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Neurologic Disorders > 418 Seizures and Epilepsy > Flashcards

418 Seizures and Epilepsy Flashcards

1
Q

Origin of the word “seizure”

A

“Sacire” which means “to take possession of”

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2
Q

What is seizure?

A

A seizure is a transient occurrence of signs or symptoms due to an abnormal excessive or synchronous neuronal activity in the brain

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3
Q

What is epilepsy?

A

Epilepsy describes a condition in which a person has a risk of recurrent seizures due to a chronic, underlying process (not a single or recurrent seizure that is due to correctable or avoidable circumstances).

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4
Q

Focal vs generalized seizure

A

Focal seizures

  • originate within networks limited to one brain region
  • usually associated with structural abnormalities of the brain

Generalized seizures

  • arise within and rapidly engage networks distributed across both cerebral hemispheres
  • may result from cellular, biochemical, or structural abnormalities that have a more widespread distribution
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5
Q

3 subtypes of Focal seizures

A

Focal seizures with intact awareness

Focal seizures with impaired awareness

Focal seizures that evolve into generalized seizures

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6
Q

Features of Focal seizures

A

1) Can have motor or nonmotor manifestations with or without impairment of awareness
2) The abnormal motor movements may begin in a very restricted region such as the fingers and gradually progress (over seconds to minutes) to include a larger portion of the extremity (“Jacksonian march”)
3) May experience a localized paresis (Todd’s paralysis) for minutes to many hours in the involved region following the seizure.
4) May continue for hours or days, in rare instances (“epilepsia partialis continua”)

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7
Q

Term used to denote the phenomenon in which there is gradual progression of a focal seizure from a small region to a larger portion of the extremity

A

Jacksonian march (described by Hughlings Jackson)

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8
Q

Term used to denote the localized paralysis for minutes to many hours in the involved region following a focal seizure

A

Todd’s paralysis

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9
Q

Term used to denote a focal seizure that continues for hours or days

A

Epilepsia partialis continua

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10
Q

Term used to denote subjective, “internal” events that are not directly observable by someone else but may actually be manifestations of a focal seizure

A

Auras

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11
Q

Illusion that objects are growing smaller

A

Micropsia

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12
Q

Illusion that objects are growing larger

A

Macropsia

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13
Q

Typical events in focal seizures with impaired awareness

A

Frequently begin with an aura that is stereotypic for the patient

Start of the ictal phase is often a motionless stare, which marks the onset of the period of impaired awareness, usually accompanied by automatisms

Confusion after the seizure

Transition to full recovery of consciousness may range from seconds up to an hour or longer. May have anterograde amnesia or transient neurological deficits

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14
Q

Usual variety of generalized seizure when it evolved from a focal seizure

A

Tonic-clonic variety

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15
Q

Region of the brain from which focal seizures that evolve into generalized seizures usually arise

A

Frontal lobe

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16
Q

Subtypes of Generalized onset seizures

A

Typical absence seizures

Atypical absence seizures

Generalized, tonic-clonic seizures

Atonic seizures

Myoclonic seizures

Epileptic spasms

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17
Q

Features of Typical absence seizures

A

Sudden, brief lapses of consciousness without loss of postural control

Usually lasts for only seconds

No postictal confusion

Usually accompanied by subtle, bilateral motor signs

Main seizure type in 15-20% of children with epilepsy

First clue is often unexplained “daydreaming” and a decline in school performance

EEG hallmark: Generalized, symmetric, 3-Hz spike-and-slow-wave discharges that begins and ends suddenly, superimposed on a normal EEG background

Hyperventilation tends to provoke these electrographic discharges

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18
Q

Features of Atypical absence seizures

A

Lapse of consciousness is usually of longer duration and less abrupt in onset and cessation

Accompanied by more obvious motor signs

EEG: Generalized, slow spike-and-slow-wave pattern with a frequency of <=2.5 per second

Associated with diffuse or multifocal structural abnormalities of the brain and therefore may accompany other signs of neurologic dysfunction such as mental retardation

Less responsive to anticonvulsants compared to typical absence seizures

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19
Q

Features of Generalized, Tonic-Clonic Seizures

A

Main seizure type in ~10% of all persons with epilepsy

Most common seizure type resulting from metabolic derangements

Usually begins abruptly without warning, but may sometimes have a prodrome

Phases:

