Epilepsy and Seizures

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  s.addText([
    { text: "Epilepsy = ≥2 unprovoked seizures; seizure = paroxysmal abnormal cerebral discharge", options: { bullet: true, breakLine: true } },
    { text: "ILAE 2017: Focal onset | Generalized onset | Unknown onset", options: { bullet: true, breakLine: true } },
    { text: "EEG + MRI are the cornerstones of investigation", options: { bullet: true, breakLine: true } },
    { text: "~2/3 of patients achieve seizure control with appropriate ASM monotherapy", options: { bullet: true, breakLine: true } },
    { text: "Status epilepticus: treat at 5 min — Benzodiazepine → IV ASM → Anesthesia", options: { bullet: true, breakLine: true } },
    { text: "Drug-refractory epilepsy: consider surgery, VNS, RNS, DBS, or ketogenic diet", options: { bullet: true } },
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// ════════════════════════════════════════════════════════════════
//  SLIDE CONTENT
// ════════════════════════════════════════════════════════════════

// SLIDE 1 – Title
titleSlide("Epilepsy & Seizures", "A Comprehensive Medical Review\nDefinition · Epidemiology · Pathophysiology · Classification\nInvestigation · Treatment · Prevention");

// SLIDE 2 – Overview / Agenda
bodySlide("Presentation Outline", [
  "1.  Definition & Historical Background",
  "2.  Epidemiology",
  "3.  Aetiology & Risk Factors",
  "4.  Pathophysiology",
  "5.  ILAE 2017 Classification of Seizures",
  "6.  Epilepsy Syndromes",
  "7.  Clinical Features of Seizure Types",
  "8.  Differential Diagnosis",
  "9.  Investigations",
  "10. Treatment – Antiseizure Medications (ASMs)",
  "11. Treatment – Non-pharmacological",
  "12. Status Epilepticus – Emergency Management",
  "13. Special Populations",
  "14. Prevention & Seizure Triggers",
  "15. Prognosis & SUDEP",
], { fs: 13 });

// ── SECTION 1: DEFINITION ───────────────────────────────────────
sectionSlide(1, "Definition & Historical Background");

// SLIDE 4
bodySlide("Definitions", [
  "SEIZURE – a paroxysmal, abnormal electrical discharge from cerebral neurons producing loss of consciousness, altered perception, convulsive movements, sensory disturbance, or autonomic features.",
  "EPILEPSY – a disorder characterised by ≥2 unprovoked seizures occurring >24 h apart; OR 1 unprovoked seizure with ≥60% risk of recurrence over the next 10 years.",
  "CONVULSION – subset of seizure involving involuntary repetitive muscular contractions; does NOT capture the full spectrum.",
  "STATUS EPILEPTICUS – seizure lasting ≥5 min (GTC) or ≥10 min (focal/absence), or repeated seizures without full recovery.",
  "PROVOKED (ACUTE SYMPTOMATIC) SEIZURE – occurs in direct relation to acute CNS insult (metabolic, toxic, structural); NOT classified as epilepsy.",
], { fs: 13 });

// SLIDE 5
bodySlide("Historical Milestones", [
  "Ancient times – epilepsy called the 'Sacred Disease' (Hippocrates, ~400 BC); he attributed it to brain disorder, not divine intervention.",
  "Medieval era – known as the 'Falling Sickness' or 'Falling Evil.'",
  "1870 – Hughlings Jackson: seizures are 'an excessive and disorderly discharge of cerebral nervous tissue on muscles.'",
  "1929 – Hans Berger invents the EEG, revolutionising seizure diagnosis.",
  "1938 – First clinical use of phenytoin (Merritt & Putnam) — first non-sedating ASM.",
  "1989 – ILAE first formal classification of epilepsies and epileptic syndromes.",
  "2017 – ILAE revised Operational Classification of Seizure Types adopted worldwide.",
]);

// ── SECTION 2: EPIDEMIOLOGY ─────────────────────────────────────
sectionSlide(2, "Epidemiology");

// SLIDE 7
bodySlide("Global Burden", [
  "~50 million people worldwide have epilepsy – one of the most common neurological disorders.",
  "~2 million individuals with epilepsy in the United States alone.",
  "Incidence: ~44 new cases per 100,000 persons/year (USA).",
  "Lifetime prevalence: ~1 in 26 people in the US will develop epilepsy.",
  "Nearly 1% of persons in the US will have epilepsy by age 20.",
  "Over two-thirds of all epileptic seizures begin in childhood (peak: first year of life).",
  "Second incidence peak occurs after age 60 – due to stroke, neurodegeneration, tumours.",
  "80% of people with epilepsy live in low- and middle-income countries; many never receive treatment.",
]);

