Epilepsias

Generalidades
Dr. Perfecto Oscar González Vargas
Neurólogo
INNN-HMP MP- MDS-CAMELICE-PPE- SOMENE
 Datos Importantes

 Trastorno neurológico común

 Se manifiesta con más de 40 tipos diferentes de crisis
epilépticas y más de 10 síndromes epilépticos
 70% sin etiología específica
 30-45% son fármaco-resistentes
 90 % de los pacientes viven en países subdesarrollados
 La mayoría atendidos por…..Medicina General
In Mexico, is the 3th most common
ILAE (International League Against Epilepsy)
Commission on Classification and Terminology, 1981.
Proposal for revised clinical and
electroencephalographic classification of epileptic
seizures. Epilepsia 22, 489–501.
 Concepto. Historia

Epilepsia: Dos o más crisis epilépticas no provocadas.

Crisis Epiléptica (Latin sacudida—ser poseído por) :

manifestación clínica de una descarga anormal, hipersincrónica
y excesiva de neuronas corticales.
ILAE OFFICIAL
REPORT

Epilepsia 55 (4): 475-482. 2014

 ILAE OFFICIAL
REPORT

Epilepsy is a disease of the brain defined by any of the following conditions

1. A least two unprovoked (or reflex) seizures occurring >24 h

apart
2. One unprovoked (or reflex) seizure and a probability of
further seizures similar to
the general recurrence risk (at least 60%) after two
unprovoked seizures, occurring
over the next 10 years
3. Diagnosis of an epilepsy syndrome
Epilepsy is considered to be resolved for individuals who had an age-dependent epilepsy
syndrome but are now past the applicable age or those who have remained seizure-free for
the last 10 years, with no seizure medicines for the last 5 years.
 Seizure versus Epilepsy

• A seizure is the event

• Epilepsy is the disease associated

with spontaneously recurring
seizures
• Some people now are treated as if they have epilepsy after 1 seizure
 • Risk of epilepsy after 2 seizures

• After two unprovoked seizures, the risk of

a 3rd by 60 months is 73% (59-87%, 95%
confidence intervals.

• So adopt 59 (~ 60%) as the lower end of

the confidence interval for the recurrence
risk we all agree is epilepsy.

Hauser et al. Risk of recurrent seizures after two

unprovoked seizures. NEJM 1998;338:429.
These are not Epilepsy because there is small risk of a
seizure in the absence of a precipitating factor

• Febrile seizures in children age 0.5 – 6 years old

• Alcohol-withdrawal seizures

• Metabolic seizures (sodium, calcium, magnesium, glucose, oxygen)

• Toxic seizures (drug reactions or withdrawal, renal failure)

• Convulsive syncope

• Acute concussive convulsion

• Seizures within first week after brain trauma, infection or stroke
 Características Clínicas de
una Crisis Epiléptica

 Paroxísticas
 No relacionadas con factores externos
 Autolimitadas (8 segundos, < 2 min)
 Impredecibles
 Repetitivas
 Conceptos

 Periodo Ictal. < 2 minutos

 Periodo Postictal. Hasta1 semana. Lo más

común es la confusión. A mayor confusiónindica un
foco en region temporal.

 Período Interictal. Cambios de personalidad

Conceptos
Comicios
 Conceptos

 Fármaco anti-comicial.

 Fármaco anti-crisis
 Conceptos
 Las crisis pueden ser: convulsivas
no-convulsivas.
 Epileptogénesis: secuencia de eventos que convierte una
red neuronal normal en una red hiperexcitable.
Epileptogénesis
 Basic Mechanisms Underlying
Seizures and Epilepsy

 Feedback and
feed-forward
inhibition,
illustrated via
cartoon and
schematic of
simplified
hippocampal circuit
Babb TL, Brown WJ. Pathological Findings in Epilepsy. In: Engel J. Jr. Ed.
Surgical Treatment of the Epilepsies. New York: Raven Press 1987: 511-540.

