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Bloc J - Neuro > Oct4 A3-Seizures: a clinical approach > Flashcards

Oct4 A3-Seizures: a clinical approach Flashcards

1
Q

steps of seizure hx

A

ask about

  • before (long before, days before, hours and minutes before)
  • during
  • after
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2
Q

what to ask about long before seizure

A
  • pregnancy
  • development
  • febrile convulsions
  • meningoencephalitis
  • head trauma
  • PMHx of seizures
  • FHx of seizures
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3
Q

what to ask about days before seizure

A
  • medication nonadherence
  • provoking factors
  • sleep deprivation
  • systemic illness
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4
Q

what to ask about the hours, minutes before seizure

A
  • provoking factors
  • prodrome
  • aura
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5
Q

what to ask about the ‘‘during’’ of the seizure

A

need info from WITNESS***

  • level of consciousness
  • duration of ictus (ictus = alteration of consciousness)
  • automatisms
  • head and eye deviation
  • skin colour
  • stiffness
  • convulsions
  • urinary incontinence
  • tongue biting
  • frothing/hypersalivation
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6
Q

what to ask about after the seizure

A
  • post-ictal confusion (yes, no, how long, to what degree)
  • fatigue
  • sleepiness
  • headache
  • muscle soreness
  • focal weakness
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7
Q

ddx of LOC (in general, not just STIC LOC = sudden transient isolated complete LOC) or altered consciousness or seizure like symptoms (possibly with no alteration of consciousness)

A
  • seizure
  • syncope
  • pseudoseizure
  • migraine with aura
  • TIA (transient ischemic attack)
  • hypoglycemia
  • narcolepsy (cataplexy)
  • anxiety (hyperventilation, panic)
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8
Q

what in the seizure hx will tell you that it was really a syncope

A

-before = dimming or blurring of vision (note this may point to vaso-vagal syncope specifically)
-during = pallor + limp muscles (in seizure, are rather stiff)
-after = no post-ictal confusion
________________
ask the observer:
1. colour of patient
2. was there an emotional triggering event

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9
Q

how can an aura help you in seizure hx

A
  • tells you there is a focus of epilepsy (doesn’t mean focal. can be focal or secondary generalized depending on hx you get from pt)
  • tells you in what part of the cortex the focus is (visual aura vs sensory vs motor, etc.)
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10
Q

ictus def

A

alteration of consciousness

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11
Q

2 good Qs to ask to discern seizure vs syncope

A
  1. colour of patient
  2. was there an emotional triggering event
    * *ask the observer**
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12
Q

syncope specialists

A

often no specialist, may refer to cardiology if is cardiac subtype (cause of STIC LOC)

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13
Q

pseudoseizure def

A
  • looks like seizure
  • no underlying epileptic activity when monitor brain waves on EEG
  • stress is manifesting in physical way
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14
Q

pseudoseizure specialists

A

psychiatry

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15
Q

3 ddx of LOC in general that are specific to neurology

A
  • migraine auras
  • seizures
  • TIAs
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16
Q

main thing for diff migraine auras vs seizures vs TIA

A

tempo and progression.

  • migraine aura = gradual onset, seizure = gradual or abrupt, TIA = abrupt
  • seizure duration of sx = < 1 min, TIA and migraine aura = 15-60 min
  • migraine aura = slow spread, seizure = rapid spread, TIA = all symptoms at once
  • migraine aura and seizure recur with same pattern, TIA doesn’t recur with identical symptoms
  • migraine aura = headache, TIA and seizure = no headache
  • migraine aura and seizure = positive sx (visual = flashing or sparkling of light, sensory = tingling), TIA = negative sx (visual = complete loss of vision, sensory = numbness)
17
Q

recommended investigations in first seizures

A
  • brain imaging (CT or MRI)
  • EEG
  • blood tests (blood counts, serum glucose, electrolytes) for reversible causes
  • urine toxicology screen
  • CSF LP (lumbar puncture) if infection (encephalitis or meningitis) suspected
18
Q

provoked vs unprovoked seizure def

A

provoked = what caused this seizure will cause a seizure in anyone (like enough hyponatremia)

