Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Higher ages. A patient who has been seizure free for 10 years has been off all anti seizure medications for five years. So seizure free for 10 years. After being off anti seizure medications for five years, you could use the word epilepsy has resolved. What do we mean by unsuccessful treatment? Treatment is unsuccessful. If it does not reduce or stop seizures or if the side effects are intolerable for the person with epilepsy, then what do we mean by drug resistant epilepsy? So it was defined by the International league against epilepsy as failure of adequate trials of two tolerated, appropriately chosen, use anti seizure medication schedules. So it could have been that you use monotherapy of two different drugs or use them in a combination. But yet the patient was unable to achieve seizure freedom. So you must have used two drugs and you must have chosen them appropriately for that type of seizure. And the patient is still not seizure free. What are the types of seizures, seizures are defined by onset? So we have focal, generalized, unknown or unclassifiable in the past focal was one we used to talk about partial seizures. So you had the um simple partial, the complex partial seizures. Now we simply say focal seizures and we grew them into two for that saying, focal aware of focal impaired awareness, seizures, generalized seizure still retains this name. And then you have a class called No, no unclassifiable, which I will still be talking about. So patients who do not meet the criteria for epilepsy, meaning that they just had a single seizure, you should still classify them according to a seizure type. But if classifications should stop there, there shouldn't be a further classification in terms of epilepsy type for that patient. So you only talk about epilepsy types when the patient has epilepsy. If it's just a single seizure, you're not sure of epilepsy is just a seizure type, then the seizure epilepsy type, we have the focal generalized the combined type and then the unknown. So quickly looking at this table, we can see focal seizure being divided into the focal aware where the patient retains the awareness level. While the next one is a focal impaired awareness. This means that at any point during the that seizure, the patient must have lost awareness. It's not necessarily loss of consciousness, but they could be hearing you but they are unable to respond. They are unable to perhaps understand what you're saying at that point. Yeah, awareness had been impaired during the seizure. So each of these is further classified into the motor onset and the non motor onset. So usually you look at the first symptom, the patient is presenting you to classify this. So on motor onset, we have the um automatisms. We have atonic clonic anaptic spasms, the hyperkinetic myoclonic and the tonic. These all do with motor movements. So the non motor onset looks as seizures without physical movement. So here you can have autonomic maybe change in BP, increased heart rate, the patient gets hungry, upper gi disturbances, um sweating comes spelled that all autonomic problems happening. Then you have the behavior arrest. Um it could be means an arrest, a stop in the activities. Basically, the patient is frozen, unable to perform any um physical activity. And for you to actually say a behavioral arrest seizure, it means that they had more of a behavioral arrest all through the seizure. In other words, they are imbo immobilized most of the seizure period. Then there is a cognitive part of um the seizures where they have um abnormal language or thinking. Then there is the emotional and the sensory component also. So looking at the um impaired awareness, you still group it on the motor onset and the non motor onset, the motor onset, looking at the same thing, automatic things. Um atonic clonic athletic, spasms, hyperkinetic, my clonic and tonic while we've already read out the same things for the non motor onset. So then there is generalized, generalized means that of course, it is involving both hemispheres of the brain and they have lost awareness. So there is no need to reclassify according to impaired awareness or um aware seizures. So we only classify into motor and nonmotor at once. Then the unknown onset and the unclassifiable. There is not so much known about these two classifications, what we and most times we don't longer use the um unclassified because already there is an unknown onset type of seizures. So most classifications just go under the unknown onset. So, unknown onset means that it used to describe uh a seizure. If doctors are unaware of where the onset came from, which part of the brain or how it started, you are not sure of it. So it's an unknown onset seizure, it could be motor still or non motor, you know how the seizure manifested or you do not know how it started. They're not classified is a term used if there is not enough information available about the person's seizure or because of the unusual nature of the seizure. So