American Epilepsy Society 2008

Kindling. Pentiltetrazol (PTZ).
 Normal CNS Function

Excitation
Inhibition

glutamate,
aspartate GABA

Modified from White, 2001

American Epilepsy Society 2008

Hyperexcitability reflects both increased excitation and
decreased inhibition

glutamate, Inhibition
aspartate

GABA

Excitation
Modified from White, 2001

American Epilepsy Society 2008

¿Edad de Afección?
 Epidemiología

Pooled life-time (LTE), active epilepsy (AE

México: 16/1000 habitantes

Etiología
 Etiología por Grupos Etáreos

• Pediátricos: hipoxia, neuroinfecciones…

• Adolescentes: TCE…..
• Adultos jóvenes: NCC, TCE, tumores…
• Mayores 55 años: EVC (infartos)….
Clasificación

www.ilae.org
Classification of the Epilepsies

Purpose: for clinical diagnosis

Transparent language: use words that mean what they say

 Seizure types
Focal Generalized Unknown
Etiology
onset onset onset Structural
Co-morbidities

Genetic

Epilepsy types Infectious

Combined
Focal Generalized Generalized Unknown
Metabolic
& Focal

Immune

Unknown
Epilepsy Syndromes
 Generalized
seizures
• Originate at some point
within and rapidly engage
bilaterally distributed
networks
• Can include cortical and
subcortical structures
but not necessarily the
entire cortex
Focal seizures

• Originate within
networks limited
to one hemisphere
• May be discretely
localized
or more widely
distributed.…
Notes
• Atonic seizures and epileptic spasms would
not have level of awareness specified
• Pedalling grouped in hyperkinetic rather
than automatisms (arbitrary)
• Cognitive seizures
• impaired language
• other cognitive domains
• positive features eg déjà vu,
hallucinations, perceptual distortions
• Emotional seizures: anxiety, fear, joy, etc
Note
When a seizure type begins with ”focal,
generalized or absence” then the word
“onset” can be presumed
Terms no longer in use

Complex partial
Simple partial
Partial
Psychic
Dyscognitive
Secondarily generalized tonic-clonic
 Seizure types
Focal Generalized Unknown
Etiology
onset onset onset Structural

Genetic

Tuberous Sclerosis Infectious

Metabolic

Immune
GLUT1 deficiency
Unknown
Old term
‘Idiopathic Generalized Epilepsies’

Idiopathic Generalized
Epilepsies

Childhood Juvenile
Absence Absence
Epilepsy Epilepsy

Juvenile Generalized
Myoclonic Tonic-Clonic
Epilepsy Seizures Alone
Epilepsy syndromes

There are no approved ILAE epilepsy

syndromes
https://www.epilepsydiagnosis.org
 ILAE Classification Task Force 2013-7

Torbjörn Tomson, Emilio Perucca, Ingrid Scheffer, Jackie French, Yue-Hua Zhang
Satish Jain, Gary Mathern, Sam Wiebe, Edouard Hirsch, Sameer Zuberi, Nico Moshe
 Síndromes Epilépticos

• Lennox-Gastaut
• West
• EMJ (Janz)
• Otahara
• Rolándica… etc, etc

C-Slide 24
 Diagnóstico
• Historial Clínica.
Historial de hipoxia, neuroinfección, TCE, etc.
Historial familiar. Raras las formas familiares
• Anamnesis.
¿Es realmente crisis epiléptica?
Tener la mayor certeza diagnóstica
¿Provocada? (hay alteración metabólica, lesión
aguda..)
 Diagnóstico
• Epilepsia.
Focal o Generalizada
Patrón de crisis
• Exámen Neurológico.
Habitualmente es NORMAL
Síndromes neurocutáneos, efectos secundarios de los FAE.
Laboratorio. Estándar.
 STURGE-WEBER

ESCLEROSIS TUBEROSA
 Diagnóstico
Imágen
• TC Cráneo Altamente Recomendable si es:
Parcial
Adultos
Difícil control
Si cambia el patrón de crisis

