Statement of Intent - Neuro

1 1 Statement of Intent This guideline is not intended to be construed or to serve as a standard of medical care. Standards of medical care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns evolve. These parameters of practice should be considered as guidelines only. Adherence to them will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care aimed at the same results. The ultimate judgement regarding a particular clinical procedure or treatment plan must be made by the health care provider in the light of the clinical data presented by the patient and the diagnostic and treatment options available.

2 2 Panel of experts: Professor Dato Dr. Raymond Azman Ali (Chairman) Senior Consultant Neurologist Department of Medicine Universiti Kebangsaan malaysia Medical Centre Professor Dato Dr. Tan Chong Tin Senior Consultant Neurologist Department of Medicine Universiti Malaya Specialist Centre Dato Dr. Md Hanip Rafia Senior Consultant Neurologist Department of Neurology Hospital Kuala Lumpur Datuk Dr. Raihanah Abdul Khalid Consultant Neurologist Assunta Hospital Professor Dr. Lim Kheng Seang Senior Consultant Neurologist Department of Medicine University Malaya Medical Centre Professor Hui Jan Senior Consultant Neurologist Department of Medicine Universiti Kebangsaan malaysia Medical Centre Associate Professor Dr.

3 Wong Sau Wei Consultant Paediatric Neurologist Department of Paediatrics Universiti Kebangsaan malaysia Medical Centre Associate Professor Dr. Fong Choong Yi Consultant Paediatric Neurologist Department of Paediatrics Universiti Malaya Medical Centre Dr. Ben Selladurai Consultant Neurosurgeon Sime Darby Medical Centre Subang, Selangor Dr. Rachel Sim Siew Hung Consultant Neurologist Borneo Medical Centre Kuching, Sarawak Dr. Eow Gaik Bee Consultant Neurologist Department of Neurology Penang Hospital Dr. Ahmad Rithauddin Consultant Paediatric Neurologist Institute of Paediatrics Kuala Lumpur Hospital Associate Professor Dr. Vairavan Narayanam Consultant Neurosurgeon Universiti Malaya Medical Centre Panel of reviewers: Dato Dr.

4 Hussain Imam bin Hj Muhammad Ismail Senior Consultant Paediatric Neurologist Penang Hospital Professor Dr. Goh Khean Jin Senior Consultant Neurologist Department of Medicine Universiti Malaya Specialist Centre Professor Dr. Hamidon Basri Senior Consultant Neurologist Department of Medicine Universiti Putra malaysia Dr. Haniffah Abdul Gafoor Consultant Neurologist Island Hospital Penang 3 Dr. Law Wan Chung Consultant Neurologist Department of Neurology Sarawak General Hospital Dr. Law Zhe Kang Neurologist Department of Medicine Universiti Kebangsaan malaysia Medical Centre Dr. Chia Yuan Kang Neurologist Department of Medicine Queen Elizabeth Hospital, Kota Kinabalu Dr.

5 Sherrini Bazir Ahmad Neurologist Department of Medicine University Malaya Medical Centre 4 Table of Contents 1. INTRODUCTION 7 2. CLASSIFICATION OF EPILEPSY 8 3. DIFFERENTIAL DIAGNOSIS OF EPILEPSY 12 4. INVESTIGATIONS IN EPILEPSY 15 5. GENERAL PRINCIPLES OF THE TREATMENT OF EPILEPSY 22 6. LONG TERM PHARMACOLOGICAL TREATMENT 27 7. SURGICAL TREATMENT OF EPILEPSY 46 8. EMERGENCY TREATMENT OF EPILEPSY 55 9. SPECIAL ISSUES 61 10. CONCLUSION 76 11. REFERENCES 77 5 Glossary ACDR Adverse Cutaneous Drug Reaction ACTH Adrenocorticotropic Hormone AED Antiepileptic Drug BCECTS Benign Childhood Epilepsy with Centro-temporal Spikes BDZ Benzodiazepines BOEC Benign Occipital Epilepsy of Childhood BP Blood Pressure CBZ Carbamazepine CNS Central Nervous System CSF Cerebrospinal Fluid CT Computed Tomography DNET Dysembryoplastic Neuroepileptical Tumour ECG Electrocardiogram EEG Electroencephalogram FDA Food and Drug Administration.

