BIOLOGY

Investigatory
Project

-KRIPAKARA M N
XI
2018-19
R.No:10
 CERTIFICATE
THIS IS TO CERTIFY THAT THIS BIOLOGY INVESTIGATORY PROJECT ON THE TOPIC “STUDY OF EPILEPSY
AND SEIZURE AWARENESS” HAS BEEN SUCCESSFULLY COMPLETED BY KRIPAKARA M N OF CLASS XI
UNDER THE GUIDANCE OF NIKHIL KUMAR M, PGT -BIOLOGY IN THE ACADEMIC YEAR 2018-19 TOWARD
PARTIAL FULFILLMENT OF CREDIT FOR THE BIOLOGY PRACTICAL EVALUATION FOR ANNUAL
EXAMINATION.
  INTRODUCTION

 SIGNS AND SYMPTOMS

 CAUSES

 PATHOPHYSIOLOGY

 CLASSIFICATION

 SEIZURE TYPES
 EPILEPSY SYNDROMES

 MANAGEMENT
 MEDICATION
 SURGERY
 OTHERS

 DEATH
 SOCIETY & CULTURE

EPILEPSY
Epilepsy is a common and diverse set of chronic neurological disorders characterized by
seizures. Some definitions of epilepsy require that seizures be recurrent and unprovoked ,
but others require only a single seizure combined with brain alteration which increase the chance
of future seizures.

Epileptic seizures result from abnormal , excessive or hyper-synchronous neuronal activity in

the brain. About 50 million people worldwide have epilepsy, and nearly 90% of epilepsy occurs in
developing countries. Epilepsy becomes more common as people age .Onset of new cases occurs
mostly frequently in infants and the elderly. As a consequence of brain surgery , epileptic
seizures ma of brain surgery , epileptic seizures may occur in recovering patients.

Epilepsy is usually controlled , but not cured , with medication . However , over 30% of people
with epilepsy do not have seizure control even with the best available medications . Surgery may
be considered in difficult cases .Not all epilepsy syndromes are lifelong – some forms are
confined to particular stages of childhood . Epilepsy should not be understood as a single
disorder , but rather as syndrome with vastly divergent symptoms , all involving episodic
abnormal electrical activity in the brain and numerous seizures.

ICD-10 G40-G41

ICD-9 345

DISEASES D.B 4366

MEDLINE PLUS 000694

e-MEDICINE neuro/415

MeSH D004827
Epilepsy is characterized by a long term risk of recurrent seizures . These seizures may present
in a number of different ways .

Causes
The diagnosis of epilepsy usually requires that the seizures occurs spontaneously . Nevertheless ,
certain epilepsy syndromes

require particular precipitants or triggers for seizures to occur . These are termed reflex epilepsy .
For example , patients with primary reading epilepsy have seizures triggered by reading .
photosensitive epilepsy can be limited to seizures triggered by flashing lights other precipitants
can trigger and epileptic seizure in patients who otherwise would be susceptible to spontaneous
seizures. For example , children with childhood absence epilepsy may be susceptible by
hyperventilation. In fact , flashing lights and hyperventilation are activating procedures used
in clinical - EEG to help trigger seizures to aid diagnosis . Emotional stress , sleep itself , heat
stress , alcohol and febrile illness are example of precipitants cited by patients with epilepsy.
Notably , the influence of various precipitants varies with the epilepsy syndrome . Likewise , the
menstrual cycle in women with epilepsy can influence patterns of seizure recurrence .
Catamenial epilepsy is the term denoting seizures linked to the menstrual cycle .

There are different causes of epilepsy that are common in certain age groups.
 During late infancy and early childhood , febrile seizures are fairly common. These may be
caused by many different things , some thought to be things such as CNS infections and
trauma .
 During childhood , well-defined epilepsy syndromes are generally seen.
 During adolescence and adulthood , the causes are more likely to be secondary to any CNS
lesion . Further , idiopathic epilepsy Is less common .Other causes associated with these age
groups are stress , trauma , CNS infections , brain tumors , and illicit drug use and alcohol
withdrawal .
 In older adults , cerebra-vascular disease is a very common cause . Other causes are CNS
tumors , head trauma , and degenerative diseases that are common in the older age group ,
such as dementia.

