Exam 1: Seizures Flashcards
What is the criteria to diagnose epilepsy?
Having had 2 or more unprovoked seizures
What is tonic?
Stiffening
What is clonic?
Jerking or spasming
Which electrolytes are most important to monitor in patients with seizures?
Sodium
Magnesium
Calcium
Which antiepileptic medication is first-line in pregnancy?
Keppra
Which antiepileptic medication is considered most teratogenic?
Valproic acid
What are the most common birth defects associated with taking an antiepileptic medication?
Cleft lip
Cleft palate
Less common birth defects are:
Cardiac abnormalities
Neural tube defects
T/F: Antileptic drugs make oral contraceptive pills less effective?
True: A backup method should be recommended (need barrier method)
How much estrogen should be included in an oral contraceptive pill if a woman is taking an antiepileptic medication?
At least 50 mcg of estrogen
How much folate/folic acid should be prescribed to all childbearing women taking an antiepileptic medication in order to prevent neural tube defects?
Nonpregnant: 1 mg daily
Pregnant: 4 mg daily or for those wanting to become pregnant
T/F: Continued use of antiepileptic medications are recommended in pregnancy?
True:
The risk of tonic-clonic seizure during pregnancy outweighs the risk of taking the medication; a seizure could cause hypoxia to the fetus
T/F: A woman should not breastfeed if taking an antiepileptic medication?
False:
Breastfeeding is encouraged if taking an antiepileptic medication
Most of the medication will be expressed in the breast milk
Infants already exposed in utero so breast milk will have less effect
What is a seizure?
A sudden surge of uncontrolled abnormal electrical activity in the brain
Which part of the brain is seizing during a generalized seizure?
The entire brain at the same time
Which part of the brain is seizing during a partial or focal seizure?
Only one part but can spread to involve the entire brain
Which type of seizure is the most dramatic and most common generalized?
Tonic-clonic (grand mal)
What manifestations are seen during a tonic-clonic seizure?
May begin as a cry
Tonic phase: stiffening
Clonic phase: rhythmic jerking that gets slower as the seizure comes to an end
Which type of seizure involves a brief lapse of consciousness?
Absence seizure (formerly known as petit mal)
Does an absence seizure have a postictal period?
No; the patient may not be aware that a seizure has occurred
Example:
Child staring off in class
Which type of seizure manifests as brief episodes of twitching or jerking, commonly after awakening in the morning or from a nap?
Myoclonic seizure
Which type of seizure is also known as a drop attack?
Atonic seizures
Which type of seizure is characterized by a sudden decrease or loss in muscle tone causing dramatic falls and orthopedic injuries?
Atonic seizures “Drop Attack”
Name the two types of generalized seizures?
Tonic-clonic (grand mal)
Absence (formerly petit mal)
Which type of seizure occurs in one part of the brain with no loss of consciousness and may involve sensory complaints such as deja vu, out-of-body experience, or a rising sensation in the stomach?
Simple partial seizure
With this type of seizure, the patient may seem alert and responsive but they are not. They can have nonsensical conversation, lip smacking, or be picking at clothing.
Complex partial seizure
A person with this type of seizure will have bursts of uncontrollable laughter not associated with anything funny.
Gelastic seizure (associated with hypothalmic hamartoma)
A child with an absence seizure may be misdiagnosed by teachers as having this disorder _________.
ADHD
In a postictal state, will the patient be hyper or hypo reflexive?
In a postictal state, the patient may be hyper reflexive (overactive, responsive reflexes that can include twitching and spasms)
Nonepileptic seizures (NES) are also known as ___________.
Pseudoseizures or psychogenic
NES or pseudoseizures will have bite marks on which part of the tongue?
The tip; not side of tongue as in epileptic seizures.
Which condition is often associated with secondary gain and psychiatric disorders?
Nonepileptic seizures (NES) or pseudoseizures; have no electrographical correlation
What are some things that happen to the patient during tonic-clonic seizures?
Bites side of tongue Incontinence No response to painful stimuli Loss of consciousness Eyes generally open Mouth generally open
What are the characteristics of a nonepileptic seizures (NES) or pseudoseizures?