1) Tonic phase 10-20s
2) Clonic phase (total ictal phase usually lasts no more than 1 min)
3) Postictal phase (bladder or bowel incontinence may occur)

Usually with postictal confusion

EEG:

1) Tonic phase - Progressive increase in generalized low-voltage fast activity, followed by generalized high-amplitude, polyspike discharges
2) Clonic phase - High-amplitude activity is typically interrupted by slow waves to create a spike-and-slow-wave pattern
3) Postictal phase - Diffuse suppression of all cerebral activity, then slowing that gradually recovers as the patient awakens

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20
Q

Features of Atonic seizures

A

Sudden loss of postural muscle tone lasting 1-2s

Consciousness is briefly impaired, but there is usually no postictal confusion

EEG: Brief, generalized spike-and-wave discharges followed immediately by diffuse slow waves that correlate with the loss of muscle tone

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21
Q

Features of Myoclonic seizures

A

Myoclonus - sudden and brief muscle contraction that may involve one part of the body or the entire body

Most commonly seen in association with metabolic disorders, degenerative CNS disease, or anoxic brain injury

EEG: Bilaterally synchronous spike-and-slow-wave discharges immediately prior to the movement and muscle artifact associated with the myoclonus

Predominant feature of juvenile myoclonic epilepsy

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22
Q

Features of Epileptic Spams

A

Briefly sustained flexion or extension of predominantly proximal muscles, including truncal muscles

Occur predominantly in infants

EEG: Hypsarrhythmia (diffuse, giant slow waves with a chaotic background of irregular, multifocal spikes and sharp waves). During the clinical spasm, there is a marked suppression of the EEG background (the “electrodecremental response”)

EMG: Characteristic rhomboid pattern

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23
Q

Which type of generalized seizure is associated with a group of genetically determined epilepsies with onset usually in childhood (ages 4-10 years) or early adolescence and are the main seizure type in 15-20% of children with epilepsy?

A

Typical absence seizures

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24
Q

Most common seizure type resulting from metabolic derangements

A

Generalized, tonic-clonic seizures

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25
Q

Type of seizure that occur predominantly in infants

A

Epileptic spasms

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26
Q

EEG: Generalized, symmetric, 3-Hz spike-and-slow-wave discharges that begins and ends suddenly, superimposed on a normal EEG background

A

Typical absence seizure

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27
Q

EEG: Generalized, slow spike-and-slow-wave pattern with a frequency of <=2.5 per second

A

Atypical absence seizure

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28
Q

EEG: Different phases with spiking then slowing

A

Generalized, tonic-clonic seizure

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29
Q

EEG: Brief, generalized spike-and-wave discharges followed immediately by diffuse slow waves

A

Atonic seizure

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30
Q

EEG: Bilaterally synchronous spike-and-slow-wave discharges and muscle artifact

A

Myoclonic seizure

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31
Q

EEG: Hypsarrhythmia with electrodecremental response

A

Epileptic seizure

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32
Q

Term used to denote the marked suppression of the EEG background during a clinical spasm

A

Electrodecremental response

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33
Q

Term used to denote diffuse, giant slow waves with a chaotic background of irregular, multifocal spikes and sharp waves

A

Hypsarrhythmia

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34
Q

Type of seizure that shows a characteristic rhomboid pattern on EMG

A

Epileptic spasm

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35
Q

3 important epilepsy syndromes

A

1) Juvenile myoclonic epilepsy
2) Lennox-Gastaut syndrome
3) Mesial temporal lobe epilepsy syndrome (MTLE)

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36
Q

Epilepsy syndrome in which the seizures are most frequent in the morning after awakening and can be provoked by sleep deprivation

A

Juvenile myoclonic epilepsy

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37
Q

Triad of Lennox-Gastaut syndrome

A

1) Multiple seizure types
2) EEG: Slow (<3 Hz) spike-and-wave discharges and a variety of other abnormalities
3) Impaired cognitive function in most but not all cases

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38
Q

Most common epilepsy syndrome associated with focal seizures with impairment of consciousness

A

Mesial temporal lobe epilepsy syndrome (MTLE)

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39
Q

Characteristic MRI finding in mesial temporal lobe epilepsy syndrome (MTLE)

A

Hippocampal sclerosis

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40
Q

Term used to denote the process in which a brain injury results in a long-lasting pathologic change in the CNS that transforms a presumably normal neural network into one that is abnormally hyperexcitable

A

Epileptogenesis

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41
Q

Term used to denote the specific changes that result in a lowered seizure threshold

A

Epileptogenic factors

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42
Q

Seizures that are due to inborn errors of metabolism usually occurs how many days after birth?