someone has uh a behavior, a particular type of um movement and you feel this is a seizure but you are not sure where it should come under. So it's going to go as unclassified according to for epilepsy types. It is still the same thing explanation. Focal, starting from one part of the brain, then you have a focal impairment and focal awareness, seizures to generalize. And then when we talk about the combined um uh seizures, you're talking about the ones that go from focal to bilateral Toni clonic seizures. So is what we used to call the secondary generalized seizures. So it starts from one part of the brain hemisphere and then involves the other hemisphere of the brain. In other words, it's going from focal to bilateral. So it's now the focal, the bilateral to any clonic seizures. So this is just a table showing the different terminology which from part um from partial to focal generalized remains generalized. You have simple to aware, complex impaired awareness. So it's no longer called a disorder. It's now called a disease because we feel that calling the disease might help to show the seriousness of the serious nature of epilepsy. I'm going to quickly talk about status epilepticus. The good thing is that the guideline basically remains almost the same thing when it comes to um status epilepticus. So first line is always the benzodiazepines. So there is no preference for either of the benzodiazepines, but depending on the setting in which the person is having the seizure, then we could have preferences on which one to use. So the patient is in the hospital we refer to as IV LORazepam reason being is fast acting, it causes rest respiratory depression. Some have shown that it accumulates less than the fast. So as you're given doses of it, you don't expect the patient going to respiratory depression as fast as if you were giving diazePAM. But in a patient that's having a seizure in a community setting that is epilepticus and you want to abort it. We prefer, you use BCA Midazolam first. If the BCA Midazolam is not available, then we can use rectal diazePAM. If you've used LORazepam and 5 to 10 minutes after this patient is having a seizure, you're allowed to repeat it. If this patient keeps having the seizure, then you have to go to the second line because you're giving more of the first line drugs might just cause more side effects of the first line growth. Highly unlikely he's going to stop the seizure at that point. The second line still no preferences. We're still using the levetiractam or phenytoin or VRE. However, because levetiractam is easier, quicker to administer, we would prefer to use that once a patient comes to the hospital and already to use the first time medications. If you try one of the second line drugs, and it's still not important the seizure, then you can try another when you try the second one and it's still not helping, then you can go to the third line drugs. The third line is going to be fab or general anesthesia quickly to investigations. So if a person's um history and examination has suggests that a person has an epileptic seizure, there is a test that we all know usually conduct for the patient and that is the eeg the electroencephalogram. So a routine E eg is carried out while awake to support diagnosis and provide information about seizure type or epilepsy syndrome. A normal E eg does not exclude epilepsy. And it's very important to take note of this. It's just like when you talk about speci it has been more specific and um um sensitive basically. So you talk about that if a patient has a normal eeg, it doesn't mean that they do not have um epilepsy. But if a patient has an abnormal eeg, that is highly likely that they do have epilepsy. So you do the first one, the E eg while awake and prefer to be done within 72 hours after the seizure. And you feel that this patient might have epilepsy. But the eeg that has just been done at that point is still not showing features of epilepsy. What do you do next? So you do consider a sleep deprived eeg. Of course, you have to explain to the family, the side effects and the benefits, the risk of it. If the routine one and the sleep deprived eeg are normal and you still have the diagnostic uncertainty, then you can consider an ambulatory eeg G for up to 48 hours. Almost like when you do the um E CG in the hospital, you feel like there's arrhythmia and then you go for 24 hours E CG uh the 48 hour and all of that. So there are also various maneuvers that we call provoking maneuvers that can be done during an E eg to help to um bring up the light from wastes. So you have things like hyperventilation photo stimulation that's basically like photosensitivity. As we know people with epilepsy sometimes have light sensitivity. So it's like you're trying to trigger it happening. Of course, you have to discuss the side effects advantages, disadvantages with the patient first when it comes to neuroimaging, MRI is the neuroimaging of choice. However, if it is for any reason, contraindicated per have um patients that