Epilepsy and Seizures Flashcards
what is a seizure
“electrical storm in brain”
paroxysmal behavioral spell generally caused by an excessive, disordered discharge of cortical nerve cells
seizure vs epilepsy
sz is a sx of epilepsy
epilepsy is a dx
they are not synonymous
why do seizures all present differently
outward sx depend on where abnormal electrical activity occurring in brain
what are convulsions
involuntary muscle contractions and relaxation
convulsions vs seizure
convulsion are motor output from sz
- not always present during sz activity
what is epilepsy (aka what is the dx criteria)
syndrome of two or more unprovoked or recurrent sz on more than one occasion
what are intractable or refractory seizures and how common are they
sz uncontrolled by antiepileptic drugs
up to 30%
what is the function of glial cells and what are 2 examples
physiologically support health of neuron
ex: astrocytes, oligodendrocytes
what is the pathophysiology behind a sz
- abnormal electrical activity
- imbalance b/w excitatory and inhibitory neurotransmitters -> NET EXCITATION -> INC ACTIVATION AND NEURONAL FIRING
- much faster neuronal firing compared to normal
what role can glial cells play w seizures
glial cell changes may affect neuronal signaling enough to contribute to a seizure
what pt populations has an inc susceptibility to sz
infants and elderly
what are general etiologies of seizures (6)
acquired
idiopathic
meds
vaccines
drugs
genetic abnormality
what are 7 acquired etiologies for seizures
TBI
stroke
brain tumor
infections
abscess
hypoxia
high fevers
onset of idiopathic epilepsy
usually starts in childhood or adolescence
what is the relationship of seizures and brain tumors
sz can be the first sign of brain tumors
- get imaging after a sz and discover tumor
what population is febrile sz common in
infants/young children
temp >103-104
what meds can cause sz (7)
anesthesia
antibiotics
anticholinergics/antipsychotics
antidepressatns
antivirals
chemo
antihistamines
what are 2 vax that can cause sz
measles
pertussis
what is the prevalence of sz caused by vax today
was documented in 40s-50s
have since changed formula
- removed some additives and preservatives
- don’t see cluster sz cases anymore
how can drug use cause sz
alcohol, illicit drugs (meth, cocaine)
- see acutely w high doses
or in withdrawal
what is an example of a genetic abnormality that can cause sz
photosensitivity
- flashing/strobe lights cause sz
at what points in your lifetime are you most likely to have a seizure and why
age 0-1
- brain in early infancy isn’t well myelinated, inc likelihood of abnormal electrical activity
age 75+
- aging, metabolic disturbances, atrophy in brain
what is the incidence of epilepsy in the US
3rd most common neurologic condition
- 1. alzheimers, 2. stroke
what are 2 sz syndromes
psychogenic non-epileptic seizures (PNES)
provoked seizures
what is a psychogenic non-epileptic seizure (PNES)
sz w/o abnormal EEG
- no abnormal brain activity detected
how do you treat psychogenic non-epileptic seizures
doesn’t respond to epilepsy meds
treat psychologic condition, stress, trauma
what are potential causes of provoked seizures (6) and what are the 3 most common
high fever
*hypoglycemia
*hyponatremia
alcohol and drugs
light
*stress
what are the 2 types of seizures
focal or partial
generalized
what are focal/partial seizures and what is a common sx
occur in isolated region of brain
auras
simple vs complex focal seizure
simple = no LOC
complex = LOC (usually brief), repetitive strange behaviors or feelings
what are auras and when are these usually experienced
illusion of some sort of sensation
- odors, tastes & sensations, memories, intense feelings or emotions, abnormal sensations in stomach
seconds to min before a focal sz
- can give them a forewarning so can set themselves up safely
what are generalized seizuures
occurs in both hemispheres
may happen after focal sz
- my start in local part of brain and then spread
3 common sx seen in generalized sz
LOC
falls
ms spasms
what are 6 types of generalized seizures
petit mal (absence sz)
tonic
myoclonic
clonic
atonic
tonic-clonic (grand mal)
petit mal seizures: sx, duration
staring, ms jerking/twitch
- stare off into space and not respond
- can be very subtle, look for pattern happening repeatedly
- tend to cluster, happen over and over
typically last <20sec
tonic seizures: sx, duration
sudden onset of tonic extension or flexion
- could be just upper or just lower body
short lived, few seconds
myoclonic seizures: sx, duration, possible secondary consequence
brief arrhythmic, jerking mvmt
- like a spasm, brief burst of ms contraction
- often don’t remember
typically las <1sec, cluster within few min
can lead to SCI, head injury
what are clonic sz
repetitive jerking of ms bilaterally
-> sustained ms contractions
atonic sz: sx, sequelae, duration, management
loss of normal ms tone
drop attack - unconscious
brief - but clustered together in rapid succession
wear a helmet
aggressive medical management is important
tonic-clonic seizures: sx, post-sz sx, duration
grand mal
mix of motor behavior
generalized tonic extension followed by clonic rhythmic mvmts
post-ictal (after sz) weakness
- can be pretty severe
