Epilepsy and Seizure Disorders Flashcards
paroxysmal episodic event caused by abnormal cortical electrical activity is …
seizure
genetic or acquired factors change the physiology of synapses to favor …. during a focal seizure
excitation over inhibition, as well as neuronal hypersynchrony
in generalized seizures, decreased inhibition from … to … results in enhance synchronization allowing thalamocortical neurons to fire simultaneously.
thalamoreticular neurons to thalamocortical neurons
focal onset seizure with preserved awareness is called…
simple partial seizure
focal onset seizure with impaired awareness is called…
complex partial seizure
generalized onset seizures will affect…
both hemispheres
What are some major imitators of seizures?
vasovagal
psychogenic nonepileptic seizure
What are key differences you will see in vasovagal syncopy from generalized seizure?
- vasovagal
- triggers - pain, anxiety, dehydration, stress
- lightheaded or dizzy
- usually while standing
- atonic
- myoclonic jerks terminate when laying flat
- brief confusion
- generalized seizure
- any position
- abrupt LOC
- fast, tonic fall
- side of tongue injury
- unusual posturing
- prolonged confusion
What is characteristic of a Psychogenic Non-epileptic event?
- relatively dramatic - weeping, moaning, crying, coughing
- tonic/clonic element is unchanged
- no self-injury
- eyes closed and pt resists eye opening
Where can EEGs not record seizures on the brain?
orbitofrontal or frontal opercular cortex
What causes an increased risk for seizures?
- remote symptomatic seizure
- abnormal EEG
- significant MRI abnormality
- nocturnal seizure
A seizure within 7 days of a stroke, brain trauma, encephalitis/meningitis would be considered…
acute symptomatic seizure
a seizure from a prior/static brain injury would be considered…
remote symptomatic seizure
If someone presents with one or multiple seizures withing 24 hours, who is more likely to have a recurrence?
no difference in recurrence
Delay in drug initiation until after the second unprovoked seizure will do what?
will not influence chance of long term remission
what is the definition of epilepsy?
disease with either recurrent seizures (>=2 unprovoked seizures that are <24 hrs apart) OR a heightened tendency toward future seizures
What is the goal of epilepsy treatment?
What if our goal is not met despite two or more AEDs on board?
goal is seizure free
pt has drug-resistant epilepsy and sx should be considered
Epileptics have an increased risk of what?
sudden death
What four AEDs are inducers of Cyt P450?
phenytoin
carbazepine
phenobarbital
primidone
What two AEDs have nonlinear kinetics and levels increase disproportionately to dose?
phenytoin (saturable metabolism)
carbamazepine (autoinduction)
What kind of drugs may worsen generalized and myoclonic seizures and should be avoided in idiopathic generalized epilepsy?
traditional sodium channel blockers:
phenytoin, carbamazepine, oxcarbazepine
What is one of the most serious AEs of AEDs, especially phenytoin?
steven johnsons syndrome
Common side effects of AED topiramate include…
metabolic acidosis and nephrolithiasis
What is the MC form of epilepsy in adulthood?
Adult Focal Epilepsy
Mesial temporal lobe epilepsy more often than lateral temporal lobe
In a mesial temporal lobe epilepsy event, how do you know what side the seizure focus is on?
The hand that wipes the nose first after a seizure is typically ipsilateral to the seizure focus
What are symptoms associated with Mesial Temporal Lobe epilepsy?
- aura: psychic (dejavu), gastric rising, olfactory hallucination
- loss of conscious awareness, oral/manual automatisms, CL limb dystonic posturing with ipsilateral hand automatisms
- 60-90 second duration
- rarely generalizes
What is the second MC focal epilepsy?
Is it shorter or longer in duration than temproal lobe epilepsy?
When do they occur?
Frontal Lobe Epilepsy
shorter duration
occur more often in sleep
In what kind of seizure are you likely to see ‘Jacksonian March’ or head turning/eye deviation CL to seizure focus or even ‘fencing’?
dorsolateral frontal lobe
What kind of seizure will present as speech and motor arrest with later motor elements and possibly proximal motor (hypermotor) activity?
