: Generalized Tonic Clonic Seizures
CPS: Complex Partial sezures ( Usually due to temporal lobe involvement, may be associated with hallucinations or other complex symptoms)
Focal seizures
Focal seizures with secondary generalization
In infants and children of less than five year of age, if single episode of seizure occurs during high grade fever, it is most likely a Febrile convulsion for which long term antileptic medication is not required.
In majority of cases , the cause of the seizure is not known. When neuroradiology does not reveal any abnormality and other causes are ruled out after detailed work up , it is labeled as idiopathic epilepsy.
The common causes are infections, neoplasm , trauma, vascular lesions, development, etc. The infective granulomas ( Tubercular, Neurocysticercus, Toxoplasma) , Abscess, Meningitis, encephalitis are the common infective etiologies.
Head injury ( Extradural hematoma, Subdural hematoma, Diffuse axonal injury,etc) may present as Post traumatic Epilepsy, immediately following trauma or at later stage, known as Post Traumatic Late onset Epilepsy.
Brain tumors can present as seizures. All the tumors which involve or compress the cerebral hemispheres may present with seizures. Supratentorial Gliomas and Meningiomas have very high incidence of seizures. Although, Meningioma is an extra axial lesion as it arises from dura ( originates from Arachnoidal Cap Cells), it is associated with brain edema, and so presents with seizures.
Brain metastasis is also associated with brain edema and presents with seizures.
Arterivenous malformation in the cerebral hemispheres usullay presents with seizures in children. Subarachnoid hemorrhage due to rupture of the intracranial aneurysm may present with seizures.
Other brain abnormalities like Schizencephaly, arachnoid cyst, epidermoid may present with seizures.
Mesial Temporal Sclerosis usually presents with Complex partial seizures.
How to investigate a case of Epilepsy?
History, Physical Examination may reveal a clue to the diagnosis, like Tuberculosis, Primary cancers elsewhere in the body.
CT scan or MRI of the brain with contrast with MR spectroscopy
EEG
How to treat Epilepsy?
Sodium Valproate or Phenyton should be used as primary antiepileptic medication, because these two antiepiletics had been in clinical use since very long time, their complications are well known and very much predictable. In case of status epilepticus , their injectable forms are available so a loading dose can easily be delivered. Because of injectable, neurosurgeons can also use them during perioperative period.
Carbamazepine can aso be used as primary antiepileptic medication.
It is very easy to remember the doses of these three very commonly used drugs.
Phenyton, 5 mg/ kg body weight ( so, in an adult of about 50 kg weight give Phenytoin 100 mg TthreeTimes a Day)
Carbamazepine, 10mg/ kg body weight ( so, in an adult of about 50 kg weight give CBZ 200 mg TDS)
Valproate, 15 mg/ kg body weight ( so, in an adult of about 50 kg weight give Valproate 300 mg TDS).Valproate is a very common conditions, like Migraine, Mood disorders, so it may help in comorbid conditions,as well)
Seizures are usually controlled with single antiepileptic drug if prescribed in proper dosage. If it is not controlled increase the dose.
For Long term Antiepileptic medication :Another add on therapy should only be given when the maximum dose of the first drug is already in use and seizures are still uncontrolled.
The first drug to be added is usually Clobazam.
For example, If in an adult operated patient of glioma , seizures were controlled earlier with Tab Phenytoin 100mg TDS, if Seizures occur, add 100 mg : So it will be 100 mg 4 times a day, and seizures are not controlled , an addition of Tablet Clobazam 10 mg can control the epilepsy.
Now, another epileptic is vigorously marketed as primary antiepileptic and also as add-on therapy, i.e., Levetiracetam. This drug has also been use in clinical practice with good safety profile. Moreover, the availability of injectable forms are added advantage, for treating status epilepticus.
Many other antiepileptics are used depending upon condition of the patient. Topiramate is used in cases of migraine and seizure patients with obesity.
So, if a person presents with seizures a detailed work up should be done. It begins with detailed history.
