Transcript
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Cerebral lobe syndromesCerebral lobe syndromes
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LAYERS OF CORTEX
1. Molecular: horizontal axons, golgi 2 cells
2. Ext. Granular: granule cells
3. Ext. Pyramidal: commisural fibers
4. Int. Granular: stellate cells, ext. band ofBaillarger
5. Int. Pyramidal: Largest cells
6. Multiform Layer
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LAYERS OF CORTEX
1 & 2: receive diffuse afferent fibers
from lower brain to control
excitability of region
3: connect two hemispheres and
ipsilateral cortico-cortico
association fibers
4: main sensory afferent input
(in sensory cortex)
5: main efferent to brain stem
and spinal cord(in motor cortex)
6: efferent fibers to thalamus
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GGENERAL ANATOMYENERAL ANATOMY Frontal Lobe
Temporal Lobe
Parietal Lobe
Occipital Lobe
Insula
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Frontal lobeFrontal lobe
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Frontal lobeFrontal lobe
Highest level of brain evolution
Involved in many functions
Lesions in different parts lead to different
syndromes
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Frontal lobeFrontal lobe
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Frontal lobe syndromeFrontal lobe syndrome
Lesions of the motor area lead to motordeficits of the opposite half of the body Irritative lesions jacksonian motor seizures
Lesions of premotor areas less importantmotor deficit Irritative lesions in premotor areas
adversive seizures, or supplementarymotor area seizures
Supplementary motor area seizures:cessation of all activity, tonical contractionsof proximal muscles, repetitions, pallilalia
Premotory areas lesions: diminishment ofspontaneous movements, delay of voluntaryactions (movements), eventually
hyopkinesia, akinesia, tremor Forced prehension
Gait and posture abnormalities; frontal ataxia
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PPREFRONTAL CORTEXREFRONTAL CORTEX
Frontal pole Areas 9,10,11
Plays a role in affective behavior and judgment
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PPREFRONTAL CORTEXREFRONTAL CORTEX
Pts with bilateral lesions neglect their appearance,act inappropriately, have no appreciation of social
norms for conduct. They are uninhibited and highly
distractable
Perseveration
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Frontal lobe syndromeFrontal lobe syndrome
Prefrontal areas lesions
Alteration of personality
Diminishment of spontaneous activity - the patient does not feel the
need to do anything, is not able to plan the future events, may be
agitated Attention deficits memory is normal, but the patient doesnt bother to
use it
Loss of abstract thinking
Perseveration
Afffective changes either apathic, flat, either excessively exuberantand childish; may show lack of inhibition, eventually sexually improper
actions
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Frontal lobe syndromeFrontal lobe syndrome
Prefrontal dorsolateral cortex lesions
Diminished fluency (verbal & nonverbal),
reasoning problems, reduction of spontaneous
responses inhibition, perseveration, attentiondeficits
Orbitofrontal cortex lesions desinhibition,
anosmia
Mezial frontal cortex, anterior cingullary
cortex lesions apathy, abulia, memory
impairments
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Cognitive function testing in frontalCognitive function testing in frontal
lobe lesionslobe lesions
MMS does not approach these problems
Frontal lobe tests:
go-no go tests patient is told to lift 2 fingers, but theevaluator lifts only 1
Speech fluency patient is asked to produce as many
words he can starting with letter Z normally more than 8
words/ 1 min
Motor tests for perseveration patient is asked to execute
series of 3 movements (fist, edge-palm tests Luria)
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Parietal lobeParietal lobe
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Parietal lobeParietal lobe
Anterior somatosensory area,posterior association area
4th neuron of sensory tracts(3, 1, 2 areas primarysomatosensory cortex
5, 7, 39, 40 areas somatosensory associationareas; areas 5 and 7 areimportant for stereognosis
Parietal regions haveappeared when the fingerswere used for more than justmobility (catching, throwing)
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Parietal lobe syndromesParietal lobe syndromes
Controlateral hemihypestesia (diminished sensation)
Astereognosis (5 & 7 areas lesions)
Sensory epilepsy (paresiae and sometimes paroxisticalpain)
Asomatognosia (left hemisphere lesions lead to one sideasomatognosia, anosognosia, anosodiaforia, neglect of leftbody half)
Right parietal lobe spatial component of activities
Apraxia loss of the ability to execute or carry out learnedpurposeful movements, despite having the desire and thephysical ability to perform the movements
Finger agnosia
Left-right agnosia
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Parietal lobe syndromesParietal lobe syndromes
Left parietal lobe symbol and experiences comprehension
ideomotor (inability to carry out a motor command or a learned gesture,
