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Clinical Medicine Lecture - Professor Kramer > Seizure Disorders > Flashcards

Seizure Disorders Flashcards

1
Q

Epilepsy usually defined as having ?

A

two unprovoked seizures at least 24 hours apart

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2
Q

Process by which the brain becomes prone to having repeated seizures (epilepsy) ?

A

Epileptogenesis

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3
Q

Pathophysiology ?

A

Abnormal electrical activity discharge; single abnormal neuron is insufficient to cause a clinical seizure

In order for seizure to occur, recruitment of excitatory neurons with inhibition of inhibitory neurons  seizure propagation

  • *single neuron mis firing is not enough to cause it seizure they need to recruit more or propagate the abnormally firing neurons to cause a seizure
  • *
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4
Q

Old theory of why seizures occurred ?

A

loss of inhibitory neurons (GABA)

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5
Q

New theories of why seizures occur ?

A

loss of excitatory neurons (that stimulate the inhibitory neurons)

Injury leads to axonal “sprouting” to other excitatory neurons

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6
Q

Basis for neuronal excitation is the ?/

A

action potential

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7
Q

Voltage gated channels

- excitatory ?

A

Sodium and calcium (hypopolarize)

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8
Q

Voltage gated channels

- inhibitory ?

A

Potassium (hyperpolarize)

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9
Q

Ligand-gated receptors

- excitatory ?

A

Glutamate – NMDA Ca++ influx

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10
Q

Ligand-gated receptors

- inhibitory ?

A

Gamma-aminobutyric acid (GABA) – Cl- influx

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11
Q

Genetic alterations in Na channels are linked to ?

A

epilepsy and febrile seizures

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12
Q

Genetic alterations in Na channels are linked to what drugs ?

A

phenytoin (Dilantin) - target Na channels

carbamazepine (Tegretol),

Lacosamide

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13
Q

Genetic alterations in Ca channels are linked to ?

A

childhood absence epilepsy

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14
Q

Drugs that affect Ca channels ?

A

ethosuximide ( remember this)

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15
Q

Genetic mutations in K+ channels are linked to what drugs ?

A

Topiramate (Topamax)

Levetiracetam (Keppra)

Retigabine

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16
Q

Role of glial cells????

A

“Supportive cells”

Removal excess glutamate from the extracellular space

Manage extracellular potassium and calcium

play a role in the likely hood these people have seizures

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17
Q

If activity remains localized , what type of seizure is it ?

A

partial seizure

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18
Q

If bilateral, generalized activity , what you of seizure ?

A

generalized

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19
Q

Most common type in adults (approx. 60%) ?

A

partial seizure

  • *Can be further categorized
  • *
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20
Q

Usually arise in the temporal lobe (temporal lobe epilepsy) ?

A

partial seizure

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21
Q

Hippocampal sclerosis aka?

A

“Ammon’s horn sclerosis”

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22
Q

Hippocampal sclerosis patho ?

A

Loss of neurons in the hippocampus from sclerosis

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23
Q

Hippocampal sclerosis is a common feature of what ?

A

temporal lobe epilepsy

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24
Q

Hippocampal sclerosis is also seen in ________ and other types of dementia.

A

Alzheimers

** Good prognostic factor for response to surgery - remove the poriuton of the brain - resolves sxs. **

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25
Q

CAUSES OF SEIZURE (Non-epileptic): Neurogenic ?

A

Brain tumor

CVA

trauma

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26
Q

CAUSES OF SEIZURE (Non-epileptic) Electrolyte / Metabolic imbalance ?

A

Hypoglycemia

hyponatremia

hypocalcemia

Hyperthyroidism

Acute renal or hepatic failure

** get a glucose level always **

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27
Q

CAUSES OF SEIZURE (Non-epileptic) Medication overdoses ?

