Epilepsy T.I.A. Cataplexy. Nonepileptic seizure. syncope. Dystonia. Epilepsy & other attack disorders Overview

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1 : Clinical presentation and management Markus Reuber Professor of Clinical Neurology Academic Neurology Unit University of Sheffield, Royal Hallamshire Hospital. Is it epilepsy? Overview Common attack disorders How to differentiate between them Medical treatment of patients with epilepsy Choosing appropriate treatment for focal or generalised epilepsy Management strategies What to do when medical treatments for epilepsy fail Epilepsy surgery Vagus nerve stimulation M. Reuber / 2 Differential diagnosis Differential diagnosis Is it epilepsy? Postural Migraine Benign syncope paroxysmal Hypoglycaemia Positional vertigo Dystonia T.I.A. Epilepsy Parasomnia Cardiogenic syncope Cataplexy Hyperventilation Nonepileptic seizure M. Reuber / 3 Is it epilepsy? Related to the heart Problem with blood circulation (Syncope) Idiopathic generalised epilepsy Low blood pressure Blackouts Epileptic seizures Unclassifiable epilepsy Disturbance of brain function Stress-related (nonepileptic seizures) Focal epilepsy M. Reuber / 4 Epileptic Seizure Definition Paroxysmal event in which changes of behaviour, sensation or cognitive processes are caused by excessive, hypersynchronous neuronal discharges in the brain. Characteristics Epileptic Seizures Duration: seconds Positive ictal symptoms Postictal symptoms Stereotypical seizures / syndromal seizure types May occur from sleep May be associated with other brain dysfunction Typical seizure phenomena: lateral tongue bite, déjà vu etc. M. Reuber / 5 M. Reuber / 6 1

2 Secondary generalised seizure Partial seizure: temporal lobe epilepsy M. Reuber / 7 M. Reuber / 8 Definition Partial seizure: frontal lobe epilepsy Syncope Paroxysmal event in which changes in behaviour, sensation and cognitive processes are caused by an insufficient blood or oxygen supply to the brain. M. Reuber / 9 M. Reuber / 10 Characteristics Syncope Situational Typically from sitting or standing Rarely from sleep Presyncopal symptoms Duration 5-30 seconds Recovery within 30 seconds Cardiogenic syncope: less warning, history of heart disease Syncope M. Reuber / 11 M. Reuber / 12 2

3 Definition Syncope Nonepileptic seizure Paroxysmal event in which changes in behaviour, sensation and cognitive function caused by mental processes associated with psychosocial distress. M. Reuber / 13 M. Reuber / 14 Characteristics Nonepileptic seizures (NES) Situational Duration 1-20 minutes Dramatic motor phenomena or prolonged atonia Eyes closed Ictal crying and speaking Surprisingly rapid or slow postictal recovery History of psychiatric illness, other somatoform disorders Nonepileptic seizures M. Reuber / 15 M. Reuber / 16 History taking: value of factual information Epilepsy versus syncope: Factors suggestive of epilepsy Hoefnagels 1991 Sheldon 2002 Sens Spec OR Sens Spec OR Tongue biting Head turning NR NR NR Muscle pain Loss of consciousness >5min NR NR NR Cyanosis Postictal confusion History taking: value of factual information Epilepsy versus syncope: Factors suggestive of syncope Hoefnagels 1991 Sheldon 2002 Sens Spec OR Sens Spec OR Prolonged upright position NR NR NR Sweating prior to LOC Nausea Presyncopal symptoms NR NR NR Pallor NR NR NR Colman N et al. Diagnostic value of history taking in reflex syncope. Clin Auton Res 2004:14 (suppl.1):i/37-44 M. Reuber / 17 Colman N et al. Diagnostic value of history taking in reflex syncope. Clin Auton Res 2004:14 (suppl.1):i/37-44 M. Reuber / 18 3

4 Epilepsy vs. NES Limitation Little differentiating value Differentiate but not noticed / described reliably Differentiate but not commonly reported Differentiate but require expert observation History taking: value of factual information Depend on observations of a seizure witness Feature in the history suggesting NES Pelvic thrusting, no ictal injury, no seizures from sleep, no incontinence or tongue biting. Long duration, closed eyes / mouth during tonicclonic movements, no cyanosis Pre-ictal anxiety symptoms, ictal crying, ictal weeping, vocalisation during tonic-clonic phase Unusually rapid or slow recovery, change in amplitude but not frequency of motor activity, reactivity Common diagnostic mistakes D. Smith et al., Q J Med 1999; 92: % of patients referred to an epilepsy clinic for specialist management of refractory seizures did not have epilepsy Most commonly made mistakes: - Incomplete history, lack of witness account - Misinterpretation syncopal, myoclonic jerks - Misinterpretation of EEG-changes Consequences of misdiagnoses: - 100% treated with anticonvulsants - 39% unemployed - 41% barred from driving M. Reuber / 19 M. Reuber / 20 Common diagnostic mistakes M. Reuber et al., Neurology 2002;58: Diagnostic delay in patients with nonepileptic seizures 120 Mean delay: 100 7,2 years 80 Manifestation 60 Diagnosis 40 Part 2 Medical treatment of patients with epilepsy >70 M. Reuber / 21 M. Reuber / 22 Starting treatment for patients with epilepsy Is it epilepsy? Is treatment indicated? What type of epilepsy is it? Seizure classification and prevalence How common are the different seizure syndromes? Focal Generalised Unclassifiable Provoked / Acute What is the most appropriate drug of first choice? From: Loiseau et al. Epilepsia 1990; 31: M. Reuber / 23 M. Reuber / 24 4