// SLIDE 8
twoColSlide("Epidemiology – Age & Sex Distribution",
  "Age Distribution",
  [
    "Bimodal incidence: childhood & elderly",
    "Neonates: metabolic, hypoxic-ischaemic causes",
    "Infancy–childhood: genetic/structural syndromes",
    "Adolescence: JME, absence epilepsy",
    "Adults 15-64: trauma, CNS infections, tumours",
    "Elderly >65: cerebrovascular disease #1 cause",
    "Absence & myoclonic seizures peak in childhood",
    "Complex partial (focal impaired awareness) predominate in adults",
  ],
  "Sex & Socioeconomic",
  [
    "Slight male predominance overall",
    "Some syndromes female-predominant (Rett syndrome, PCDH19 epilepsy)",
    "Mortality 2–3× higher than general population",
    "SUDEP (Sudden Unexpected Death in Epilepsy) ~1/1000 patient-years",
    "Significant psychosocial burden: depression, anxiety, stigma",
    "Employment and driving restrictions common",
    "Annual economic cost in USA: >$15 billion",
  ]
);

// ── SECTION 3: AETIOLOGY ────────────────────────────────────────
sectionSlide(3, "Aetiology & Risk Factors");

// SLIDE 10
twoColSlide("Aetiology – ILAE Framework (2017)",
  "Structural",
  [
    "Post-stroke or post-traumatic gliosis (50% of new adult focal)",
    "Hippocampal sclerosis (mesial temporal lobe epilepsy)",
    "Cortical dysplasia / malformations of cortical development",
    "Brain tumours (primary & metastatic) – 15%",
    "Vascular malformations (cavernomas, AVMs) – 15%",
    "Traumatic brain injury",
    "Post-infectious encephalitis/abscess",
    "Perinatal hypoxic-ischaemic injury",
  ],
  "Genetic / Metabolic / Immune / Unknown",
  [
    "Genetic: ion channel mutations (SCN1A, KCNQ2, GABRG2); copy-number variants",
    "Metabolic: pyridoxine deficiency, mitochondrial disease, GLUT1 deficiency",
    "Immune: autoimmune encephalitis (anti-NMDAR, LGI1, CASPR2)",
    "Infectious: neurocysticercosis (most common cause worldwide), HSV encephalitis, HIV",
    "Unknown – no cause found in ~40%",
    "Risk factors: family history, febrile seizures, head trauma, CNS infections, prematurity",
  ]
);

// ── SECTION 4: PATHOPHYSIOLOGY ──────────────────────────────────
sectionSlide(4, "Pathophysiology");

// SLIDE 12
bodySlide("Cellular & Molecular Mechanisms", [
  "Core principle: imbalance between EXCITATION and INHIBITION in neuronal networks.",
  "Seizure initiation – 'paroxysmal depolarisation shift' (PDS): prolonged abnormal depolarisation of a neuron (epileptic focus) → burst of action potentials.",
  "Excessive glutamate (AMPA & NMDA receptor) activation drives depolarisation.",
  "Impaired GABA-mediated inhibition allows synchronous firing to spread.",
  "Ion channel dysfunction is central: Na⁺ channel gain-of-function (e.g. SCN1A in Dravet), K⁺ channel loss-of-function (KCNQ2 in BFNC), GABA_A receptor mutations.",
  "Focal seizures: abnormal discharge confined to one cortical network.",
  "Generalised seizures: thalamocortical circuits involved from the outset; corticothalamic loop drives synchrony.",
  "Epileptogenesis: process by which a normal brain becomes chronically epileptic — involves structural/synaptic remodelling, mossy fibre sprouting in hippocampus.",
]);

// SLIDE 13
bodySlide("Neuropathology of Common Epileptic Substrates", [
  "HIPPOCAMPAL SCLEROSIS – neuronal loss in CA1, CA3, CA4 (Sommer's sector); gliosis; mossy fibre sprouting into molecular layer. Hallmark of mesial temporal lobe epilepsy.",
  "FOCAL CORTICAL DYSPLASIA (FCD) – abnormal cortical lamination and neuronal morphology; highly epileptogenic; identified on high-resolution MRI (FLAIR sequences).",
  "TUMOUR-RELATED EPILEPSY – low-grade tumours (DNET, ganglioglioma) near cortex are particularly epileptogenic; mechanisms include K⁺/glutamate dysregulation by tumour cells.",
  "CORTICAL SCARS – post-traumatic or post-infarct gliosis creates irritative zone that generates ictal discharges.",
  "STATUS EPILEPTICUS INJURY – prolonged seizure activity causes glutamate excitotoxicity → hippocampal neuronal death → worsening epileptogenesis (secondary hippocampal sclerosis).",
]);

// ── SECTION 5: CLASSIFICATION ───────────────────────────────────
sectionSlide(5, "ILAE 2017 Classification of Seizures");

