Epilepsy

Question 1

seizure

Answer 1

*the clinical symptom of an abnormal, hypersynchronous discharge of a population of cortical neurons
*may produce clinical symptoms or may only be apparent as electrical activity on the EEG
*a singular event!

Question 2

epilepsy

Answer 2

*RECURRENT seizures (2+) which are not provoked by systemic or acute neurologic insults

Question 3

focal (partial) seizures

Answer 3

*affect one area of the brain (BEGINS in one area on EEG)
*commonly originate from temporal lobe
*may be preceded by a seizure aura
*can be focal aware or focal impaired awareness

Question 4

focal aware seizures

Answer 4

*no alteration of consciousness
*can be motor, sensory, autonomic, psychic

Question 5

focal impaired awareness seizures

Answer 5

*impaired consciousness (may range from mild confusion to loss of consciousness)
*clinical manifestations vary with site of origin and propagation of electrical activity through brain
*duration typically < 2 minutes
*often present as “staring spells”

Question 6

focal to bilateral tonic-clonic seizures

Answer 6

*BEGINS focally, with or without obvious focal neurological symptoms
*variable symmetry, intensity, and duration of tonic (stiffening) and clonic (jerking) phases
*typical duration 1-3 minutes
*postictal confusion, somnolence, with or without transient focal deficit

Question 7

non-motor generalized seizures (typical absence seizures)

Answer 7

*brief staring spells with impairment of awareness
*3-20 seconds
*sudden onset & sudden resolution
*often provoked by hyperventilation
*onset typically between 4 and 14 years of age
*often resolve by 18 years of age
*normal development and intelligence
*EEG: generalized 3 Hz spike-wake discharges

Question 8

what is the EEG finding for non-motor generalized seizures (typical absence seizures)

Answer 8

generalized 3 Hz spike-wave discharges

Question 9

what type of seizure is characterized by generalized 3 Hz spike-wave discharges

Answer 9

non-motor generalized (typical absence seizures)

Question 10

motor generalized seizures

Answer 10

*associated with loss of consciousness and post-ictal confusion/lethargy
*duration 30-120 seconds
* tonic phase: stiffening and fall; may be associated with ictal cry
*clonic phase: rhythmic extremity jerking
*EEG: generalized polyspikes

Question 11

etiologies of seizures and epilepsy - infancy and childhood onset

Answer 11

-prenatal or birth injury
-inborn error of metabolism
-congenital malformation

Question 12

etiologies of seizures and epilepsy - childhood and adolescence onset

Answer 12

-idiopathic/genetic syndrome
-CNS infections
-trauma

Question 13

etiologies of seizures and epilepsy - adolescence and young adult onset

Answer 13

-head trauma
-maturation effects of structural foci
-drug intoxication and withdrawal

Question 14

etiologies of seizures and epilepsy - older adult onset (50+)

Answer 14

-STROKE
-brain tumor
-acute metabolic disturbances
-neurodegenerative

Question 15

Lennox Gastaut Syndrome

Answer 15

*multiple seizure types
*slow (< 3 Hz) spike and wave on EEG
*developmental delay

Question 16

examples of structural causes of epilepsy

Answer 16

-medial temporal sclerosis
-migration abnormality

Question 17

evaluation after a first seizure

Answer 17

-history and physical
-blood tests
- +/- lumbar puncture
-blood or urine screen for drugs
-EEG (best if pt is sleep deprived)
-MR brain scan

Question 18

seizure precipitants

Answer 18

-metabolic and electrolyte imbalance
-sleep deprivation
-ASM non-compliance
-hormonal variations
-stress
-fever/infection
-head injury
-stimulants and other drugs

Question 19

medications that can trigger a seizure

Answer 19

*wellbutrin
*diphenhydramine (benadryl)
*tramadol
*some stimulants or antibiotics

Question 20

key metabolic abnormalities associated with triggering a seizure

Answer 20

1) hyponatremia (low sodium in blood)
2) hypoglycemia

Question 21

electroencephalogram (EEG)

Answer 21

*graphical depiction of cortical electrical activity, usually recorded from the scalp
*advantage of high temporal resolution, but poor spatial resolution of cortical disorders
*most important neurophysiological study for the diagnosis, prognosis, and treatment of epilepsy

Question 22

background abnormalities on EEG

Answer 22

significant asymmetries and/or degree of slowing inappropriate for clinical state or age, may not relate to seizures

Question 23

interictal abnormalities associated with seizures and epilepsy

Answer 23

**spike-wave complexes are pathognomonic for epilepsy
-spikes (< 70 msec)
-sharp waves (< 200 msec)

Question 24

psychogenic non-epileptic spells

Answer 24

*NOT seizures (“functional neurologic disorder”)
*females > males; h/o abuse; may coexist with epilepsy
*psychiatric mechanism - dissociation, conversion - malingering is rare
*common association with physical, emotional, or sexual abuse
*NO EEG CORRELATION

Question 25

cellular mechanisms for seizure generation

Answer 25

*too much excitation
-ionic: inward Na+ and Ca++ currents
-neurotransmitter: glutamate and aspartate

*too little inhibition
-ionic: inward Cl-, outward K+ currents
-neurotransmitter: GABA

Question 26

vagus nerve stimulator

Answer 26

*intermittent programmed electrical stimulation of left vagus nerve
*may improve seizures, etc

Question 27

ethosuximide only works for what type of seizures

Answer 27

absence seizures

Question 28

epidiolex (CBD) for seizures

Answer 28

*only approved for:
1) Dravet syndrome (SCM1A)
2) tuberous sclerosis complex
3) Lennox Gastaut syndrome

Question 29

Stevens-Johnson Syndrome (SJS)

Answer 29

-blisters and erosions of the skin, particularly palms and soles and mucous membranes
-fever and malaise
-rare condition
-rapid titration of lamotrigine especially in combination with valproate increases risk

Question 30

surgical treatment for epilepsy - potentially curative

Answer 30

-resection of epileptogenic region avoiding significant new neurologic deficit
-laser thermal ablation

Question 31

surgical treatment for epilepsy - palliative

Answer 31

-partial or staged resection of epileptogenic region
-disconnection procedures to prevent seizure spread (callostomy)

Question 32

surgical treatment for epilepsy - devices

Answer 32

-responsive neurostimulation
-deep brain stimulation

Question 33

status epilepticus

Answer 33

*a medical emergency
*traditionally, > 30 minutes of convulsive seizure activity or 2+ sequential seizures without full recovery between seizures for > 30 minutes
*current: defines earliest time when treatment should be started (t1) and the time when long term consequences are increasingly likely (t2)

t1 = 5 min and t2 = 30 min

Question 34

sudden unexpected death in epilepsy (SUDEP)

Answer 34

sudden, unexpected, witnessed or unwitnessed, nontraumatic and non-drowning death in a patient with epilepsy where the autopsy does not reveal any other cause of death