Clinical Epilepsy-Bloch Flashcards
1
Q
What is this:
the clinical manifestation of an abnormal excessive excitation and synchronization of a populatio of cortical neurons
A
seizure
2
Q
What is this: recurrent seizures (two or more) which are not provoked by systemic or acute neurologic insult
A
epilepsy
3
Q
A seizure is the manifestation of an abnormal, (blank) discharge of a population of cortical neurons
A
hypersynchronous
4
Q
The hypersynchronous discharge of neurons caused by a seizure may produce symptoms or objective signs which is called a (blank) seizure, or it may be apparent only on EEG in which case it is a (blank) seizure
A
- clinical
- electrographic (subclinical) seizure
5
Q
What is the incidence of seizure?
What is the lifetime incidence of seizures?
A
80/100,000 per year
9% (1/3 febrile convulsions)
6
Q
What is the incidence of epilepsy?
What is the point prevalence of epilepsy?
What is the cumulative lifetime incidence?
A
45/100,000
0.5-1%
3%
7
Q
The incidence of new-onset seizures in the general population is approximately 80 per 100,000 per year; approximately (blank) percent of these patients will have epilepsy, a tendency toward recurrent unprovoked seizures.
A
60%
8
Q
At least (blank) unprovoked seizures are required for the diagnosis of epilepsy. OR one seizure with (blank) findings
A
two
abnormal MRI or EEG
9
Q
What are the major categories of seizures?
A
partial (one hemisphere)
generalized (both hemispheres)
10
Q
What are three types of partial seizures?
A
- simple partial
- complex partial
- secondarily generalized
11
Q
What are the five types of generalized seizures?
A
- absence
- myoclonic
- atonic
- tonic
- tonic-clonic
12
Q
What is another name for partial seizures?
A
focal seizures
13
Q
During simple partial seizures, (Blank) is preserved. What is the patient like?
A
consciousness
alert, responive, intact memory of what occured during seizure
14
Q
What is a complex partial seizure?
A
consciousness is altered or lost; impaired attention and responsiveness, loss of memory during seizure
15
Q
Why is it important to distinguish between simple partial and complex partial seizures?
A
complex partial seizure patients should not drive
16
Q
Partial onset seizures may progress to (blank) seizures.
A
secondarily generalized
17
Q
What are secondarily generalized seizures?
A
start partial and become generalized and involve motor activity on both sides of the body
18
Q
What are the subtypes of simple partial seizures?
A
- with somatosensory or special sensory symptoms
- with motor signs
- with autonomic symptoms or signs
- with psychic or experiential symptoms
19
Q
What would a simple partial seizure with autonomic symptoms or signs look like?
A
Autonomic seizures are common, evoking changes in autonomic activity (e.g., altered heart or breathing rate, sweating) or visceral sensations (e.g., in abdomen or chest)
20
Q
What is a complex partial seizure and what is the duration?
A
a partial seizure with impaired consciousness and lasts less than 2 minutes
21
Q
What is the clinical manifestation of a complex partial seizure?
A
-varies with site of origin and degree of spread
presence and nature of aura, automatisms, other motor activity
22
Q
The majority of complex partial seizures originate in the (blank) lobe and can affect consciousness while still remaining focal.
A
temporal
23
Q
What are some clinical manifestations of complex partial seizures?
A
patients tend to stare off and have impaire responsiveness, cognitive function, and recall, although some degree of responsiveness may be preserved (e.g. orienting toward a stimulus)
24
Q
(blank) movements are common in complex partial seizures. What are some examples of these?
A
automatic
commonly involve the mouth (e.g lip smacking, chewing, swallowing), upper extremities (e.g fumbling, picking), vocalization/verbalization (e.g. grunts, repeating a phrase), or complex acts (e.g. shuffling card).
25
Occasionaly with complex partial seizures, there are dramatic automatisms manifested as what?
screming, running, disrobing, pelvic thrusting
26
How do secondarily generalized seizures start? are there focal neurological symptoms?
What is the typical duration?