// SLIDE 15
tableSlide("ILAE 2017 Seizure Classification", ["Category", "Type", "Former Name", "Key Feature"],
  [
    ["Focal Onset", "Focal Aware", "Simple Partial", "Consciousness preserved"],
    ["Focal Onset", "Focal Impaired Awareness", "Complex Partial", "Consciousness impaired; automatisms"],
    ["Focal Onset", "Focal-to-Bilateral Tonic-Clonic", "Secondarily Generalised", "Focal onset → bilateral spread"],
    ["Generalised Onset", "Tonic-Clonic (GTC)", "Grand Mal", "LOC + tonic → clonic phases"],
    ["Generalised Onset", "Absence (typical)", "Petit Mal", "Brief stare; 3 Hz spike-wave"],
    ["Generalised Onset", "Absence (atypical)", "—", "Slower spike-wave; Lennox-Gastaut"],
    ["Generalised Onset", "Myoclonic", "—", "Sudden brief muscle jerks"],
    ["Generalised Onset", "Atonic (drop)", "Astatic", "Sudden loss of muscle tone"],
    ["Generalised Onset", "Epileptic Spasms", "Infantile Spasms", "West syndrome"],
    ["Unknown Onset", "Unknown", "—", "Insufficient data to classify"],
  ],
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// ── SECTION 6: SYNDROMES ────────────────────────────────────────
sectionSlide(6, "Epilepsy Syndromes");

// SLIDE 17
tableSlide("Major Epilepsy Syndromes – Childhood Onset",
  ["Syndrome", "Age Onset", "Seizure Types", "EEG / Key Feature", "Prognosis"],
  [
    ["West Syndrome", "3–12 mo", "Infantile spasms", "Hypsarrhythmia", "Poor if untreated; developmental regression"],
    ["Dravet Syndrome", "6–12 mo", "Febrile + afebrile; multiple types", "Non-specific; SCN1A mutation", "Drug-resistant; intellectual disability"],
    ["Childhood Absence Epilepsy", "4–12 yr", "Typical absence", "3 Hz generalised spike-wave", "Often resolves in adolescence"],
    ["Lennox-Gastaut Syndrome", "1–7 yr", "Tonic, atonic, atypical absence", "Slow spike-wave <2.5 Hz", "Drug-resistant; lifelong disability"],
    ["BECTS (Rolandic)", "3–13 yr", "Focal motor; nocturnal GTC", "Centrotemporal spikes", "Self-limiting; resolves by 16 yr"],
    ["Panayiotopoulos Syndrome", "3–6 yr", "Autonomic focal seizures", "Occipital spikes", "Benign; spontaneous remission"],
  ],
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// SLIDE 18
tableSlide("Major Epilepsy Syndromes – Adolescent & Adult Onset",
  ["Syndrome", "Age Onset", "Seizure Types", "Key Feature", "Treatment"],
  [
    ["Juvenile Myoclonic Epilepsy (JME)", "12–20 yr", "Morning myoclonus + GTC ± absence", "4–6 Hz poly-spike-wave; photosensitive", "Valproate / levetiracetam; lifelong"],
    ["Juvenile Absence Epilepsy", "10–17 yr", "Absence + GTC", "3.5–4 Hz spike-wave", "Valproate / ethosuximide"],
    ["Mesial Temporal Lobe Epilepsy", "Any; peak 20s", "Focal impaired awareness; aura", "Hippocampal sclerosis on MRI", "Surgically remediable"],
    ["Autosomal Dom. Nocturnal Frontal Lobe", "Childhood–adult", "Nocturnal hypermotor seizures", "CHRNA4/CHRNB2 mutations", "Carbamazepine"],
    ["Progressive Myoclonic Epilepsies", "Variable", "Myoclonus + GTC + cerebellar signs", "Multiple causes (Unverricht, Lafora)", "Symptomatic; poor prognosis"],
  ],
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// ── SECTION 7: CLINICAL FEATURES ────────────────────────────────
sectionSlide(7, "Clinical Features of Seizure Types");

// SLIDE 20
bodySlide("Generalised Tonic-Clonic Seizure – Phase by Phase", [
  "PRODROME (hours before): mood change, irritability, myoclonic jerks on awakening — not universal.",
  "AURA: epigastric rising sensation, déjà vu, fear (if focal onset preceding GTC).",
  "TONIC PHASE (10–20 sec): sudden LOC + fall; brief flexion → sustained rigid extension of neck, back, limbs; piercing cry (air through closed cords); apnea → cyanosis; pupils dilated & unreactive.",
  "CLONIC PHASE (~30 sec): rhythmic flexor spasms at 8/sec → 4/sec; tongue bite (lateral margin); hypersalivation, sweating, tachycardia, elevated BP, urinary incontinence.",
  "TERMINAL PHASE: movements cease; deep coma; stertorous breathing; pupils return to light.",
  "POSTICTAL PHASE (min–hours): gradual awakening; confusion, agitation, amnesia for event; headache; muscle soreness.",
]);

