Is it epilepsy? Does the patient need long-term therapy?

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3 Is it a seizure? Definition Transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain Is it provoked or unprovoked? Is it epilepsy? Does the patient need long-term therapy?

4 Syncope Transitory global hypo perfusion of the brain Migraine Drug reaction or intoxication Psychogenic

5 Transient LOC History & Physical Light-headedness Sweating Prolonged standing Precipitants e.g. micturition Chest pain Palpitations Bradycardia Hypotension Deja and Jamais vu Aphasia Olfactory aura Epigastric sensation Tongue biting Post-event delirium Focal Neurology Syncope Seizure

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7 Transient LOC Witness Account Pallor Sweating Bradycardia Hypotension Myoclonus Convulsion Pallor, sweating and collapse Aphasia Delirium Head turn Automatisms Posturing Convulsion Postictal delirium Postictal paresis Syncope Convulsive Syncope Seizure

8 Generalized Tonic-clonic Absence Myoclonic Atonic Focal Unknown Epileptic Spasms ILAE guidelines 2010

9 Primary Goal Is it a seizure? Secondary Goal Provoked (Acute symptomatic seizure) Unprovoked

10 Alcohol & drug intoxication or withdrawal Acute neurologic disorders (within one week of the episode) Infection, stroke, brain trauma, cerebral hemorrhage Metabolic derangement Hypo/ hyperglycaemia Hypo/ hypernatremia Hypomagnasemia Hypocalcaemia Uraemia Hypoxia Hyperthyroidism Dialysis disequilibrium syndrome Porphyria

11 Cryptogenic Unknown aetiology Remote symptomatic seizure Occurs longer than 1 week following a neurological disorder Pre-existing brain injury or lesion Trauma; stroke or tumour Idiopathic Genetic

12 Trauma Minimal risk in patients with a brief period of LOC 12 fold increase (over 10years) Prolonged amnesia Sub-dural haematoma Brain contusion Antiseizure drugs prevent seizures in the first week after head injury; they do not prevent the development of epilepsy Stroke May be an underlying cause in elderly patients

13 Laboratory Evaluations FBC; U&E&G; CMP;LFT; Toxicology Lumbar Puncture EEG Neuroimaging Studies AAN Practice Parameter 2007; Krumholtz et al

14 A Effective; ineffective or harmful At least 2 consistent Class I studies B Probably effective; ineffective or harmful C At least 1 Class I study/ 2 consistent Class II studies Possibly effective; ineffective or harmful At least 1 Class II study/ 2 consistent Class III studies U Inadequate or conflicting data

15 FBC; U&E&G; CMP;LFT; Toxicology Insufficient evidence to support/ refute routine testing Level U Lumbar Puncture Insufficient evidence to support/ refute routine testing* Level U NB! History and clinical examination can guide decision making Persistent altered mental status Focal neurologic deficits Pyrexia

16 Probably helpful Level B 29% demonstrate significant abnormalities Epileptiform activity i.e. spike or sharp waves Predict the risk for recurrence 50% in patients with abnormal EEGs 27% in patients with normal EEGs

17 Probably useful Level B 10% have significant abnormalities Structural lesions Risk for seizure recurrence CT or MRI Yield of MRI is at least as high and likely higher

18 Most seizures remit spontaneously Acute symptomatic seizures Identify and treat underlying aetiology Avoid rapid correction of severe hyponatraemia Anti-seizure drug Seizure lasts >2 minutes Metabolic derangement is expected to persist

19 2 or more epileptic seizures Unprovoked Occur more than 24 hours apart 1 unprovoked and a probability of further seizures Remote structural lesions such as stroke, central nervous system infection or certain types of traumatic brain injury Diagnosis of an epilepsy syndrome NB!! In epidemiologic studies Status epilepticus is considered a single seizure. Febrile and neonatal seizures are excluded from this category

20 Seizure Type First-line Drugs Second-line Drugs Drugs to be avoided GTC Carbamazepine Clobazam Tiagabine Lamotrigine Levetiracetam Vigabatrin Sodium Valproate Oxcarbazepine Topiramate Absence Ethosuximide Clobazam Carbamazepine Lamotrigine Clonazapam Gabapentin Sodium Valproate Topiramate Oxcarbazepine Tiagabine Vigabatrin Myoclonic Sodium Valproate Clobazam Carbamazepine (Topiramate) Clonazapam Gabapentin Lamotrigine Oxcarbazepine Levetiracetam Tiagabine Piracetam

21 Battling Seizure Robots.mp4