When investigating the causes of seizures, it is important to understand physiological

conditions that may predispose the individual to a seizure occurrence . Several clinical and
experimental data have implicated the failure of blood-brain barrier (BBB) function in
triggering chronic or acute seizures , some studies implicate the interaction between a common
blood protein-albumin and atrocities . These findings suggest that acute seizures are a
predictable consequence of disruption of the BBB by either artificial or inflammatory
mechanisms .

PATHOPHYSIOLOGY
Mutation in several genes have been linked to some types of epilepsy . Several genes that code
for protein subunits of voltage-gated and ligand-gated ions channels have been associated
with forms of generalized epilepsy and infantile seizure syndromes .

One speculated mechanism for some forms of inherited epilepsy are mutation of the genes that
code for sodium channel proteins;these defective sodium channel stay open for too long, thus
making the neuron hyper excitable . Glutamate, an excitatory neuron transmitter , may
,therefore , be released from these neurons in large amounts , which – by binding with nearby
glutamatergic neuron –triggers excessive calcium (Ca2+) release in these post-synaptic cells .
Such excessive calcium release can be neurotoxin to the affected cell .The hippocampus , which
contains a large volume of just such glutamatergic neurons (and NMDA receptor, which are
permeable to Ca2+ entry after binding of both glutamate and glycine) , is especially vulnerable
to epileptic seizure , subsequent spread of excitation , and possible neuronal death . Another
possible mechanism involves mutations leading to ineffective GABA (the brain‘s most common
inhibitory neurotransmitter) action. Epilepsy related mutation in some non-ion channel gene
have also been identified.

Much like the channelopathies in voltage-gated ion channels , several ligand-gated ion
channels have been linked to some type of frontal and generalized epilepsies.

Epileptogenesis is the process by which a normal brain develops epilepsy after trauma , such as a
lesion on the brain . One interesting finding in animal is that repeated low-level electrical
stimulation to some brains sites can lead to permanent decrease in seizure “threshold”. This
phenomenon, known as kindling (by analogy with the use of burning twigs to start a large
fire) was discovered by Dr. Graham Goddard in 1967. It is important to note that “kindled“
animal do not experience spontaneous seizures. Chemical stimulation can also induce seizures ;
repeated exposures to some pesticides have been shown to induce seizures in both humans and
animals. One mechanism proposed for this is called excite-toxicity. The roles of kindling and
excite-toxicity , if any , in human epilepsy are currently hotly debated.

CLASSIFICATION
Epilepsies are classified in five Categories:

1. By their first cause(or etiology).

2. By the observations of the seizures , known as semiology.
3. As a part of discrete ,identifiable medical syndromes.
4. By the event that triggers the seizure , such as reading or music.

In 1981 , the International League Against Epilepsy(ILAE) proposed a classification scheme for
individual seizures that remains in common use. This classification is based on observation
(clinical and EEG) rather than the underlying pathophysiology or anatomy and is outlined
later on in this article. In 1989, the ILAE proposed a classification scheme for epilepsies and
epileptic syndromes. This can be broadly describe as a two-axis scheme having the cause on one
axis and the extent of localization within the brain on the other. Since 1997, the ILAE have been
working on a new scheme that has five axes: Descriptive ictal phenomenon, (pertaining to an
epileptic seizure), seizure type syndrome, etiology, impairment.
 SEIZURE TYPES
Seizure types are organized firstly according to whether the source of the seizure within the
brain is localized (partial or focal onset seizures) or distributed ( generalized seizures).
Partial seizures are further divided on the extent to which consciousness is affected. If it is
unaffected, otherwise it is a simple partial seizure ; otherwise it is a complex partial
(psychomotor) seizure. A partial seizure may spread with in the brain – a process known as
secondary generalization. Generalized seizures are divided according to the effect on the
body but all involve loss of consciousness. These include absence (petit mal),myoclonic ,
clonic , tonic , tonic- clonic (grand-mal), and atonic seizures.

Children may exhibit behaviors that are easily mistaken for epileptic seizures but are not caused
by epilepsy.

These include:

 Inattentive staring.
 Begin shudders (among children younger than age 2, usually when they are tired or
exited )
 Self-gratification behaviors (nodding, rocking , head banging)
 Conversion disorder(flailing and jerking of the head ,often in response to severe
personal stress such as physical abuse )

Conversion disorder can be distinguished from epilepsy because the episodes never occur during
sleep and do not involve incontinence or self-injury.

