epilepsy

Question 1

causes of seizures?

Answer 1

genetic: genetic mutations of ion channels, chromosomal abnormalities (angelman, prader-willi), metabolic disorders (PKU)

structural: tumors, traumatic brain injury, hippocampal sclerosis

immune: autoimmune encephalitides

infectious: meningitis, encephalitis, toxoplasmosis, neurocysticercosis

electrolyte imbalances (hypoglycemia, hyponatremia, hypocalcemia), alcohol withdrawal, stopping seizure medications

Question 2

describe generalized tonic-clonic seizures?

Answer 2

sudden onset of rigid tonic phase then clonic phase where muscles jerk rhythmically while eyes remain open.

may be associated with tongue biting, urine incontinence, shoulder dislocation (falls)

followed by post-ictal phase of fatigue and drowsiness lasting several hours

Question 3

describe typical absence seizures, myoclonic seizures, tonic seizures, akinetic seizures?

Answer 3

absence: child stops activity and unresponsive and stares and pales for only a few seconds. characterized by 3-hz spike and wave activity on EEG.

myoclonic: isolated muscle jerking
tonic: body stiffening
akinetic: cessation of movements with fall and loss of consciousness

Question 4

describe jacksonian seizures and temporal lobe seizures?

Answer 4

both focal seizures
jacksonian: originates in the motor cortex. starts with jerking movements of the corner of the mouth or fingers then spreading to involve the limbs on the opposite side of the focus. followed by limb paralysis for a few hours (todd’s paralysis)

temporal lobe: associated with olfactory and visual hallucinations, deja vu, jaime vu, and blank staring. common cause is hippocampal sclerosis. its mostly refratory epilepsy and treated better with surgical resection of temporal lobe

Question 5

define epilepsy, unprovoked seizure, status epilepticus, familial or not? triggers for epilepsy? focal vs generalized?

Answer 5

having two or more unprovoked seizures. strong family history

unprovoked means in the absence of an identifiable cause
status epilepticus: seizure lasting >5 min or 2 or more separate seizures

flashing lights, sleep depravation, physical exertion, stopping anti-epileptic meds

focal means originates in single hemisphere (esp temporal lobe) and common to have aura. generalized originates from both hemispheres and uncommon to have aura

Question 6

initial evaluation of patient with seizure hx?

Answer 6

1. take complete hx from witness of all phases, establish if patient is known to have epilepsy, differentiate from mimicers (migraine, syncope, vasovagal reflex, postural hypotension)
2. lab tests (CBC, GLUCOSE, electrolytes, prolactin (high within 15 min), toxicology screen, CK (high within 6 hours), bacterial cultures, LP if indicated)
3. brain imaging MRI to rule out structural causes
4. EEG will be abnormal during seizures (eeg monitoring or video EEG) to clear clinical suspicions

Question 7

general measures and acute control of seizures?

Answer 7

1. remove harmful objects nearby, keep patient in lateral position, dont put anything in their mouth
2. stabilize the patient (administer oxygen, place cardiorespiratory monitor and pulse oximetry) establish IV line and send lab tests esp glucose

acute control:
first line: IV (benzodiazepine) lorazepam (alternatively: buccal/IM/intranasal midazolam or rectal diazepam
REPEAT EVERY 10 MINUTES IF NO RESPONSE

second line: IV phenytoin/ valproic acid or IV phenobarbital

third line: call anesthesia for intubation