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EPYLEPSY

Epilepsy (from the


Ancient Greek
epilpsa) is
a common chronic
neurological disorder
characterized by
recurrent
unprovoked seizures.

History and stigma


The word epilepsy is derived from the
Ancient Greek epilpsa, which
was from epilambnein "to
take hold of", which in turn was combined
from ep "upon" and
lambnein "to take".
"Sacred Disease"
'disease of the assembly hall'

Classification

Epilepsies are classified in five ways:


By their first cause (or etiology).
By the observable manifestations of the seizures,
known as semiology.
By the location in the brain where the seizures
originate.
As a part of discrete, identifiable medical
syndromes.
By the event that triggers the seizures, as in
primary reading epilepsy or musicogenic epilepsy.

The
International League Against Epilep
sy
1. ictal phenomenon,(pertaining to an
epileptic seizure)
2. seizure type,
3. syndrome,
4. etiology,
5. impairment.

Precipitants
Certain epilepsy
Photosensitive epilepsy
Emotional stress, sleep deprivation, sleep
itself, and febrile illness are examples of
precipitants cited by patients with epilepsy.
Catamenial epilepsy

Example of EEG

Epidemiology

The prevalence of active epilepsy is roughly in


the range 510 per 1000 people.
Up to 5% of people experience non febrile
seizures at some point in life; epilepsy's lifetime
prevalence is relatively high because most
patients either stop having seizures or (less
commonly) die of it.
Epilepsy's approximate annual incidence rate is
4070 per 100,000 in industrialized countries
and 100190 per 100,000 in resource-poor
countries; socioeconomically deprived people
are at higher risk.

Seizure types
Partial or focal seizures
Generalized seizures
Simple partial seizure
Complex partial (psychomotor) seizure
Generalized seizures: absence (petit mal),
myoclonic, clonic, tonic, tonic-clonic
(grand mal) and atonic seizures

Children may exhibit behaviors that are


easily mistaken for epileptic seizures but are
not caused by epilepsy

Inattentive staring
Benign shudders (among children younger than
age 2, usually when they are tired or excited)
Self-gratification behaviors (nodding, rocking,
head banging)
Conversion disorder (flailing and jerking of the
head, often in response to severe personal
stress such as physical abuse)

Epilepsy syndromes

Absence seizures
atonic seizures
benign Rolandic epilepsy
childhood absence
clonic seizures
Juvenile Absence Epilepsy
lennox-gastaut syndrom
Landau-Kleffner Syndrome
myoclonic seizures

complex partial seizures


frontal lobe epilepsy
Febrile seizures
Infantile spasms
Juvenile Myoclonic
Epilepsy
Progressive Myoclonic
Epilepsies
Psychogenic Seizures
Reflex Epilepsy
Simple Partial seizures

Partial epilepsy

., 2003

--Syndromes are
divided into
localization-related
epilepsies,
generalized
epilepsies, or
epilepsies of
unknown
localization.

-- Epilepsy

syndromes
are further divided by
presumptive cause:
idiopathic,
symptomatic, and
cryptogenic.

Below are some common seizure syndromes:

Autosomal dominant nocturnal frontal lobe ep


ilepsy

Catamenial epilepsy
Childhood absence epilepsy
Frontal lobe epilepsy
Juvenile myoclonic epilepsy
Lennox-Gastaut syndrome
Progressive myoclonic epilepsies
Symptomatic localization-related epilepsies
Temporal lobe epilepsy
West syndrome

Treatment

Epilepsy is usually treated with medication


prescribed by a physician; primary caregivers,
neurologists, and neurosurgeons all frequently
care for people with epilepsy. In some cases the
implantation of a stimulator of the vagus nerve,
or a special diet can be helpful. Neurosurgical
operations for epilepsy can be palliative,
reducing the frequency or severity of seizures;
or, in some patients, an operation can be
curative.

status epilepticus

a dangerous condition requiring hospitalization


and emergency treatment.
Objects should never be placed in a person's
mouth by anybody - including paramedics during a seizure as this could result in serious
injury to either party. Despite common folklore, it
is not possible for a person to swallow their own
tongue during a seizure. However, it is possible
that the person will bite their own tongue,
especially if an object is placed in the mouth.

Pharmacologic treatment

anticonvulsant medication treatment will be lifelong

carbamazepine (Tegretol), clorazepate


(Tranxene), clonazepam (Klonopin),
ethosuximide (Zarontin), felbamate (Felbatol),
fosphenytoin (Cerebyx), gabapentin (Neurontin),
lacosamide (Vimpat), lamotrigine (Lamictal),
levetiracetam (Keppra), oxcarbazepine
(Trileptal), phenobarbital (Luminal), phenytoin
(Dilantin), pregabalin (Lyrica), primidone
(Mysoline), tiagabine (Gabitril), topiramate
(Topamax), valproate semisodium (Depakote),
valproic acid (Depakene), and zonisamide
(Zonegran)

Treatment

Effectiveness - 50% of
the patient treatment
group had at least a 50%
improvement in the rate of
epileptic seizures. About
20% of patients with
epilepsy continue to have
breakthrough epileptic
seizures despite best
anticonvulsant treatment.

88% of patients with


epilepsy, in a European
survey, reported at least
one anticonvulsant related
side effect: mood changes,
sleepiness, or
unsteadiness in gait, drug
rashes, liver toxicity
(hepatitis), or aplastic
anemia, the consideration
of teratogenicity.

