Lecture 11: Epilepsy

Question 1

Essentials of Dx

Answer 1

• recurrent seizures
• characteristic EEG changes accompanying seizures
• mental status abnormalities or focal neuro sx’s may persist for hrs postictally

Question 2

epilepsy definition

Answer 2

= any disorder characterized by recurrent unprovoked seizures

Question 3

seizures

Answer 3

= transient disturbance of cerebral fxn due to an abnormal paroxysmal neuronal change in the brain

Question 4

3 categories of Etiology of Epilepsy

Answer 4

1) Genetic Epilepsy: inherited autosomal dominant fashion
2) Structural/Metabolic Epilepsy
3) Uknown

Question 5

Structural/Metabolic Epilepsy subtypes

Answer 5

• Pediatric age grps: congenital abnormalities and perinatal injuries may result in seizures
• metabolic disorders: withdrawal from EtOH/drugs, uremia or hypoglycemia
• Trauma ; important in young adults
• tumors: important cause in middle age; seizure is commonly initial sx
• Vascular dz: most common cause of seizures after 60 y/o
• Degenerative: AD
• Infectious Dz’s: bacterial meningitis, herpes encephalitis, neurosyphilis, cysticerosis, AIDs

Question 6

Classification of Seizures

Answer 6

1) Focal: with or without altered consciousness

2) Generalized: tonic-clonic, atonic, absence or myoclonic

Question 7

Focal (aka Partial) Seizure: features and types

Answer 7

• sx’s are very specific and can help localize lesion/source
• NO LOSS OF CONSCIOUSNESS
• Types= Simple Partial and Complex partial

Question 8

Simple Partial Seizure

Answer 8

• without impairment of consciousness
• focal motor sx’s = twitching, convulsive jerking
• sensory sx’s = parathesias, abnormal visions/sounds/smells and distortions of perception
• autonomic = flushing, tingling, nausea

Question 9

Complex Partial Seizure

Answer 9

• Loss of awareness of the surroundings, altered consciousness
• Aura = warning for the seizure; familiar feeling, nausea, heat, tingling or distortion of sensory perceptions
• other sx’s = autonisms: lip smacking, picking at clothes, walking around aimlessly, or saying nonsense phrases over and over again

Question 10

Generalized Seizures types

Answer 10

1) Absence seizures (Petit Mal)
2) Tonic Clonic (Grand-Mal)
3) Atonic Seizure
4) Myoclonic Seizure
5) tonic seizure

Question 11

Absence Seizure (petit mal)

Answer 11

• usually childhood but can persist into adulthood
• sx’s = staring spells lasting several secs in conjunction with eye fluttering or head nodding
• able to resume activities
• typical EEG: 3 Htz spike and wave

Question 12

Tonic Clonic (Grand-Mal)

Answer 12

• sudden LOC and tonic activity (stiffening)
• followed by clonic activity (rhythmic jerking) of limbs
• eyes roll up, typically emit cryocontraction of resp. muscles (epileptic cry)
• lasts 1-3 min
• post ictal –> sluggish, sleepy, and confused for hrs

Question 13

Atonic seizures

Answer 13

• drop attacks: suddenly become limp and fall to ground

- typically occurs in children/adults with widespread brain injuries

Question 14

Myoclonic seizure

Answer 14

-brief unsustained jerking or series of jerks

Question 15

Tonic seizure

Answer 15

• stiffening of muscles
• arms/legs mat extend forward and rise in air
• consciousness may or may not be altered

Question 16

Most common type of seizure in adults

Answer 16

Complex partial

-followed by: simple partial, tonic clonic, absence, others

Question 17

Steps of a Workup of acute seizures

Answer 17

• BMP: electrolyte abnormalities
• EtOH level
• Drug screen- Benzos
• LP
• MRI
• EEG

Question 18

Tonic Clonic Management

Answer 18

• turn pt on side with head inclined toward ground to keep airway clear
• do not put anything in pts mouth

Question 19

Medication Tx: Focal seizures

Answer 19

• carbamezapine, phenytoin, valproic acid

- other newer drugs: gabapentin, topiramate, lamotrigine, oxcarbazepine, levetiracetam, zonidamide, lacosamide

Question 20

Tx: Generalized

Answer 20

• valproic acid

- DO NOT USE: phenytoin, carbamezapine, and oxcarbazine

Question 21

Myoclonic Seizure tx

Answer 21

-Keppra, clonezapam

Question 22

Absence Seizure

Answer 22

-depakote, topamax, ethosuxamide, clonazepam

Question 23

Rational for Seizure Tx

Answer 23

• use least amnt of med needed for control
• use mono therapy
• use appropriate med for seizure type
• if use multiple meds: pick complimentary mechanism
• use side effects to advantage (topomax: wt loss)
• give Folate and Ca to protect bones

Question 24

Other Facts for Tx

Answer 24

• Do not use rescue drugs (Benzos) routinely
• Do not use valproic acid/phenobarb is pregnant
• Phenytoin: nonlinear PK
• Carbamezapine: autoinduction
• Genetics can affect metab

Question 25

When to D/C drugs

Answer 25

• only when pts have been seizure free for 2 yrs

- dose reduction should be gradual and withdrawn one at a time

Question 26

Status Epilepticus

Answer 26

• NEURO EMERGENCY
• seizure or series of seizures lasting for 30 m in without return to normal
• any seizure that lasts > 5 min while on EEG; seizure that lasts until presentation in ER; seizure lasting longer than usual (postictal period)

Question 27

Refractory seizures

Answer 27

-seizures are so frequent or so severe that they limit the pt’s ability to live life fully according to his/her wishes OR necessitates the use of meds that produce adverse effects