No loss of consciousness Forced eye closure Forced mouth closure Tongue bite to tip Normal response to painful stimuli Episode can wax and wane for hours
What are the causes of epilepsy?
Childhood: most are idiopathic
Adults: most often caused by stroke in developed countries
What are some causes of epilepsy in neonates?
Perinatal hypoxia and ischemia Intracranial hemorrhage and trauma Acute CNS infection Metabolic (hypo/hyperglycemia) Drug withdrawal Developmental/genetic disorders
What are some causes of epilepsy in infants and children (1 month - 12 years old)?
Fever (Febrile seizures) CNS infection Trauma Genetic disorders Idiopathic
What are some causes of epilepsy in adolescents (12-18 years old)?
Brain tumor Illicit drug use Infections Trauma Genetic disorders Idiopathic
What are some causes of epilepsy in young adults (18-35 years old)?
ETOH withdrawal Illicit drug use Brain tumor Trauma Idiopathic
What are some causes of epilepsy in older adults (> 35 years old)?
CVA (embolic > hemorrhagic) Metabolic disorders (electrolyte disturbances) ETOH withdrawal Brain tumor Idiopathic
When do you initiate an antiepileptic medication?
Generally after the second unprovoked seizure
May be initiated prophylactically in conditions that predispose patient to seizures (brain tumors, vascular malformations)
What is secondary generalization?
Seizure begins in one part of the brain but then spreads to both sides.
Example: Person first has a partial/focal seizure followed by a generalized seizure.
T/F: Simple seizures don’t lose consciousness?
True - simple seizures maintain consciousness
Complex seizures have a loss of consciousness
When can you allow the patient to drive post seizure?
Driving laws very by state
Law usually stipulates “loss of conscious episodes” in general
Some neurologists say those with simple partial seizures are okay to drive
What are the differences between syncope and seizures?
Seizures:
Loss of consciousness often immediately and lasting minutes
Motor manifestations lasting more than 30 seconds
Cyanosis, drooling
Postictal disorientation; may take a couple of hours to resolve
Tongue biting - sometimes
Incontinence - sometimes
Headache - sometimes
Muscle soreness
Syncope:
Event provoked by external stimuli (anxiety, rising from sitting position, valsalva, orthostatic hypotension)
Stereotyped transition to unconsciousness with: tunnel vision, tiredness, sweating, nausea
Loss of consciousness gradual over seconds (tunnel vision) and lasting seconds
Pallor
Tongue biting - rarely
Incontinence - sometimes
Headache - rarely
What is early myoclonic encephalopathy?
Myoclonic encephalopathy:
Onset is usually within the first 3 months of life
Erratic, fragmentary or massive myoclonus, focal seizures and late tonic spasms
Prognosis is severe
May become West’s Syndrome (infantile spasms) after several months
What is Ohtara Syndrome?
Ohtara Syndrome:
Earliest onset age-related epileptic encephalopathy
Onset often within first 10 days of life to 3 months
What is Dravet Syndrome?
Dravet Syndrome:
Severe myoclonic epilepsy in infancy
Severe febrile seizures
Status epilepticus: seizures that continue repeatedly without breaking
What is the cause of West Syndrome (infantile spasms)?
Cause of West Syndrome (infantile spasms):
Trauma Brain malformations Cortical dysplasia Infections Downs Syndrome Tuberous sclerosis Complex (non-cancerous tumors) Microcephaly Severe hydrocephalus Encephalitis
What is the goal of treatment of West Syndrome?
Improve quality of life
What type of diet is thought to be helpful for kids with hard to control epilepsy?
Ketogenic diet
What is the prognosis for children with West’s Syndrome?
Poor
70% with severe mental retardation
What is Lennox-Gastaut Syndrome?
Lennox-Gastaut Syndrome:
Neurodevelopment is normal until first seizure
Multiple seizure types:
Tonic and atonic seizures
May also have absence and myoclonic seizures
Mental retardation or regression with or without neurologic abnormalities and psychotic symptoms
Drugs not very effective
What are some causes of Lennox-Gastaut Syndrome?
Head injuries Meningitis Encephalopathies Genetic disorders Neurocutaneous syndromes
T/F: The MMR vaccine may cause an infantile febrile seizure?