19
Q

provoked vs unprovoked first seizure prognosis

A

provoked much less likely to recur

20
Q

RFs for seizure recurrence

A
  • pre-existing neuro condition
  • partial focal seizure
  • nocturnal seizure
  • abnormal neuro exam, EEG OR MRI
  • FHx of seizures
  • age <16 or>59
  • status epilepticus
21
Q

first seizure management (tx)

A 
NO strict guidelines. depends on RFs for recurrence, risk of injury, risk of stigma, occupational hazards
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
usually not tx with anticonvulsants IF
-no RFs for recurrence
-normal neuro exam
-normal imaging
-normal EEG
22
Q

prognosis of a second seizure

A

the risk of recurrence is 75%

23
Q

second seizure management (tx)

A

initiate AED for sure

24
Q

principles of AED choice

A
  1. select most efficacious AED for the seizure type or epilepsy syndrome
  2. consider unique pt and AED drug charact MOST IMPORTANT PART
  3. consider convenience (posology)
  4. consider cost (with pt). 2nd gen AED more $ than 1st gen
  5. monotherapy (1 AED) is preferred
  6. drug levels are only a guide
25
Q

some 1st gen AEDs

A
  • valproic acid
  • CBZ
  • clonazepam
  • phenobarbital
  • phenytoin
  • diazepam
26
Q

some 2nd gen AEDs

A
  • gabapentin
  • lacosamide
  • lamotrigine
  • levetiracetam
  • oxcarbazepine
27
Q

how to select most efficacious AED for the seizure type or epilepsy syndrome: some examples

A
  • complex partial = CBZ (tegretol)
  • secondary generalized = CBZ
  • primary GTC = valproic acid, lamotrigine
28
Q

how to consider unique pt and AED drug charact MOST IMPORTANT PART

A
  • some AEDs can help for another sx, dz

- some AEDs have to be avoided in certain dz or populations of pts

29
Q

why prefer monotherapy in AEDs

A

more AEDs = more risk of adverse effects

30
Q

why drug levels of AEDs are only a guide

A
  • if need better control, can give a bit more than maximum if no adverse effects
  • if seizures controlled, can give a bit less than minimum
  • PREFER BOOSTING DOSE over increasing nbr of AEDs
31
Q

(EXAM) 4 common AEDs

A
  • phenytoin (Dilantin)
  • carbamazepine (Tegretol)
  • valproic acid (Epival)
  • levetiracetam (Keppra)
32
Q

(EXAM) phenytoin (Dilantin) indication, SEs, adv and disadv

A
  • focal (partial) AND generalized
  • SE = rash
  • adv = once a day + can be given IV as well (not just oral)
  • disadv = enzyme induction (interferes with hepatic enzymes, careful if pt takes other meds)
33
Q

(EXAM) CBZ (tegretol) indication, SEs, adv and disadv

A
  • focal (partial) ONLY
  • SE = rash, hyponatremia
  • adv = well tolerated
  • disadv = enzyme induction
34
Q

(EXAM) valproic acid (epival) indication, SEs, adv and disadv

A
  • generalized ONLY
  • SE = tremor, weight gain
  • adv = effective
  • disadv = neural tube, congenital defects CAN’T GIVE TO WOMEN OF CHILD-BEARING AGE
35
Q

(EXAM) levetiracetam (keppra) indication, SEs, adv and disadv

A
  • focal (partial) AND generalized
  • SE = psychiatric
  • adv = no interactions (metab renally, not in liver)
  • disadv = less effective
36
Q

reasons for recurrent seizures after AED tx (‘‘refractory’’ seizures)

A
  • provoking factors
  • poor adherence (common reason is SE)
  • wrong med
  • wrong dx (focal vs generalized = diff tx)
37
Q

principles of tx ‘‘refractory’’ seizures

A
  • maximize the dose of one med as long as the dose is tolerated. when really at the max and no control, add new agent.
  • when add agent B, taper agent A once seizures are controlled. means increase med B gradually and decrease med A gradually if B helps) one or introducing
38
Q

what MRIs can show that CTs don’t show

A
  • mesial temporal sclerosis (scarred region in temporal lobe, bright on MRI. removed = curative)
  • malformations of corticol developmental (focal cortical dysplasia)
  • etc.
39
Q

what CT helps for in imaging and what’s relevant to seizure

A
  • done in patients with first seizure
  • gives gross image of the brain
  • can detect: big strokes, big tumors, bleeding in the brain

Bloc J - Neuro (60 decks)

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