for example, "act as if you are brushing your teeth" or "salute")
limb apraxia when movements of the arms and legs are involved,
nonverbal-oral or buccofacial (inability to carry out facial movements oncommand, e.g., lick lips, whistle, cough, or wink),
ideational (inability to create a plan for or idea of a specific movement,
for example, "pick up this pen and write down your name")
Inability to use the informations on spatial relations
Constructive apraxia
Topographic agnosia
Prosopagnosia
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AAPRAXIAPRAXIA
Apraxia = inability to perform skilled, learned, purposefulmotor acts correctly despite intact motor and sensory
systems, and normal attention and comprehension
Ideomotor Apraxia
Inability to carry out, on verbal command, an activity
that can be performed spontaneously
Summary of path activatedwhen pt. asked to move his
left hand
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AAPRAXIAPRAXIA
Ideational Apraxia
Abnormality in the conception of movement so that
the the pt. has difficulty sequencing the different
components of a complex motor task
Lesion in dominant temporo-parieto-occipital area
Constructional Apraxia
Inability of the pt to put together or articulate
component parts to form a single shape or figure, eg
assembling blocks to form a design
Can be seen with either dominant or nondominant
posterior parietal lesions, although more common
and severe in nondominant lesions
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Constructive apraxiaConstructive apraxia
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Parietal lobe syndromesParietal lobe syndromes
Speech problems frequentlyassociated with writing problems
Motor abnormalities (diminishmentof spontaneous movements,unstable hand, syncynesia)
Balance problems
Taste problems (area 43)
Hemianopia
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Parietal lobeParietal lobe
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Adaptative
possibilities of
parietal lobes
blind boy readswith the tip of his
nose
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Temporal lobeTemporal lobe
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TTEMPORALEMPORAL LLOBEOBE Two transverse sulci divide into
Superior Temporal Gyrus
Middle Temporal Gyrus
Inferior Temporal Gyrus
Transverse (Heschls) Gyrus runs anterolaterally oversuperior aspect of first temporal Gyrus
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Temporal lobeTemporal lobe
Underneath the lateral sylvian fissure, continues with occipital andparietal lobes
Primary and associative auditory areas (41, 42), association areas(38, 20, 21, 22);
Area 38 involved in taste perception
Areas 41, 42 sound perception and interpretation Limbic system (hypocampal uncus and gyrus, girus cinguli,
subcalossal areas, olfactory areas) critical role in emotions andaffect
Optic radiations
Dominant temporal lobe perception and decoding ofwords/language
Nondominant temporal lobe perception of intonation, music,conversation
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Temporal lobe syndromesTemporal lobe syndromes Temporal lobe lesions
Troubles of hearing, balance, taste, smell, language, sight, memory,dietary comportment, sexual behaviour
Epilesy with temporal lobe generators reason troubles, halucinations,abnormal behaviour
Hearing loss area 41 unilateral lesion; bylateral lesions
cortical deafness; iritative lesions lead to auditory illusions,auditory hallucinations
Taste and smell problems: olfactory halucinations as part ofepileptic crysis. Destruction of olfactory areas in thehippocampal uncus and hypocampic gyrus lead to anosmia.Olfactory hallucinations may precede seizures (aura)
Visual damage hemianopia, visual memory impairment
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AAPHASIAPHASIA
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WWERNICKES APHASIAERNICKES APHASIA
Fluent, Receptive
Normal to supranormal speech output
Paraphrasia, Substitutions, Neologism,
Circumlocution
Empty speech or word-salad
Cannot comprehend
Lesion in Wernickes area= posterior part of Superior
Temporal gyrus (22)
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AAPHASIAPHASIATYPE FLUENCY COMPREHESION REPETITION
BROCAS - + -
TRANSCORTICAL + - -
MOTOR
GLOBAL - - -
WERNICKES + - -
TRANSCORTICAL + - +
SENSORY
CONDUCTION + + -
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Temporal lobe syndromesTemporal lobe syndromes
Memory impairment Recent memory in billateral inferior
hypocampic lesions
Short term memory bilateral lesionsof mamillary bodiesAfectarea memorieipentru cuvinte
Long time memory mamillothalamicor cortical bilateral lesions
Storage of new memories andcomprehension of those elements isperformed by the Papez circuit(hypocampus, mammilary bodies,thalamus, girus cinguli)
Sexual and feeding behaviour
Temporal lobe epilepsy EEG
Simple or complex psychosensorialhalucinations, aphasia, olfactory orauditory halucinations
Recall and recognition impairment dj vu, deja pense, jamais vu
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Papez circuitPapez circuit James Papez in 1937
One of the major pathways of the limbic system
Chiefly involved in the cortical control of emotion.