• Focal. Lóbulo Temporal IRM

Displasia Cortical Focal Atrofia Hipocampal
Diagnóstico
 EEG
• Se analizan diversas variables. La más común es la
Frecuencia. En base a esto (la frecuencia), hay ritmos:

-Delta. 1-3 cps (Hz)

-Theta. 4-7 Hz
-Alfa. 8-12 Hz. Adulto, ojos cerrados, reposo.
-Beta. › 12 Hz
Ausencias. Punta-Onda-Lenta 3 Hz
- Electrocorticografía.
- EEG Alta Densidad
- Video-EEG…
 Tratamiento
• Medidas Generales. Evitar los factores
desencadenantes (supresión de sueño, alcohol,
etc.)
• Tratamiento Farmacológico
• Tratamiento Quirúrgico Estimulación del Nervio Vago
• Otros Tratamientos: Dieta Cetogénica
 Tratamiento Farmacológico

• No hay fármaco ideal.

• El FAE debe ser acorde al tipo de crisis epiléptica
• Iniciar con dosis bajas e incrementar progresivamente
• Monoterapia
• Nunca mas de 4 FAE
• Buscar dosis máximas tolerables y seguras
Antes de 1970 1990 y reciente
 Simbología de FAE

• CBZ: Carbamacepina
• VPA: valproato de magnesio
• LMT: lamotrigina
• TPM: topiramato
• FB: fenobarbital
• DFH: fenidantoína
 Tratamiento
Aspectos Básicos

• Generalizadas. VPA, DFH, LMT, LVT, TPM

VGT, FB, PMD.

• Focales. CBZ, DFH, TPM, LEV,

LMT, OxCBZ
LMT, TPM, VPA
FB, OxCBZ
 Tratamiento
Aspectos Básicos

• Ausencias. 1ª ESM, VPA

2ª LMT

• Mioclónicas. VPA, LMT, TPM, LVT, CNZ

No suministrar DFH
 ¿Qué descontrola un paciente Epiléptico?
• Indisciplina
• Estrés, ansiedad
• Insomnio
• Cambios hormonales
• ………
 Duración del Tratamiento

• No bien claro
• Adulto. 4 años ≈ de tiempo Interictal
asintomático, EEG normal….
• Pediátrico. 2 años ≈

• Pero hay otros factores a determinar.

Tratamientos No Farmacológicos
 Cirugía Funcional
Cirugía de Epilepsia
 Otros Tratamientos
• Dieta cetogénica. Grasa saturada abundante,
utilizada en Epilepsias Catastróficas
• Estimulación del Nervio Vago.
USD 25 mil, eficacia 2-2
Estado Epiléptico
 Status Epilepticus. History..
• A condition when consciousness does not return between
seizures for more than 30 min. This state may be life-
threatening with the development of pyrexia, deepening coma
and circullatory collapse. Death occurs in 5-10%.
• Status epilepticus may occur with frontal lobe lesions (incl.
strokes), following head injury, on reducing drug therapy, with
alcohol withdrawal, drug intoxication, metabolic disturbances or
pregnancy.
• Treatment: AEDs intravenously ASAP, event. general
anesthesia with propofol or thipentone should be commenced
immediately.
Epilepsia. 56 (10): 1515-1523.
2015
 Status Epilepticus
Treatment
Time Treatment

Onset Adequate ventilation/O2/EEG/finger-stick glucose

2-3 min. IV line with NS, rapid assessment, blood draw

4-5 min. Lorazepam 4 mg (0.1 mg/kg) or diazepam 10 mg (0.2 mg/kg)

over 2 minutes IV or rectal
7-8 min. Thiamine 100 mg, 50% glucose 25 mg IV Phenytoin or
fosphenytoin 20 mg/kg IV at  50 mg/per minute phenytoin.
Cardiac rhythm (DFH extrasystoles)
15 min Maximum total dose 30 mg/kg DFH
25 min Intubated. ICU. Pentobarbital, Propofol.
Con esto, un poco de Epileptología.

Sin duda, tienen que estudiar.