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Neurology Module > Seizure Disorders > Flashcards

Seizure Disorders Flashcards

1
Q

Seizure Types

A

Not all seizures = epilepsy

Symptomatic Seizure
Cryptogenic Seizure

Acute vs Remote

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2
Q

Prevalence of Seizures

A

1 in 10 adults will have had a seizure

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3
Q

Seizure where cause is identified

A

Symptomatic Seizure

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4
Q

No cause of seizure is identified

A

Cryptogenic Seizure

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5
Q

Pathophysiology of Seizure

A

Basis for neuronal excitation is the action potential

Seizure results from increased frequency burst of action potentials- spikes

Glutamate- excitatory neurotransmitter- allows Ca++ influx which keeps Na+ voltage gated channels open (perpetuates depolarization)

Depolarization activates NMDA channels open which allows further Ca++ influx

GABA- inhibitory neurotransmitter

Old theory: loss of inhibitory neurons (GABA)

New theories:

  • loss of excitatory neurons (that stimulate the inhibitory neurons)
  • Injury leads to axonal “sprouting” to other excitatory neurons
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6
Q

Causes of Non-epileptic Seizure

A

> 70-80% Idiopathic

Neurogenic: Brain tumor, CVA, trauma

Electrolyte/Metabolic imbalances

Hypoglycemia, hyponatremia, hypocalcemia

Hyperthyroidism

Acute renal or hepatic failure

Medication overdoses

Antidepressants, antipsychotics, cyclosporine, interferon, INH, Lithium, Demerol, tramadol (Ultram), quinolone atbs

Drug withdrawal

Drugs: Cocain, m-amphetamine, nitrous oxide, IV contrast dye, lead or mercury poisoning, acetylcholinesterase inhibitors

Infection and/or fever

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7
Q

Common seizure causes <10 yo

A

Idiopathic
congenital
birth injury
metabolic disorders

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8
Q

Common seizure causes 10-40 yo

A

Idiopathic, congenital, birth injury, metabolic disorders

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9
Q

Common seizure causes 40-60 yo

A

Brain Tumor

Head Trauma

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10
Q

Common seizure causes >60 yo

A 
CVA
brain tumor
subdural hematoma
CNS infection
Alzheimers
metabolic disturbance
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11
Q

Age of Febrile Seizure Occurance

A

6 mo - 5 yo

Peak age 2 yo

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12
Q

Prevalence of Febrile Seizures

A

66% male

3-5% children <5

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13
Q

First Febrile Seizure Risk Factors

A

Fever >38 (100.4)
Day care attendance
Developmental delay
Neonatal nursery >30 days
FH (sibling- 10% risk)
Viral infections (HHV6, influenza, others)
Vaccinations (influenza, DTP, MMR (fever))

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14
Q

Common Viral pathogen for Febrile Seizures

A

HH6

Influenza

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15
Q

Recurrent Febrile Seizure Risk Factors

A

30-50% will experience subsequent szs

Age <104F)
First degree relative with febrile

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16
Q

Simple Febrile Seizure

A

last less than 15 min; no underlying neuro problems, ie. Cerebral palsy

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17
Q

Evaluation of Febrile Seizure

A 
History & Physical:
FH
PMH
HPI
Recent vaccines
Meningeal irritation - If yes, LP

Imaging?
Most do not require. MRI preferred (due to less radiation)

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18
Q

Management of Febrile Seizures

A 
Antipyretics Tylenol/ibuprofen
   -For comfort 
   -Do NOT prevent seizure
Recurrence likely
No increased morbidity/mortality
No behavioral/developmental disorders
No prophylaxis required- adverse effects, lack of efficacy
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19
Q

Febrile Seizure Prognosis

A

By age 5 - 98% seizure free

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20
Q

Risk of developing later seizures after febrile seizure:

A

Underlying neuro disease (cerebral palsy)
FH epilepsy
Complex seizures

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21
Q

Types of Seizures

A

Partial

Generalized

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22
Q

Partial Seizures

A

Simple

Complex

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23
Q

Generalized Seizures

A

Absence (“Petit Mal”)
Generalized tonic-clonic (“Grand Mal”)
Myoclonic
Atonic

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24
Q

Causes of Absence Seizures

A

Inherited idiopathic disorder

Secondary disorder: AVM, neoplasm, ID

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25
Absence seizures vs Partial-complex seizures
AGE is critical. In adult, with similar symptoms, think partial-complex seizures. Tx different!
26
Age of onset of Absence Seizures
age 5-18 Rare under age 2 or beyond adolescense
27
Signs and Symptoms of Absence Seizures
NO AURA!!! Vacant, dazed expression Staring Pallor Timing: 10 seconds max Multiple times throughout day (50-100x) Other: eye blinking, head movements, autonomic movements (incontinent stool or urine) Post-ictal: brief recovery, picking clothes, pursing lips EEG: diffuse 3Hz spike pattern (see later)
28
What are absence seizures mistaken for?
Often escape detection. Mistaken for ADHD, daydreaming.
29
Treatment of Absence Seizures
Usually cease by age 20 Progress (if untreated) to generalized tonic-clonic seizures in 33% Treatment: Ethosuximide (Zarontin) Valproic acid (Depakote) +/- clonazepam (historically)
30
Pharmacologic Treatment of Absence Seizures
Ethosuximide (Zarontin) Valproic acid (Depakote) +/- clonazepam (historically)
31
Tonic Clonic Seizures AKA
Grand Mal
32
What often proceeds Tonic Clonic seizures?
Aura
33
Aura symptoms
``` Irritability Apathy HA Scintillating scotoma nausea choking sensation paresthesias ```
34
Signs of Tonic Clonic seizures
``` Aura (often precedes Sudden LOC Tonic- muscular rigidity (adduction and flexion of arms; extension of legs) Clonic- jerking Incontinence Tongue biting ```
35
Treatment of Tonic Clonic Seizures
Valproic acid (Depakote) (first line) Phenytoin (Dilantin) Carbamazepine (Tegretol) +/- phenobarbital ``` Others: Primidone (Mysoline) Lamotrigine (Lamictal) Topiramate (Topamax) Zonsisamide (Zonegran) Levetiracetam (Keppra) ```
36
Myoclonic Seizures feel like
Sudden, single or multiple jerks
37
Myoclonic seizures and chidren manfest as
"Infantile spasms"
38
S/S Atonic Seizures
LOC Head drops, loss of posture “drop attack” Falls cause Injury
39
Treatment for Atonic Seizures
Resistant to drug therapy
40
Simple Partial Seizure occurs in a
focal area (may spread to other areas)
41
Sensory manifestations of Simple Partial seizures
visual auditory olfactory gustatory
42
Autonomic manifestations of Simple Partial seizures
GI sxs | flushing
43
Motor manifestations of Simple Partial Seizure
Jerking limbs | Paresthesias
44
Other manifestations of Simple Partial Seizurs
Hallucinations Deja vu Jamais vu
45
Treatment of Simple Partial Seizures
Phenytoin (Dilantin) Carbamazepine (Tegretol) Valproic acid (Depakote) +/- others… (phenobarbital, primidone, zonisamide)
46
Most common type of seizure
Complex Partial
47
S/S Complex Partial Seizures
LOC “Temporal lobe” may travel to frontal Aura: GI symptoms, Sense of fear Stare, automatisms-picking/fumbling, facial movements Last 30 sec – 2min May progress to generalized tonic-clonic Resemble petit mal
48
Treatment of a Complex Partial Seizure
Carbamazepine (Tegretol) Phenytoin (Dilantin) Surgery: temporal lobe resection Failed medical treatment after 1-2 years
49
Rolandic Epilepsy are a type of
partial seizure.
50
Rolandic epilepsy only occurs in
children.
51
Rolandic epilepsy originates in
rolandic area of brain but may generalize to tonic-clonic
52
Symptoms of Rolandic epilepsy
Face/cheek twitching Drooling Difficulty speaking
53
Rolandic epilepsy EEG pattern
Centrotemporal Spikes
54
Rolandic seizures often occur
during sleep
55
Treatment of Rolandic Seizures
Carbamazepine (Tegretol) Oxcarbazepine (Trileptal) Gabapentin (Neurontin)
56
Gelastic or Dacrocystic seizures only occur in