Begins focally, with or without focal neurological symptoms
-variable symmetry, intensity, and duration of tonic (stiffening) and clonic (jerking) phase
1-3 minutes
27
How will a patient with a secondarily generalized seizure present postictally?
confusion, somnolence, with or without transient focal deficit
28
Partial seizures can progress to generalized seizures with (blank) activity
tonic-clonic
29
Once a partial seizure secondarily generalizes it is generally (possible/impossible) to differentiate from a primarily generalized seizure.
impossible
30
In secondarily generalized seizures, patients may recall an (blank) prior to the convulsive activity or witnesses may observe a simple partial or complex partial seizure prior to generalization. In addition, following a secondarily generalized seizure, the patient may have (blank) on the side contralateral to seizure onset.
aura
focal weakness (Todd’s paralysis)
31
The (blank) state is the altered state of consciousness after an epileptic seizure. It usually lasts between 5 and 30 minutes
postictal
32
During (blank) scalp-recorded EEG may be normal, or show quite localized or lateralized abnormal rhythmic activity.
simple partial seizures
33
During (blank), rhythmic activity, which is often bilateral, is seen.
complex partial seizures
34
During (blank), rhythmic activity is usually high amplitude, bilateral and diffuse, although it is usually obscured by artifact from the abundant muscle activity characterizing these seizures.
secondarily generalize activity
35
(blank) seizures affect both cerebral hemispheres from the beginning of the seizure
Generalized
36
What are the 5 types of generalized seizures?
- absence
- myoclonic
- atonic
- tonic
- tonic-clonic
37
Generalized seizures affect both cerebral hemispheres from the beginning of the seizure. They produce (blank), either briefly or for a longer period of time.
loss of consciousness
38
```
What is an absence seizure?
How long do they last?
What is the onset and resolution like?
What provokes them?
What age is the onset?
What age is resolution?
```
- a type of generalize seizure with brief staring spells ("petit mal")
- 3-20 seconds
- sudden onset and quick resolution
- hyperventilation
- 4-14 years of age
- 18 years
39
Do absence seizures affect intelligience and development?
| What is the EEG like?
NO
| generalized 3 Hz spike-wave discharges
40
(Blank) seizures are brief episodes, usually lasting 3-20 seconds, of staring with impairment of awareness and responsiveness.
Absence (petit mal)
41
Is there a warning before an absence seizure?
| What is the person like after the seizure? Why is this significant?
no
alert and attentive
-this lack of postictal period is a key feature that allows one to distinguish b/w absence and partial complex seizures.
42
What happens if you have an absence seizure greater than 10 seconds?
you get accompanying motor phenomena (e.g. eye blinks, brief automatic mouth or hand movements, changes in muscle tone).
43
What is an Atypical absence seizure?
-brief staring spells with variably reduced responsiveness
44
Whats the difference betwen and atypical absence seizure and a typical absence seizure?
Atypical lasts longer (5-30 seconds)
Has a gradual onset and resolution (typical is sudden)
Is not provoked by hyperventilation (typical is)
Has a later onset (typically after 6 years of age)
45
Who typically gets atypical absence seizures?
Children with global cognitive impairment
46
What is the EEG like in a atypical absence patient?
generalized slow spike-wave complexes less than 2.5hz (typical is 3 hz)
47
T or F
Atypical absence seizures usually arise during childhood, but may persist into adulthood. Atonic and tonic seizures often occur in patients with atypical absence seizures.
T
48
What is a epileptic myoclonus seizure?
| What does the EEG look like?
it is a generalized seizure characterized by a brief, shock-like jerk of a muscle or group of muscles
-generaized 4-6 Hz polyspike-wave discharge
49
(blanK) seizures involve a brief, shock-like jerk of a muscle or group of muscles.
Myoclonic
50
(blank) myoclonus occurs in healthy people (e.g while falling asleep). This is not a myoclonic seizure.