can have significant neurologic damage
severe and prolonged
what is the definition of epilepsy
more than 2 sz that are provoked w/o pinpointed reason (ie metabolic, cause)
what term is epilepsy synonymous with
sz disorder
what 5 characteristics are epilepsy syndrome based on
presentation (behavior)
age of onset
location of origin
etiology
EEG
what is status epilepticus (SE)
continuous epileptic activity for >30min or 2+ more serial sz w/o return to normal state of consciousness b/w sz
what are the potential consequences of status epilepticus
permanent damage to neurons d/t prolonged abnormal firing can result in long term disability
high mortality rates
what are 3 reasons for high mortality rates in status epilepticus
cardiac dysrhythmia
metabolic dysfunction
aspiration
what are medical evaluations done in the ED after a sz and what is the main reason for these tests (6)
imaging
blood glucose
blood counts
electrolyte panel
lumbar puncture
toxicology screen
try to find a cause of the seizure
what are medical evaluations done in the ED after a sz and what is the main reason for these tests (6)
imaging
blood glucose
blood counts
electrolyte panel
lumbar puncture
toxicology screen
try to find a cause of the seizure
what imaging is preferred after a seizures and what is the imaging looking for
MRI preferred or CT
help r/i/o stroke, tumor
why is blood glucose taken in the ED after a seizure
if metabolic changes caused the seizure
why are blood counts taken in the ED after a seizure
changes in blood counts can provoke a sz
what electrolyte level do we care especially ab in the panel taken in the ED after a sz
sodium
who is a lumbar puncture appropriate for after a sz
if febrile
- determine if infectious cause
who is a toxicology screen appropriate for after a sz
suspicion of substance use/abuse
when do you and do you not call 911 after a sz
if dx w epilepsy and consistent w past sz - don’t need to call 911
if lasts longer or presents differently from other sz, then call 911
what are dx tools for epilepsy (4)
EEG*
neuroimaging
LP/CSF sampling
blood work
what is the gold standard for epilepsy dx
EEGs
what is an EEG and what is a consideration of its use
electroencephalogram
records brain wave forms and electrical activity
non-invasive, but can be noxious as trying to induce sz
what neuroimaging is used (6) and what info can it tell
MRI, CT, PET, fMRI, SPECT, TMS
localize source of abnormal electrical charges
why is LP/CSF sampling done for dx
infection likely if marked elevation in WBC
- culture and try target medical intervention to infectious agent to minimize impact on neuro tissue
what bloodwork is done and why for dx
CBC, chemistry panel
identify potential trigger
- infection, anemia, hypoglycemia
assess liver and kidney function - may affect pharm interventions
what is the effectiveness of anti-epileptic drugs (AEDs)
control sz effectively for 70% affected pts
what is the biggest side effect of AEDs
suicidal ideation (SI)
what is the most common AED prescribed
phenytoin (dilantin)
what is phenytoin effective for
partial and generalized sz, except for absence sz
what are considerations of phenytoin
small therapeutic range
- need to be monitored closely
make sure taking proper dosage
- high levels can be toxic
what are s/sx of phenytoin toxicity (5)
sedation
nystagmus
diplopia
cog decline
death
what are potential adverse effects of phenytoin (4) and how common are they
many people don’t tolerate well
gingival hyperplasia
skin rash
congenital defects
sudden cardiac death
- heart block
- v-tach or v-fib
who is phenytoin often prescribed to
prophylactically for people w TBIs and CVAs
what is carbamazepine effective for
partial and generalized sz
very effective for wide range of sz
what is a pro of carbamazepine
better tolerated than phenytoin
what are 3 ways that carbamazepine is better tolerated than phenytoin
- less side effects
- dose less stringent
- not same risk of toxicity
what are potential adverse effects of carbamazepine and how is this mitigated
leukopenia
anemia
thrombocytopenia
CBC checked often
what is valproic acid effective for
partial, generalized, absence, and myoclonic sz
what are potential adverse effects of valproic acid (2)
fatal pancreatitis
liver damage
- esp in <2yo
what is the primary reason benzodiazepines is administered
dec activity in CNS
what pharm treatment is given for acute sz
IV lorazepam, benzodiazepines, or diazepam
- CNS depressants to chill out
then IV phenytoin
- monitor closely w regular blood draws bc small therapeutic range
what do we monitor for in long term use of drugs (3)
toxicity
adjustment of dosage
compliance
what is a consideration in dc a medication
wean slowly over weeks to months to avoid adverse effects
- withdrawal can have severe effects
what are 7 non-pharm med interventions
transcranial magnetic stim
transcranial DC stim (tDCS)
surgery
deep brain stim
vagus nerve stim
medidal marijuana
diet (ketogenic)
how can transcranial magnetic stim aid in dx
localize foci or origin point of sz activity
how can transcranial magnetic stim aid in dx
localize foci or origin point of sz activity
how can transcranial magnetic stim aid in dx
localize foci or origin point of sz activity