Role in storing memory.
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KKLUVERLUVER-- BBUCYUCY SYNDROMESYNDROME
Heinrich Kluver, Paul Bucy,1939
Bilateral temporallobectomy
Blunted Affect with Apathy Psychic Blindness or visual
agnosia with inability todistinguish between friendsand strangers
Hypermetamorphosis =hypersensitivity tominute/fine visual stimuli
Hyperorality
Bulemia or unusual dietaryhabits
Hypersexulaitity
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Occipital lobeOccipital lobe
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Occipital lobeOccipital lobe
Small part of dorsolateral part of the hemispheres
Visual function Visual perception
Recognition in relation to spatial and temporal parameters
17, 18, 19 Brodmann areas
17th area
Near the calcarine sulcus
Reception center for visual information (colour, shape, size, movement, light,transparency)
18th area (parastriate) and 19th area (peristriate) association cortex
Disorders of the occipital lobe can be the result of distruction (defficit) orirritation, and symptoms may be uni- or bylateral
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PPRIMARY VISUAL CORTEXRIMARY VISUAL CORTEX
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Occipital lobe syndromesOccipital lobe syndromes
Irritative pathology: Visual hallucinations simple (elementary) or complex, with sensory
and cognitive aspects
Elementary hallucinations:stars, flashes, colours, lights, geometric figures
Complex hallucinations: objects, persons, animals of normal or abnormalsize; patients may perceive those object as unreal, or believe that they are
real Visual illusions (metamorphopsia) objects have abnormal visual
properties: shape, size, colours
Images may be related to previous experiences
Mycropsia, macropsia, megalopsia, moving objects
Abnormal colours (erithropsia), lack of colour (acromatopsia), reversesight, poliopia (one object appears in multiple instances), monoculardiplopia,
Loss of spatial sight, reappariton of images after the source has ceased toexist in the visual fields, false orientation of objects in space
Occipital lobe epilepsy elementary visual hallucinations, mobile/fixedin the visual fields
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PPRIMARY VISUAL CORTEXRIMARY VISUAL CORTEX
Occipital lobe syndromes Lesions produce visual field defect in
contralateral visual field
e.g. lesion of inferior calcrine cortex = contralateralquadrantanopsia
Lesions of the whole visual cortex in onehemishpere result in a loss of vision in thecontralateral visual field
If lesion is vascular (eg occlusion of PCA)
results in macular sparing because macula areareceives collateral blood supply from the MCA
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Occipital lobe syndromesOccipital lobe syndromes
Deficit syndromesDeficit syndromes
Colour agnosia loss of correctperception of colours, impossibility ofcolour naming and identification
Cortical blindness Both primary visual areas are damaged
Patient cannot interpret visual information,and acts as in the case of a peripheralblindness
Some patients try to act as if they were seeing Anton syndrome (associates parietal lesionsand sensory neglect)
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Balints syndrome
Bylateral lesions of occipital lobes
Optic Ataxia, Ocular Apraxia
Inability to direct eyes to a certain point in
visual fileld despite intact vision and eye
movements
Seen with Bilateral Parieto-Occipitallesions
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AGNOSIAAGNOSIA
Agnosia = the inability to recognize perceived sensory informaton
Often modality specifiv: visual, auditory or tactile
Visual Agnosias
Visual Object Agnosia= inability to recognize visually presented objects Prosopagnosia= inability to recognize faces
Visual color agnosia= inability to recognize colors
Simultanagnosia= inability to recognize the whole
Auditory Agnosias Auditory Verbal Agnosia= inability to recognize spoken language
Auditory Sound Agnosia= inabiltiy to recognize non-verbal sounds Sensory Amusia= inability to recognize music
Tactile Agnosias Astereognosia= inability to judge form of object by touch
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EpilepsyEpilepsy
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DefinitionDefinition
Epilepsy: A group of recurrent disorders of
cerebral function characterized by both seizures
and convulsions.