have pacemakers that cannot be compatible with an MRI. You can consider act scan for these patients. Do not carry out a CT scan for people with established epilepsy presenting at an emergency department after a typical seizure. So we know that people have epilepsy, they come to the hospital with a seizure, they normally have the absent seizure or the generalized clinic seizures and that is what they just had nothing else. We do not need to go do an E CT scan on that patient except we have other concerns. Genetic testing can also be offered usually when you talk about epilepsy syndromes and um other genetic diseases that could be causing epilepsy. And of course, some people also offer things like antibody testing. So to the pharmacological treatment. So before we dive into the pharmacological treatment proper, there are about 3 to 4 things that we need to take note of one sodium VPO when given is only given to boys and men, girls aged on that 10 years who are unlikely to need further treatment when they get to childbearing age or women who are unable to have Children. So these are the only groups that you can give so evaporate at any time too. When someone or a woman is able to have Children who do not give so evaporate and treatment of epilepsy. You can either be using a drug, just one as monotherapy or you could be using two drugs. In other words, one is an add-on treatment for the add-on treatments. You could either have the first line drugs that can be used as add on and there are second line drugs usually that can be used as add on therapy. So for generalized chronic clonic seizure and epilepsy, we have to offer sodium val as a first line monotherapy. Of course, only in the groups that I have mentioned earlier. If so, if first line immunotherapy, sodium va is unsuccessful, then we can offer lamoTRIgine or levetiracetam as a second line immunotherapy treatment. If one is unsuccessful, you could use the other. Just like I said, the caveat here then is that for women and girls that are able to have Children, we will not offer to operate, but I would use lamoTRIgine or Levora as the first line monotherapy option for them. So if monotherapy is unsuccessful in people that you already use um maybe sodium vocate for that, we can consider the first line add on treatments. So there are drugs like clobazepam, um lamoTRIgine, levetiractam, perampanel. Um So the evaporate, if that was why you use topiramate, this can be add on therapies. If one is so unsuccessful, you could use the other. So if first line add-on treatments are tried and they are unsuccessful, then there are the second line add-on treatment options. Just like I said, this group now includes the um brivaracetam, lacosamide fab primidone soem. If one isn't successful, you can try the other. So focal seizures for focal seizures, you can consider lamoTRIgine or levetiractam as a first line monotherapy for people with focal seizures. So in this case, we're not using sodium V. So there's no need for the caveats there. We're going straight lamoTRIgine or levetiractam. So if first line monotherapy are unsuccessful for people with focal seizures, then consider one of the following second line monotherapy options. The second line monotherapy could be carBAMazepine o carbazepine zonisamide. So you could use the other if one is unsuccessful after having used the second line and it still unsuccessful. You can consider lacosamide as a third line monotherapy agent. If unsuccessful, then you can go on to add on treatment options that have been listed here. The carBAMazepine, lacosamide, lamoTRIgine levetiractam, o carBAMazepine, topiramate zonisamide to absent seizures for absent seizures. What we use is eide as a first line treatment for absence seizures. That is absence's seizures only if first line treatment is not successful then you can offer sodium valerate as a second line monotherapy option or add, if second line treatment is unsuccessful, then you can consider lamoTRIgine or levetiractam as a third line monotherapy or add on treatment option. So the following anti seizure medications may exist the base seizures in people with absent seizures. This is why it's necessary to know the type of seizure before you come in an antiepileptic medication. As some drugs could exert other types of seizures. In this case, for some seizures, drugs like carbazepine gabapentin or carbazepine, pital phenytoin, pregabaline, tiaGABine fabr. These can all exacerbate as well seizures. I've talked about absent seizures only but there are patients who present the combination of absent seizures and another type of seizure. For these patients. You're not going to use eem alone because eys is effective mostly for just absent seizures. So if you're going to use it, you will need to still add on another drug. So what's going to be the first line? In this case, sodium evaporate, we then consider lamoTRIgine a Levora time. Of course, for people who are able to have Children, women and girls able to have Children. A first line treatments are tried and