Benign
51
Pathologic myoglonus can result from (blank and blank) causes
epileptic and nonepileptic
52
(blank) usually causes bilateral, synchronous jerks most often affecting the neck, shoulders, upper arms, boy and upper legs.
epileptic myoclonus
53
Is consciousness impaired in myoclonic seizures? How long do myoclonic seizures last?
consciouness does not usually seem to be impaired
| -less than 1 second
54
EEG during a myoclonic seizure typically shows a (blank) discharge
polyspike and slow wave discharge
55
(blank) occur in a variety of epilepsy syndromes. Rarely they may be seen as part of a progressive, degenerative condition
Myoclonic seizures
56
What is this:
symmetric, tonic muscle contraction of extremities with tonic flexion of waste and neck
How long do they last?
What does the EEG look like?
A type of generalized seizure called a Tonic seizure
2-20 seconds
Sudden attenuation with generalized, low voltage fast activity (most common) or generalized polyspike wave
57
```
What is an atonic seizure (type of generalized seizure)?
What will result if it is severe case?
What about a mild case?
Is consciousness impaired?
How long is do they last?
What will the EEG look like?
```
sudden loss of postural tone
-falls
-head nods or jaw drops
YES
usually seconds, rarely more than 1 minutes
-Sudden diffuse attenuation or generalized polyspike-wave
58
Who are atonic and tonic seizures occur in?
people with neurologic abnormalities
59
In contrast to partial motor seizures, tonic seizures are generalized, involving bilateral musculature in a (blank) manner.
symmetric or nearly symmetric
60
(blank) seizures are characterized by flexion at the waist and neck, abduction and flexion or extension of the upper extremities, and flexion or extension of the lower extremities. They typically occur during (blank) and last (blank) seconds.
What does the EEG look like?
Tonic seizures
sleep
2-20
EEG usually shows generalized, low-voltage, fast polyspikes.
61
(blank) seizures consist of a sudden loss of postural tone, often resulting in falls, or, when milder, head nods or jaw drops. Consciousness is usually impaired and significant injury may occur. Duration is usually several seconds, rarely more than 1 minute. EEG often shows an electrodecremental response.
Atonic
62
What is this:
associated with loss of consciousness and post-ictal confusion and lethargy. It lasts 30-120 seconds
-there is some stiffening and falling, often associated with ictal cry and rhythmic extremity jerking
Generalized tonic-clonic seizures
63
What is another name for primary generalized tonic-clonic seizures?
grand mal or convulsive seizures
64
What do primary generalized tonic-clonic seizures cause?
loss of consciousness associated with an initial tonic phase of stiffening, a fall, and often a cry evoked by air forced through contractd vocal cords.
65
What is this:
There may be drooling or foaming resulting from lack of swallowing and excessive salivation; biting of the tongue, cheek, or lip, causing bleeding; and bladder or bowel incontinence. Postictal lethargy and confusion often last minutes to hours, and may be followed by transient agitation.
Generalized tonic-clonic seizures
66
What does an EEG look like for a generalized tonic-clonic seizure?
generalized polyspikes
67
What can cause seizures and epilepsy in infancy and childhood?
- prenatal or birth injury
- inborn error of metabolism
- congenital malformation
68
What can cause seizures and epilepsy in childhood and adolescence?
- idiopathic/genetic syndrome
- CNS infection
- trauma
69
What can cause seizures and epilepsy in adolescene and young adult?
- Head trauma
| - Drug intoxication and withdrawal
70
What can cause seizures and epilepsy in older adults?
- stroke
- brain tumor
- acute metabolic disturbances
- neurodegenerative
71
If someone has their first seizure, what should you check for?
if it was actually a seizure or caused by something else, look for partial onset, look for CNS dysfunction, check for metabolic disorders, classify seizure type, get proper tx
72
How do you evaluate a first seizure?
- H and P
- Blood tests (electrolytes, glucose, calcium, magnesium, phosphate, hepatic and renal function
- Lumbar puncture (only if meningitis or encephalities suspected and potential for brain herniation is excluded)
- blood or urine screen for drugs
- Electroencephalogram (EEG)
- CT or MR brain scan
73
If a patient recalls localized motor activity before losing consciousness what does this suggest?
a simple partial motor seizure
74
The examination of the patient who has experienced a seizure is often most revealing when conducted when? should you repeat it? and why?
as soon after the seizure as possible,
| should be frequently repeated to determine whether or not any observed deficits are transient.