A

2-3 days after birth (once regular feeding begins)

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43
Q

Most common seizures arising in late infancy and early childhood

A

Febrile seizures

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44
Q

What are febrile seizures?

A

Seizures associated with fevers but without evidence of CNS infection or other defined causes

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45
Q

Peak incidence of febrile seizures

A

18 to 24 months

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46
Q

Simple febrile seizures differ from complex febrile seizures in that…

A

Single, isolated event, brief, and symmetric in appearance

Not associated with an increase in the risk of developing epilepsy

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47
Q

Complex febrile seizures differ from simple febrile seizures in that…

A

Repeated seizure activity, duration >15 mins, or by focal features

Have a 2-5% risk of developing epilepsy

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48
Q

Recurrence of febrile seizure is much more likely when the febrile seizure occurs in what year of life?

A

In the first year of life

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49
Q

TRUE OR FALSE: The likelihood of developing epilepsy is strongly correlated with the severity of the injury.

A

TRUE

50
Q

Definition of Mild head injury

A

A concussion with amnesia or loss of consciousness <30 mins

51
Q

Condition that may account for ~50% of new cases of epilepsy in patients >65 years

A

Cerebrovascular disease

52
Q

Acute seizures are seen more often with which type of stroke? Embolic, hemorrhagic, or thrombotic?

A

Embolic

53
Q

TRUE OR FALSE: There is variety of antiepileptic drugs that is effective for the prevention of seizure after CNS injury.

A

FALSE. There are currently no drugs known to prevent the formation of a seizure focus following CNS injury.

54
Q

First priorities when a patient presents shortly after a seizure

A

Vital signs, respiratory, and cardiovascular support, and treatment of seizures if they resume

55
Q

What diagnostic study is mandatory in all patients infected with HIV, even in the absence of symptoms or signs suggesting infection?

A

Lumbar puncture

56
Q

Predominant rhythm on EEG in normal awake adults lying quietly with the eyes closed

A

8- to 13-Hz alpha rhythm intermixed with a variable amount of generalized faster (beta) activity (>13 Hz)

57
Q

What rhythm on EEG is attenuated when an awake adult opens his eyes?

A

Alpha rhythm

58
Q

Predominant rhythm on EEG during light sleep

A

Theta (4-7 Hz) and delta (<4 Hz)

59
Q

A lumbar puncture is mandatory in all patients infected with _____.

A

HIV

60
Q

TRUE OR FALSE: A patient with a possible seizure disorder should undergo an EEG 7 days after the seizure.

A

FALSE. All patients who have a possible seizure disorder should be evaluated with an EEG as soon as possible.

61
Q

TRUE OR FALSE: The EEG is always abnormal during generalized tonic-clonic seizures.

A

TRUE

62
Q

TRUE OR FALSE: The absence of electrographic seizure activity excludes a seizure disorder.

A

FALSE. Focal seizures may originate from a region of the cortex that cannot be reached during generalized tonic-clonic seizures.

63
Q

TRUE OR FALSE: The initial routine interictal EEG may be normal in up to 60% of individuals with known epilepsy.

A

TRUE

64
Q

What is the only potential exception in the rule that almost all patients with new-onset seizures should have a brain imaging study to determine whether these in a underlying structural abnormality?

A

Children who have an unambiguous history and examination suggestive of a benign, generalized seizure disorder such as absence epilepsy

65
Q

Imaging that is superior to other modalities for the detection of cerebral lesions associated with epilepsy

A

MRI

66
Q

Features that distinguish generalized tonic-clonic seizure from syncope

A

Page 3060, Table 418-7

67
Q

Seizure or Syncope?

