Diagnóstico y Tratamiento de la Epilepsia Marcelo E. Lancman, M.D. Director, Northeast Regional...
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Transcript of Diagnóstico y Tratamiento de la Epilepsia Marcelo E. Lancman, M.D. Director, Northeast Regional...
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Diagnóstico y Tratamiento de Diagnóstico y Tratamiento de la Epilepsiala Epilepsia
Marcelo E. Lancman, M.D.Marcelo E. Lancman, M.D.
Director,Director,Northeast Regional Epilepsy GroupNortheast Regional Epilepsy Group
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Referidos Centro de Epilepsia
Evaluación:●Historia clínica/Exam
●EEG●Imaging
Controlado No controlado
Video-EEG
Convulsiones no epilépticas Epilepsia
Medicamentos CirujíaReferir
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Epilepsia y ConvulsionesEpilepsia y Convulsiones
Qué es la epilepsia?Qué es la epilepsia?
Qué es una convulsión?Qué es una convulsión?
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Con qué frecuencia se da?Con qué frecuencia se da?
EpilepsiaEpilepsia
0.5-1% 0.5-1%
ConvulsionesConvulsiones
5-10%5-10%
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ClasificaciónClasificación
ParcialParcialSimpleSimple
ComplejaCompleja
GeneralizadaGeneralizadaAusenciaAusencia
AtónicaAtónica
ClónicaClónica
TónicaTónica
Tónica-clónicaTónica-clónica
MioclónicaMioclónica
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Evaluacion… Un abordaje de Evaluacion… Un abordaje de equipoequipo Consulta inicialConsulta inicial
– Historia clínicaHistoria clínica– Examen físicoExamen físico– Revisar los archivosRevisar los archivos
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Plan …Plan …
TesteoTesteo– EEG, laboratoriosEEG, laboratorios
ImágenesImágenes– MRI, CTMRI, CT
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Diagnostico y ControlDiagnostico y Control
Cuando el diagnóstico es claroCuando el diagnóstico es claro
Se usan drogas antiepilépticas apropiadasSe usan drogas antiepilépticas apropiadas
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El paciente que no responde a los El paciente que no responde a los medicamentosmedicamentos
A pesar de usar muchos medicamentosA pesar de usar muchos medicamentos
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Monitoreo con Video-EEGMonitoreo con Video-EEG
Registro simultáneo de EEG y videoRegistro simultáneo de EEG y video
Requiere admisión al hospitalRequiere admisión al hospital
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Objetivos del Video-EEGObjetivos del Video-EEG
Epilepsia vs. Epilepsia vs. episodios no episodios no epilépticosepilépticos
Caracterizar el tipo de Caracterizar el tipo de epilepsiaepilepsia
Evaluación pre-Evaluación pre-quirúrgicaquirúrgica
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MedicamentosMedicamentos
Depende del tipo de epilesia, efectos adversos, y Depende del tipo de epilesia, efectos adversos, y costocosto
Ideal usar un solo medicamentoIdeal usar un solo medicamento Usar más de un medicamento requiere cuidado Usar más de un medicamento requiere cuidado
con interacciones y efectos adversoscon interacciones y efectos adversos
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““Medicamentos viejos”Medicamentos viejos”
Carbamazepine Carbamazepine (Tegretol)(Tegretol)
PhenobarbitalPhenobarbital
Ethosuximide (Zarontin)Ethosuximide (Zarontin)
Phenytoin Phenytoin (Dilantin/Cerebyx)(Dilantin/Cerebyx)
Valproic acid (Depakote)Valproic acid (Depakote)
Primidone (Mysoline)Primidone (Mysoline)
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Medicamentos mas nuevosMedicamentos mas nuevos
Gabapentin (Neurontin)Gabapentin (Neurontin) Lamotrigine (Lamictal)Lamotrigine (Lamictal) Topiramate (Topamax)Topiramate (Topamax) Felbamate (Felbatol)Felbamate (Felbatol) Diastat (Diazepam)Diastat (Diazepam) Rufinamide (Banzel)Rufinamide (Banzel)
Tiagabine (Gabitril)Tiagabine (Gabitril) Zonisamide (Zonegran)Zonisamide (Zonegran) Levetiracetam (Keppra)Levetiracetam (Keppra) Oxcarbazepine (Trileptal)Oxcarbazepine (Trileptal) Lacosamide (Vimpat)Lacosamide (Vimpat)
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El medicamento se elije El medicamento se elije basado en el tipo de basado en el tipo de epilepsia…epilepsia…
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Epilepsia ParcialEpilepsia Parcial
TegretolTegretol DilantinDilantin DepakoteDepakote NeurontinNeurontin LamictalLamictal PhenobarbitalPhenobarbital VimpatVimpat
KeppraKeppra TopamaxTopamax GabitrilGabitril ZonegranZonegran TrileptalTrileptal MysolineMysoline
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Epilepsia generalizadaEpilepsia generalizada
DepakoteDepakote LamictalLamictal Topamax Topamax ZonegranZonegran KeppraKeppra BanzelBanzel
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Como combinar Como combinar medicamentosmedicamentos Cómo actuan ?Cómo actuan ?
