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Neuro 2 > Epilepsy > Flashcards

Epilepsy Flashcards

1
Q

Seizure

A

-episode of abnormally synchronized & high frequency firing of neurons resulting in abnormal behavior or experience

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2
Q

Epilepsy

A

-chronic brain disorder of various etiologies characterized by recurrent, unprovoked seizures

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3
Q

Epilepsy Syndromes

A

-grouping of similar epileptic patients according to seizure type, EEG age of onset, prognosis & clinical signs

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4
Q

Epidemiology of Epileptic Seizures

A
  • 0.5% of pop.
  • 2.5 million prevalent cases
  • 150,000 to 200,000 new cases/year
  • age-specific incidence had dec. in younger age groups, inc. in patients over age 60
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5
Q

Causes of Adult-onset Epileptic Seizures

A
  • Cerebrovascular disease
  • Trauma
  • Tumors
  • Infections
  • Cerebral Degeneration
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6
Q

ILAE Classifications of Epileptic Seizures

A

-Clinical Observation + EEG FIndings

partial seizures and generalized seizures

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7
Q

Types of Partial Seizure

A
  • Simple (consciousness preserved)
  • Complex (consciousness impaired)
  • Secondarily Generalized (consciousness lost + bilateral cerebral involvement)
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8
Q

Simple Partial Seizures

A
  • Signs/symptoms depend on focus: motor (Jacksonian - move up body part), somatosensory, autonomic, psychic
  • consciousness is intact
  • EEG may appear normal
  • Auras are brief, simple partial seizures with no overt behavioral manifestations
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9
Q

Complex Partial Seizures

A
  • impaired consciousness
  • lasts ~1min
  • blank stare
  • oral/ipsilateral hand automatisms
  • contralateral dystonic posturing
  • amnesia for ictal event
  • focal abnormality on routine EEG
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10
Q

Primary Generalized Seizures

A
  • absent (Petit Mal)
  • tonic-clonic
  • clonic
  • tonic
  • myoclonic
  • atonic
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11
Q

Absence Seizure Features

A
  • brief loss of consciousness (10-20sec)
  • staring spell
  • no post-ictal confusion
  • subtle myoclonic movement, eyelid flutter
  • no baseline neurologic deficits
  • baseline EEG may show generalized 3Hz spike -wave discharges
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12
Q

Tonic-Clonic Seizures

A

-typical presentation:
cry, loss of consciousness, muscular rigidity (tonic), patient may fall, rhythmic jerking (clonic), tongue-biting/injury common, bladder/bowel incontinence, post-ictal confusion/sleep
-Grand Mal

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13
Q

Myoclonic Seizure

A

-brief, shock-like muscle contractions (head, upper extremities)
-usually bilaterally symmetrical
-consciousness preserved
-precipitated by awakening or falling asleep
-may progress into tonic-clonic seizures
(juvenile myoclonic epilepsy)

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14
Q

Atonic Seizure

A
  • impaired consciousness
  • loss of muscle tone
  • head drop, fall
  • brief duration (few seconds)
  • injury common
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15
Q

Seizure Diagnosis

A
  • History from patient & witnesses
  • Physical & neurological examination
  • CBC, CMP, AED levels
  • Inter-ictal EEG
  • Epilepsy protocol MRI
  • Video-EEG monitoring
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16
Q

Prevalence of Inter-ictal Epileptiform Discharges in Epileptic Patients

A
  • initial EEG detects on epileptiform discharge in 29-55% of patients
  • serial EEGs reveal epileptiform discharges in 80-90% of patients
  • Repeat studies, with sleep deprivation & extended recording times, helps inc. chances of detecting epileptiform discharges in patients with epilepsy
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17
Q

Focal Epileptiform Discharge

A
  • seizure focus is in left anterior temporal head region

- sharp waves, spikes, & sharp-and slow wave discharges

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18
Q

Generalized Epileptiform Discharge

A
  • bilateral burst of epileptiform spike & slow wave discharges
  • discharge simultaneously & symmetrically in both hemispheres
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19
Q

Seizure MRI

A

-Recent-onset epilepsy in adults requires imaging sequences, including gadolinium-DPTA enhanced sequences to find primary or secondary tumors, infection or inflammation

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20
Q

Epilepsy Protocol MRI

A
  • Coronal high resolution T1-weighted volume data set through the whole brain
  • a coronal T2-weighted sequence, typically using 3 mm thin sections, should also be done in order to detect hippocampal sclerosis
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21
Q

Video-EEG monitoring

A
  • simultaneous recording of EEG & seizure
  • useful in differentiating epileptic seizures from non-epileptic seizures
  • useful for characterizing seizure type
  • essential for pre-surgical localization of the seizure focus
22
Q

Pathophysiology of Seizures

A
  • Ligand-gated ion channels can be excitatory or inhibitory depending on their ion selectivity
  • GABA activates GABA a receptors that mediate fast synaptic inhibition (IPSP) by permitting rapid influx of Cl ions, resulting in hyperpolarization
  • glutamate activated 3 classes of ion channels (AMPA, Kainate, NMDA) that mediate fast synaptic excitation by permitting a rapid influx of NA and Ca ions
  • in most neuronal circuits, GABAergic inhibition exerts a powerful suppression of excitability
  • this inhibition is overcome during the development of a focal seizure
23
Q