A

Antidepressants, antipsychotics

cyclosporine

interferon

INH

Lithium

Demerol

tramadol (Ultram)

quinolone atbs

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28
Q

CAUSES OF SEIZURE (Non-epileptic) Drug Withdrawal ?

A

ambein

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29
Q

CAUSES OF SEIZURE (Non-epileptic) Drugs ?

A

Cocaine

m-amphetamine,

nitrous oxide,

IV contrast dye,

lead or mercury poisoning,

acetylcholinesterase inhibitors

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30
Q

CAUSES OF SEIZURE (Non-epileptic) exogenous ?

A

Infection and/or fever

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31
Q

> 70-80% causes of seizures ?

A

Idiopathic

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32
Q

Causes of seizures by age: <10 yo ?

A

Idiopathic, congenital, birth injury, metabolic disorders, febrile seizures

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33
Q

Causes of seizures by age: 10-40 yo ?

A

Idiopathic, Head trauma, pre-existing focal lesion (ie. AVM), medication or drug usage/drug withdrawal

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34
Q

Causes of seizures by age: 40 -60 yo ?

A

Brain tumor, head trauma

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35
Q

Causes of seizures by age: >60 yo ?

A

CVA ( stroke) , brain tumor, subdural hematoma, CNS infection, Alzheimers/dementia, metabolic disturbance

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36
Q

FEBRILE SEIZURES: Prevalence ?

A

3-5% children <5

6m – 5 yo (peak age 2 yo)

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37
Q

FEBRILE SEIZURES: Demographic ?

A

66% male

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38
Q

FEBRILE SEIZURES: Simple type ?

A

lasts less than 15 minutes;

no associated sxs. or weakness

**simple is the most common type **

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39
Q

FEBRILE SEIZURES: Complex type ?

A

lasts longer than 15 minutes;

may have temporary weakness in arms/legs

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40
Q

FEBRILE SEIZURES pathophysiology ?

A

multifactorial genetic inheritance???

Zinc and iron deficiency????

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41
Q

FEBRILE SEIZURES: First seizure (Risk Factors) ?

A

Fever >38 (100.4)

Day care attendance

Developmental delay

Neonatal nursery >30 days

FH (sibling- 10% risk)

Viral infections (HHV6 - roseola, influenza, others)

Vaccinations (influenza, DTP, MMR )

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42
Q

RECURRENT FEBRILE SEIZURES risk factors ?

A

Age <15 months ( younger age of onset)

Have frequent fevers

Short interval between fever and sz (<1 hr)

Lower peak fever

First degree relative with hx. febrile

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43
Q

RECURRENT FEBRILE SEIZURES: _______ will experience subsequent szs

A

30-50%

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44
Q

FEBRILE SEIZURES: History and Physical ?

A

HPI
PMH
FH ( looking for a sibling)
Recent vaccines

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45
Q

FEBRILE SEIZURES: Imaging ?

A

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

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46
Q

FEBRILE SEIZURES: Lumbar Puncture ?

A

Main concern is meningitis

Old guidelines recommended for all children <12 months and strongly considered 12-18 months

Due to immunizations, incidence of meningitis dramatically decreased

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47
Q

FEBRILE SEIZURES: Lumbar Puncture - Newer guidelines ?

A

Signs of meningeal irritation

Recent antibiotics - for URI or ear infection
concern is that ABS can mask the meningeal sxs.

6-12 months of age- immunization deficient/status unknown
H. influenzae
Streptococcus pneumoniae

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48
Q

FEBRILE SEIZURES: treatment ?

A

Antipyretics Tylenol/ibuprofen

For comfort
Do NOT prevent seizure

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49
Q

FEBRILE SEIZURES: management ?

A

Recurrence likely

No increased morbidity/mortality

No behavioral/developmental disorders

No prophylaxis required- adverse effects, lack of efficacy

Low risk of developing epilepsy

**no anti siezure meds cause the benefits of the meds are not big enoughh **

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50
Q

FEBRILE SEIZURES- PROGNOSIS ?