Convulsion: Sudden attack of involuntary muscularcontractions and relaxations.
Seizure: Abnormal central nervous system electrical
activity.
Sezures are generated by abnormal
synchronous electrical brain activity
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EtiologyEtiology
Idiopathic genetic conditions
Acquired:
Trauma Brain tumors
Stroke
Infections
Degenerative diseases
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Ion channelsIon channels
Proteins that are organised into small pores in the
cell membrane
They allow selective passage of ions (Na, Ca, K,
Cl), with an important contribution in maintaining themembrane potential and in forming the trans
membranare electric flow.
Intercelular signals, transmembrane transport, pH
and cell volume
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Calcium channelCalcium channel
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Natrium channelNatrium channel
Na channel
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Potassium channelPotassium channel
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ClassificationClassification
Partial (focal) Simple
Motor
Sensitive Vegetative
Psichical
Complex Secondary generalized
Generalized Tonic
Atonic
Clonic Tonic-clonic
Mioclonic
Absenceunclassifiable
International Classification of SeizuresInternational Classification of Seizures (ILAE, Epilepsia 1981)(ILAE, Epilepsia 1981)
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Epileptogenesis
The abnormal
discharge originates
usually in a definite
area
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InvestigatiiInvestigatii
Electroencefalogrphy spectral analysis Cerebral Computed Tomography (CT)
MRI
Functional imagistics techniques: PET
fMRI
SPECT Magnetoencephalography
video EEG monitoring
S l EEG D t A i itiS l EEG D t A i iti
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Scalp EEG Data AcquisitionScalp EEG Data Acquisition
1010 second EEGs: Seizure Evolutionsecond EEGs: Seizure Evolution
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1010--second EEGs: Seizure Evolutionsecond EEGs: Seizure EvolutionNormal Pre-Seizure
Seizure Post-Seizure
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EEG- normal
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--
Spike-wave complexes
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fMRIfMRI
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PETPET
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MagnetoMagneto--
encefalographyencefalography
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TYPES OF SEIZURESTYPES OF SEIZURES
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Generalized SeizuresGeneralized Seizures
Grand Mal
Absence
Tonic seizures Atonic seizures
Mioclonic seizures
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Generalized SeizuresGeneralized Seizures
Excessive electrical activity in both
cerebral hemispheres.
Usually originates in the thalamus or
brainstem.
Affects the whole body.
Loss of consciousness is common.
G li d S iG li d S i
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Generalized SeizuresGeneralized Seizures Myoclonic: Brief shock-like muscle jerks generalized or
restricted to part of one extremity.
Atonic: Sudden loss of muscle tone.
Tonic Seizures: sudden stiffening of the body, arms, or
legs
Clonic Seizures: rhythmic jerking movements of the
arms and legs without a tonic component
Tonic-clonic (grand mal): Tonic phase followed by clonic phase
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G li d S iG li d S i
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Generalized SeizuresGeneralized Seizures
Absence (petit mal): Person appears to blankout - Daydreaming Simple Absence (primarily effects consciousness only)
Complex Absence
Atypical Absence (Includes physical symptoms like eye blinking orlip movements)
Status Epilepticus: A seizure lasting longer than
30 min, or 3 seizures without a normal period inbetween
May be fatal
Emergency intervention required
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Grand Mal epilepsyGrand Mal epilepsy
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AbsencesAbsences
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Partial (focal) SeizuresPartial (focal) Seizures
Excessive electrical activity in one
cerebral hemisphere. -Affects only part of
the body.
