10 - Seizures

Question 1

What is a seizure?

Answer 1

Abnormal electrical activity in the brain.

This activity takes atypical “pathways” compared to a psychiatric event which takes normal “pathways”

It’s not a diagnosis, its a symptom of somethign else.

Question 2

How does a seizure start? What do the symptoms of a seizure depend on?

Answer 2

As a single group of cells and propagates throughout the brain.

Depend on the region activated:

• motor pathways: motor symptoms
• both hemispheres: loss of consciousness
• language pathway: unable to speak

Question 3

What are three events that can be confused as seizure sbut are NOT?

Answer 3

1. Pseudo-seizures - a psychiatric event similar in pathology to when someone vomits because they’re nervous
2. Movement disorders - hard to differentiate except by observing the movement
3. Purposeful spells

Question 4

What are characteristics of a pseudo-seizure?

Answer 4

Hip thrusting, talking during the event, bilateral involvement without loss of consciousness.

No rhythmic movement.

Question 5

What are the five steps to a seizure evaluation?

Answer 5

1. Is it a seizure?
2. Is it provoked?
3. Seizure semiology (what seizures look like)
4. Electroclinical diagnosis (how does it correlate with the electricity)
5. Epileptic diagnosis (is there an underlying diagnosis)

Question 6

What are typical seizures characteristics?

Answer 6

Rhythmical, repetitive, stereotyped, symmetrical movements

Loss of consciousness if both hemispheres involved

Open eyes

Random - not correlated to a trigger (but may be worsened with lack of sleep and/or illness)

Question 7

What are the typical stages of a seizure?

Answer 7

1. Pre-ictal: Aura may or may not occur based on located where seizure starts
2. Ictal - actual seizure part
3. Post-ictal: Often sleepy or not fully alert and interactive, duration can vary widely (none-days)

Question 8

What are things that can provoke a seizure?

Answer 8

Hypoglycemia

Hyponatremia

Fever and/or infection

Certain medications

Post-syncopal seizures

Question 9

What should you do if the seizure if provoked by hypoglycemia or hyponatremia?

Answer 9

Hypoglycemia: administer glucose and determine what is causing the hypoglycemia

Hyponatremia: Slowly correct the sodium level or you may cause brain damage

Question 10

What should you do if the seizure if provoked by fever?

Answer 10

Called a febrile seizure and may occur in otherwise normal children (6 mo - 6 yrs)

You should rule out infection in the brain or meninges

May be caused by a toxin as a result of an infection elsewhere (“shigella shakes”)

Question 11

What causes a post-syncopal (post-fainting) seizure? What should be done?

Answer 11

Not enough blood to the brain.

Patients often have movements after they hit the floor (not as they fall).

Treat the cause of syncope (fainting).

Question 12

What is the important of seizure semiology?

Answer 12

Identified origin of seizure

Correlates with imaging and other neurologic features

Affects treatment

Question 13

How would you classify pre-ictal aura?

Answer 13

Epigastric rising feeling: temporal lobe

Auditory aura: parietal lobe

Visual aura: occipical lobe

Vestibular aura (dizziness): occipital lobe

Sensory aura: parital lobe

Question 14

Describe the onset, vocalization, automatisms, duration, and postictal period of a frontal lobe seizure?

Answer 14

Onset: explosive

Vocalization: grunting/screaming

Automatisms: less common

Duration: brief

Postictal: short or absent

Question 15

Describe the onset, vocalization, automatisms, duration, and postictal period of a focal temporal lobe seizure?

Answer 15

Onset: slow

Vocalization: speech (non-dominant temporal)

Automatisms: more common

Duration: longer

Postictal period: longer

Question 16

How do focal ipsilateral seizures differ from focal contralateral seizures?

Answer 16

Ipsilateral: early head turning

Contralateral: Late head turning, eye deviation, tonic limbic (contra), and post-ictal paralysis (Todd’s paralysis).

*Eyes deviate away from the side of the seizure*

Question 17

What is the location of jacksonian seizures? What is the location of a seizure that causes Fencer’s posture?

Answer 17

Jacksonian seizures: primary motor cortex seizure

Fencer’s posture: supplementary motor cortex

Question 18

What are characteristics of generalized seizures?

Answer 18

Tonic: stiff

Clonic: shaking

Absence/staring: not just staring spennds, typically short (<30 sec), cannot be stopped (if it can, it may be behavioral or ADHD).

Question 19

How do you get an electroclinical diagnosis?

Answer 19

Combine EEG with the clinical data.

Question 20

What can result from prolonged seizures? At what point does this occur?

Answer 20

Brain damage, reduced energy metabolites, and toxin build-up.

This happens at 30 minutes or more and constitutes an emergency.

Question 21

What steps should be taken when evaluating someone with a seizure?

Answer 21

1. Stop the active seizure if possible
2. Ensure they are safe
3. Order an electroencephalogram (EEG) to help localize and tell the type of seizure
4. Order MRI of brain (in all but known generalized epilepsy syndromes)
5. Determine cause of epilepsy

Question 22

What is the definition of epilepsy? What are the treatments?

Answer 22

One seizure and a greater than 50% chance of having another.

Treatments: medication (70-80% of pts controlled on meds), surgery (resection), or diet (ketogenic).

Question 23

What is the impact of seizures on individuals that experience them?

Answer 23

They can lead to cardiac arrest (sudden unexplained death in epilepsy pts)

Sate laws prohibit driving (anywhere from 6mo-2yrs)

Social stigmata

Question 24

Seizures are naturally ________, and mostly ________.

Answer 24

Seizures are naturally uncontrollable, and mostly unpredictable.