they are unsuccessful um for seizure, absent seizures and all seizure types, then we can use lamoTRIgine or Levozem as second line monotherapy or add on treatment or we can use eide as a second line. Add on treatment just like I said, not alone you have to add another drug to eide when using it for patients who have absent seizures alongside other types of seizures. The next one is a myoclonic seizures. So for myoclonic seizures, we offer sodium VPO G as a first line treatment option. Then levetiracetam would be used for women and girls able to bear Children if we have used to upgrade for a male and is also successful as the first line treatment, then we can offer them the Levora as a second line monotherapy or a treatment. If levetiracetam is still unsuccessful, then we can consider one of the following as a monotherapy or add on treatment option such as B brivaracetam, cloBAZam, um clonazePAM, lamoTRIgine, phenyl biol piracetam, topiramate zonisamide, a lot of names and a lot of drugs to know, be aware that lamoTRIgine can occasionally do ex mono chronic seizures and not just um lamoTRIgine. The other medications listed earlier to affect absent seizures. Most of them also exacerbate um mild clonic seizures. So we have to be careful with the medications we use for patients with either of these seizures. The next is the atonic or tonic seizures. So we have to offer sodium to operate again as a first line treatment. But if it's a girl or a woman able to have Children, we will be going with laboratory gene. If sodium val is unsuccessful as first line treatment for tonic or atonic seizures, then we can consider lamoTRIgine. So basically, you see that whenever you have sodium val, you're not going to use it for women and girls able to get Children. So you're going to use either lamoTRIgine in case of atonic seizures or tera in case of malonic seizures. So if the sodium valproate doesn't work for the um males or the boys or women don't need to have Children, then you have to use that second drug, which you will use for women and Children able to bear ch women and girls able to bear Children as you add on a second line drug. So if lamoTRIgine is unsuccessful for treating tonic or atonic seizures, you can then consider one of the following cloBAZam. Um The pyramid can also be used if third line treatment is unsuccessful, then we're going to start talking about things like cic diet which I'm going to talk about later. And then if this is unsuccessful, we can talk about fell by me. But of course, by then, a neurologist would have been involved going to the nonhematological management, which is where some new things that come up in epilepsy management. The first one is going to be vagus nerve stimulation. Um This could be considered as an adjunctive treatment for patients with drug resistant epilepsy who are not candidates for surgery. Of course, this intervention doesn't work for everyone and it has its own risk. So I just according to the picture here to show you how exactly it looks like. So it almost looks like the pacemaker. Yes, the pacemaker like device put under the skin beside the um underneath the left chest and then you have the generator that's what's called. And you have wires that leads that attach to the vagus nerve. So you have the lead that generates the um electricity uh stimuli taken from the lead to the vagus nerve. So as this happens, the lead that's connected to the vagus nerve, which then carries the stimulation all the way to the rest of the brain. So once a patient, the vagal neck keeps giving out stimuli to stop the electric activity that comes up when someone is having seizures. So you have someone that might be having seizures, but then you have the electrical stimulation coming on from the vagus name to in be and stop that electrical abnormal electrical activity that's coming as a result in terms of the seizure. Basically. So current coming from vagal inhibiting, firing against the ones that are coming as a result of the of the seizure or the epilepsy. The next one is the responsive neurostimulation. So it's a surgical approach through three seizures that are not controlled by medication. A neurostimulator is placed under the scalp with seeing the skull and then connected to electrodes. That's the picture there. So you have it there for the electrodes connected here is shown in the brain. It's, it's used to treat people who have failed um to be seizure free on about two antiepileptic medications and are not suitable for resective surgery. I will still be talking about resective surgery. So it's a closed lip system. You basically um have to continuously monitor brain electrical activity. So the you have the um, responsive neurostimulator in the brain is monitoring the electrical activity and once it sees or not any abnormal electrical activities coming up, in terms of the epilepsy wave patterns, it quickly sends a stimulus and stops it. It also tend it's also programmed to learn and to know the pattern of waves in that patient that's exemplify the type of