Cómo entran al Cómo entran al cuerpo ?cuerpo ?– AbsorciónAbsorción
– Distribución Distribución
– EliminaciónEliminación
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Efectos negativosEfectos negativos
Relacionados a la Relacionados a la cantidad cantidad
Independientes de la Independientes de la cantidadcantidad
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Medicaciones:Medicaciones:Consideraciones Especiales Consideraciones Especiales Dilantin:Dilantin: 90% protein bound; metabolized by liver; 90% protein bound; metabolized by liver;
Stevens-Johnson, gingival hyperplasia, hirsutismStevens-Johnson, gingival hyperplasia, hirsutism
Depakote:Depakote: 90% protein bound; metabolized by liver; 90% protein bound; metabolized by liver; liver toxicity, pancreatitis, weight gainliver toxicity, pancreatitis, weight gain
Tegretol: Tegretol: Mildly protein bound; metabolized by liver; Mildly protein bound; metabolized by liver; leukopenia, hyponatremialeukopenia, hyponatremia
Phenobarbital: Phenobarbital: Metabolized partially by liver; sedation; Metabolized partially by liver; sedation; elixir contains alcohol (not for neonates)elixir contains alcohol (not for neonates)
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Consideraciones (cont)Consideraciones (cont)
Mysoline: Mysoline: similar characteristics as similar characteristics as Phenobarbital; sedationPhenobarbital; sedation
Zarontin: Zarontin: main use for absence seizures; main use for absence seizures; minimally bound to protein; metabolized by minimally bound to protein; metabolized by liver; GI disturbancesliver; GI disturbances
Neurontin:Neurontin: Not protein-bound or metabolized by Not protein-bound or metabolized by liver; sedation possibleliver; sedation possible
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Consideraciones (cont)Consideraciones (cont)
Lamictal:Lamictal: 55% protein bound; skin rash 55% protein bound; skin rash
Topamax:Topamax: Not protein bound or metabolized by Not protein bound or metabolized by liver; psychomotor slowing.liver; psychomotor slowing.
Felbatol:Felbatol: Metabolized by liver; low protein Metabolized by liver; low protein binding; restricted use due to “Black Box” binding; restricted use due to “Black Box” warning (aplastic anemia)warning (aplastic anemia)
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Consideraciones (cont)Consideraciones (cont)
Gabitril:Gabitril: 96% protein bound; metabolized by liver; 96% protein bound; metabolized by liver; sedationsedation
Zonegran:Zonegran: Low protein binding; metabolized by liver; Low protein binding; metabolized by liver; renal calculirenal calculi
Keppra:Keppra: Not protein bound or metabolized by liver; Not protein bound or metabolized by liver; sedationsedation
Trileptal:Trileptal: 40% protein bound; metabolized by liver; 40% protein bound; metabolized by liver; hyponatremiahyponatremia
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Para pacientes que no Para pacientes que no responden a medicamentosresponden a medicamentos Dieta ketogénicaDieta ketogénica Vagus nerve stimulatorVagus nerve stimulator Cirugía de epilepsiaCirugía de epilepsia
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Ketogenic DietKetogenic Diet
Alta en grasa, baja en proteinas y azucaresAlta en grasa, baja en proteinas y azucares
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Vagus Nerve StimulatorVagus Nerve Stimulator
Marcapaso para las convulsionesMarcapaso para las convulsiones Ayuda a un grupo de pacientesAyuda a un grupo de pacientes
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