Epilepsy is a common neurological condition that affects millions of people around the world, and therefore it is considered an important topic for medical PG exams. Studying epilepsy in the context of the NEET PG exam is rooted in its high prevalence, clinical relevance, diagnostic challenges, and therapeutic options.
In this blog, we have touched upon some important details about this high-yield medicine topic. Read on.
Overview
Epilepsy and seizures are not the same thing. Seizure means abnormal electrical activity due to some metabolic cause. Epilepsy is 2 or more than 2 unprovoked seizures. Convulsion is motor manifestation of seizure.
International league against epilepsy (ILAE) 2017 classified epilepsy as focal seizures (earlier named as partial seizures). There are of the following types -
Focal seizures with intact awareness
Focal seizures with impaired awareness.
Motor or Non-motor
Non motor means hallucinations e.g.: gustatory hallucinations, smell of burning kerosene or burning rubber, complex hallucinations in temporal lobe epilepsy.
Motor focal seizures include: Lip smacking, picking movements, automatism.
Generalized onset
Tonic-clonic
Myoclonic
Absence
Generalized tonic clonic seizures- tonic means tone will increase and a person will give out a loud cry (ictal cry), after that patient falls. In clonus, there is intermittent relaxation also. So initially there is stiffness and after that there will be jerking movement and in between jerking movements muscles will relax. Most GTCS episodes terminate by themselves within one minute. Do not restrain the patient during GTCS as it may cause soft tissue injuries in this patient.
Myoclonus: involuntary sudden jerky movement of limbs.
Absence seizures: characterized by vacant staring spells.
5-10 % of the normal population will have at least one seizure with highest incidence in childhood/late adulthood. Overall incidence of epilepsy: 0.3-0.5%
Seizures
Syncope/vasovagal
Prodromal features
AURA is seen.
Aura is visual blurring seen in migraine or focal seizures. (aura is not seen in GTCS)
Triggered by sight of blood, or on pain
Loss of consciousness
Minutes to hours
Few seconds to minutes.
Tonic clonic movements
Occurs for 30-60 seconds
Occurs for less than 15 seconds.
Facial appearance
Perioral cyanosis
Circum-oral paleness
Tongue bite
Sometimes
Rarely
Disorientation
++
+
Urinary incontinence
++
+
Headache
Sometimes
Rarely
Aching muscles
++
Important information Serum PROLACTIN level rises after an episode of convulsion.
In GTCS lamotrigine and valproate are given. Lamotrigine: side effects are Steven Johnson syndrome (SJS). Hence, lamotrigine is started at the lowest possible dose. Upon development of skin rash lamotrigine is stopped immediately. Valproate is highly teratogenic (7-20%). It causes neural tube defects. Hence it is not used in pregnancy. In pregnancy with GTCS lamotrigine or levetiracetam are used.
Carbamazepine: causes leukopenia, aplastic anemia, hepatotoxicity as a side effect. So, in a patient of liver damage carbamazepine is not given instead oxcarbazepine is given. Eslicarbazepine is given once/day. Phenytoin: phenytoin has nonlinear pharmacokinetics. So, toxicity can develop very fast, hence it is less preferred. Levetiracetam: It is used in elderly individuals due to lack of drug-to-drug interactions
In absence seizures the first line drug is Valproate, but if the age of child is less than 5 years ethosuximide is used.
When to Stop Epilepsy Medication?
Epilepsy medication can be stopped in the following scenarios -
1. Complete medical control for 1-5 years.
2. Single seizure type
3. Normal CNS examination including intelligence
4. No family history
5. Normal EEG
Reasonable to attempt withdrawal after 2 years if all of above are satisfied. Sudden stoppage of Anti-epilepsy medications can lead to rebound epilepsy (frequency, severity and duration of epilepsy can increase).
Important information Lennox-gastaut syndrome: Multiple seizure types in an individual
Valproate and topiramate are not used. All anti-epileptic drugs are teratogenic. But the most teratogenic drug is valproate (7-20% adverse fetal outcome). Phenytoin, carbamazepine, oxcarbazepine causes decrease in vitamin K dependent clotting factors. This can increase the risk of hemorrhagic disease of the newborn. Safest antiepileptic drugs in pregnancy are levetiracetam and lamotrigine. If the patient comes in the 2nd or 3rd trimester, continue the same anti-epileptic drug.
Drug in breast milk /Drug in serum
For valproate it is 5%
Levetiracetam: 300%
Continue anti-epileptic drug in breastfeeding also, but watch for drowsiness and lethargy of baby, if excessive decrease the dose.
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