75
Post-ictal weakness, aphasia, or sensory dysfunction provide powerful (blank) and sometimes localizing information.
lateralizing
76
Signs which are not transient may indicate a (blank) or a new condition (e.g., stroke), and may lead to the diagnosis of an (blank), that is, a seizure resulting from a new brain insult, which does not necessarily imply the existence of epilepsy (although epilepsy may later develop).
pre-existing structural lesion (e.g., tumor)
| acute symptomatic seizure
77
What are helpful hints that an event was a seizure?
bites on the side of the tongue or cheek, urinary and/or fecal incontinence
78
Any suspicion of meningitis or encephalitis mandates (blank)
lumbar puncture
79
Patients who have had a new onset seizure should undergo an (balnk) and (blank)
EEG
| MR brain scan
80
A (blank) is useful if an acute process is suspected (i.e intracerebral hemorrhage) but is inadequate to exclude small tumors or vascular malformations, hippocampal atrophy and cortical dysplasia.
CT scan
81
What are metabolic and electrolyte seizure precipitants?
metabolic electrolyte imbalance caused by
- low blood glucose (or high glucose, esp. w/ hyperosmolar state)
- low sodium
- low calcium
- low magnesium
82
What are some stimulants and pro-convulsants that can cause intoxication and seizure?
- IV drug use
- Cocaine
- Ephedrine
- Other herbal remedies
- Medication reduction
83
What are some medications that can lower seizure threshold?
```
Antidepressants
-Bupropion
-Tricyclics
Neuroleptics
-phenothiazines
-clozapine
```
Other
- theophylline
- isoniazid
- penicillins
- cyclosporin
- meperidine
84
SHould you treat the first seizure?
Its controversial but within 5 years 16-62% of unprovoked seizures will recur within 5 years
85
How can you reduce the seizure relapse rate?
| what factors will increase the relapse rate?
via AED
| -abnormal imaging, abnormal neuro exam, abnormal EEG, family history
86
(blank) is more likely if there has been an earlier neurologic injury sufficient to cause seizures; a structural abnormality on neuroimaging; an abnormal, particularly epileptiform, EEG; or a family history of epilepsy.
Recurrence
87
What types of seizures are most likely to recur?
partial (including secondary generalized)
88
Choice of AED for (blank) epilepsy depends largely on drug side-effect profile and patient’s preference/concerns
partial
89
Choice of AED for (blank) epilepsy depends on predominant seizure type(s) as well as drug side-effect profile and patient’s preference/concerns
generalized
90
(blank) are useful in the treatment of both primary generalized seizures and partial-onset seizures. What are some examples?
Broad-spectrum agents
- valproate
- lamotrigine
- levetiracetam
91
(blank) are used to treat partial-onset seizures but are generally avoided in primary generalized epilepsy as they can potentially exacerbate some seizure types (eg atypical absence seizures).
What are some examples?
narrow-spectrum agents
phenytoin
carbamazepine
gabapentin
92
What drug do you use for absence seizures?
ethosuximide
93
In the monotherapy for partial seizures:
| What AEDs have the best evidence and are FDA indicated?
Carbamazepine, Oxcarbazepine, Phenytoin, Topiramate
94
In the monotherapy for partial seizures:
| In partial onset seizures with secondary generalization, what are the drugs you use?
- carbamazepine
- phenytoin
- valproate
- phenobarbital
- primidone
95
In the monotherapy for partial seizures:
| Of the new AEDs, only (blank) has FDA approval for monotherapy in new-onset partial seizures.
oxcarbazepine
96
In the monotherapy for generalized onset tonic-clonic seizures, what are the drugs with the best evidence and have FDA indication?
```
Valproate
Topiramate (makes you dopey)
```
97
In generalized epilepsies characterized by tonic-clonic seizures, myoclonic seizures, and/or absence seizures, or in photosensitive epilepsy, (blank) is usually considered the drug of choice.
valproate
98
(blank) may exacerbate some generalized-onset seizures including absence and myoclonic seizures.
(blank) may also worsen myoclonic seizures.
With (blank) you make lose your "filter" when speaking
Carbamazepine
Lamotrigine
Levetiracetam
99
What drugs are best used in absence seizures?