// SLIDE 21
twoColSlide("Clinical Features – Focal & Absence Seizures",
  "Focal Aware (Simple Partial)",
  [
    "Consciousness PRESERVED",
    "Symptoms reflect cortical origin:",
    "• Motor: Jacksonian march (hand → arm → face)",
    "• Somatosensory: tingling, numbness",
    "• Visual: lights, spots, formed images",
    "• Auditory: buzzing, voices",
    "• Autonomic: flushing, epigastric sensation",
    "• Psychic: déjà vu, jamais vu, fear",
    "Todd's paralysis: post-ictal focal weakness",
  ],
  "Absence (Typical) Seizure",
  [
    "Sudden onset & offset (5–20 sec)",
    "Blank staring, unresponsive",
    "Subtle automatisms (eye blinking, lip smacking)",
    "NO fall, NO postictal confusion",
    "Easily induced by hyperventilation",
    "EEG: classic 3 Hz generalised spike-wave",
    "Multiple episodes per day possible",
    "May be mistaken for daydreaming",
  ]
);

// SLIDE 22
twoColSlide("Clinical Features – Focal Impaired Awareness & Myoclonic",
  "Focal Impaired Awareness (Complex Partial)",
  [
    "Consciousness IMPAIRED (not fully lost)",
    "Most often temporal lobe origin",
    "Typical aura: rising epigastric sensation",
    "Automatisms: lip smacking, hand fumbling, chewing, ambulation",
    "Duration: 1–3 minutes",
    "Post-ictal confusion & amnesia",
    "Can spread to bilateral tonic-clonic",
    "Hippocampal sclerosis on MRI common",
  ],
  "Myoclonic & Atonic Seizures",
  [
    "MYOCLONIC: sudden brief bilateral jerks, typically proximal limbs",
    "• Morning predominance in JME",
    "• Preserved consciousness",
    "• Can cause drop or fall",
    "ATONIC (Drop Attacks):",
    "• Sudden loss of muscle tone → fall",
    "• Risk of head injury → helmet use",
    "• Common in Lennox-Gastaut syndrome",
    "• Very brief; rapid recovery",
  ]
);

// ── SECTION 8: DIFFERENTIAL DIAGNOSIS ───────────────────────────
sectionSlide(8, "Differential Diagnosis");

// SLIDE 24
bodySlide("Differential Diagnosis of Seizures", [
  "SYNCOPE – most common mimic; prodrome of lightheadedness, dimming vision; brief convulsive movements possible (anoxic convulsions); rapid full recovery; triggered by standing/pain/emotion.",
  "TRANSIENT ISCHAEMIC ATTACK (TIA) – usually negative symptoms (weakness, numbness) vs positive motor symptoms of seizure; no postictal phase.",
  "MIGRAINE with aura – slow spreading aura (minutes); headache follows; no LOC.",
  "PSYCHOGENIC NON-EPILEPTIC SEIZURES (PNES) – resemble seizures; variable across episodes; prominent pelvic thrusting, eye closure during 'convulsions'; no EEG correlate; often history of trauma/abuse.",
  "PANIC ATTACKS – prolonged duration (>5 min); linked to specific triggers; no tonic-clonic activity; no postictal state.",
  "HYPOGLYCAEMIA / HYPONATRAEMIA – acute symptomatic seizures; blood tests reveal cause; correct metabolic abnormality.",
  "PAROXYSMAL MOVEMENT DISORDERS – dyskinesias, chorea; maintain consciousness; no EEG correlate.",
  "NARCOLEPSY / CATAPLEXY – sudden muscle atonia triggered by emotion; mimics atonic seizures.",
]);

// ── SECTION 9: INVESTIGATIONS ────────────────────────────────────
sectionSlide(9, "Investigations");

// SLIDE 26
bodySlide("Investigation Overview", [
  "History & Eyewitness Account – cornerstone; detailed description of events before, during, and after episode.",
  "ELECTROENCEPHALOGRAM (EEG) – keystone investigation in all patients with seizures and epilepsy.",
  "BRAIN MRI – should be performed in essentially ALL patients with new-onset seizures.",
  "BLOOD TESTS – electrolytes, glucose, calcium, magnesium, liver/renal function, FBC, toxicology screen.",
  "LUMBAR PUNCTURE – indicated if CNS infection suspected or in HIV-positive patients.",
  "GENETIC TESTING – guided by syndrome; highest yield with intellectual disability + autism + dysmorphic features.",
  "Functional imaging (PET, SPECT), magnetoencephalography (MEG) – used in pre-surgical evaluation.",
  "Neuropsychological assessment – pre-surgical mapping of cognitive function.",
]);

// SLIDE 27
bodySlide("EEG – The Keystone Investigation", [
  "EEG diagnoses epilepsy definitively ONLY if electrical seizure is recorded simultaneously with clinical event.",
  "Interictal initial EEG is NORMAL in up to 60% of known epilepsy patients — normal EEG does NOT exclude epilepsy.",
  "Epileptiform abnormalities present in >80% of focal epilepsy patients if 3 or more EEGs are performed.",
  "Syndrome-specific patterns:",
  "  • Generalised absence epilepsy: 3 Hz spike-and-wave",
  "  • West syndrome: hypsarrhythmia (chaotic high-amplitude pattern)",
  "  • Rolandic epilepsy: centrotemporal spikes",
  "  • Juvenile myoclonic epilepsy: 4–6 Hz poly-spike-and-wave",
  "  • Lennox-Gastaut: slow spike-and-wave (<2.5 Hz)",
  "Video-EEG monitoring – mandatory for pre-surgical evaluation and when diagnosis is uncertain.",
  "Continuous EEG – used in ICU for suspected nonconvulsive status epilepticus in comatose patients.",
]);