A

By age 5- 98% seizure free - good news

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51
Q

FEBRILE SEIZURES- PROGNOSIS: Risk of developing later szs/epilepsy ?

A

Underlying neuro disease (cerebral palsy)

FH epilepsy

Complex seizures

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52
Q

COMPLEX PARTIAL facts ?

A

Most common

LOC

“Temporal lobe” may travel to frontal

Aura

**they do involve a loss of awareness - lose what is going on around them ( kinda spacing out for a moment ) **

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53
Q

Aura for Complex partial seizures ?

A

GI symptoms- nausea

Sense of fear ahead of time

Sensory

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54
Q

Complex partial seizures duration ?

A

Last 30 sec – 2min

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55
Q

Complex partial seizures frequency ?

A

up to several times/day

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56
Q

Complex partial seizures pre seizure ?

A

Stare, automatisms-picking/fumbling, facial movements

“picking at there cloths before”

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57
Q

Complex partial seizures do they have confused afterwards?

A

yes

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58
Q

Complex partial seizures may progress to ?

A

generalized tonic-clonic

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59
Q

Complex partial seizures resemble generalized absence seizures (“Petit mal”) but the different is that ?

A

but complex partial can happen in kid and adults but generalized absence happen only in kids

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60
Q

Complex partial seizures Treatment ?

A

Carbamazepine (Tegretol)

Phenytoin (Dilantin) - older

Valproic acid (Depakote)

Others!

61
Q

Complex partial seizures: surgeries ?

A

Temporal lobe resection
-Failed medical treatment after 1-2 years

Vagal nerve stimulator (?) - place a stimulator in the neck that stimulate the vagal nerve delivering pulses of activity and it resets the brian

magnets across neck to release a extra jolt to prevent the siezure if the feel the aura

62
Q

Main 3 first line seizure medicines ?

A
  1. Carbamazepine (Tegretol)
  2. Phenytoin (Dilantin) - older
  3. Valproic acid (Depakote)
63
Q

Simple Partial seizures facts ?

A

No LOC

Focal area ( may spread to other areas)

64
Q

Simple Partial seizures sensory sxs. ?

A

visual

auditory

olfactory

gustatory

65
Q

Simple Partial seizures autonomic sxs. ?

A

GI sxs

Flushing

66
Q

Simple Partial seizures motor sxs. ?

A

Jerking limbs

Paresthesias

67
Q

Simple Partial seizures other sxs. ?

A

hallucinations

déjà vu

jamais vu

68
Q

Simple Partial seizures treatment ?

A

Carbamazepine (Tegretol)

Phenytoin (Dilantin) - older

Valproic acid (Depakote)

Temporal lobe resection
-Failed medical treatment after 1-2 years

Vagal nerve stimulator

69
Q

ABSENCE SEIZURES onset ?

A

age 5-18

Rare under age 2 or beyond adolescence

**mimic closes to complex partial seizure , absence seizures is only kids you will not see these in adults **

70
Q

ABSENCE SEIZURES causes ?

A

Inherited idiopathic disorder

Secondary disorder
AVM, neoplasm, ID

71
Q

AGE is critical.
In adult, with similar symptoms, think _________________.
Tx different!

A

partial-complex seizures

72
Q

ABSENCE SEIZURES facts ?

A

NO AURA !

Vacant, dazed expression

Staring

Pallor

Usually no automatisms

73
Q

ABSENCE SEIZURES ofte escape detection and are mistaken for what ?

A

ADHD

day dreaming

74
Q

ABSENCE SEIZURES duration ?

A

10 seconds max (20 if complex)

75
Q

ABSENCE SEIZURES frequency ?

A

Multiple times throughout day (50-100x)

76
Q

ABSENCE SEIZURES other sxs. ?

A

eye blinking, head movements, picking clothes, pursing lips

77
Q

ABSENCE SEIZURES my have ?