Immediate precipitating factors: Usually none

A

Seizure

68
Q

Seizure or Syncope?

Premonitory symptoms: Tiredness, nausea, diaphoresis, tunneling of vision

A

Syncope

69
Q

Seizure or Syncope?

Posture at onset: Usually erect

A

Syncope

70
Q

Seizure or Syncope?

Transition to unconsciousness: Often immediate

A

Seizure

71
Q

Seizure or Syncope?

Duration of unconsciousness: Seconds

A

Syncope

72
Q

Seizure or Syncope?

Duration of unconsciousness: Minutes

A

Seizure

73
Q

Seizure or Syncope?

Duration of tonic or clonic movements: Never >15 s

A

Syncope

74
Q

Seizure or Syncope?

Facial appearance during event: Pallor

A

Syncope

75
Q

Seizure or Syncope?

Disorientation and sleepiness after event: <5 min

A

Syncope

76
Q

Seizure or Syncope?

Aching of muscles after event: Often

A

Seizure

77
Q

Seizure or Syncope?

Biting of tongue: Sometimes

A

Seizure

78
Q

Seizure or Syncope?

incontinence: Sometimes

A

Both

79
Q

Seizure or Syncope?

Headache: Sometimes

A

Seizure

80
Q

What are psychogenic seizures?

A

Nonepileptic behaviors that resemble seizures, often part of a conversion reaction precipitated by underlying psychological distress

81
Q

Measurement of serum _____ may help to distinguish between epileptic and psychogenic seizures.

A

Prolactin

(Most generalized seizures and some focal seizures are accompanied by rises in serum prolactin during the immediate 30-min postictal period, whereas psychogenic seizures are not.)

82
Q

An almost universal precipitating factor for seizures

A

Sleep deprivation

83
Q

Mainstay of treatment for most patients with epilepsy

A

Antiepileptic drug therapy

84
Q

Most generalized seizures and some focal seizures are accompanied by rises in the serum level of this substance

A

Prolactin

85
Q

Overall goal of antiepileptic drug therapy

A

To completely prevent seizures without causing any untoward side effects, preferably with a single medication and a dosing schedule that is easy for the patient to follow

86
Q

TRUE OR FALSE: Antiepileptic drug therapy should be started in a patient with history of a single seizure.

A

FALSE. Antiepileptic drug therapy should be started in any patient with recurrent seizures of unknown etiology or a known cause that cannot be reversed. Whether to initiate therapy in a patient with a single seizure is controversial.

87
Q

Risk factors associated with recurrent seizures

A

1) Abnormal neurologic examination
2) Seizures presenting as status epilepticus
3) Postictal Todd’s paralysis
4) Strong family history of seizures
5) Abnormal EEG

88
Q

First-Line Drugs for Generalized-onset tonic-clonic seizures

A

Lamotrigine
Valproic acid

(4 syllables for GTC)

89
Q

First-Line Drugs for Focal seizures

A 
Lamotrigine
Carbamazepine
Oxcarbazepine
Phenytoin
Levetiracetam
90
Q

First-Line Drugs for Typical absence seizures

A

Lamotrigine
Valproic acid
Ethosuximide

(Absence of LaVE)

91
Q

First-Line Drugs for Atypical absence, Myoclonic, and Atonic seizures

A

Valproic acid
Lamotrigine
Topiramate

92
Q

Drug that is considered first-line for almost all types of seizures (based on the table)

A

Lamotrigine

93
Q

Mutation in the SLC2A1 gene, which encodes the glucose type 1 transporter (GLUT-1) and is a cause of GLUT-1 deficiency, should immediately prompt treatment with _____

A

Ketogenic diet

94
Q

Mutations of the ALDH7A1 gene, which encodes antiquitin, can cause alterations that can reversed by treatment with _____

A

Pyridoxine

95
Q

Asian individuals carrying the human leukocyte antigen allele, _____, are at particularly high risk of developing serious skin reactions from carbamazepine, phenytoin, oxcarbazepine, and lamotrigine.