// SLIDE 28
bodySlide("Neuroimaging in Epilepsy", [
  "BRAIN MRI (preferred over CT) – performed in essentially all patients with new-onset seizures.",
  "Most common findings in adults with new-onset focal seizures:",
  "  • Post-stroke/post-traumatic gliosis: ~50%",
  "  • Tumours (primary/metastatic): ~15%",
  "  • Vascular malformations: ~15%",
  "  • Developmental abnormalities (FCD, cortical dysplasia): ~15%",
  "  • Mesial temporal sclerosis: ~9%",
  "FLAIR sequences – increased sensitivity for hippocampal sclerosis and focal cortical dysplasia.",
  "PET (FDG-PET) – identifies hypometabolic seizure focus; used in pre-surgical workup.",
  "SPECT (ictal > interictal) – blood flow imaging; ictal SPECT identifies hyperperfused seizure onset zone.",
  "MEG (magnetoencephalography) – maps interictal discharges + eloquent cortex for surgical planning.",
]);

// ── SECTION 10: ASM TREATMENT ────────────────────────────────────
sectionSlide(10, "Treatment – Antiseizure Medications (ASMs)");

// SLIDE 30
bodySlide("General Principles of ASM Therapy", [
  "Goal: complete seizure freedom with minimal adverse effects.",
  "Monotherapy preferred — reduces adverse effects; adequate in ~2/3 of patients.",
  "Choice depends on seizure type / epilepsy syndrome and patient factors.",
  "Start low, titrate slowly to effective dose.",
  "Pharmacoresistance: failure of ≥2 appropriate ASMs at adequate doses = drug-refractory epilepsy (affects ~30–40%).",
  "Women of childbearing age: avoid valproate if possible due to teratogenicity (neural tube defects, cognitive effects on offspring).",
  "Monitor for idiosyncratic reactions: rash (carbamazepine, lamotrigine — SJS), hepatotoxicity (valproate), aplastic anaemia (felbamate).",
  "Drug interactions: enzyme-inducers (carbamazepine, phenytoin, phenobarb) reduce efficacy of OCP, anticoagulants, immunosuppressants.",
]);

// SLIDE 31
tableSlide("ASM Selection by Seizure Type",
  ["Seizure Type", "First-Line ASMs", "Alternative ASMs", "Avoid"],
  [
    ["Generalised Tonic-Clonic", "Valproate, Levetiracetam, Lamotrigine", "Topiramate, Zonisamide", "Carbamazepine (worsens absence/myoclonus)"],
    ["Typical Absence", "Ethosuximide, Valproate, Lamotrigine", "Zonisamide, Clobazam", "Carbamazepine, Phenytoin, Gabapentin"],
    ["Myoclonic", "Valproate, Levetiracetam, Clonazepam", "Zonisamide, Topiramate", "Carbamazepine, Gabapentin, Pregabalin"],
    ["Focal (Aware/Impaired)", "Carbamazepine, Oxcarbazepine, Levetiracetam, Lamotrigine", "Lacosamide, Brivaracetam", "—"],
    ["Focal-to-Bilateral TC", "Carbamazepine, Levetiracetam, Lamotrigine", "Lacosamide, Eslicarbazepine", "—"],
    ["Lennox-Gastaut", "Valproate, Lamotrigine, Clobazam, Rufinamide", "Fenfluramine, Cannabidiol (CBD)", "Vigabatrin (worsens absence)"],
    ["Infantile Spasms (West)", "ACTH, Vigabatrin, Prednisolone", "Pyridoxine (if B6-dep.)", "—"],
  ],
  { colW: [2.0, 2.5, 2.5, 2.5], rowH: 0.44 }
);

// SLIDE 32
bodySlide("Mechanisms of Major ASMs", [
  "SODIUM CHANNEL BLOCKERS (most common mechanism) – phenytoin, carbamazepine, oxcarbazepine, lamotrigine, lacosamide, eslicarbazepine → reduce sustained repetitive firing by prolonging Na⁺ channel inactivation.",
  "CALCIUM CHANNEL MODIFIERS – ethosuximide, valproate → block T-type Ca²⁺ channels in thalamic neurons → suppress absence seizures.",
  "GABA ENHANCEMENT – benzodiazepines (GABA_A Cl⁻ channel opening), phenobarbitone (GABA_A duration), vigabatrin (inhibits GABA transaminase → ↑ GABA), tiagabine (blocks GABA reuptake).",
  "GLUTAMATE ANTAGONISM – perampanel (AMPA receptor antagonist) — first in class.",
  "SV2A (Synaptic Vesicle Protein 2A) modulation – levetiracetam, brivaracetam → reduce presynaptic neurotransmitter release.",
  "MULTIPLE MECHANISMS – valproate (Na⁺ block + T-Ca²⁺ block + ↑GABA), topiramate (Na⁺ + GABA + AMPA block + CA inhibition), zonisamide (Na⁺ + T-Ca²⁺).",
]);

