Epilepsy and Seizures

Question 1

Seizure definition

Answer 1

• uncontrolled, excessive, hypersynchronous discharge of cortical neurons
• in the cortex
• hypersynchronous: see big changes on EEG

Question 2

Epilepsy definition

Answer 2

defined as recurrent seizures

Question 3

Partial (focal) seizures

Answer 3

• simple partial seizures (no LOC)
• motor signs
• somatosensory or special sensory sx
• autonomic sx or signs
• psychic sx
• an area of neuronal membrane hyperecitability often starts firing and activation spreads to adjacent areas
• activity may remain localized to an area of the brain, or may spread and become generalized

Question 4

Complex partial seizures

Answer 4

• consciousness impaired
• simple partial onset followed by impaired consciousness
• consciousness impaired at onset
• simple partial seizures to generalized seizures
• complex partial seizures to generalized seizures
• simple partial seizures to complex to generalized
• if it begins as a partial seizure and evolves it is still considered a complex partial even if it becomes secondarily generalized

Question 5

Generalized seizures

Answer 5

• non focal origin
• absence
• myoclonic (no LOC)
• tonic, clonic, and tonic-clonic seizures
• atonic seizures

Question 6

Absence seizures

Answer 6

• type of generalized seizures
• typical: brief stare, eye flickering, no emotion
• atypical: associated w/ movement-subtle
• more common in kids
• don’t have post ictal state

Question 7

Tonic, Clonic, and Tonic-Clonic seizures

Answer 7

• can be either one or both

- typically: tonic-clonic begins w/ muscular stiffening (tonic) and evolves to rapid muscle contractions (clonus)

Question 8

Atonic seizures

Answer 8

suddle loss of postural tone, may fall

Question 9

Usual presentation of seizures

Answer 9

• may be a prodrome/aura
• usually begin w/ arrest of motion and blank stare
• simple hand movements, mouth movements, verbal utterances
• last only a minute or two or less
• post-ictal state

Question 10

Variations for usual seizure presentation

Answer 10

• temporal lobe epilepsy looks like absence, but has post ictal confusion
• simple partial seizures have no impairment of consciousness
• generalized seizures: convulsions and may have loss of bowel or bladder

Question 11

Seizure vs syncope

Answer 11

• syncope can also have tonus or clonus
• syncope usually does not have a prodrome
• syncopal episodes usually not followed by a post-ictal state
• pallor usually indicates syncope
• when syncope occurs it can re-occur with changes in posture
• syncope will stay they feel dizzy right before (not a prodrome)

Question 12

Evaluation of seizure

Answer 12

• history is your best tool
• careful review of events leading up to seizure
• presence of prodromes or auras
• description of seizure by a reliable witness
• post-ictal observations
• time to complete recovery
• frequency if this is not the first seizure

Question 13

Seizure PMH

Answer 13

• febrile convulsions
• head injury in past
• vascular disease (CVA, CAD)
• cancer
• infectious disease
• sleep disorder
• medications

Question 14

Seizure PE

Answer 14

• injury pattern
• cardiovascular exam
• skin exam
• neurologic exam: focal postictal deficits, focal neurologic deficits after recovery, other neurologic findings

Question 15

Seizure lab workup

Answer 15

• CBC
• serum electrolytes, calcium, magnesium, phosphorous, and glucose
• urine toxicology screen
• serum drug level

Question 16

Seizure diagnostic testing

Answer 16

• EEG
• CT if acute
• MRI in most cases
• LP
• cardiovascular eval

Question 17

Mesial temporal sclerosis

Answer 17

• very subtle

- can find on EEG

Question 18

Specific foci for epileptogenesis

Answer 18

• stroke
• trauma
• tumor
• vascular abnormality (aneurysm)
• multiocal (tuberous sclerosis
• diffuse (hypoxemic-ischemic injury) hypoglycemic

Question 19

First seizure tx

Answer 19

• increased risk of 2nd with: interictal epileptiform EEG spikes, abnormal imaging, family hx, occurrence post-injury
• if no features of increased risk, generally do not tx first event, but if recurs tx

Question 20

Non-epileptic causes of seizures

Answer 20

• cardiogenic
• electrolyte imbalance
• metabolic disorders
• drug withdrawals, intoxication or overdose
• metal toxicity
• infection disease
• migraine HA
• psychogenic
• miscellaneous

Question 21

Pertient syndromes

Answer 21

• febrile seizures
• childhood absence
• fictive or pseudoseizures

Question 22

Management of epilepsy

Answer 22

• immediate first aid measure for seizure (ABCs)
• things for pt to avoid: excessive EtOH, recreational drug use, sleep deprivation
• assure medication compliance

Question 23

Anti-epileptic drugs

Answer 23

-start monotherapy: increase dose until good control or adverse effects or switch if it does not work

Question 24

Status Epilepticus

Answer 24

• prolonged seizure condition that can result in brain damage or death
• when seizure lasts or recurs for more than 30 minutes
• half has hx of epilepsy
• half due to fever, infection, metabolic changes (EtOH withdrawals), structural lesions
• death due to neuronal excitotoxic damage (excess CA influx)

Question 25

Status Epilepticus tx

Answer 25

• ABCs (airway)
• first line tx: lorazepam (Ativan)
• if epileptic, reestablish anticonvulsants
• if not, search for cause and correct

Question 26

Other seizure issues

Answer 26

• sleep deprivation lowers seizure threshold
• nicotine, caffeine and energy drinks can be pro convulsive
• EtOH reduces seizure threshold and withdrawal can induced seizures (EtOH and benzos)

Question 27

Refractory seizures

Answer 27

• surgery (temporal lobectomy, corpus callosotomy)
• vagal nerve stimulation
• deep brain stimulation
• ketogenic diet