A

urinary incontinence

78
Q

ABSENCE SEIZURES: EEG results ?

A

diffuse 3Hz spike pattern

79
Q

ABSENCE SEIZURES usually cease by what age ?

A

20

80
Q

ABSENCE SEIZURES con progress to ?

A

generalized tonic-clonic seizures in 33%

81
Q

ABSENCE SEIZURES: Treatment ?

A

Ethosuximide (Zarontin)

Valproic acid (Depakote)- used less often due to hepatotoxicity

Lamotrigine (Lamictal)- usually adjunct

82
Q

GENERALIZED TONIC- CLONIC: History and Physical ?

A

“Grand Mal”

Aura (often precedes)

Sudden LOC

Tonic- muscular rigidity (adduction and flexion of arms; extension of legs)

Clonic- jerking

Incontinence

Tongue biting

83
Q

GENERALIZED TONIC- CLONIC: Aura sxs. ?

A

Irritability

Apathy

HA

Scintillating scotoma

nausea, choking sensation, paresthesias

84
Q

GENERALIZED TONIC CLONIC: treatment ?

A

Valproic acid (Depakote)

Phenytoin (Dilantin)

Carbamazepine (Tegretol)

+/- phenobarbital
-not used any more people get hooked on it

Tend to be first line and may be monotherapies…

85
Q

GENERALIZED TONIC CLONIC: treatment-others ?

A

Primidone (Mysoline)

Lamotrigine (Lamictal) - tremor

Topiramate (Topamax) - migrane headaches -prevention

Zonsisamide (Zonegran)

Levetiracetam (Keppra)

Tend to be adjunct therapies…

86
Q

Myoclonic seizures sxs ?

A

Sudden, single or multiple jerks of trunk/limbs

87
Q

Myoclonic seizures duration ?

A

Last only a second or two

88
Q

Myoclonic seizures often associated with ?

A

other seizure disorders/syndromes

89
Q

Myoclonic seizures own notes ?

A

Awareness

Several different types including juvenile myoclonic epilepsy

**just involve jerking of the limbs ,kids end up growing out of it unless the siezure is cause by something else **

90
Q

Infantile spasms
 aka ?

A

West’s Syndrome

91
Q

Infantile spasms
 (“West’s Syndrome”) prevalence ?

A

rare

92
Q

Infantile spasms
 (“West’s Syndrome”) onset ?

A

Start around 3-8 mos of age; stop around age 2-4

93
Q

Infantile spasms
 (“West’s Syndrome”) characteristics ?

A

arms fling out

knees draw up to body

bend forward

94
Q

Infantile spasms
 (“West’s Syndrome”) often occur around what times ?

A

around sleep-

waking up or falling asleep

95
Q

Infantile spasms
 (“West’s Syndrome”) Treatment ?

A

steroid therapy or sz medications

96
Q

ATONIC/AKINETIC siezure sxs. ?

A

LOC

Head drops, loss of posture

“drop attack”

Falls = Injury

**BIZARRE

sudden head drop and LOC**

97
Q

ATONIC/AKINETIC treatment ?

A

resistant to drug therapy - unfortunately

98
Q

Rolandic Epilepsy is a type of what ?

A

partial seizure

no LOC

**not really a total zebra cause it is sorta common in children, get drooling or cheek twitches **

99
Q

Rolandic Epilepsy only occur in?

A

ONLY occur in children (account for 15%)

Usually outgrow by age 15

100
Q

Rolandic Epilepsy originate from where ?

A

Originate in rolandic area of brain

101
Q

Rolandic Epilepsy EEG pattern ?

A

centrotemporal spikes

102
Q

Rolandic Epilepsy sxs. ?

A

Face/cheek twitching

Drooling

Difficulty speaking

103
Q

Rolandic Epilepsy often occur when ?

A

at night so may not require tx

104
Q

Rolandic Epilepsy tx ?