// ── SECTION 11: NON-PHARM TREATMENT ─────────────────────────────
sectionSlide(11, "Treatment – Non-Pharmacological");

// SLIDE 34
bodySlide("Epilepsy Surgery", [
  "Indicated in pharmacoresistant epilepsy (failed ≥2 ASMs) with identifiable seizure focus.",
  "Pre-surgical evaluation: video-EEG, high-resolution MRI, neuropsychological testing, PET, MEG, Wada test (language/memory lateralisation).",
  "TEMPORAL LOBE RESECTION – most commonly performed; ~60–70% seizure-free rate at 2 years; most effective for mesial temporal lobe epilepsy with hippocampal sclerosis.",
  "EXTRATEMPORAL CORTICAL RESECTION – lower success rates; requires precise localisation.",
  "LESIONECTOMY – resection of discrete lesion (tumour, cavernoma, FCD); potentially curative.",
  "HEMISPHERECTOMY / HEMISPHEROTOMY – for severe unilateral hemisphere disease (Rasmussen's encephalitis, large perinatal stroke); best outcomes when done early.",
  "CORPUS CALLOSOTOMY – palliative for drop attacks (atonic seizures); reduces spread between hemispheres.",
]);

// SLIDE 35
bodySlide("Neurostimulation & Dietary Therapies", [
  "VAGUS NERVE STIMULATOR (VNS) – implanted pulse generator; helical electrode on left vagus nerve; open-loop stimulation; approved for drug-refractory focal seizures; ~50% achieve ≥50% seizure reduction.",
  "RESPONSIVE NEUROSTIMULATOR (RNS) – closed-loop system; detects abnormal EEG pattern in seizure focus → delivers stimulation to prevent seizure.",
  "DEEP BRAIN STIMULATION (DBS) – bilateral open-loop stimulation of anterior nuclei of thalamus; indicated as adjunctive therapy for focal seizures ± secondary generalisation.",
  "KETOGENIC DIET – high fat, low carbohydrate, controlled protein; produces ketosis → anticonvulsant effects; particularly effective in children with refractory epilepsy; beneficial in specific metabolic epilepsies (GLUT1 deficiency, pyruvate dehydrogenase deficiency).",
  "MODIFIED ATKINS DIET / LOW GLYCAEMIC INDEX DIET – less restrictive alternatives to classic ketogenic diet; comparable efficacy in some studies.",
  "TRANSCRANIAL MAGNETIC STIMULATION (TMS) – investigational; may reduce cortical excitability at seizure focus.",
]);

// ── SECTION 12: STATUS EPILEPTICUS ───────────────────────────────
sectionSlide(12, "Status Epilepticus – Emergency Management");

// SLIDE 37 – emergency style
emergencySlide("Status Epilepticus – Recognition", [
  "DEFINITION: GTC seizure ≥5 minutes OR focal/absence seizure ≥10 minutes OR repeated seizures without full recovery between.",
  "TYPES:",
  "  1. Generalised Convulsive SE – bilateral limb jerking + impaired consciousness; LIFE-THREATENING",
  "  2. Nonconvulsive SE (NCSE) – behaviour change + continuous EEG epileptiform activity WITHOUT major motor signs",
  "     • Absence SE, Focal SE with/without impaired awareness",
  "     • NCSE in coma – often follows undertreated convulsive SE; requires EEG for diagnosis",
  "RISKS OF DELAY: neuronal injury (glutamate excitotoxicity → hippocampal cell death), systemic complications (hyperthermia, acidosis, rhabdomyolysis), death",
  "ECG and O₂ monitoring mandatory; establish IV access; check glucose",
]);

// SLIDE 38 – emergency style
emergencySlide("Status Epilepticus – Treatment Algorithm", [
  "T = 0: Assess ABCs; O₂; IV access; bloods (glucose, electrolytes, drug levels, toxicology); ECG monitoring",
  "T = 5 min — FIRST LINE (Benzodiazepines):",
  "   • IV Lorazepam 0.1 mg/kg (max 4 mg) — preferred",
  "   • IV Diazepam 0.15–0.2 mg/kg (max 10 mg) — alternative",
  "   • IM Midazolam 10 mg (>40 kg) or 5 mg (13–40 kg) — prehospital / no IV access",
  "   • Rectal diazepam / intranasal midazolam — if above unavailable",
  "T = 20 min — SECOND LINE (if seizure continues): IV Levetiracetam 60 mg/kg (max 4500 mg) OR IV Valproate 40 mg/kg (max 3000 mg) OR IV Fosphenytoin 20 PE/kg (max 1500 PE) — equally effective",
  "T = 40 min — REFRACTORY SE: ICU admission; anaesthetic infusions — Propofol OR Midazolam infusion OR Thiopental/Pentobarbital; continuous EEG monitoring required",
  "SUPER-REFRACTORY SE (≥24h): consider ketamine, lacosamide, ketogenic diet, immunotherapy",
]);

