4.10 clinical decision making - epilepsy

Question 1

What’s the #1 etiology of epilepsy?

Answer 1

idopathic/cryptogenic (65%)

Question 2

List some risk factors for seizure recurrence

Answer 2

-First seizure prior to age 16 -Seizures during sleep or in early morning -Mental retardation -Neurological deficits -Sibling with epilepsy -hx of head trauma, meningitis or hemorrhage

Question 3

list 5 ways to assess a new-onset seizure

Answer 3

1. Investigate the seizure episode historically 2. physical examination 3. Neurological examination 4. labs 5. neuroimaging, EEG

Question 4

simple partial seizures may not induce a change in scalp-recorded EEG activity. why?

Answer 4

recall that EEGs just monitor activity in cortices - superficially. if activity is deep to cortices, EEG won’t detect this activity.

Question 5

Prodrome

Answer 5

a forewarning hours earlier of a possible seizure

Question 6

Aura

Answer 6

actual manifestation of the partial seizure and aids in localization

Question 7

vizualize the seizure scheme

Answer 7

Question 8

pt comes in with husband describing episode of 1-minute episode including sligh muscle jerks, foul smell in the middle of a rose garden, and a general feeling of fear for no reason. pt denies LOC. diagonsis?

Answer 8

Simple Partial Seizures. image is of L ant. temporal version

Question 9

pt comes in with husband describing episode of 2-minute smacking of lips and randomly repeating the same word over and over. Pt seemed obtunded during episode but did not lose consciousness. diagnosis?

Answer 9

Complex Partial Seizures. image is L ant. temporal

Question 10

pt and wife come in describing an 3-minute eposide of: first, smacking lips and just wandering around aimlessly. then pt dropped to the ground and had full-body muscle contactions followed by rigidity. pt had urinary incontincence episode and LOC. diagnosis

Answer 10

Complex Partial With Secondary Generalization

Question 11

pt and wife come in describing 4-minute episode of alternating between total body rigidity and rhythmic muscle contrtactions. urinary incontinence, and LOC. no aura. they are freaked out! diagnosis?

Answer 11

Generalized Tonic-Clonic Seizure

Question 12

13 yo pt with father come in and describe 10-second episode of
Staring or blinking, upward rotation of eyes, no motor activity. teacher told dad pt “kid loses consciousness briefly then immediately resumes activity” diagnosis?

Answer 12

Absence Seizures

*EEG – classic 3Hz. spike/wave

Question 13

pt comes in describing “short” episode of rapid jerks of both arms. did not have LOC. diagnosis?

Answer 13

Myoclonic Seizure

Question 14

pt and wife come in descibing ~10 second episode of sudden loss of muscle control. pt falls to floor, totally flacid. banged his head too. LOC. diagnosis?

Answer 14

Atonic Seizures (Drop Attacks)

Question 15

Childhood Febrile Seizures

Answer 15

Simple symptomatic generalized seizure in a normal patient <5yoa with fever

Question 16

List and consider some Epilepsy-Related Comorbid Conditions

Answer 16

• Cognitive impairment
• Social
• Psychological - Depression
• Injury
• Sudden death
• Endocrine dysfunction
• Migraine
• Sleep Disorders

Question 17

can a seizure kill you acutely? yes. what’s this called?

Answer 17

Sudden Unexpected Death in Epilepsy (SUDEP)

Question 18

aged based classification for epilepsy: infacy

Question 19

age based classification for epliepsy: childhood

Answer 19

*Lennonx-Gastaut syndrome - (EEG image) cryptogenic
*Childhood onset Absence epilepsy

Question 20

age based classification for epliepsy: adolescence-YA

Answer 20

• *Primary Juvenile Myoclonic epilepsy (JME)
• Mesial Temporal Lobe Sclerosis

Question 21

age-based epilepsy classification: geriatric

Answer 21

• Partial Complex
• Generalized – tonic clinic

Question 22

can you stop seizure anticonvulsant therapy after 2-year seizure-free period?

Answer 22

you can. you and the pt should know, however,
Relapse rates :

–> Adults: 50% Children: 25 - 33%

And discontinue treatment with a slow taper period

Question 23

when starting anticonvulsant pharmacotherapy, remember the following:

Answer 23

*Monotherapy is preferable whenever possible

• Start at low dose of AED and titrate to therapeutically effective dose
• If seizures persist, consider an alternative drug
• If a second drug is added, dose of the first drug may need to be adjusted due to interactions

Question 24

how does pregnancy influence seizure activity?

Answer 24

-20% increase in seizures

Question 25

what’s a pseudoseizure?

Answer 25

• not a true seizure
• may difficult to diagnose
• more commen in women than men
• often hx of anxiety/depression, sexual abuse