A

none

105
Q

Gelastic or Dacrystic seizures occur in ?

A

children

106
Q

Gelastic or Dacrystic seizures sxs. ?

A

Falling asleep

emotional stress

107
Q

Gelastic = ?

A

laughing

108
Q

Dacrystic= ?

A

crying

109
Q

Gelastic or Dacrystic seizures facts ?

A

May generalize
Difficult to treat

Partial (focal

**BIZARRE!

another type of partial seizure

tend to occur under stress or around sleep **)

110
Q

Lennox seizures aka ?

A

Lennox-Gastaut

111
Q

Lennox seizures etiology and RF ?

A

Developmental delay

  • *ass. with developmental delay secondarily
  • *
112
Q

Lennox seizures secondary causes (80%) ?

A

Encephalopathy

Meningitis

Birth injuries- hypoxia ( cerebral palsy)

113
Q

Lennox seizures often occur when ?

A

nocturnal

114
Q

Lennox seizures frequency ?

A

frequent szs-daily

115
Q

Lennox seizures EEG result ?

A

interictal spikes

116
Q

Lennox seizures tx ?

A

difficult

  • *tx. never cure just minimizing seizures
  • *
117
Q

Lennox seizures own notes ?

A

very frequent seizure - hence helmet for protection

more of a seizure syndrome

118
Q

Common Seizure Triggers ?

A

Hypoglycemia - biggest triggers
make sure they are eating regularly

Sleep deprivation - HUGE!
dont let them sleep

Flashing lights/strobe lights

Fever/Infection/Illness

Stress

Hormonal changes/menstrual cycle

Alcohol or drug use

Medications: lower seizure threshold

  • Tramadol (Ultram)
  • Buproprion (Wellbutrin)
  • Diphenhydramine, -pseudoephedrine
  • Many others! - PCN
119
Q

POST ICTAL PERIOD what sxs. typically last 5-30 min ?

A

Headache

Exhaustion

Confusion, drowsiness

120
Q

POST ICTAL PERIOD: rare sxs. ?

A

Todd’s paresis: (6% of grand mal)-paralysis 15h-36h

Postictal psychosis: lucid phase 2-6h, psychosis 9-10d - very rare!

Postictal bliss: euphoric / manic

121
Q

STATUS EPILEPTICUS patho ?

A

2 or more seizures without recovery period

122
Q

STATUS EPILEPTICUS risk factors ?

A

MEDICATION! ( WD)
-hx of seizure and they on the seizure meds and they stop cold turkey

Alcohol withdrawal

Drug overdose

Intracranial infections (meningitis, encephalitis)

Neoplasms

**during a seizure they become hypoxic **

123
Q

MANAGEMENT OF STATUS EPILEPTICUS ?

A

Check glucose

Lorazepam (long acting) or diazepam (short acting) … +/- midalzolam

Fosphenytoin or phenytoin - BBW for cardiac

Phenobarbital

Propofol, Depakote, Keppra

**Benzos main stay **

124
Q

Phenytoin (Dilantin) side effects ?

A

Gingival hyperplasia, blood dyscrasias, SJS, Black box warning for rapid infusion and cardiac arrhythmias

125
Q

Carbamazepine (Tegretol) side effects ?

A

Black Box- Asians SJS/TEN,

BM suppression in all

126
Q

Valproic Acid (Depakote) side effects ?

A

Black Box warning: hepatotoxicity;

associated with neural tube defects - never give to pregnant women

127
Q

Primidone (Mysoline) side effects ?

A

Related to phenobarbital

128
Q

Lamotrigine (Lamictal) side effects ?

A

Black box warning: SJS

129
Q

Topiramate (Topamax) side effects ?

A

Associated with narrow angle glaucoma

130
Q

Safest seizure medications for pregnancy ?

A

Lamictal or Keppra may be safest

131
Q

SPECIAL POPULATIONS: PREGNANCY notes ?