-ethosuximide (safer) and Valproate (dont give to pregnant people)
(also can you lamotrigine)
100
What drugs shoud you use in myoclonic seizures?
Valproate
Levetiracetam (FDA indication as adjunctive tx)
Clonazepam (FDA indication)
101
What is lennox-gastaut syndrome and how do you treat it?
- mentally impaired children have 5-12 seizures (of differing type) a day.
- Topiramate, felbamate, clonazepam, lamotrigine, rufinamide, valproate
102
When converting to monotherapy, what drugs do you eliminate first? How do you withdraw AEDs?
eliminate sedative drugs first
| -slowly over several months
103
What AEDs may induce metabolism of other drugs?
- carbamazepine
- phenytoin
- phenobarbital
- primidone
104
What AEDS inhibit metabolism of other drugs?
- valproate
| - felbamate
105
What AEDs are highly protein bound?
-valproate, phenytoin, tiagabine
carbamazepine, oxcarbazepine
topiramate is moderately protein bound
106
All AEDs are metabolized in the liver except for (blank and blank)
gabapentin and levetiracetam
107
What drugs may decrease the efficacy of oral contraceptives?
How do you remedy this situation?
```
Phenytoin
Carbamazepine
Phenobarbital
Topiramate* (at high doses)
Oxcarbazepine (at high doses)*
Felbamate* (at high doses)
```
-"high dose" birth control pills
108
Should you use lamotrigine with your birth control?
no
Oral contraceptives decrease lamotrigine levels by 50%
Their levels can increase signif during placebo week causing toxicity
-AND it can decrease progesterone levels
109
What AEDs cause dizziness, fatigue, ataxia, and diplopia?
All AEDs
110
What AEDs cause irritability?
Levetiracetam
111
What AEDs cause word-finding difficulty?
Topiramate
112
What AEDs cause weight loss/anorexia problems?
Topiramate, zonisamide, felbamate
113
What AEDs cause weight gain?
valproate
Carbamazepine
gabapenten
pregabalin
114
What AED can cause teratogenicity and polycystic ovarian syndrome?
Valproate
115
What AEDs can cause renal stones?
topiramate
| zonisamide
116
What AEDs can cause anhydrosis (lack of sweating), and heat stroke?
topiramate
117
What AEDs can cause acute closed-angle glaucoma?
topiramate
118
What AEDs can cause hyponatremia?
carbamazepine
| oxcarbazepine
119
What AEDs can cause aplastic anemia?
felbamate
zonisamide
valproate
carbamazepine
120
What AEDs can cause hepatic failure?
valproate
felbamate
lamotrigine
phenobarbital
121
What AEDs can cause peripheral vision loss?
vigabatrin
122
What AEDs can cause rash?
phenytoin, lamotrigine, zonisamide, carbamazepine
123
(blank) percent of patients experience a rash attribute to AED
16%
124
Who most likely will get an AED rash?
an asian who already got a rash from a diffferent AED
125
What are 2 types of serious rashes you can get with AEDs?
-Steven Johnson Syndrome (SJS)
| Toxic Epidermal Necrolysis (TENS)
126
What is this:
severe life threatening allergic reaction
blisters and erosions of the skin, particularly palms/soles and mucous membranes
fever and malaise
rare: severe risk roughly 1-10/10,000 for many AEDs
-rapid titration of lamotrigine especially in combination with valproate increases risk
Toxic Epidermal Necrolysis (TENS)
127
What 2 drugs have the highest risk of rash?
Phenytoin and lamotrigine
128
What the three most common comorbidites of epilepsy and AEDs?
Osteoporosis
Migraine
Depression
129
What drugs can cause osteoporosis?
| How do you prevent this?
phenytoin, phenobarbital, primidone (all enzyme inducers)
| -take 1000-1500/day of calcium and 400-4000 vit D /day
130
What drugs can cause migraine?
topiramate
| valproate
131
What drugs can cause depression?
| What drugs should be used instead?
levetiracetam
| -lamotrigine, gabapentin, pregabalin
132
What are the three strages of epileptic depression?
| What is the suicide rate in epileptics?