(abnormal pelvis movement)
Frontopolar/orbitofrontal seizure
an opercular/cingulate seizure may present as…
fear or emotion
With Frontal Lobe Epilepsy, usually there is only a brief post-ictal confusion but there may be…
frank paralysis/Todd’s paralysis that slowly resolves
What is the difference between simple and complex febrile seizures?
- simple
- nonfocal convulsions <15 minutes
- complex
- convulsions >15 minutes or more than one event in 24 hours
>30 minutes of seizure associated with HHV-B6 virema or associated with hippocampal sclerosis
febrile status epilepticus
To dx a febrile seizure in a child >1 month old, what must be ruled out?
hypoglycemia, hyponatremia, and dehydration
What increases risk of recurrence of febrile seizure?
younger age at onset
If there is a family hx of seizures, what should you be thinking for dx of child with febrile seizures? What is this?
GEFS+
Generalized Epilepsy with Febrile Seizures Plus
- onset 6 mo to 6 yo
- multiple sz types
- drug resistant
- self-limited
- resolves by puberty
- normal development
What is an extreme form of GEFS+?
Dravet Syndrome a/w Reflex sz
What is the MC epileptic encephalopathy? When does it occur and what is the triad that goes with it?
- West Syndrome
- onset first 2 y
- triad
- epileptic spasms (baby jerking forward, chin to chest)
- hypsarrhythmia on EEG (pure chaos)
- psycomotor arrest/regression
What is the treatment and what is the most often prognosis?
ACTH, prednisone, Vigabatrin
Most have intellectual disability; 50% develop Lennox-Gastaut syndrome or other forms of epilepsy
male in preschool, intellectual disability, multiple sz types (predominantly tonic seizures)
less than 3 Hz EEG
rarely achieve seizure freedom
Lennox-Gastaut Syndrome
- onset 7-8 yo, cant talk, is drooling
- m >f
- previously well, presenting with focal sz involving lower face or early morning generalized tonic-clonic seizure
Dx?
Prognosis?
- Benign epilepsy with Centrotemporal Spikes (Rolandic Epilepsy)
- MRI normal, prognosis v good, AED not always needed
- 5-7 yo (f>m)
- abrupt blank stare with eyelid fluttering lasting <30 seconds
- 3Hz spike wave complex
Dx?
Tx?
Absence Seizures
ethosuximide
What type of seizure usually has a structural cause and responds to carbamazepine?
partial complex
What is the MC genetic generalized epilepsy?
How does it present?
What is the tx?
Juvenile Myoclonic epilepsy
- generalized tonic/clonic seizure provoked by sleep deprivation, stress, etoh, flashing lights with myoclonic jerks in the morning
- female tx - levetiracetam
- male tx - valproic acid
two seizures occurring back to back without return to patient baseline or one seizure lasting at least 5 minutes is considered -
status epilepticus and a medical emergency
What happens in the brain with a prolonged seizure?
protein phosphorylation, NT modulation, GABA receptor endocytosis and degradation, glutamate receptor recruitment into synapsis, neuropeptide modulation
longer goes on, harder to turn off
What are three ways to treat status epilepticus?
- IM midazolam
- IV lorazepam
- rectal diazepam
BENZOS
Should I be concerned about pregnant women with epilepsy?
- 10x increase mortality in women with epilepsy during pregnancy and post partum period
- route of major congenital malformations
- AED exposure in utero increases major congenital malformation incidence (esp. valproic acid)
What three drugs should I definitely avoid giving my pregnant epilpetic pt?
topiramate
valproate
phenobarbital
What AEDs are okay to give in pregnancy?
lamotrigine and levetiracetam
Valproate is likely to cause what congenital issue while barbituates risk…
valproate - neural tube defects, hypospadias
barbituates - cardiac malformations
What should I warn my nonpregnant pt on OCP and AED?
AEDs can increas rate of metabolism of OCP - should use second form of protection
