Seizure Disorder

Question 1

Treatment of focal epilepsy and complex partial seizures

Answer 1

Carbamazepine

Question 2

Epilepsy v. Seizures

Answer 2

Epilepsy is characterized by recurrent seizures and is divided into syndromes on the basis of various causes, seizure types, associated neurologic symptoms, anatomic correlates, age, and family history

A seizure can be defined as an isolated event in which a group of neurons produces excessive electrical discharges in the brain

Question 3

Two Broad Categories of Seizures

Answer 3

Focal - activity is in one hemisphere

Generalized - activity is in both hemispheres

Question 4

Simple Partial Seizures

Answer 4

No impairment of consciousness
Focal
May have aura
May have motor or non-motor types

Question 5

Complex Partial Seizure

Answer 5

Activity spreads to both hemispheres or the brainstem
Altered consciousness or behavior occurs
Automatisms more common

Question 6

Primary Generalized Seizures

Answer 6

primary generalized seizures occur when the initial abnormal electrical activity begins in both cerebral hemispheres and involves bilaterally distributed neuronal networks. These seizures are usually seen with idiopathic or hereditary types of epilepsy. Consciousness is almost always impaired, and the seizure may be convulsive or nonconvulsive

Question 7

Secondary Generalized Seizure

Answer 7

Focal seizure that spreads to both hemispheres and involves the motor cortex

Question 8

Non-convulsive Generalized Seizures

Answer 8

Absence seizure is the most common

Question 9

New Onset Seizures Assessment

Answer 9

Recent history of headache, illness, trauma, neurological deficits
Any unusual feeling, aura, or signs?
General exam and assessment to rule out causes (Neuro, CV, Infection)

Question 10

Seizure Diagnostics

Answer 10

CBC, CMP, Alcohol / Tox
EKG
MRI preferred but CT useful
EEG, Lumbar Puncture

Question 11

Referral to Epilepsy Center

Answer 11

If a diagnosis of epilepsy cannot be confirmed or excluded after an accurate history, EEG, or imaging study

Question 12

Seizure Differentials

Answer 12

CV causes (syncope, etc.)
CVA/TIA
Movement Disorders
Psych
Tumors
Trauma

Question 13

Nonepileptic Seizures

Answer 13

Psychogenic seizures / pseudo seizures
treatment with an anti-epileptic drug results in increase in seizure frequency

Stress or conversion disorder

Question 14

Status Epilepticus

Answer 14

Continuous seizure lasting 5 mins or more or 2 consecutive seizures in a row without mental clearing

Medical emergency

Question 15

Status treatment

Answer 15

ABC management
EKG
Check glucose (treat if low)
IV Access - CBC / CMP / Tox
Benzodiazepines

Question 16

Benzos for SE

Answer 16

IM midazolam 10mg for >40kg, 5mg for 13-39 kg
IV lorazepam 0.1mg/kg - max 4mg
IV diazepam 0.15-0.2 mg/kg - max 10mg

OR

IV IV phenobarbital 15mg/kg

Question 17

When to start anti-epileptic meds

Answer 17

Most first seizures are not treated with anti-epileptic meds
complex partial seizures are more likely to be recurrent than generalized tonic-clonic ones
abnormal EEG or imaging may prompt need for meds

Question 18

Preferred AEDs for women

Answer 18

Levetiracetam (safer in pregnancy)

Lamotrigine (safer in pregnancy)

Question 19

Levetiracetam

Answer 19

Effective for focal and generalized
Does not cause sedation or have liver effects
Risk of agitation, anxiety, depression

Question 20

Lamotrigine

Answer 20

Wide spectrum of efficacy, preferred for women

High rate of allergic rash (SJS risk)

Question 21

Valproate

Answer 21

Good for Generalized Seizures

Side effects - weight gain, hair loss, PCOS, Liver toxic, severe fetal toxic

Question 22

Carbamazepine

Answer 22

Most effective for focal and complex-partial seizures
Cheap
Makes generalized seizures worse - so not for patients with multiple seizure types

Question 23

Toprimate

Answer 23

Broad spectrum of efficacy
Significant cognitive side effects - not a first line option
May cause weight loss and prevent migraines

Question 24

Gabapentin

Answer 24

Worsens generalized epilepsy
Only for focal seizures
Useful for pain management, so may help patients with pain and focal seizures

Question 25

Adding or Changing AED medications

Answer 25

Add new medication to current regimen, once well tolerated and effective, slowly reduce/withdraw the first one.

Some patients require 2 or 3 drugs with different mechanisms of action

Question 26

AED Side Effects

Answer 26

CNS such as somnolence, cognitive issues
GI issues
Rashes
Weight changes

Monitor drug levels to achieve steady state with dosing

Question 27

AEDs and Vitamin D / Calcium

Answer 27

All patients taking enzyme-inducing AEDs are at risk for osteoporosis and should be taking calcium and vitamin D