A

HLA-B*1502

96
Q

Antiepileptic drug that can precipitate Stevens-Johnson syndrome

A

Lamotrigine

97
Q

Antiepileptic drug that causes the following cosmetic effects: hirsutism, coarsening of facial features, gingival hypertrophy

A

Phenytoin

98
Q

Antiepileptic drug with the advantage of having no known drug-drug interactions

A

Levetiracetam

99
Q

Antiepileptic drug that can cause an irreversible, fatal hepatic failure appearing as an idiosyncratic rather than dose-related side effect

A

Valproic acid

100
Q

Considered the best initial choice for the treatment of primary generalized, tonic-clonic seizures

A

Lamotrigine
Valproic acid
Levetiracetam

(LVL for GTC)

101
Q

Antiepileptic drug that is teratogenic and may effect fertility

A

Valproic acid

102
Q

What should be periodically monitored during treatment with ethosuximide?

A

Blood cell counts (rarely causes bone marrow suppression)

103
Q

TRUE OR FALSE: Monotherapy should be the goal whenever possible.

A

TRUE

104
Q

Patient profile that yields the greatest chance of remaining seizure free after drug withdrawal

A

1) Complete medical control of seizures for 1-5 years
2) Single seizure type, with generalized seizures having a better prognosis than focal seizures
3) Normal neurologic examination, including intelligence
4) No family history of epilepsy
5) Normal EEG

105
Q

Most seizure recurrences occur in the first _____ after discontinuing therapy, and patients should be advised to avoid potentially dangerous situations.

A

3 months

106
Q

If there is a response to a third drug, which of the first 2 drugs should be gradually withdrawn?

A

The less effective or less well tolerated of the first 2 drugs

107
Q

Most common surgical procedure for patients with temporal lobe epilepsy

A

Temporal lobectomy or Amygdalohippocampectomy

108
Q

What is status epilepticus?

A

Continuous seizures or repetitive, discrete seizures with impaired consciousness in the interictal period. Duration is traditionally specified as 15-30 min.

A more practical definition is a situation in which the duration of seizures prompts the acute use of anticonvulsant therapy. For GCSE, this is typically when seizures last beyond 5 mins.

109
Q

TRUE OR FALSE: Generalized convulsive status epilepticus (GCSE) is an emergency and must be treated immediately.

A

TRUE

110
Q

What should be done when a patient with status epilepticus stops having overt seizures, yet remains comatose?

a. Stop treatment
b. Brain imaging
c. EEG
d. Check for serum prolactin

A

EEG (may be the only method of establishing diagnosis because after 30-45 mins of uninterrupted seizures, the signs may become increasingly subtle)

111
Q

First drug given in impending and early status epilepticus

A

IV benzodiazepine

112
Q

Typical duration of seizure that prompts the acute use of anticonvulsant therapy

A

5 mins

113
Q

TRUE OR FALSE: Postictal psychosis usually resolves spontaneously.

A

TRUE

114
Q

Most of the increased mortality in epilepsy is due to _____.

A

The underlying etiology of epilepsy (i.e. tumors or strokes)

115
Q

Syndrome that usually affects young people with convulsive seizures and tends to occur at night and causes death

A

Sudden unexpected death in epilepsy (SUDEP)

116
Q

Seizure frequency during pregnancy will remain unchanged in __% of women, increase in __%, and decrease in __%.

A

Seizure frequency during pregnancy will remain unchanged in ~50% of women, increase in ~30%, and decrease in ~20%.

117
Q

Most common fetal malformations due to antiepileptic treatment were defects in _____.

A

Cardiovascular and musculoskeletal system

118
Q

The newer antiepileptic drugs are safer in pregnancy except for

A

Topiramate

Valproic acid

119
Q

What supplement should be given to pregnant women undergoing antiepileptic treatment to prevent fetal malformation?

A

Folate (1-4mg/d)

120
Q

What should be given to women and infants to prevent neonatal hemorrhage caused by the transient and reversible deficiency of vitamin K-dependent clotting factors due to enzyme-inducing antiepileptic drugs?

A

The mother should be treated with oral vitamin K in the last 2 weeks of pregnancy

The infant should receive intramuscular vitamin K at birth

121
Q

Ratio of drug concentration in breast milk relative to serum with regards to valproic acid and levetiracetam

A

~5% valproic acid

~300% levetiracetam

Neurologic Disorders (26 decks)

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