True especially if family history of seizures
Give MMR and varicella instead of combo
Which pieces of patient history would help to identify a particular seizure type in a new patient?
LOC? Postictal period? Tongue bite location? Muscle jerk Twitching Staring off, picking at clothing, lip smacking Drop attack/loss of muscle tone/falling down Facial tingling
Which birth control options are not affected by antiepileptic medications?
Levonorgestrel IUD (Mirena) Depo-Provera Copper IUD (ParaGard) Condom Female condom Contraceptive sponge Diaphragm with spermicide
What is the treatment for juvenile myoclonic epilepsy?
Antiepileptic drugs
Surgical treatment
Ketogenic diet
What is juvenile myoclonic epilepsy?
Patient typically healthy with one or more of the following seizures: absence, myoclonic jerks, generalized convulsions
Typically preteens to teens
Seizures can be well controlled with medications
Life-long disorder needing treatment
Good prognosis of normal cognitive development
Which medication for seizure treatment is more commonly used in pediatrics than adults?
Vigabatrin
Which 3 systems should be checked after a syncopal episode for causation?
Neuro
Cardiac
Endocrine (blood sugar)
What is the differential diagnoses for neonate with seizures?
Benign familial neonate seizure (recurrent, outgrows by 1-4 months)
Early myoclonic encephalopathy - may become West Syndrome
Ohtahara Syndrome: earliest onset age 10 days to 3 months of epileptic encephalopathy, may become West’s or Lennox Gastaut
Which medications are used for an adult with tonic-clonic (grand mal) seizures without a known cause?
Levetiracetam (Keppra)
Valproate (Depakote)
Lamotrigine (Lamictal)
Does a complex seizure cause loss of consciousness?
Yes, there is a loss of consciousness during a complex seizure
Does a simple seizure cause loss of consciousness?
No, consciousness is maintained during a simple seizure
What are the symptoms of a complex partial seizure?
Loss of awareness
Seems alert and responsive but they are not
May seem engaged in conversation but will have nonsensical answers
Picking a clothing
Lip smacking
T/F: Patients who have seizures are at a higher risk of suicide as a side effect of the medications?
False: These patients are at a higher risk for suicide
from dealing with the disease and/or the social aspects of the disease, not from the medications.
What causes syncope?
Prolonged decreased cerebral perfusion.
T/F: Patients can have seizures when switching from brand to generic AED medications, or vice versa?
True: The differences in bioavailability between brand and generic can provoke a breakthrough seizure. May also occur in some patients with a generic to generic switch too.
What is early myoclonic encephalopathy?
Frequent intractable myoclonic seizures
Severe early onset encephalopathy
May develop into West’s Syndrome or Lennox-Gastaut Syndrome
Decreased growth and cognitive development
What is childhood absence epilepsy?
Loss of awareness for 5-10 seconds; may seem to by daydreaming
Can be misdiagnosed as ADHD
Can have eye fluttering, eye rolling, lip smacking, flushing, tachycardia
EEG is normal with interictal spike
What are the main points regarding the ketogenic diet and some side effects?
Diet should be supervised by a professional at an epilepsy center
Diet should not be followed for more than 2 years
Side effects:
Dehydration
GI issues: N/V/D/Constipation
Metabolic acidosis
Osteopenia (prescribe calcium and Vit D supplements)
** The low glycemic index diet is easier but not as effective
Which surgical treatment for epilepsy is most common?
Temporal lobectomy
What is the goal in epilepsy syndromes?
Epilepsy tends to be very focal so treatment is avoidance of specific stimuli such as:
Emotions
Sounds
Which commonly used medication in children can cause tunnel vision?
Vigabatrin
There is a 30% risk of irreversible visual field constriction
Patient should get formal visual field testing done every 6 months
What is the difference between a focal seizure and a partial seizure?
Nothing; a partial seizure is also known as a focal seizure
ETOH withdrawal can cause seizures and/or status epilepticus. Which drug class do we use to cover those seizures and why?
Benzos
Binds to GABA receptors
Benzos cover almost every withdrawal except barbiturates; they can only be covered by barbiturates.