6 United States of America FLAIR Fluid-attenuated Inversion Recovery GLUTI Glucose Transporter 1 GTCS Generalised Tonic-clonic Seizures HIV Human Immunodeficiency Virus HLA Human Leukocyte Antigen HLA-B Human Leukocyte Antigen B HRT Hormone Replacement Therapy ICU Intensive Care Unit ILAE International League Against Epilepsy IPTA Institut Pengajian Tinggi Awam (Public Institute of Higher Education) IQ Intelligence Quotient IRPF SPGR Inversion Recovery Prepared Fast Spoiled Gradient Echo IV Intravenous JME Juvenile Myoclonic Epilepsy JPJ Jabatan pengangkutan Jalan (Road Transport Department malaysia ) MAE Myoclonic-Astatic Epilepsy MPRAGE Magnetization Prepared Rapid Gradient Echo MR Magnetic Resonance MRI Magnetic Resonance Imaging MSN Malaysian Society of Neurosciences NCSE Non-convulsive Status Epilepticus 6 NEAD Non-epileptic Attack Disorder NTD Neural Tube Defects OCP Oral Contraceptive Pill PCOS Polycystic Ovarian Syndrome PET Positron Emission Tomography SE Status Epilepticus SJS Stevens Johnson Syndrome SMEI Severe Myoclonic Epilepsy in Infancy SPECT Single Photon Emission Computerised Tomography STIR Short T1 Inversion Recovery SUDEP Sudden Unexpected Death in Epilepsy TEN Toxic Epidermal Necrolysis TIA Transient Ischaemic Attacks UK United Kingdom USA

7 United States of America VEMP Vestibular evoked myogenic potential WHO World Health Organization 71 INTRODUCTION The Epilepsy Council, Malaysian Society of Neurosciences was established in February 2002 to complement the activities organised by the Malaysian Epilepsy Society. In 2005, the Council published a set of guidelines for the management of epilepsy in the country and a revised edition was published in 2010. It had sufficient expertise to make strong recommendations to family physicians, internists, paediatricians, psychiatrists, neurologists, and all relevant healthcare providers pertaining to the management of epilepsy. Local specialists who have national, regional and/or international recognition in the field of epilepsy wrote the chapters in the guidelines.

8 This is the third edition of the guidelines. Most of the chapters have been written and updated by the same authors as the first edition. The chapter on epilepsy classification is written with the knowledge that a new classification is still under construction. The recommendations in the guidelines are based on recent publications as well as the expert opinions of the panel. 82 CLASSIFICATION OF EPILEPSY Introduction The ILAE (International League Against Epilepsy) defines an epileptic seizure as a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain. On the other hand, epilepsy is a disorder of the brain characterised by an enduring predisposition to generate epileptic seizures.

9 The diagnosis of epilepsy normally requires the occurrence of at least two seizures more than 24 hours apart. The diagnosis of epilepsy can also be made after one unprovoked seizure if there is at least a 60% risk of further seizures, such as in patients with a past history of stroke, brain infection or brain trauma. However, seizures arising from an acute brain insult that has a low risk of seizure recurrence, such as hyperglycaemia or hypoglycaemia, do not qualify as epilepsy and are termed acute symptomatic seizures . Classification of epilepsy is firstly a scientific taxonomy to reflect the natural order and classes of the different illnesses that manifest as seizures.

10 It thus reflects the scientific community s current understanding of epilepsy. Classification is also a diagnostic scheme as a practical clinical guide to prognosis and management. The first major internationally accepted classification of epileptic seizures was the 1981 ILAE Classification of Epileptic Seizures (Table 1), which is still widely used worldwide. It is based on clinical and EEG features. Seizures are primarily divided into partial (focal) or generalised. Partial seizures are those where initial activation is limited to a part of one cerebral hemisphere. Generalised seizures are those where the initial involvement is in homologous areas of both hemispheres.