Epilepsy

Question 1

Is consciousness lost during a partial seizure?

Answer 1

NO; epileptic d/c consists of repetitive firing of a few cortical neurons; confined to a specific cortical area or focus

Question 2

simple partial seizure clinical manifestation

Answer 2

-functionally related to cortical area involved by neuronal discharge
-seizure in L frontal motor cortex=rhythmical contractions or jerking of R. face, arm, and leg for 1-2min
(b/c neuronal d/c doesn’t spread or generalize diffusely pt can speak/follow commands d/r spell, remains conscious, is fully aware; recalls event, does not appear confused)

Question 3

what are some other symptoms of simple partial seizures?

Answer 3

localized sensory, visual, or autonomic (sweating, flushing, nausea) disturbances WITHOUT loc

Question 4

is consciousness lost d/r a complex partial seizure

Answer 4

YES; d/t b/l neuronal d/c usually in the medial TEMPORAL or hippocampal areas
-pt cant follow commands d/r spell, after event has NO recollection, appearing confused for a brief period (POST-ICTAL phase)

Question 5

automatisms in complex partial seizures

Answer 5

semi-purposeful, stereotyped gestures or “automatic movements”: chewing, finger tapping, uttering short phrases, wondering about

Question 6

what can happen with both simple partial and complex partial seizures

Answer 6

they can secondarily spread or generalize diffusely to other b/l cortical areas causing loc…motor cortex usually involved=rhythmical vigorous jerking of trunk and limbs

• there is a post ictal phase
• pt doesnt remember the generalized convulsion
• BUT may recall inititating symptoms (aura)

Question 7

What happens in many secondarily generalized seizures that confuses categorization

Answer 7

focal d/c spreads so rapidly pt cant recall a specific aura and sz appears to be a generalized convulsion

Question 8

primarily generalized seizures

Answer 8

occur when an electrical d/c simultaneously arises from widespread, b/l areas of cerebral cortex

Question 9

what are the two types of generalized seizures (1/2)

Answer 9

1. absence seizures of childhood=non convulsive primarily generalized; last several seconds, occur many times daily
   - brief impairment of consciousness; no postictal confusion or recall of event
   - 3hz spike and slow wave electrical discharge
2. generalized tonic clonic (convulsive) sz

Question 10

what are the two types of generalized seizures (2/2)

Answer 10

1. absence seizures of childhood
2. generalized tonic clonic (convulsive) sz
   - LOC, fall to ground, injuries
   - can be 2/2 primarily or secondarily generalized cortical d/c
   - aura may be recalled which is actually a simple partial thats generalizing

Question 11

phases of a generalized tonic clonic (convulsive) sz

Answer 11

a. tonic phase-sudden stiffness from contraction of limb and trunk muscles
- apnea leads to a cyanotic dusky face and consciousness is lost
b. clonic phase-happens seconds after tonic
- rhythmic forceful synchronous jerking of limbs and face, oral trauma, xs drooling
c. post-ictal phase (5-15mins)-bladder incontinence may be noted; pt sleepy, confused, unavle to recall what happened

Question 12

Why is the post ictal phase important

Answer 12

If sz wasnt observed it is important clue that consciousness was lost from a preceding sz and not from syncope or fainting

Question 13

what is epilepsy

Answer 13

tendency or predisposition for seizures to recur

Question 14

primarily generalized sz are a result of?

Answer 14

global synchronous cortical discharge from diffuse cortical disinhibition

• disinhibition may be due to:
• –diffuse, permanent brain injury (anoxia, hereditary metabolic d/o, congenital brain malformations)
• –transient metabolic disorders (cocaine, EtOH withdrawal, tetanus, electrolyte disturbances )

Question 15

secondarily generalized seizures are a result of?

Answer 15

• cortical discharge that begins at a focus, the site of an acquired lesion
• lesion may be d/t: head trauma (recent/remote), viral encephalitis, stroke (hemorrhage or infarction), or tumor
• may be super quick and appear to be primary, so always check for focal lesion

Question 16

non-epileptic pseudoseizures

Answer 16

• may appear as episodic jerking or thrashing movements without spontaneous cortical discharge
• noted in pts with h/o depression, physical abuse, and real epilepsy

Question 17

diagnostic testing for seizures

Answer 17

• MRI (way better than CT)

- EEG-chances of recording a sz are inc by sleep deprivation, hyperventilation, phonic stimulation (flashing lights)

Question 18

tx of seizures

Answer 18

• start with one anticonvulsant at a time

- the drugs enhance cortical inhibition by: affecting sodium or calcium channels, acting as GABA analogues, or a combo

Question 19

Valproate, Lamotrigine, BZ

Answer 19

• treat many sz types:
• –primarily generalized convulsive or nonconvulsive (absence)
• –partial sz
• –secondarily generalized sz

Question 20

Ethosuximide

Answer 20

effect for absence seizures

Question 21

*What are side effects of anticonvulsants?

Answer 21

• at high serum levels: confusion, somnolence, ataxia (+nystagmus, dysarthria, dysmetria)
• at minimal serum levels: teratogenicity

Question 22

epilepsy surgery

Answer 22

-use EEG to id seizure focus which is then surgically resected

Question 23

generalized tonic-clonic (convulsive) STATUS epilepticus

Answer 23

• continuous, unabated seizure or series of repeated seizures from which the pt doesnt recover, for a period of 30 mins or longer
• neurological emergency

Question 24

consequences of status

Answer 24

-if it persists for a long time pts can have permanent deficits of memory or cognition

Question 25

what do pts in STATUS require

Answer 25

• emergent life support measures
• -mechanical ventilation and oxygenation
• -immediate correction of any hypoglycemia

Question 26

drug of choice for STATUS

Answer 26

Benzo such as diazepam or lorazepam d/t their rapid onset of action…longer-acting anticonvulsants are added later

Question 27

LUMC protocol for treating generalized STATUS epilepticus

Answer 27

1. Lorazepam 0.1mg/kg (4-8mg) as an IV bolus, repeatable in 5-10 mins
2. Phenytoin 20mg/kg IV, given in saline no faster than 50mg/min (OR…fosphenytoin 20 phenytoin equivalents/kg IV no faster than 150mg/min)

Question 28

focal seizures

Answer 28

-caused by abnml neuronal discharges originating in a single hemisphere

Question 29

how can focal seizures present

Answer 29

• motor (head turning)
• sensory (paresthesias)
• autonomic (sweating)
• impairment of consciousness and automatisms (chewing)

Question 30

what should raise suspicion for seizure

Answer 30

• sudden loc
• l/o postural tone
• delayed return to baseline mental status (d/t postictal state of transient confusion, lethargy, and/or focal neurologic deficits)