5. Seizures Flashcards
A 25 year-old woman is referred for episodes of altered behavior. These episodes last for 2 minutes, and are associated with lip-smacking movements and repetitive behavior. The patient does not remember these events, but says that she feels “butterflies in my stomach” and a sense of fear before they occur. Sometimes she says she smells burning rubber as well. What is the most likely diagnosis?
Complex partial seizure
Most focal epilepsies arise from which location?
Mesial temporal areas/hippocampus
An otherwise healthy 65 year-old man has the first seizure of his life. You suspect…
A brain tumor
The rate of epilepsy is high in early childhood (Ages 0-14).
Causes of most seizures in children:
- Genetic factors
- Congenital malformations
- Trauma
- Neoplasms
The risk of epilepsy declines significantly until age 60.
Causes of most seizures in old people:
- Vascular disease (>50%)
- Neoplasms
- Trauma
- Infection
- Neurodegenerative disorders
After a seizure, a patient is noted to be weak on the left side of her body, primarily her leg. This helps you determine…
The location of the epileptic focus in her brain
A patient is observed to suddenly lose consciousness and have tonic- clonic movements of their extremities with urinary incontinence and tongue-biting. The best term for this would be…
Primary generalized seizure
- A seizure that affects the whole brain at the same time
- Consciousness is lost
- Examples:
- Absence seizures, atonic seizures, and tonic-clonic seizures
*Often focal seizures can generalize almost instantly, making them indistinguishable from primary generalized seizures!
A 7 year-old boy is noted by his teacher to be day-dreaming numerous times during the day. His grades start to suffer, though the child has no recollection of these events.
- If this is a seizure, this is most typical of…
- The EEG would show…
-
Absence seizures
- A type of primary generalized seizure
- Hyperventilation can bring out such seizures
- Spike and wave activity at 3 cycles per second (3-Hz spike/wave pattern)
In what way are absence seizures different from complex partial seizures?
There is no post-ictal state with absence seizures.
A 15 year-old boy has been teased by his family for being clumsy, especially early in the morning when he is noted to drop his utensils on the floor. The teasing stops when he has a seizure after staying out late for a party. An MRI and neurological exam are normal, but an EEG shows a normal background with frequent generalized polyspike and wave discharges diffusely throughout at 4-6Hz.
- This is consistent with…
- Suggested treatment…
- Juvenile myoclonic epilepsy
-
Starting valproic acid (Depakote)
- Levetiracetam (Keppra) works as well
Juvenile myoclonc epilepsy
- Characterized by myoclonic jerks, typically upon wakening
-
Triggered by sleep deprivation
- Classically, a teenager seizes after pulling an all-nighter
- Seizures do not remit, and treatment is needed
A patient with a known brain tumor in the left frontal lobe experiences shaking of her right hand that progresses up to her right arm and shoulder before terminating. The patient is wide awake and alert throughout this event. What is this called?
Simple partial seizure
Simple partial seizure
- A seizure that begins in a definitive area in the brain and does NOT affect consciousness
- May manifest with motor, sensory, autonomic, or psychiatric symptoms
- Often comes with a sense of overwhelming fear or depersonalization
Complex partial seizure
- A seizure that begins in a definitive area in the brain and DOES affect consciousness
- An aura is always a sign of a focal seizure
A patient with a known brain tumor in the left frontal lobe experiences shaking of her right hand that progresses up to her right arm and shoulder. This continues until the patient loses consciousness and has tonic-clonic movements of their entire body. What is this called?
Secondary generalized seizure
- A seizure that affects a single area of the brain initially, and then spreads to include the rest of the brain
-
Jacksonian March
- Pattern of seizure progressing up someone’s body before generalizing
What is Todd’s paralysis?
A focal neurological deficit, usually weakness, that persists for up to 24 hours after a seizure.
A five year old child is brought to you by his concerned mother – she has noticed a severe decline in his ability to comprehend and produce speech.
- What is this disorder called?
- What is the most common finding of this disorder on EEG?
- Landau-Kleffner syndrome
- Bilateral spike-and-wave discharges during non-REM sleep
Landau-Kleffner syndrome
- Characterized by progressive aphasia in children, affecting both Broca’s and Wernicke’s areas
- Onset is between 3-7 years old
- 80-85% of children will demonstrate epileptiform activity during non-REM sleep
A parent brings in her 2 month- old baby to the pediatrician because of colic pain. The baby cries a lot in pain and often bends himself forward at the level of the trunk. It is noted that there are 3 hypopigmented lesion on the baby’s skin that are more apparent with UV light.
- What is the diagnosis?
- What would be the most appropriate treatment after confirming the diagnosis?
- Tuberous sclersois (TS)
- ACTH
Tuberous sclerosis
- Signs
- Infantile spasms
- Cortical tubers
- Ash-leaf macules
- GERD
- Treatment = ACTH
- Prevents infantile spasms associated with TS by reducing the corticotropin releasing hormone (CRH)
- CRH normally causes excess excitability
- Prevents infantile spasms associated with TS by reducing the corticotropin releasing hormone (CRH)
What is West syndrome?
A syndrome of infants that consists of the triad of:
- Infantile spasms
- Hypsarrhythmia = EEG pattern of high amplitude waves and background of irregular spikes
- Mental retardation
Treatment = ACTH
What is Lennox-Gastaut syndrome?
Epilepsy syndrome that occurs in children age 2-6.
Multiple seizure types:
- Tonic - stiffening of the body, upward deviation of the eyes
- Atonic - brief loss of muscle tone and consciousness
- Atypical absence
- Myoclonic - sudden muscle jerks
Seizures are very difficult to control
A 10 year-old child has seizures characterized by laughing fits. His MRI is below. These are most characteristic of seizures due to a neoplasm of the…
Hypothalamus
- These are known as gelastic seizures
- Symptoms of seizure depend on what part of the brain it originates from
A 35 year-old man falls while riding his bike hitting his head on the ground. He got up immediately, clearly shaken, but otherwise normal. 30 minutes later, when telling the story to his friends, he “turned as white as a ghost,” fell to the ground and had some shaking movements of his arms and legs. He got back up within minutes and seemed fine again. The most likely diagnosis is…
Vasovagal syncope
- Recurrent episodes of loss of consciousness in the absence of an emotional cue would suggest a cardiac etiology of the syncope
- Convulsive syncope = convulsive movements during syncope
- Which anti-epileptic medication is most strongly associated with neural tube defects when given to pregnant women?
- Which anti-epileptic medication is contraindicated in patients with a history of kidney stones?
- Which anti-epileptic medication is associated with hyponatremia?
- Which anti-epileptic medication is associated with gum enlargement?
- Valproic acid (Depakote)
- Topiramate
- Carbamazepine, oxcarbazepine
- Phenytoin (Dilantin)
*Chronic anti-epileptic therapy can cause cerebellar atrophy.
What are the surgical treatments of epilepsy?
-
Removal of temporal lobe
- Removal from other lobes can occur as well
- Corpus callosotomy
Removal of temporal lobe:
- Most common surgical procedure in epilepsy
- Careful brain mapping of the proposed area of resection is required prior to any epilepsy surgery to ensure the patient is not left with severe language or cognitive deficits
Corpus callosotomy:
- Lesion is made in the corpus callosum
- Used in patients with refractory epilepsy to prevent partial seizures from spreading across the brain to become generalized
*Certain conditions (seizures of Sturge-Weber syndrome) or cases of severe cortical dysplasia may require dramatic surgical procedures to control the seizure
