Epilepsy and EEG in Clinical Practice

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1 Mayo School of Professional Development Epilepsy and EEG in Clinical Practice November 10-12, 2016 Hard Rock Hotel at Universal Orlando Orlando, FL Course Directors Jeffrey Britton, MD and William Tatum, DO 2016 MFMER slide-1

2 Mayo School of Professional Development Common Pediatric Epilepsy November 10-12, 2016 Hard Rock Hotel at Universal Orlando Orlando, FL Raj D. Sheth, MD 2016 MFMER slide-2

3 Disclosures Relevant financial relationship(s) with industry None References to off-label usage(s) of pharmaceuticals or instruments None 2016 MFMER slide-3

4 Seizure either Focal Generalized FP1-F7 F7-T3 T3-T5 T5-O1 FP1-F3 F3-C3 C3-P3 P3-O1 FP2-F4 F4-C4 C4-P4 P4-O2 FP2-F8 F8-T4 T4-T6 T6-O2 50 µv 1 sec FP1-F7 F7-T3 T3-T5 T5-O1 FP1-F3 F3-C3 C3-P3 P3-O1 FP2-F4 F4-C4 C4-P4 P4-O2 FP2-F8 F8-T4 T4-T6 T6-O2 50 µv 1 sec 2016 MFMER slide-4

5 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% <1m 1m-2y 2-10y 10-18y 18-60y >60y Generalized Seizures 2016 MFMER slide-5

6 Electroclinical Syndromes EEG Clinical Imaging Syndrome 3 Hz SW 4yo Nl CAE Hypsarrhythmia spasms +/- West Spikes O1 visual Tram-track Sturge-Weber 2016 MFMER slide-6

7 EEG helps in Epilepsy Syndrome Diagnosis Development Exam Imaging EEG background Idiopathic Normal Normal Normal Normal Symptomatic /cryptogenic MR Deficits + Lesion+ Slow + Epileptiform discharges Focal or Gen Focal or Gen 2016 MFMER slide-7

8 Epilepsy Syndrome = Seizure type + EEG Background + Epileptiform discharge + Neuro Exam + Imaging + Cognitive development Why bother? AED selection Prognosis Seizure freedom?out grow epilepsy genetics 2016 MFMER slide-8

9 Focal Epilepsy Syndromes Idiopathic BRE BPEOP Symptomatic Rasmussen s Temporal epilepsy 1m 1 y 2y 5y 10y 15y 18y Adult 2016 MFMER slide-9

10 2016 MFMER slide-10

11 Centro-Temporal Spikes 2016 MFMER slide-11

12 17 yo with epigastric rising & Staring 2016 MFMER slide-12

13 2016 MFMER slide-13

14 2016 MFMER slide-14

15 Seizure either Focal Generalized Idiopathic Symptomatic Idiopathic Symptomatic BRE TLE eg= Absence LGS 2016 MFMER slide-15

16 Generalized Epilepsy JME Idiopathic Absence Symptomatic West LGS 1m 1 y 2y 5y 10y 15y 18y Adult 2016 MFMER slide-16

17 Childhood Absence Epilepsy Hz bisynchronous and symmetrical spike and wave Frontal central voltage predominance Precipitated by hyperventilation May be associated with OIRDA Discharges fragmented during sleep 2016 MFMER slide-17

18 GSW distribution before AED 2016 MFMER slide-18

19 GSW distribution after initiation of AED 2016 MFMER slide-19

20 GSW distribution with maintenance AED 2016 MFMER slide-20

21 Poly-Spike & wave - JME Hz generalized spike and wave /polyspike and wave Prominent in the frontal central regions Precipitated by photic stimulation and hyperventilation Less prominent during sleep, but abundant upon awakening 2016 MFMER slide-21

22 EEG in Catastrophic Epilepsies of childhood Common: West - Infantile Spasms Lennox Gastaut Syndrome Sturge Weber Syndrome 2016 MFMER slide-22

23 Infantile Spasms West syndrome Triad: Infantile Spasms EEG Hypsarrhythmia MR Onset: 3-18 months Most <12 mo (clustering between 4 and 7 months) 2016 MFMER slide-23

24 Infantile Spasms Frequency: Clusters, brief, consisting of as many as 150 seizures At onset of sleep or after awakening. Crying or irritability during or after a flurry of spasms is commonly observed. Dramatic correlation between irritability/regression and onset of spasms and improvement following successful Rx! 2016 MFMER slide-24

25 IS: EEG patterns Hypsarrhythmia High-voltage, slow record dominated by delta activity with frequent and multifocal spikes, sharp waves, and spike and slow wave complexes Chaotic! 2016 MFMER slide-25

26 2016 MFMER slide-26

27 Lennox-Gastaut Syndrome Slow spike & wave (2 Hz) Seizures Tonic Atonic Atypical Absence MR 2016 MFMER slide-27

28 Lennox-Gastaut Syndrome 2016 MFMER slide-28

29 3 year old Perinatal L MCA stroke Wyllie E et al. Neurology 2007;69: American Academy of Neurology 2016 MFMER slide-29

30 Sturge-Weber 8 yo 2013 American Academy of Neurology Wyllie E et al. Neurology 2007;69: MFMER slide-30

31 2016 MFMER slide-31

32 2016 MFMER slide-32

33 Less common: Ohtahara Infantile epileptic encephalopathy with suppression burst neonatal myoclonic encephalopathy and early epileptic encephalopathy in the neonatal period Dravet s Severe myoclonic epilepsy of infancy Doose Astatic-myoclonic epilepsy Rasmussen encephalitis Continuous spike waves in slow sleep and Hemimegalencephaly Other migrational disorders Progressive myoclonus epilepsy 2016 MFMER slide-33

34 Ohtahara syndrome or Early Infantile Epileptic Encephalopathy Onset age:<3 months (often <10 days) Tonic seizures Can have partial seizures Rarely myoclonic seizures. Often unknown Metabolic disorders non-ketotic hyperglycinemia Hemispeheric underdevelopment EEG Burst suppression 2016 MFMER slide-34

35 EEG in PME 2010 P Satishchandra, S Sinha 2016 MFMER slide-35

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