epilepsy they have. So there are waves that the patient might have known for them because of the type of epilepsy they have. Hence, the neurostimulator already knows the types and patterns of waves. And once that wave pattern is coming up, the neurostimulator immediately fires to stop that electrical activity from going on. Apart from this is you can also download the data from the neurostimulator. So daily the person is giving um a laptop, basically download all the information from the neurotransmitter into the laptop and then you upload it weekly to a database that a neurologist can view Asciis. Though, if for any reason you do have a seizure, um patient has a seizure while he has his responsive neurostimulator, he can wave something like a magnet across it which was signaled neurostimulator to record all the patterns, the brain waves, the brain patterns that have occurred during that time. So basically, it saves the electrical activity that happened during the seizure so that your neurologist could look at it later. So these are new advancements. So the patient continues on their A EDS but they have these to help stop the epilepsy or reduce the frequency. And some studies have shown that as much as 82% of patients within three years become almost seizure free with these devices. Then the resective epilepsy surgery, which is known to be the only cure for epilepsy. So unfortunately, it's not something that can be used for everyone in the sense that some people with epilepsy comes from just one focus while other people's own, there are cars in different parts of the brain. So you have a lot of foci. So when you go resecting, you're likely going to have to, it's like the whole large area of the brain, which is not possible. So it's best suited for people that just have single fo um focus of uh or scar causing that epilepsy. So for people who have epilepsy, sometimes there might be a scar, a part of the brain where the focus is coming. So once you remove that um um scar of or part of the brain, then the person becomes seizure free. So it's used usually for Children and young people and adults with drug resistant focal epilepsy. So the next one is the dietary therapies, which according to nice guidelines is not, is not really been found to be so effective, but for a small amount of people because it still has good um um responses in them, we still leave it there. So you have different types of diets. But the ones that seems to be the most common is the ketogenic diet. So you have a lot of um fatty acids in the blood and a low low carbohydrate um diet. So basically, it's not 100% understood how this works. But it is expected that the high amount of the acid is fatty acid tends to reduce certain um chemicals in the brain that helps with epilepsy. So you have a decrease in those chemicals and increase in some inhibitory chemicals. So the person has a less likelihood of having epilepsy and it's necessary that once it start at the diet is continued strictly on. And the next is conclusion, the new classifications um provide a good framework to improve our understanding of seizure and epilepsy diagnosis. Reason being that when you use a classification, when you um state the seizure type, now you're almost telling the person the exact type of seizure the patient has had instead of just saying simple seizure, um partial seizure, you talking now more specifically, which helps the the clinician, which helps the patient also to understand the type of seizure or epilepsy they might have. And when it comes to the treatment of epilepsy, there is great need to individualize it, meaning that even if it's, although we don't routinely that um a EDS as antiepileptic drugs for all patients that come in, that we think have epilepsy. There are times where we might need to start it almost at that first seizure. You know, that was depending on maybe the patients, um does drugs that are high risk or needs the drug started immediately because of the high likelihood that next one is going to be much more damaging. So basically, you need to individualize it. Some people might need drugs that are faster acting, they might need drugs that cause them less cognitive side effects because their jobs have a lot to do with cognition. So every treatment has to be streamlined based on the lifestyle and the justices of the patient. Thank you. These are my references. OK. Um Thank you very much doctor and um your lecture was quite enlightening and uh I will say it was very good. Um It has opened our eyes to a lot of questions and um also it's a lot of things that we didn't know about. Um So I am going to open the floor now for questions. So if you have any question, please, can you as OK, good feedback for her should be in the inbox now. Yes. OK. OK. So the feedback form has been sent. OK. So in the absence of any other question, doctor, um thank you very much for connect. Thank you. So much. Yes. So, um we have come to the end of this um lecture series. Thank you once again and thank you very much for attending.