EPILEPSY SYNDROME
Just as there are many types of seizures, there are many types of epilepsy syndromes. Epilepsy
classification includes more information about the person and the episodes than seizure type
alone, such as clinical features (eg; behavior during the seizure) and expected causes.

Each type of epilepsy presents with its own unique combination of seizure type, typical age of
onset , EEG findings , treatment, and prognosis. The most widespread classification of the
epilepsies divides epilepsy syndromes by location or distribution of seizure (as reveled by the
appearance of the seizure and by EEG) and by cause. Syndromes are divided into localization-
related epilepsies epilepsy, or epilepsies of unknown localizations .
 Localizations-
related epilepsies , sometimes termed partial or focal epilepsies , arise from an epileptic focus, a
small portion of the brain that serves as the irritant the epileptic response. Generalized epilepsy,
in contrast , arise from many independent(multi focal epilepsies) or from epileptic circuits that
involve the whole brain . Epilepsies of unknown localization remain unclear as to whether they
arise from a portion of the brain or from more widespread circuits.

Epilepsy syndrome are further divided by presumptive cause: idiopathic, symptomatic, and
cryptogenic .In general, idiopathic epilepsies are thought to arise from genetic abnormalities that
lead to alternation of basic neuronal regulation.
Symptomatic epilepsies arise from the effects of an epileptic lesion , whether that lesion is focal,
such as tumor , or a defect in metabolism causing widespread injury to the brain. Cryptogenic
epilepsies involve a presumptive lesion that is otherwise difficult or impossible to uncover during
evaluation.

The genetic components to epilepsy is receiving particular interest from the scientific
community. Conditions such as ring chromosome 20 syndromes are gaining acknowledgment,
and although only 60 cases have reported in the literature since 1976 “more
widespread cytogenetic chromosomal karyotyping in non etiological cases of epilepsy”is likely.

Some epileptic syndromes are difficult to fit within this classification scheme and fall in the
unknown localization/etiology category. People with seizure that occur only after specific
precipitants (“provoked seizure”), have “epilepsies” that fall into this category. Febrileare an
example of seizure bound to a particular precipitants. Landu-kleffner syndrome is epilepsy
that , because of its variety of EEG distributions, falls uneasily in clear categories. What can be
even more confusing is that certain syndromes, such as infantile spams, can be classified as
idiopathic, syndromic, or cryptogenic depending on cause and can arise from both focal and
generalized epileptic lesions.

Management
Epilepsy is usually treated with medication prescribed by a physician; primary
caregivers, neurologists ,and neurosurgeons all frequently care for people with
epilepsy. However, it has been stressed that accurate differentiation between generalized and
partial seizure is especially important in determining the appropriate treatment. In some cases
the implantations of a stimulator of the vagus nerve, or a special diet can be helpful.
Neurosurgical operations for epilepsy can be palliative , reducing the frequency or severity of
seizures; or in some patients, an operation can be curative.

The proper initial response to a generalized tonic-clonic epileptic seizure is to roll the person
on the side(recovery position)to prevent ingestion of fluids into the lungs, which can result in
choking and death. Should the person regurgitate , this should be allowed to drip out the side
of the person‘s mouth . The person should be prevented from self-injury by moving them away
from sharp edge , and placing something soft beneath the head. If a seizure lasts longer than 5
minutes ,or if more than one seizure occurs without regaining consciousness emergency
medical services should be contacted.

Medication

The mainstay of treatment of epilepsy is anticonvulsant medications. Often , anticonvulsant

medication treatment will be life long and can have major effects on quality of life .The choice
among anticonvulsant and their effectiveness differ by epilepsy syndromes , and side-effects
differ among the individual anticonvulsant medications. Some general findings about the use
of anticonvulsants are outlined below.

Effectiveness –the definition of “effective” varies. FDA approval usually requires that 50% of
the patient treatment group had at least a 50% improvement in the rate of epileptic seizures.
About 20% of patients with epilepsy continue to have breakthrough epileptic seizures despite
anticonvulsant treatment

Safety and side effects – 88% of patient with epilepsy, in a European survey ,
reported at least one anticonvulsant related side-effect. Most side effects are mild and
“dose-related” and can often be avoided or minimized by the use of the smallest effective
amount. Some example include mood changes , sleepiness ,or unsteadiness in gait. Some
anticonvulsant medication have “idiosyncratic” side effects that can not be predicated by
dose. Some examples include drug rashes, liver toxicity(hepatitis), or a plastic anemia
.safety includes the consideration of teratogenicity (the effects of medication on fetal
development) when women with epilepsy become pregnant.
Some of the medicines usually
prescribed for treatment are;

1.Tablet Eptoin

2.Phenytoin

3.Carbamazepine

4.Gabapentin

5.Valproic acid
 Surgery
Epilepsy surgery is an option for people with focal seizure that remains resistant to
treatment. The goal for these procedure Is total control of epileptic seizure, although
anticonvulsant meditation may still be required.