// ── SECTION 13: SPECIAL POPULATIONS ─────────────────────────────
sectionSlide(13, "Special Populations");

// SLIDE 40
twoColSlide("Special Populations",
  "Women with Epilepsy",
  [
    "Catamenial epilepsy: seizures cluster around menstruation (progesterone withdrawal)",
    "Contraception: enzyme-inducing ASMs reduce OCP efficacy; use ≥50 µg EE pill or non-hormonal method",
    "Pregnancy counselling BEFORE conception:",
    "• Lowest effective ASM dose",
    "• Avoid valproate (teratogen; 4–10× risk NTD; cognitive effects in child)",
    "• Folic acid 5 mg/day pre-conception",
    "• Lamotrigine / levetiracetam safest",
    "• Seizure monitoring frequency ↑",
    "Breastfeeding: generally permitted; most ASMs low excretion",
  ],
  "Elderly & Paediatric",
  [
    "ELDERLY:",
    "• Most common new epilepsy after stroke",
    "• Drug interactions with polypharmacy",
    "• Prefer levetiracetam, lamotrigine, gabapentin (better tolerated)",
    "• Fall risk with sedating ASMs",
    "PAEDIATRIC:",
    "• Fever can lower seizure threshold",
    "• Febrile seizures (6 mo – 6 yr): usually benign; prophylactic ASMs rarely needed",
    "• Neonatal seizures: treat underlying cause (hypoglycaemia, hypocalcaemia) first",
    "• Infantile spasms: ACTH or vigabatrin — early treatment critical",
  ]
);

// SLIDE 41
twoColSlide("Epilepsy & Driving / Psychosocial Issues",
  "Driving",
  [
    "Most countries: seizure-free period required (6–12 months) before driving",
    "Physician must counsel patients and document",
    "Reporting obligations vary by jurisdiction",
    "Commercial vehicle licensing has stricter rules",
    "Breakthrough seizures while driving = significant mortality risk",
  ],
  "Psychiatric & Social Comorbidities",
  [
    "Depression: 2–3× more prevalent in epilepsy than general population",
    "Anxiety disorders: highly prevalent",
    "Cognitive impairment: memory deficits common in TLE",
    "Stigma: major barrier to treatment adherence globally",
    "Employment: epilepsy affects career choices and job security",
    "SUDEP risk: highest in nocturnal uncontrolled GTC; sleeping alone increases risk",
    "Comprehensive epilepsy care includes neurologist + neuropsychologist + social worker",
  ]
);

// ── SECTION 14: PREVENTION ───────────────────────────────────────
sectionSlide(14, "Prevention & Seizure Triggers");

// SLIDE 43
twoColSlide("Seizure Triggers (Common)",
  "Lifestyle Triggers",
  [
    "Sleep deprivation – most potent trigger; adequate sleep critical",
    "Alcohol consumption / alcohol withdrawal",
    "Recreational drug use (cocaine, amphetamines)",
    "Missed ASM doses – most common preventable cause of breakthrough seizure",
    "Physical or emotional stress",
    "Fever / systemic illness",
    "Menstrual cycle (catamenial epilepsy)",
    "Flashing lights / visual patterns (photosensitive epilepsy – ~3% of epilepsy)",
    "Overhydration / electrolyte disturbance",
  ],
  "Medical / Pharmacological Triggers",
  [
    "Withdrawal of ASMs (abrupt)",
    "Medications lowering seizure threshold:",
    "• Antibiotics: fluoroquinolones, imipenem",
    "• Antidepressants: bupropion, clomipramine",
    "• Antipsychotics: clozapine, chlorpromazine",
    "• Theophylline, tramadol, lithium toxicity",
    "Drug–drug interactions reducing ASM levels",
    "Hypoglycaemia, hyponatraemia, hypocalcaemia",
    "Contrast agents (intrathecal – rare)",
  ]
);

// SLIDE 44
bodySlide("Primary & Secondary Prevention", [
  "PRIMARY PREVENTION (preventing epilepsy from developing):",
  "  • Reduce head trauma: helmet laws, seatbelts, fall prevention in elderly",
  "  • Reduce CNS infections: vaccination (measles, H. influenzae, Neisseria meningitidis), anthelmintic campaigns (neurocysticercosis)",
  "  • Perinatal care: prevent hypoxic-ischaemic birth injury with skilled obstetric care",
  "  • Stroke prevention (hypertension, AF management, lipid control) — critical in elderly",
  "  • Avoid teratogenic exposure in utero (valproate in pregnancy)",
  "SECONDARY PREVENTION (preventing seizure recurrence once epilepsy diagnosed):",
  "  • Adherence to ASMs — missed doses are #1 cause of breakthrough seizures",
  "  • Avoid known personal triggers (maintain diary)",
  "  • Regular adequate sleep; avoid sleep deprivation",
  "  • Abstain from alcohol / recreational drugs",
  "  • Wear medical alert bracelet; ensure caregivers know rescue medication protocol",
  "TERTIARY PREVENTION (minimising disability):",
  "  • Access to epilepsy specialist care; surgical evaluation when pharmacoresistant",
  "  • Psychosocial support; driving safety counselling; vocational rehabilitation",
]);