Broadly epilepsy is classified as:
GTCS: Generalized Tonic Clonic Seizures
CPS: Complex Partial sezures ( Usually due to temporal lobe involvement, may be associated with hallucinations or other complex symptoms)
Focal seizures
Focal seizures with secondary generalization
In infants and children of less than five year of age, if single episode of seizure occurs during high grade fever, it is most likely a Febrile convulsion for which long term antileptic medication is not required.
In majority of cases , the cause of the seizure is not known. When neuroradiology does not reveal any abnormality and other causes are ruled out after detailed work up , it is labeled as idiopathic epilepsy.
The common causes are infections, neoplasm , trauma, vascular lesions, development, etc. The infective granulomas ( Tubercular, Neurocysticercus, Toxoplasma) , Abscess, Meningitis, encephalitis are the common infective etiologies.
Head injury ( Extradural hematoma, Subdural hematoma, Diffuse axonal injury,etc) may present as Post traumatic Epilepsy, immediately following trauma or at later stage, known as Post Traumatic Late onset Epilepsy.
Brain tumors can present as seizures. All the tumors which involve or compress the cerebral hemispheres may present with seizures. Supratentorial Gliomas and Meningiomas have very high incidence of seizures. Although, Meningioma is an extra axial lesion as it arises from dura ( originates from Arachnoidal Cap Cells), it is associated with brain edema, and so presents with seizures.
Brain metastasis is also associated with brain edema and presents with seizures.
Arterivenous malformation in the cerebral hemispheres usullay presents with seizures in children. Subarachnoid hemorrhage due to rupture of the intracranial aneurysm may present with seizures.
Other brain abnormalities like Schizencephaly, arachnoid cyst, epidermoid may present with seizures.
Mesial Temporal Sclerosis usually presents with Complex partial seizures.
How to investigate a case of Epilepsy?
History, Physical Examination may reveal a clue to the diagnosis, like Tuberculosis, Primary cancers elsewhere in the body.
CT scan or MRI of the brain with contrast with MR spectroscopy
EEG
How to treat Epilepsy?
Sodium Valproate or Phenyton should be used as primary antiepileptic medication, because these two antiepiletics had been in clinical use since very long time, their complications are well known and very much predictable. In case of status epilepticus , their injectable forms are available so a loading dose can easily be delivered. Because of injectable, neurosurgeons can also use them during perioperative period.
Carbamazepine can aso be used as primary antiepileptic medication.
It is very easy to remember the doses of these three very commonly used drugs.
Phenyton, 5 mg/ kg body weight ( so, in an adult of about 50 kg weight give Phenytoin 100 mg TthreeTimes a Day)
Carbamazepine, 10mg/ kg body weight ( so, in an adult of about 50 kg weight give CBZ 200 mg TDS)
Valproate, 15 mg/ kg body weight ( so, in an adult of about 50 kg weight give Valproate 300 mg TDS).Valproate is a very common conditions, like Migraine, Mood disorders, so it may help in comorbid conditions,as well)
Seizures are usually controlled with single antiepileptic drug if prescribed in proper dosage. If it is not controlled increase the dose.
For Long term Antiepileptic medication :Another add on therapy should only be given when the maximum dose of the first drug is already in use and seizures are still uncontrolled.
The first drug to be added is usually Clobazam.
For example, If in an adult operated patient of glioma , seizures were controlled earlier with Tab Phenytoin 100mg TDS, if Seizures occur, add 100 mg : So it will be 100 mg 4 times a day, and seizures are not controlled , an addition of Tablet Clobazam 10 mg can control the epilepsy.
Now, another epileptic is vigorously marketed as primary antiepileptic and also as add-on therapy, i.e., Levetiracetam. This drug has also been use in clinical practice with good safety profile. Moreover, the availability of injectable forms are added advantage, for treating status epilepticus.
Many other antiepileptics are used depending upon condition of the patient. Topiramate is used in cases of migraine and seizure patients with obesity.
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