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Aside 25 Jan

11.7. EPILEPSY
A discrete recurrent abnormality in electrical
activity of the brain, resulting in behavioural, motor
or sensory changes. There may be associated
changes in consciousness.
Causes
􀁺 Idiopathic
􀁺 Brain infections
􀁺 Brain trauma
􀁺 Metabolic disorders, eg. hypoglycaemia
􀁺 Congenital malformation, brain tumour
Clinical features
􀁺 Will depend on the type of epilepsy:
Grand mal
􀁺 May commence with a warning sensation in the
form of sound, light or abdominal pain (aura)
􀁺 There may be a sharp cry followed by loss of
consciousness and falling
􀁺 Tonic contraction of muscles occurs followed by
jerking movements (clonic phase)
􀁺 There may be urinary incontinence, frothing and
tongue biting
􀁺 A period of deep sleep follows
􀁺 Episodes of mental confusion may follow
(post-ictal psychosis)
Petit mal
􀁺 Mainly a disorder of children
􀁺 The attack is characterized by a brief loss of
consciousness (5-10 seconds) in which posture is
retained but other activities cease
􀁺 The child has a vacant stare
􀁺 Previous activities are resumed at the end of the
attack
􀁺 Several attacks may occur in a single day
11. Neurological/Psychiatric conditions
UCG 2010 235
Complex–partial seizures (Temporal lobe
epilepsy)
􀁺 Has varied symptoms
􀁺 Signs of autonomic nerve dysfunction, i.e.
sweating, flushing and gastric sensation
􀁺 Mental confusion with perceptual disorders
(illusions, hallucinations), memory loss or
distortion, mood variation, abnormal repetitive lip
movement, automatism.
Focal epilepsy
􀁺 Fits begin with motor contraction or sensory
change in a particular point of the body such as
the thumb.
Myoclonus epilepsy
􀁺 Abnormal jerking movements occur usually in the
limbs but may involve the whole body.
Status epilepticus
􀁺 Convulsive state in which the seizure lasts >30
minutes or several epileptic seizures occur in
succession without recovery of consciousness in
between.
Differential diagnosis
􀁺 Syncope
􀁺 Hypoglycaemia
􀁺 Migraine
􀁺 Hypocalcaemia
􀁺 Conversion disorder
􀁺 Hyperventilation and panic attacks
Investigations
􀂾 Electroencephalogram (EEG)
– useful in petit mal and temporal lobe epilepsy
􀂾 X-ray: skull
􀂾 Other investigations are guided by suspected
cause.
11. Neurological/Psychiatric conditions
UCG 2010 236
Management (depends on type of epilepsy)
Petit-mal
􀁦 ethosuximideinitially 500mg daily in 2 divided doses
– increase if necessary by 250mg every 4-7 days
up to a usual daily dose of 1-1.5g
child >6 yrs: as above
<6 yrs: initially 250mg single dose at night
increased gradually as required to usual
20mg/kg daily in 2 divided doses
Grand-mal
􀁦 phenytoin initially 3-4mg/kg (150-300mg) daily
as single dose or 2 divided doses
− increase gradually prn to usual 200-500mg daily
or carbamazepine
initially 100-200mg 1-2 times HC4
daily increased prn in 100mg increments every 2
weeks to usual 800-1,200mg daily in divided doses
or phenobarbitone 60-180mg at night HC4
child:
􀁦 phenytoin initially 5mg/kg daily in 2 divided
doses HC3
− usual range: 4-8mg/kg daily, max: 300mg daily
or carbamazepine 10-20mg/kg daily
in at least 2 divided doses
or phenobarbitone 8mg/kg daily
Temporal lobe epilepsy
􀁦 carbamazepine – doses as for Grand mal above
Focal epilepsy
􀁦 phenytoin – doses as for Grand mal above
Myoclonic epilepsy
Management as for focal epilepsy
Status epilepticus
􀁦 diazepam 10mg rectally child <4: 5mg
– repeat once prn after 5 mins
or diazepam 10-20mg slow IV (5mg/min)
– repeat once prn after 30-60 mins
11. Neurological/Psychiatric conditions
UCG 2010 237
child: 200-300 micrograms/kg IV or IM per dose
Note:
􀂋 Diazepam: in serious cases of status epilepticus,
doses of 20-40mg, titrated to individual patient
response, may be needed
􀂋 Treatment should always continue until patient is
seizure-free for at least 2 years then gradually
taper off the doses
Prevention
􀁺 Good antenatal care and delivery
􀁺 Control causative factors

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