children. Often occur when falling asleep or under emotional stress. May generalize.
57
Gelastic seizures manifest as
laughing.
58
Dacrocystic seizures manifest as
crying.
59
Treatment of Lennox pts
Difficult
60
Lennox seizures occur from...
Lennox-Gastraut
61
Also seen with Lennox seizures
Developmental delay
62
Lennox seizures occure secondarily to:
Encephalopathy Meningitis Birth injuries- hypoxia
63
Lennox Seizure Timing
Nocturnal Frequent seizures daily Often wear helmet because seizures are SO frequent.
64
Lennox EEG pattern
interictal spikes
65
Management of Status Epilepticus
Check glucose Lorazepam or diazepam… +/- midalzolam Lorazepam 0.1mg/kg IV max 4 mg (duration 12-24h) Diazepam 0.1-0.3mg/kg IV max 10mg (short acting)
66
Biggest risk factor for status epilepticus
Medication Withdrawal!
67
Status epilepticus is...
LIFE THREATENING!!!
68
Status epilepticus seizures last
>30 minutes 2 or more seizures without recovery period.
69
Risk factors for status epilepticus
``` MEDICATION! Alcohol withdrawal Drug overdose Intracranial infections (meningitis, encephalitis) Neoplasms ```
70
What occurs after seizure?
Post Ictal Period
71
How long is the post ictal period?
5-30 minutes
72
S/S Post Ictal period
Headache Exhaustion Confusion Drownsiness
73
Rare manifestations of the Post Ictal Period
Todd’s paresis: (6% of grand mal)-paralysis 15h-36h Postictal psychosis: lucid phase 2-6h, psychosis 9-10d Postictal bliss: euphoric
74
Medication Treatment for Seizures
LOOK IN CURRENT LOOK OVER SIDE EFFECTS - fatigue, drowsiness, sedation, ataxia KNOW A FEW FOR EACH DRUG
75
Medications to avoid during pregnancy
Valproate | Carbamazepine
76
Supplementation for pregnancy
Folic Acid | Vitamin K
77
Lactation for women with seizures
Breast feeding still recommended
78
What to monitor for breast feeding women
Irritation Altered Sleep Poor weight gain
79
Anovulatory Cycles
Have to do with seizures and pregnancy - look up.
80
Anti-seizure medications may effect
Hormones. May increase risk of miscarriage Birth defects 2-3% risk v 4-8%
81
How should medications be prescribed for pregnant women?
Lowest possible dose but dilution factor.
82
Seizures onset due to progesterone withdrawal
Catemenial Seizures
83
Pathophysiology of Catemenial Seizures
Mid-cycle ovulation due to estrogen surge.
84
Common occurence in women with seizures
Polycystic Ovary Disease 40% women with epilepsy Subset related to valproate - Depakote
85
Drugs that do not affect the eficacy of OCs
``` Gabapentin (Neurontin) Levetiracetam (Keppra) Lamotrigine (Lamictal) Valproate (Depakote) Zonisamide (Zonegran) ```
86
Atypical Seizure Activity
Nonfocal: opposite arm/leg Pelvic thrusting Head turning side to side Eyes closed, tight Tongue biting limited tip Postictal crying Memory of the event May be triggered by emotional/stressful situations
87
Causes of Psychogenic Nonepileptic Seizures
Anxiety attacks/ PTSD | Conversion Disorder
88
Pseudoseizures
Psychogenic Nonepileptic Seizures
89
Who may experience pseudoseizures?
Epilepsy patients | Women
90
Labs to order for new onset seizures
``` CBC CMP Ammonia (cirrhosis) Tox screen +/- ESR +/- prolactin- 40-60% within 20min sz ``` LP if you suspect infection.
91
Imaging for Seizures
Head CT if acute bleed suspected | MRI preferred
92
Favorable Factors for pts with seizures
Provocative condition EEG NL No seizure within first year
93
Negative Factors for pts with seizures
Abnormal EEG Underlying neuro condition Remote condition- CVA
94
Approach to pt with seizures:
Recurrent? Favorable factors? Negative factors?
95
Seizure Prophylaxis
``` Structural abnormality: neoplasm, AVM, infection Head trauma, CVA Sibling with epilepsy Hx prior seizure Abnormal EEG Status epilepticus Todd’s paresis +/- Unprovoked seizure ```
96
Do not attempt prophylaxis for pateints with
``` Febrile Electrolyte abnormality Secondary to stimulant abuse Sleep deprivation Alcohol/drug withdrawal ```
97
Stop/Tapering Medication
Seizure Free x 2 Years AND Normal EEG
98
Patient Education: Driving
No driving 6 months from last seizure.

Neurology Module (7 decks)

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