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Epilepsy (Consequences (localization-related cognitive defects, different…
Epilepsy
Consequences
localization-related cognitive defects
different cognitive consequences even at the same anatomical site
severity of impairment related to extent of lesion
ictal psychic symptoms: fear & anxiety
ictal aggression is very rare & usually verbal or directed towards inanimate objects
biggest impact on cognition is through postictal effects
generalized seizures: doing less well on tasks needing sustained attention, poorer mental abilities
generalized absence seizures are less damaging on cognitive function than tonic-clonic seizures
confounding factor: medication
the earlier in life it begins, the lower the mental abilities, diminished educational attainment
progressive neuronal damage --> cumulative effect of seizures
high seizure frequency & episodes of status epileptics associated with more severe impairment
increased rate of anxiety & panic disorders: especially when seizures of limbic origin
Treatment
Drug Therapy (anticonvulsants eg. Valproate, Carbamazepine) --> preferably monotherapy
surgery for most severe cases e.g. anterior temporal lobectomy
side effects of some drugs: hair loss, depression, behavioral & cognitive disturbance, skin rashes, withdrawal seizures
although anti epileptic drugs can impair NP functioning, their positive effect on seizure control might improve cognition & behavior
Vagal Nerve Stimulation: implanted simulator, reduces neuronal excitability
assess everyone individually (unique seizure & treatment)
newer drugs: lower drop out rates, fewer complaints
A seizure or epileptic attack: consequence of sudden, violent, usually recurring, uncontrolled discharge of neurons in CNS
stereotyped & uncontrollable nature of attack
EEG abnormalities: you can only diagnose epilepsy by doing EEG, by looking at neuronal discharge
central role of glutamate
GABA prevents the development of generalized seizures
complex inheritance
for the majority, the cause remains UNCLEAR
Cause
often a symptom of disease
75%no cause found
CNS infection, vascular disease, head trauma, congenital disorders, neoplasms, anoxia, drugs, alcohol
antidepressants, antipsychotics
multifaceted, overlapping influences
Epileptic discharges
Ictal, Interictal, Subclinical, Focal vs. Generalised, Pattern of spread, Frequency, Status Epilepticus, Age of status, Duration of Epilepsy
Psychosocial
Public attitudes, self-esteem, education opportunities, employment status, marriage status --> STIGMA
Neuropathology
Laterality, Anatomical site, Nature of pathology, Single or Multiple lesions
Antiepileptic Drugs
Monotherapy vs. Polytherapy, Established vs. New Dosage, Concentration in serum
all contribute to poorer QoL
Vocabulary
aura: symptom immediately before a seizure, will localize the attack to its point of origin within nervous system
ictus: attack or seizure itself
prodroma: mood or behavioral changes which precede the attack by some hours
postictal period: time immediately after the ictus during which the patient may be confused, disoriented & demonstrate automatic behaviors
Classification
New: 2017
importance of etiology
based on 3 key factors:
Where seizures begin in the brain?
Level of awareness during a seizure
Other features of seizures
WHERE
Focal: replaces Partial, on one side of the brain
Generalized: engage both brain sides
Unknown onset
Focal to Bilateral
AWARENESS
Focal Aware: replaces Simple Partial Seizure
Focal Impaired Awareness: replaces Complex Partial Seizure
Awareness Unknown eg. if a person lives alone or if seizures occur at night
Generalized seizures --> no special terms needed
Motor & OTHER SYMPTOMS in focal seizures
Focal Motor: some type of movement occurs eg. twitching, stiffening, automatisms
Focal Non-Motor: other symptoms occur first eg. changes in sensation, emotions
Auras: not in the new classification but can be descriptively used
Generalized onset seizures
Motor: Tonic/Clonic
Non-Motor: Absence seizures
Flexible (use of other descriptions is encouraged)
Old: 1989
based upon nature of the attack
Partial (focal, local)
80% of adult epilepsies
Simple Motor: frontal motor cortex, clonic movement, Todd's paralysis after the seizure
Simple Sensory: sensory cortex, tingling on the face
Complex Partial (Focal Impaired Awareness)
temporal lobes, disturbance (visceral, memory, motor, affective)
Partial evolving into tonic/clonic convulsion: subcortical --> cortical
Tonic/Clonic Attacks: Loss of consciousness --> Tonic phase --> Clonic phase
Generalized (convulsive or non-convulsive)
Absences (Petit mal): usually in childhood, staring vacantly
Myoclonic seizures
Tonic (sustained muscular contraction) or Clonic (shaking) or Tonic/Clonic
Atonic: loss of muscle tone & sudden fall
Unclassified
West Syndrome: infants with abnormal EEG, tonic/clonic convulsions, infantile spasms
Lennox- Gastaut Syndrome
Reflex Epilepsies eg. musicogenic, reading, arithmetic
loss of consciousness would always depend on severity
Status Epilepticus
serial epilepsy
when consciousness doesn't return between attacks: life threatening
no satisfactory treatment
Incidence
usually presents in childhood or adolescence
5% of the pop. suffer a single seizure t some time
0.5% have recurrent seizures (70% can be controlled by drugs & 30% resistant to drug treatment)
Methodological pitfalls in research
small numbers & multiple testing
not taking differential elements in individual patients into account
lack of standardization of NP tests
Differential Diagnosis
Cardiac Arrhythmia, Migraine, Hypoglycemia, Episodic confusion, Panic Attacks, Narcolepsy, dPseudoseizures, Regular fainting (vasovagal collapse)