Certain lesions require Long-term video-EEG

monitoring with the use of intra-cranial electrodes if
noninvasive testing was inadequate to identify the
epileptic focus or distinguish the surgical target from
normal brain tissue and function. Brain mapping by
the technique of cortical electrical stimulation are other
procedures used in the process of invasive testing in some
patients.

The most common surgeries are the resection of lesion like tumor or arteriovenous
malformation which , in the process of treating the underlying lesion, often result in control
of epileptic seizure caused by these lesions.

Other lesions are more subtle and feature epilepsy as the main or sole symptom. The most
common form of intractable epilepsy in these disorders in adult is temporal lobe epilepsy
with hippocampal sclerosis, and the most common type of epilepsy surgery is the
anterior temporal lobectomy, or the removal of the front portion of the temporal lobe
including the amygdala . Some neurosurgeons recommend selective surgery because of
possible benefits in postoperative memory or language functions. Surgery for temporal lobe
epilepsy is effective, durable, and result in decrease health care costs. Despite the efficacy is
epilepsy surgery, some patients decide not to surgery owing to fear or the uncertainty of having
a brain operation.

Palliative surgery for epilepsy is intended to reduce the frequency or severity of seizure from
generalization (spreading to involve the entire brain), which result in a loss of consciousness.
This procedure can therefore prevent injuries due to the person falling to the ground after losing
consciousness. It is performed only when the seizure cannot be controlled by other means.
Multiple subpial transections can also be used to decrease the spread of seizures across the cortex
especially when the epileptic focus is located near important functional areas of the cortex.
Respective surgery can be considered palliative if it is undertaken with the expectation that it
will reduce but not eliminate seizure.

DEATH
Body symptoms of the underlying diseases that can be a part of certain epilepsies, people with
epilepsy are at risk for death from four main problem: status epilepticus (most often
associated with anticonvulsant noncompliance),suicide associated with depression ,
trauma from seizure, and Sudden Unexpected Death In Epilepsy (SUDEP). Those at highest risk
for epilepsy-related death usually have underlying neurological impairment or poorly controlled
seizures; those with more benign epileptic syndrome have little risk for epilepsy-related death.

The NICE National Sentinel Audit of Epilepsy-Related Deaths, led by ”Epilepsy Bereaved” drew
attentions to this important problem. The Audit revealed; “ 1,000 deaths occurs every year in the
UK as a result of epilepsy” and most of them are associated with seizure and 42% of deaths were
potentially avoidable.

Certain diseases also seem to occur in higher than expected rates in people with epilepsy , and the
risk of these “co-morbidities” often varies with the epilepsy syndrome.
SOCIETY & CULTURE

LEGAL IMPLICATION
Many jurisdictions forbid certain activities to person suffering from
epilepsy. He most commonly prohibited activities involve operation of
vehicle or machinery, or other activities in which continuous vigilance is
required. However, there are usually exceptions for those who can prove
that they have stabilized their condition. Those few whose seizures do not cause impairment of
consciousness, have a lengthy aura preceding impairment of consciousness, or whose seizure
only arise from sleep, may be exempt from such restrictions, depending on local laws. There is
an ongoing debate in bioethics over who should bear the burden of ensuring that an epilepsy that
an epilepsy patient does not drive a car or fly an airplane.

AUTOMOBILES
In US, people with epilepsy can drive if their seizures are controlled with treatment and they
meet the licensing requirement in their seizures are controlled, but is most likely to be between
three months and a year. The majority of 50 states place the burden
on patients to report their privileges can be revoked where appropriate.
A minority of states place the burden of reporting on the patient’s
physician. After reporting is carried to, it usually the driver’s
licensing agency that decided restrict a driver’s license.
BIBLIOGRAPHY
 http://en.wikipedia.org/wiki/Epilepsy
 http://answers.yahoo.com/question/inde
x?qid=20080712105034AAiTvq8
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 http://www.google.co.in/#hl=en&cp=8&
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