Simple Partial: Person may experience a
range of strange or unusual sensations.
Motor
Sensory
Autonomic
Key feature: preservation of consciousness.
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Partial (focal) SeizuresPartial (focal) Seizures
Complex Partial:
Loss of awareness at seizure onset. Person
seems dazed or confused and exhibits
meaningless behaviors.
Typically originate in frontal or temporal lobes(e.g. Temporal lobe epilepsy)
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Motor partial seizuresMotor partial seizures
Motor (Jacksonian) seizures Oculo-cefalogiric seizures
Adversive seizures
Supplementary motor area seizures Tonic seizures
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Sensory partial seizuresSensory partial seizures
Jacksonian sensory seizures
Visual
Auditive Vestibulary
Olfactive & gustative
Vegetative
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Partial complex seizuresPartial complex seizures
Association areas are involved:
Partial loss of awareness
Dream state, Dj vu,
Jamais vu
Anger, fear, joy crisis
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Partial motor & sensory seizuresPartial motor & sensory seizures
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Complex partial seizuresComplex partial seizures
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Drugs
Cetogenic diet
Surgery
Vagal stimulation
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Treatment principlesTreatment principles
Monotherapy
Politherapy
Titration
Treatment cessation
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Absence seizuresAbsence seizures
Etosuximide
Oxazolidindione
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Drugs that work in seizures otherDrugs that work in seizures other
than absencethan absence
Phenobarbital
Phenitoin
Carbamazepine
Primidone
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Drugs efficient in all types ofDrugs efficient in all types of
seizuresseizures
Sodium valproate
Clonazepam
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Status epilepticusStatus epilepticus
Prolonged seizure or seizures without
remission periods between
Parenteral treatment:Clonazepam
Diazepam
Phenitoin
A ti il ti ffiA ti il ti ffiA ti il ti ffiA ti il ti ffi
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Antiepileptics: efficacy rangeAntiepileptics: efficacy rangeAntiepileptics: efficacy rangeAntiepileptics: efficacy rangeLarge range of efficacy Narrow range
*Based on preliminary evidence*Based on preliminary evidence
Sodium valproate
Levetiracetam
Phenobarbital
Benzodiazepines
Topiramate
Lamotrigine
Zonisamide*
Phenytoin
Carbamazepine
Ethosuximide Gabapentin
Oxcarbazepine
Tiagabine
Pregabalin
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Modern AntiepilepticsModern Antiepileptics
Topiramate
Vigabatrin
Oxcarbazepine Lamotrigine
Clobazam
Gabapentin
Pregabalin
Tiagabine Levetiracetam
Zonisamide
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ff
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Adverse efectsAdverse efects
Gingival hyperplasia
Hirsutism/ Transient hair loss
Vitamine/folate deficiency Polycystic ovary syndrome and menstrual
disturbances
Bone loss
SS
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SurgerySurgery
Resection of epileptic abnormal
discharge source
Lobectomiy
Hemispherectomy
Calosotomy
V l ti l tiV l ti l ti
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Vagal stimulationVagal stimulation
Electrodes are
attached to the vagus
nerve
Intermittent
stimulation
Indication in treatment
resistent epilepsy
S i l iS i l i
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Special issuesSpecial issues
Driving
Extreme/risky sports
Special professions
Pregnancy and breast feeding
eop e w ep epsy aveeop e w ep epsy ave
ll d i ll d i
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Lord Byron
excelled in every area.excelled in every area.
Margaux
Hemingway
Gustave Flaubert
Jeanne d'Arc
Hermann von
Helmholtz
Alfred Nobel
Sokrates
G. Julius
Caesar
NapoleonBonaparte
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