5 Epilepsy syndromes Hippocampal sclerosis (mesial temporal sclerosis) Associated with focal brain abnormality, may start at any age Seizure types: - Partial seizures without impairment of consciousness. (e.g.: Jacksonian seizures, Déjà vu) - Partial seizures with impairment of consciousness (e.g.: Psychomotor seizures) - Secondary generalised seizures First line treatment: Carbamazepine or lamotrigine M. Reuber / 25 M. Reuber / 26 EEG during a right temporomesial seizure (1) EEG during a right temporomesial seizure (2) M. Reuber / 27 M. Reuber / 28 Epilepsy syndromes EEG during a right temporomesial seizure (3) Idiopathic (primary) generalised epilepsy No associated brain abnormality, manifestation usually <30 years Seizure types: - Absence seizures (e.g.: childhood absence epilepsy, juvenile absence epilepsy) - Myoclonic seizures (e.g.: in juvenile myoclonic epilepsy) - Primary generalised tonic clonic seizures (e.g.: Grand mal on awakening) First line treatment: Valproate or lamotrigine M. Reuber / 29 M. Reuber / 30 5

6 Generalised epilepsy Generalised epilepsy Genetic (primary) generalised epilepsy Genetic (primary) generalised epilepsy M. Reuber / 31 M. Reuber / 32 Focal seizures Carbamazepine Oxcarbazepine Eslicarbazepine Phenytoin Vigabatrin Gabapentin Tiagabine Pregabalin Focal & generalised Generalised seizures Valproate Lamotrigine Topiramate Levetiracetam Zonisamide Felbamate Phenobarbitone Primidone Lacosamide Perampanel Ethosuximide (absence only) Rufinamide Modes of action of AEDs M. Reuber / 33 M. Reuber / 34 Modes of action of AEDs Modes of action of AEDs M. Reuber / 35 M. Reuber / 36 6

7 Modes of action of AEDs Using antiepileptic drugs (AEDs) Monotherapy: increase to lowest possible effective dose Monotherapy: increase to fully effective / maximum tolerated dose Consider alternative monotherapy / combination therapy Consider epilepsy surgery (vagal nerve stimulator) Consider reduction to monotherapy in very refractory epilepsy M. Reuber / 37 M. Reuber / 38 Effectiveness of AEDs General principles Common side effects of AEDs Treatment scenario % of patients seizure-free Drawback Drugs All patients (N=525) 63% First AED monotherapy 47% Second / third AED monotherapy 14% Combination therapy 3% From: Kwan P, Brodie JM, NEJM 2000, 342: M. Reuber / 39 Significant cognitive side-effects Significant longterm side-effects High teratogenic potential Hepatic enzyme induction / (inhibition) Non-linear pharmacokinetics Common cause of drug interaction CBZ, PB, PRM, PHT, TPM, ZNS VPA, PHT, CBZ, PB, PRM, VGB VPA CBZ, PHT, PB, PRM / (VPA) CBZ, PHT, VPA CBZ, VPA, PHT, PB, PRM M. Reuber / 40 Epilepsy: clinical presentation and management Available procedures for the treatment of refractory epilepsy Part 3 Curative intent Palliative intent Resective Sx Hemispherectomy Tractotomy Electrostimulation B A M. Reuber / 41 M. Reuber / 42 7

8 Epilepsy: clinical presentation and management Basic conditions for epilepsy surgery with curative intent Movement Epilepsy: clinical presentation and management Outcomes of epilepsy surgery Tonini et al. 1997, meta-analysis, focal epilepsy, : - Engel Class I: 59% - Engel Class II: 15% - Engel Class III: 12% - Engel Class IV: 12% - Frontal lobe (EC I): 40% Memory Vision Wiebe et al. 2000, randomised, ant. temporal lobectomy vs. AED, complete seizure remission at one year: - Epilepsy surgery: 38% (ITT analysis, otherwise 64%) - AEDs: 8% M. Reuber / 43 M. Reuber / 44 Epilepsy: clinical presentation and management Vagal nerve stimulation Epilepsy: clinical presentation and management Summary Diagnosis Medical treatment Other treatments Stimulates 30 sec every 5 minutes Evidence: - 28% mean seizure reduction - 1/3 of patients >50% reduction - Very few patients seizure-free Misdiagnosis is common Epilepsy is overdiagnosed Patient and witness history are essential Consider syncope and NES 70% of patients should become seizure-free with AEDs New AEDs are no more effective than conventional AEDs but have fewer side-effects Epilepsy surgery is very effective if feasible Vagus nerve stimulation is a palliative treatment option for refractory epilepsy M. Reuber / 45 M. Reuber / 46 The End M. Reuber / 47 8