// SLIDE 45
bodySlide("Patient & Caregiver Education – First Aid for Seizures", [
  "STAY calm and stay with the person.",
  "TIME the seizure — call emergency services if >5 minutes.",
  "PROTECT from injury: clear area, cushion head, loosen tight clothing.",
  "POSITION: place in recovery (lateral) position when convulsions stop — prevents aspiration.",
  "DO NOT restrain movements or put anything in the mouth.",
  "DO NOT give food or water until fully conscious.",
  "RESCUE MEDICATION: administer prescribed rescue benzodiazepine (rectal diazepam, intranasal midazolam, buccal midazolam) if seizure ≥5 minutes.",
  "AFTER seizure: stay until fully conscious; explain what happened; be supportive.",
  "DOCUMENT: date, time, duration, nature of seizure; report to physician.",
]);

// ── SECTION 15: PROGNOSIS & SUDEP ───────────────────────────────
sectionSlide(15, "Prognosis & SUDEP");

// SLIDE 47
bodySlide("Prognosis of Epilepsy", [
  "Overall: ~60–70% of patients achieve long-term seizure remission with appropriate treatment.",
  "~2/3 of patients achieve seizure control with first or second appropriate ASM.",
  "~30–40% are pharmacoresistant; surgical evaluation should be pursued early.",
  "Favourable prognosis: idiopathic/genetic epilepsy (especially childhood onset), normal neurological exam, normal MRI, single seizure type.",
  "Unfavourable prognosis: structural aetiology, abnormal MRI, early onset, multiple seizure types, intellectual disability.",
  "Seizure remission after ASM withdrawal: ~60% remain seizure-free after slow taper if seizure-free ≥2 years and normal EEG/MRI.",
  "Temporal lobe epilepsy surgery: ~60–70% seizure-free at 2 years vs <10% with continued medical management.",
]);

// SLIDE 48
bodySlide("SUDEP – Sudden Unexpected Death in Epilepsy", [
  "DEFINITION: sudden, unexpected, witnessed or unwitnessed, non-traumatic and non-drowning death in epilepsy, with or without evidence of seizure.",
  "INCIDENCE: ~1 per 1000 patient-years in adults; up to 1 per 150 in high-risk groups.",
  "RISK FACTORS:",
  "  • Nocturnal generalised tonic-clonic seizures – strongest risk factor",
  "  • High seizure frequency (≥3 GTC/year)",
  "  • Sleeping alone (unable to intervene)",
  "  • Uncontrolled epilepsy; non-adherence to ASMs",
  "  • Male sex; early onset; duration of epilepsy >15 years",
  "MECHANISM (incompletely understood): post-ictal autonomic dysfunction → cardiac arrhythmia (prolonged QT, bradycardia), central respiratory depression → asphyxia.",
  "PREVENTION: optimise seizure control; nocturnal monitoring devices / mattress sensors; supervised sleeping; avoid prone sleeping position.",
]);

// SLIDE 49
bodySlide("Antiseizure Drug Reference Summary", [
  "VALPROATE – broad spectrum; Na⁺ + T-Ca²⁺ + ↑GABA; avoid in women of childbearing age; monitor LFTs, platelets; pancreatitis, weight gain, tremor.",
  "LAMOTRIGINE – broad spectrum; Na⁺ blocker; slow titration required (SJS risk); interacts with valproate; safe in pregnancy (relatively).",
  "LEVETIRACETAM – broad spectrum; SV2A; well tolerated; IV form available; behavioural side effects (irritability, depression) notable.",
  "CARBAMAZEPINE / OXCARBAZEPINE – focal epilepsy; Na⁺ blocker; enzyme inducer (carbamazepine); hyponatraemia with oxcarbazepine; avoid in generalised epilepsy.",
  "ETHOSUXIMIDE – absence only; T-Ca²⁺ blocker; nausea; not effective for GTC.",
  "PHENYTOIN / FOSPHENYTOIN – Na⁺ blocker; narrow therapeutic window; gingival hyperplasia, hirsutism, ataxia; zero-order kinetics (non-linear).",
  "TOPIRAMATE – Na⁺ + AMPA + CA; cognitive side effects ('Dopamax'); kidney stones; weight loss; teratogenic.",
  "LACOSAMIDE – Na⁺ (slow inactivation); focal seizures; PR prolongation; IV form.",
  "PHENOBARBITONE – GABA_A; sedation; cognitive impairment; enzyme inducer; widely used in low-income settings.",
]);

// SLIDE 50 – Closing
closingSlide();

// ── WRITE FILE ───────────────────────────────────────────────────
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