Goal of Antiepileptic Drug (AED) Therapy

A

-2 types of remission:
Medical remission: seizure free without side effects on 1 or 2 AEDs
-Disease Remission: seizure free off all AEDs
-major goal of AED therapy is to achieve medical remission
-surgical therapy is well-selected cases may result in disease remission

24
Q

AED Selection

A
  • efficacy for specific seizure types or epilepsy syndrome
  • efficacy for co-morbid conditions
  • interactions with other drugs
  • ease of introduction, follow-ip
  • drug safety
  • cost
25
Q

Phenobarbital

A
  • enhances activity of GABA receptor, depresses gluatmate activity, reduces Na, K conductance
  • SE: hepatotoxicity, connective tissue disorder, SJS
  • P450 inducer
26
Q

Phenytoin

A
  • blockade of Na channels & inhibitory action of Ca and Cl conductance
  • SE: aplastic anemia, hepatic failure, SJS
  • P450 inducer
27
Q

Carbamazepine

A
  • block of neuronal Na channel conductance
  • SE: aplastic anemia, hepatotoxicity, Stevens Johnsons syndrome, Lupus-like syndrome
  • P450 inducer
28
Q

Valproate

A
  • affects GABA glutamatergic activity & reduce threshold of Ca and K conductance
  • Hepatotoxicity, hyperammonemia, leukopenia, thrombocytopenia, pancreatitis
29
Q

Ethosuximide

A
  • inhibits Ca T channel conductane

- SE: bone marrow depression, hepatotoxicity

30
Q

Lamotrigine

A
  • blockage of voltage dep. sodium conductance

- SE: SJS or toxic epidermal necrolysis

31
Q

Oxcarbazepine

A
  • Na channel blockage
  • SE: hyponatremia, rash
  • P450 inducer
32
Q

Topiramate

A
  • blockage of Na channels, enhancement of GABA medicated Cl influx
  • SE: renal calculi, hypohidrosis
  • P450 inducer
33
Q

Zonisamide

A
  • Blockade of Na, K, & Ca channels, inhibits glutamate excitation
  • SE: renal calculi, hypohidrosis
34
Q

Gabapentin

A

-Modulation of N-type Ca channel

35
Q

AEDs for Partial & Tonic-Clonic Seizures

A

-Valproate, Phenytoin, Carbamazepine & Phenobarbital

36
Q

AEDs for Absence Seizures

A

-Ethosuximide & Valproate

37
Q

New AEDs for partial seizures

A

-Gabapentin & Oxcarbazepine

38
Q

New AEDs for Partial & Generalized seizures

A

-Lamotrigine, Topiramate, Levetiracetam, & Zonisamide

39
Q

P450 inducers

A
  • lead to failure of oral contraceptives
  • cause osteopenia, osteoporosis, fractures
  • inc. metabolism of androgens & estrogens

don’t want to give for: women oral contraceptives, patient on oral coagulation, transplant patients, AIDS patients on protease inhibitors, patients predisposed to osteoprorsis

40
Q

AED Birth Defects

A
  • older cause malformations in 4-8% of children (twice normal rate) with risk inc. with higher AED dose & polytherapy Cat D
  • newer not teratogenic in animals, Cat C in humans

-to reduce risk: lower effective dose, monotherapy, preconceptual folic acid supplementation, 0.8-4mg/day, prenatal diagnostic testing at 16-18 weeks: maternal serum alpha fetoprotein, ultrasound studies

41
Q

Probability of Medical Remission in Newly Diagnosed Patients

A

-for 2 or more years
47%with 1st AED used in monotherapy
14% with 2nd AED used in monotherapy
4% with 2 AEDs used

42
Q

Intractable Epilepsy

A
  • have disabling seizures recurring despite optimized therapy
  • Disabling seizures: seizures causing impaired quality of life, limited educational or occupational opportunities, physical injuries or social compromise
  • Optimized Treat: AED treatment is optimum with 2 AEDs at max tolerated dose
43
Q

Prevalence of Intractable Epilepsy

A
  • controlled with AEDs in 70-80% of patients

- 20-30% are not seizure-controlled using currently available AEDs and are therefore intractable

44
Q

Burden of Intractable Epilepsy

A
  • poor quality of life
  • restriction of psychosocial, educational, & occupational performance in child & adult
  • risk of injuries from seizures
  • higher risk of SUDEP (sudden unexplained death in epilepsy)
45
Q

Therapy of Refractory Epilepsy

A
  • polytherapy with antiepileptic drugs
  • vagus nerve stimulator
  • epilepsy surgery
46
Q

Vagus Nerve Stimulation

A
  • Electrical pulse generator implanted subcutaneously on chest
  • Lead attached to left vagus nerve
  • mechanism of action unknown
  • about 40-50% have >50% seizure reduction, but rarely seizure free
47
Q

Epilepsy Surgery

A
  • temporal lobectomy
  • lesionectomy
  • corticectomy
  • corpus callosotomy
  • multiple subpial transections
  • hemispherectomy
48
Q

Generalized Convulsive Status Epilepticus

A
  • continuous, generalized, convulsive seizure lasting more than 5 min. or 2 or more sequential seizures occurring without full recovery of consciousness
  • non-convulsive status epilepticus is an EEG diagnosis
49
Q

Management of GCSE

A

-

50
Q

Treatment of Refraactory GCSE

A
  • refractory if patient fails to respond to lorazepam
  • if convulsive seizures persist, consider intubation
  • start continuous EEG monitoring

Neuro 2 (16 decks)

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