Clinical Approach to Seizures and Syncope

Question 1

How is epilepsy defined?

How common is it?

Answer 1

2 or more unprovoked SZs.

4th most common - 1/26 people will develop epilepsy in their lifetime.

Question 2

What are the percent positive findings for epilepsy on a single EEG?

All types
Generalized tonic-clonic
Petit mal (w/ HV)
Partial

Answer 2

All types - 40%
Generalized tonic-clonic - 20%
Petit mal (w/ HV) - 90%**
Partial - 30%

Question 3

What is the percent positive for epilepsy (all types) with 3 sleep-derived EEGs?

Answer 3

85%

Question 4

EEG is helpful in diagnosing epilepsy, but what is most important?

Answer 4

History of the event(s), preferably by a witness. A positive or negative EEG does not rule in/out a SZ.

Question 5

What are the 3 partial seizures and their characteristics?

Answer 5

Simple partial = focal motor or sensory activity, no LOC, lasts seconds and has no post-ictal state.

Complex partial = non-responsive staring, possible preceding aura, automatisms, LOC, lasts 1-3 min., has a post-ictal state.

*Secondary generalized (partial onset) = BL tonic-clonic activity, LOC, lasts 1-3 min., post-ictal state.

Question 6

What are the characteristics of generalized seizures?

Absence (petit mal)
Tonic-clonic
Myoclonic
Atonic

Answer 6

Absence (petit mal) = nonresponsive staring, blinking, chewing, clonic hand motions, LOC, lasts 10-30 sec., no post-ictal state.

Tonic-clonic = BL extension followed by symmetrical jerking of extremities, LOC, lasts 1-3 min., has a post-ictal state.

Myoclonic = brief, rapid symmetrical jerking of extremities and/or torso, LOC, lasts < few sec., minimal post-ictal state.

Atonic = sudden loss of muscle tone, head drops or patient collapses.

Question 7

What combo of anti-epileptic drugs is shown to be synergistic in the treatment of epilepsy (especially primary generalized SZs)?

Answer 7

Valproic acid + Lamotrigine

Question 8

How is status epilepticus defined?

Answer 8

Prolonged SZ (> 10 min.) or repeated SZs without recovery in between.

Question 9

What is involved in the treatment of status epilepticus?

Answer 9

ABCs + IV

Obtain history if possible.

Labs: Accucheck, CBC, chemistry panel, drug allergy.

Non-contrast CT of head

Give benzodiazepines (e.g. lorazepam 2-4 mg IV) - buys time, but must give longer lasting AED at some point.

Question 10

Which AED can be given IV and IM if needed?

Answer 10

Fosphenytoin - give at rate of 100 mg/min. but may need to adjust if BP drops.

Question 11

Which AED can only be given if the patient is intubated first? Why?

Answer 11

Phenobarbital, because it may cause respiratory depression.

Question 12

Which AED can cause cardiac conduction abnormalities?

Answer 12

Lacosamide

Question 13

What are the general principles to use in treatment of epilepsy with meds? (3)

Answer 13

Try to use monotherapy.

Consider drug interactions (OCPs, Carbamazepine)

Consider long-term effects of the drug (e.g. bone loss w/ Carbamazepine or Phenytoin)

Question 14

Pregnant women should be on what supplement, which is extra important if she is epileptic?

What should be avoided in pregnancy?

In general, which AEDs are safer in pregnancy? What’s the ultimate factor in choosing an AED in pregnancy?

Answer 14

MVI w/ 1 mg. folate

Valproic acid

Newer AEDs (lamotrigine, leviteracetam) are probably better than older drugs (phenytoin, valproic acid), BUT the best option is the one that best controls her SZs.

Question 15

Transient global amnesia is defined as…

What are some symptoms?

How long does it last? Does it recur?

Answer 15

Sudden, temporary, isolated episode of loss of memory (amnesia) without other neurological signs/symptoms.

Patients know self and close family/friends, but may not recognize others.

Lasts a few hours, then resolves. Usually does NOT recur.