what are 3 uses for TMS
dx
info on effectiveness of meds
treat sz activity
how can TMS provide info on effectiveness of meds
detect changes in excitability before and after AEDs
how does TMS treat sz activity
repetitive electrical brain stim leads to lasting changes in neuron to neuron signaling
low frequency TMS reliably dec regional cortical excitability
what does support is there for TMS
not FDA approved yet for sz control
- can treat migraines and MDD
clinical trials conducted
low level evidence but no main adverse effects noted
what is tDCS
neuro stim or neuromodulation applied at low levels on scalp over brain
- can inc or dec activity in underlying region
how is tDCS different from TMS
tDCS - use electrical impulses
TMS - magnetic
what support is there for tDCS
not FDSA approved yet for sz
- studies promising
who are candidates for surgical management of sz (2)
lack of response to meds
disability resulting from chronic sz
what is the most common part of the brain that sz originate from
temporal lobe
what cases has there been the highest success rate in surgical management (3)
focal sz
sz that begin as focal
unilateral, multifocal
what are surgical options (3)
lobectomy
hemispherectomy
corpus callostomy
what are surgical options (3)
lobectomy
hemispherectomy
corpus callostomy
what are surgical options (3)
lobectomy
hemispherectomy
corpus callostomy
what are surgical options (3)
lobectomy
hemispherectomy
corpus callostomy
what are surgical options (3)
lobectomy
hemispherectomy
corpus callosotomy
what is the most common surgical procedure and why
temporal lobectomy
most common location for sz origination
successful outcomes
effectiveness of lobectomies
70-90% reduction or complete relief from sz
what is a corpus callosotomy and what does this do and what doesn’t this do
sever neural connections b/w R and L hemispheres
prevents spread of sz from one side to other
- limits reach of abnormal electrical activity
- doesn’t cure focal sz
what is a deep brain stimulator and what does it do
stimulator implanted under scalp
detects abnormal signals and transmits a corrective electrical signal
- adding more electrical activity can jam signals and stop it
what is the effectiveness of deep brain stimulator and what is a good way to implement this
dec sz activity by 50% in those resistant to AEDs
good adjunct treatment
what is a risk of deep brain stimulator
high risk of infection bc invasive
what support is there for deep brain stimulators
FDA approved
what is a vagus nerve stimulator
delivers small electrical current to brain via vagus nerve reducing electrical bursts
who is the vagus nerve stimulator appropriate/effective for
FDA approved for 12+yo w refractory partial epilepsy
dec frequency of partial or focal sz
what support is there for the use of medical cannabis
wide range of outcomes
- isolated case of SE
becoming more common w legalization
- legal issues with access in 3 states
- compassion access in other states where not legal
what dietary intervention can be used and who is this seen to be most effective for
ketogenic diet
pedi population w poor response to AEDs
how is it thought that a ketogenic diet can dec sz activity
diet rich in fat and low in protein, carbs
ketosis = break down fats instead of carbs for energy
by-produce of ketosis is betahydroxybutyrate (BHB) which inhibits sz in animals
what are potential side effects of a ketogenic dietary intervention
nutritional deficiency
kidney stones
what is a consideration with using a ketogenic dietary intervention
very rigid
have to measure food portions carefully
what are alternative management options (6)
yoga and meditation
biofeedback
aerobic exercise
music therapy
acupuncture
herbal remedies
what support is there for alternative management
no evidence to support
- no studies, nothing in literature
anecdotal evidence, and is healthy for you anyway
what are 5 common co-morbidities of epilepsy
memory deficits
hemiplegia
learning disability
visual field deficits
activity
why are memory deficits a common co-morbidity of epilepsy
if unconscious for parts of day, then limits ability to form memories
what risk of mortality is there for epilepsy
higher than sudden death in general population
sudden unexpected death in epilepsy (SUDEP)
- cardiac or respiratory failure
- may occur in period following sz
why may death occur with status epilepticus
brain physiology changes resulting in cardiac arrhythmia and/or respiratory failure, hypoxia
what are 5 main activity precautions for someone w epilepsy
driving motorized vehicles
drowning / water activity
ascending heights / falls
working w fire/cooking
working w power tools
what is a consideration of drowning precautions
can drown in an inch of water in a minute
- avoid water or make sure monitored by someone
what is Todd’s paresis
weakness seen in post-ictal state tends to last for long period of time
what are PT considerations for sz management (6)
- adhere to sz precautions
- awareness of triggers and prodromal signs
- post-ictal sx
- clinical reasoning of when to call 911
- empower self management
- consider setting specific
what are some post-ictal sx (5)
weakness
lethargy
confusion
HA
todd’s paresis