A

Anovulatory cycles

Drugs may affect hormones

Increased risk of miscarriage

Birth defects:
General population 2-3% risk v. 4-8%

Lowest possible dose but dilution factor

Folic acid supplement prior to pregnancy

Lactation: just monitor

Breast feeding still recommended

Monitor: irritation, altered sleep, poor weight gain

132
Q

Avoid what seizure medications if pregnant ?

A

valproate

phenytoin

133
Q

Catemenial seizures onset due to what ?

A

Onset due to progesterone withdrawal

Mid-cycle/ovulation due to estrogen surge ( mid cycle)

134
Q

Catemenial seizures prevalence ?

A

50% of women with epilepsy

135
Q

Drugs that do not affect the efficacy of OCs ?

A

Gabapentin (Neurontin)

Levetiracetam (Keppra)

Lamotrigine (Lamictal)

Valproate (Depakote)

Zonisamide (Zonegran)

**hx of seizure and they want to be on BC, alot of these drugs affect the efficacy but above are some that dont effect it **

136
Q

Polycystic ovary disease : ___ women with epilepsy

A

40%

Subset related valproate (Depakote)

137
Q

PSYCHOGENIC NONEPILEPTIC SEIZURE
 aka ?

A

“Pseudoseizures”

138
Q

PSYCHOGENIC NONEPILEPTIC SEIZURE
 causes ?

A

Anxiety attacks/PTSD

139
Q

PSYCHOGENIC NONEPILEPTIC SEIZURE
 facts ?

A 
Conversion Disorder (Functional Neurological 
Symptoms Disorder)

Not malingering!

1-3/100,000

Females 2/3

**these people truly believe they are having seizure it is not fake for work avoidance or anything

honest believe they are having full blow seizures
**

140
Q

Atypical seizure activity so catch people faking it ( PSYCHOGENIC NONEPILEPTIC SEIZURE
) ?

A

Nonfocal: opposite arm/leg ( head usually not involved)

Pelvic thrusting

Head turning side to side

Eyes closed, tight

Tongue biting limited tip

Postictal crying

Memory of the event ( no memory with true seizures)

May be triggered by emotional/stressful situations

Often occur in MD waiting rooms and almost always witnessed

141
Q

Labs to evaluate for a new onset seizure ?

A

CBC

CMP

Ammonia (cirrhosis)

Tox screen

+/- prolactin- 2x within 10-20min sz (May help distinguish between seizure and “pseudoseizure”)
real or psuedo-siezure - get a prolactin level

142
Q

Evaluation of seizure: LP ?

A

only if infectious etiology suspected

143
Q

Evaluation of seizure: Imaging ?

A

Head CT if acute bleed suspected

MRI preferred

144
Q

Approaching patients with recurrent seizures: favorable prognosis factors ?

A

Provocative condition

EEG NL

No seizure within first year

145
Q

Approaching patients with recurrent seizures: negative prognosis factors ?

A

Abnormal EEG

Underlying neuro condition

Remote condition- CVA

146
Q

Seizure prophylaxis ?

A

Structural abnormality: neoplasm, AVM, infection

Head trauma (guys) , CVA

Sibling with epilepsy

Hx prior seizure

Abnormal EEG

Status epilepticus

Todd’s paresis

+/- Unprovoked seizure

147
Q

When do you not want to treat seizures prophylaxitly ?

A

Febrile

Electrolyte abnormality

Secondary to stimulant abuse

Sleep deprivation

Alcohol/drug withdrawal

148
Q

When can you discontinue seizure medications ? What two things ?

A

Seizure free fro 2 years

Normal EEG

**then consider tapering medication **

149
Q

Patient education if seizures ?

A

Driving

No driving 6 months from last seizure (good rule of thumb)

DMV (OH)

  • Physician reporting not mandatory
  • Patient reports and will need to obtain medical report on annual basis

Clinical Medicine Lecture - Professor Kramer (28 decks)

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