Prodromal, peri-ictal, interictal
| Suicide rate 5 times higher than normal pop
133
Do AEDs lead to more suicide attempts or less?
MORE
134
How can you get a patient off of AEDs?
Seizure free for more than 2 years (greater than 60% chance of successful withdrawal in some epilepsy syndromes)
135
What are favorable factors to pull someone off of AEDs?
Control achieved easily on one drug at low dose
No previous unsuccessful attempts at withdrawal
Normal neurologic exam and EEG
Primary generalized seizures except Juvenile Myoclonic Epilepsy
“Benign” syndrome
136
What are some non-drug tx/lifestyle modifications for epilepsy/seizures?
Adequate sleep
Avoidance of alcohol, stimulants, etc.
Avoidance of known precipitants
Stress reduction — specific techniques
137
The (blank) diet has been used for more than 80 years in children with severe seizure disorders. It is based on the observation that ketosis and acidosis have anti-seizure effects, although recently glucose stabilization, caloric restriction, and direct anticonvulsant effects of polyunsaturated fatty acids have been reported in animal models.
ketogenic
138
What makes up a ketogenic diet?
What are the SEs?
Does it reduce seizues?
Low carbohydrate, adequate protein, high fat
-Kidney stones, weight loss, acidosis, dyslipidemia
50% patients had a 50% reduction in seizures
30% of patients had a greater than 90% reduction in seizures
139
What is the modified atkins diet and does it help reduce seizures?
10 g/day carbohydrates to start, fats encouraged
No restrictions on protein, calorie, or fluid
47% all children with >50% seizure reduction
140
What is the low glycemic index tx? Is it helpful?
40-60 g/day low-glycemic carbohydrates
Portions generally controlled
-Single report from Massachusetts General
141
When should you give an epileptic surgery?
| What are the surgeries like?
- when not responsive to med management (despite max toleratd dose of 2-3 app drugs as monotherapy)
- when it will help
- typically cut corpus callosum
142
what percent of patients were seizure free after anterior temporal resection?
What about neocrotical resection?
66%
49%
Sugery showed improvement in both cases :)
143
What is vagus nerve stimulator? Does it work?
What are the adverse effects?
What does the FDA approve this for?
intermittent programmed electrical stimulation of left vagus nerve
- yes! improves mood, allows AED reduction and reduces seizure frequency! (doesnt make them seizure free but reduces seizure)
- local and related to stimulus (i.e hoarseness, throat discomfort, dyspnea)
-refractory partial onset seizures and refractory depression
144
(blank) is a dangerous condition in which epileptic seizures follow one another without recovery of consciousness between them.
Status epilepticus (SE)
145
Why is status epilepticus a medical emergency?
The adverse consequences can include hypoxia, hypotension, acidosis, hyperthermia, rhabdomyolysis and neuronal injury
*****you need to stop seizure as soon as possible
146
What is the treatment algorithm for status epilepticus within the first 5 minutes?
```
Within the first 5 minutes:
Check emergency ABC’s
Give O2
Obtain IV access
Begin EKG monitoring
Check fingerstick glucose
Draw blood for Chem-7, Magnesium, Calcium, Phosphate, CBC, LFTs, AED levels, ABG, troponin
Toxicology screen (urine and blood).
```
147
What is the treatment algorithm for status epilepticus within minutes 6-10 minutes?
- Thiamine IV
- Dextrose IV
- Lorazepam IV
- If no rapid IV access give diazepam 20 mg PR or midazolam 10 mg intranasally, buccally or IM.
148
What is the treatment algorithm for status epilepticus within minutes 10-20?
If seizures persist:
fosphenytoin IV at
Reasonable to bypass this step, or perform subsequent step simultaneous with fosphenytoin loading
149
What is the tx for status epilepticus within 10-60 minutes?
```
Continous IV midazolam
OR
Continuous IV proprofol
OR
IV valproate
OR
IV phenobarbital
```
150
As a physician what must you tell the DMV? What are exceptions to this?
if your patient has epilepsy
-if medically induced seizure, if only one seizure with recurrence unlikely, if only nocturnal seizures, only simple partial seizures, seizure related to temporary illness)
