Main objective of ILAE’s latest classification of Seizures is to provide communication framework for clinical use

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 Dr. Sameer Zuberi’s presentation at NEC/EAP meeting

Main objective of ILAE’s latest classification of Seizures
is to provide communication framework for clinical use

Now patients have access to lot of information but doctors
will have to help them interpret it

KARACHI: Prof. Sameer M. Zuberi, Consultant Paediatric Neurologist, Royal Hospital for Children at Glasgow, UK was the guest speaker at a meeting organized by National Epilepsy Centre in collaboration with Epilepsy Association of Pakistan here on March 30, 2017. Prof. Sameer Zuberi discussed in detail the latest ILAE (International League Against Epilepsy) classification of Seizures and Epilepsies 2017 which was published online on March 9, 2017. The main objective of these classification, it was stated was to provide a communication framework for clinical use. Last classification was published in 1989.

To begin with Prof. Sameer Zuberi who also chairs the ILAE Commission on Classifications and Terminology, pointed out that about fifty million people in the world suffer from epilepsy and eighty seven new cases of epilepsy are diagnosed every day   in UK having a population of   sixty four million. One can thus imagine the number of people suffering from epilepsy in Pakistan. The usual life time prevalence is reported to be one in one hundred thirty, he added.

Continuing Prof. Sameer Zuberi said that laws are changing. We need to make changes in the classification as well. There have been tremendous developments and our ability to understand etiology of epilepsy has also changed. These classifications are based on three position papers by the ILAE. These are based on lot of work by various commissions and task force besides individuals. We had many papers on classification in 2010 which were professional documents which were discussed by epilepsy community who gave their feedback. These papers are now published and they are the official final documents of the ILAE. Some people might find some problems with these classifications, there could be some practical problems but he reiterated that no one is going to have new classification for the next two decades or so. One of these papers is Instructional Manual of Seizure types. In the previous classification some of the terms were not understood easily by the doctors, patients and their families. Now the patients are much more educated, informed than doctors and they come after reading lot of information on the net, looking at the seizures on YouTube. Previously medical education we had was from the books but now the patients have access to lot of information but they do not know how to interpret that. It is something which the doctors will have to interpret for them, he remarked.

Prof. Sameer Zuberi further stated that previous classifications were proposals but they got established.

The seizure types are Focal Seizures, Generalized Seizures and Unknown seizures. To find out which type of seizures it is, one has to take history from the patient. EEG may help to classify them. He also talked about epilepsy syndrome, EEG features and laid emphasis that one must think about etiology and the underlying cause of epilepsy. I am fortunate as I at my institution have the facilities of MRI, immune testing and screening of over hundred genes related to epilepsy. However, even if you do not have all these facilities, still think about structural epilepsy. He then referred to genetic epilepsy, metabolic epilepsy which all have different treatments. He discussed in detail immune epilepsy, metabolic epilepsy, and genetic epilepsy, infectious and structural epilepsy and laid emphasis that one should constantly think about the underlying cause. There are some seizures which were not recognized before.

There is focal onset, generalized onset, motor and non-motor onset of seizures. There are ten different types of consciousness which can be described. He also talked about focal impaired seizures and said that it was important that one uses the language which can be easily translated into different languages of the world. Seizures, Dr. Sameer Zuberi opined begins somewhere and then it spreads bilaterally. All epilepsies are focal but not everybody agrees with this. Most focal epilepsies are due to genetics. Generalized seizures rapidly spreads to both hemispheres. One should change partial to focal and then there are seizures of unknown onset which may have features which can still be classified. He also referred to new focal and new generalized types of seizures. The new classification has also updated the glossary of various terms used in epilepsy. Diagnosis may be clinical supported by EEG. Generalized epilepsy should have generalized seizures. As regards genetic and idiopathic epilepsy, there is a chance that 5% of these patients’ siblings may develop genetic epilepsy. Once it is known, they may have problems in getting married or they may have to face social isolation because genetic epilepsy has lot of stigma. There are over five hundred genes of epilepsy and in familial studies people were reluctant to use the word genetic, hence people had to compromise and it was named as generalized epilepsy with unknown cause. He was of the view that the word idiopathic will go away in next ten to fifteen years. Metabolic disorder are also genetic in nature and it is also possible that one can have more than one etiology. Classifications are always changing. There are differences in languages and cultures. The website www.epilepsydiagnosis.org gives lot of useful information and it was also a very good educational source, Dr. Sameer Zuberi concluded.

Responding to questions during the discussion Dr. Sameer Zuberi said that infantile spasm and epileptic spasms are two different things. While infantile spasm is just one type of epileptic seizure while   epileptic seizures is a particular type which is used as term. One of the participants asked that if patient has generalized seizures but EEG constantly shows it focal, he said it will be generalized seizures. There may be some patients with epilepsy who are amenable to surgery, they are candidates for surgery in early stages. Responding to another question he said that they did not go into sub-classification like febrile seizures which will be looked into at a later stage. One can use brain image, EEG and if one has not seen the seizures, it is possible to name it after taking careful history from the patient. Drug treatment for various types of seizures, he clarified, remains the same. Sine some drugs are used in particular conditions in clinical trials, they are named as first choice in that particular types of seizures. Neonatal seizures has always been classified by neonatologists which are not good. Many neonatal seizures he said are because of some condition as in some cases these conditions may be temporary but all are focal.

Earlier Prof. Hasan Aziz who has founded the National Epilepsy Centre at JPMC in his introductory remarks thanked the guest speaker and said that classifications are important but one has to revisit them after some years on regular basis. Over the years many things have evolved and science is in evolution which makes is essential to revisit the classifications.

Prof. Shaukat Ali another noted neurologist in his vote of thanks said that it is always difficult to understand new classifications. He hoped that the National Epilepsy Center will organize some workshops to make it understandable. Prof. Hasan Aziz has always been a pioneer, has done lot of work in this field and keeps on organizing such meetings to keep us all update on epilepsy, he added.

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