Surgical treatment

Epilepsy surgery is an
option for patients whose
seizures remain resistant
to treatment with
anticonvulsant
medications who also
have symptomatic
localization-related
epilepsy

Resection of lesions like


tumors or arteriovenous
malformationsions
Anterior temporal
lobectomy
Selective amygdalahippocampectomy
callosotomy or
commissurotomy
Multiple subpial
transection

Other treatment

Ketogenic diet
Electrical stimulation
Vagus nerve stimulation
Responsive Neurostimulator System
Deep brain stimulation
Noninvasive surgery
Avoidance therapy
Warning systems
Alternative or complementary medicine

Pathophysiology
Mutations in several genes
Epileptogenesis
Abnormal mass of tissue in an area of the
brain

Many jurisdictions forbid certain activities to


persons suffering from epilepsy.
In the U.S., people with epilepsy can drive if their
seizures are controlled with treatment and they
meet the licensing requirements in their state.
In the UK, it is the responsibility of the patients to
inform the Driver and Vehicle Licensing Agency
if they have epilepsy.
Persons with a history of epilepsy are usually
prohibited from piloting aircraft, unless it can be
shown beyond a reasonable doubt that future
seizures are extremely improbable.

Vascular Dementia

Vascular dementia is the second most


common form of dementia after Alzheimer
disease (AD). The condition is not a single
disease; it is a group of syndromes relating
to different vascular mechanisms. Vascular
dementia is preventable; therefore, early
detection and an accurate diagnosis are
important.

Vascular disease produces either focal or diffuse


effects on the brain and causes cognitive decline.
Focal cerebrovascular disease occurs secondary
to thrombotic or embolic vascular occlusions.
Common areas of the brain associated with
cognitive decline are the white matter of the
cerebral hemispheres and the deep gray nuclei,
especially the striatum and the thalamus.
Hypertension is the major cause of diffuse
disease, and, in many patients, both focal and
diffuse disease are observed together. The 3
most common mechanisms of vascular dementia
are multiple cortical infarcts, a strategic single
infarct, and small vessel disease.

multiinfarct dementia
single-infarct dementia
Binswanger disease
lacunar state
vascular dementia

Frequency:

Vascular dementia is the second most common cause of dementia in the


United States and Europe, but it is the most common form in some parts of
Asia.
The prevalence rate of vascular dementia is 1.5% in Western countries and
approximately 2.2% in Japan.
In Japan, it accounts for 50% of all dementias that occur in individuals
older than 65 years.
In Europe, vascular dementia and mixed dementia account for
approximately 20% and 40% of cases, respectively.
In Latin America, 15% of all dementias are vascular.
In community-based studies in Australia, the prevalence rate for vascular
and mixed dementia is 13% and 28%, respectively.
The prevalence rate of dementia is 9 times higher in patients who have had
a stroke than in controls.
One year after a stroke, 25% of patients develop new-onset dementia.
Within 4 years following a stroke, the relative risk of incident dementia is
5.5%.

Sex:
The prevalence of vascular dementia
is higher in men than in women.
Age:
Incidence increases with age.

Binswanger disease

The average age of onset is between the


fourth and seventh decades of life, and 80% of
patients have a history of hypertension.
Patients also show progressive motor,
cognitive, mood, and behavioral changes over a
period of 5-10 years. Mood and behavioral
changes are observed early and, in some
patients, may be the presenting feature.
Patients may be apathetic or abulic.
Intellectual deficits are also observed early in
the disease, and patients are frequently
described as confused, inattentive, and vague.
Patients with Binswanger dementia often have
early-onset urinary incontinence and gait
disturbances.

Cerebral autosomal
dominant arteriopathy
The onset of the disease occurs
between the third and fourth decades
of life.
The clinical picture is similar to
Binswanger disease but without a
history of hypertension and risk factors
for cerebrovascular disease.

Vascular dementia in
general
Patients with vascular dementia commonly have
mood and behavioral changes.
Severe depression is more common in persons
with vascular dementia than in those with AD.
In some patients with lacunar state and
Binswanger disease, such problems may be
more prominent than intellectual deficits.
Even psychotic symptoms, particularly
delusions, have been described in patients with
vascular dementia.

The Folstein Mini-Mental State


Examination

Orientation
Registration
Attention
Recall
Language

Scoring:

The DSM-IV diagnostic criteria


The patient has developed multiple cognitive deficits
manifesting as both (1) memory impairment and (2)
one or more of the following cognitive disturbances:
aphasia, apraxia, agnosia, and disturbance in
executive functioning.
The cognitive deficits in the above criteria cause
significant impairment in social or occupational
functioning and represent a significant decline from
the previous level of functioning.
Focal neurological signs and symptoms or radiological
evidence indicative of cerebrovascular disease are
present that are judged to be etiologically related to
the dementia.
The deficits do not occur exclusively during the
course of delirium.

Causes:
Risk factors for vascular dementia
include
hypertension,
smoking,
hypercholesterolemia, diabetes, and
cardiovascular and cerebrovascular
disease.

Medical Care

Recent guidelines from the American


Psychiatric Association provide both
treatment principles and possible specific
therapies

Drug treatment is primarily used to prevent


further worsening of vascular dementia by
treating the underlying disease such as
hypertension and diabetes.

The general management of dementia


includes appropriate referral to community
services, judgment and decision making
regarding legal and ethical issues (eg,
driving, competency, advance directives),
and consideration of caregiver stress.

Diet

In the Rotterdam study, an


increased risk of vascular
dementia was associated with
total fat intake, whereas fish
consumption
was
inversely
related to dementia. Low levels
of folate, vitamin B-6, and
vitamin B-12 are associated with
increased homocysteine levels,
a risk factor for stroke.

Prognosis

According to some studies, vascular


dementia shortens life expectancy by
approximately 50% in men, in
persons with lower education, and in
persons who perform worse on
neuropsychological tests.
The causes of death are due to
complications of dementia,
cardiovascular disease, and
miscellaneous factors, including
malignancy.

Thank you for


attention!