Seizure Disorders Flashcards
Epilepsy usually defined as having ?
two unprovoked seizures at least 24 hours apart
Process by which the brain becomes prone to having repeated seizures (epilepsy) ?
Epileptogenesis
Pathophysiology ?
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
- *
Old theory of why seizures occurred ?
loss of inhibitory neurons (GABA)
New theories of why seizures occur ?
loss of excitatory neurons (that stimulate the inhibitory neurons)
Injury leads to axonal “sprouting” to other excitatory neurons
Basis for neuronal excitation is the ?/
action potential
Voltage gated channels
- excitatory ?
Sodium and calcium (hypopolarize)
Voltage gated channels
- inhibitory ?
Potassium (hyperpolarize)
Ligand-gated receptors
- excitatory ?
Glutamate – NMDA Ca++ influx
Ligand-gated receptors
- inhibitory ?
Gamma-aminobutyric acid (GABA) – Cl- influx
Genetic alterations in Na channels are linked to ?
epilepsy and febrile seizures
Genetic alterations in Na channels are linked to what drugs ?
phenytoin (Dilantin) - target Na channels
carbamazepine (Tegretol),
Lacosamide
Genetic alterations in Ca channels are linked to ?
childhood absence epilepsy
Drugs that affect Ca channels ?
ethosuximide ( remember this)
Genetic mutations in K+ channels are linked to what drugs ?
Topiramate (Topamax)
Levetiracetam (Keppra)
Retigabine
Role of glial cells????
“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
If activity remains localized , what type of seizure is it ?
partial seizure
If bilateral, generalized activity , what you of seizure ?
generalized
Most common type in adults (approx. 60%) ?
partial seizure
- *Can be further categorized
- *
Usually arise in the temporal lobe (temporal lobe epilepsy) ?
partial seizure
Hippocampal sclerosis aka?
“Ammon’s horn sclerosis”
Hippocampal sclerosis patho ?
Loss of neurons in the hippocampus from sclerosis
Hippocampal sclerosis is a common feature of what ?
temporal lobe epilepsy
Hippocampal sclerosis is also seen in ________ and other types of dementia.
Alzheimers
** Good prognostic factor for response to surgery - remove the poriuton of the brain - resolves sxs. **
CAUSES OF SEIZURE (Non-epileptic): Neurogenic ?
Brain tumor
CVA
trauma
CAUSES OF SEIZURE (Non-epileptic) Electrolyte / Metabolic imbalance ?
Hypoglycemia
hyponatremia
hypocalcemia
Hyperthyroidism
Acute renal or hepatic failure
** get a glucose level always **
CAUSES OF SEIZURE (Non-epileptic) Medication overdoses ?
Antidepressants, antipsychotics
cyclosporine
interferon
INH
Lithium
Demerol
tramadol (Ultram)
quinolone atbs
CAUSES OF SEIZURE (Non-epileptic) Drug Withdrawal ?
ambein
CAUSES OF SEIZURE (Non-epileptic) Drugs ?
Cocaine
m-amphetamine,
nitrous oxide,
IV contrast dye,
lead or mercury poisoning,
acetylcholinesterase inhibitors
CAUSES OF SEIZURE (Non-epileptic) exogenous ?
Infection and/or fever
> 70-80% causes of seizures ?
Idiopathic
Causes of seizures by age: <10 yo ?
Idiopathic, congenital, birth injury, metabolic disorders, febrile seizures
Causes of seizures by age: 10-40 yo ?
Idiopathic, Head trauma, pre-existing focal lesion (ie. AVM), medication or drug usage/drug withdrawal
Causes of seizures by age: 40 -60 yo ?
Brain tumor, head trauma
Causes of seizures by age: >60 yo ?
CVA ( stroke) , brain tumor, subdural hematoma, CNS infection, Alzheimers/dementia, metabolic disturbance
FEBRILE SEIZURES: Prevalence ?
3-5% children <5
6m – 5 yo (peak age 2 yo)
FEBRILE SEIZURES: Demographic ?
66% male
FEBRILE SEIZURES: Simple type ?
lasts less than 15 minutes;
no associated sxs. or weakness
**simple is the most common type **
FEBRILE SEIZURES: Complex type ?
lasts longer than 15 minutes;
may have temporary weakness in arms/legs
FEBRILE SEIZURES pathophysiology ?
multifactorial genetic inheritance???
Zinc and iron deficiency????
FEBRILE SEIZURES: First seizure (Risk Factors) ?
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 )
RECURRENT FEBRILE SEIZURES risk factors ?
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
RECURRENT FEBRILE SEIZURES: _______ will experience subsequent szs
30-50%
FEBRILE SEIZURES: History and Physical ?
HPI
PMH
FH ( looking for a sibling)
Recent vaccines
FEBRILE SEIZURES: Imaging ?
Most do not require. MRI preferred (due to less radiation)
FEBRILE SEIZURES: Lumbar Puncture ?
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
FEBRILE SEIZURES: Lumbar Puncture - Newer guidelines ?
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
FEBRILE SEIZURES: treatment ?
Antipyretics Tylenol/ibuprofen
For comfort
Do NOT prevent seizure
FEBRILE SEIZURES: management ?
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 **
FEBRILE SEIZURES- PROGNOSIS ?
By age 5- 98% seizure free - good news
FEBRILE SEIZURES- PROGNOSIS: Risk of developing later szs/epilepsy ?
Underlying neuro disease (cerebral palsy)
FH epilepsy
Complex seizures
COMPLEX PARTIAL facts ?
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 ) **
Aura for Complex partial seizures ?
GI symptoms- nausea
Sense of fear ahead of time
Sensory
Complex partial seizures duration ?
Last 30 sec – 2min
Complex partial seizures frequency ?
up to several times/day
Complex partial seizures pre seizure ?
Stare, automatisms-picking/fumbling, facial movements
“picking at there cloths before”
Complex partial seizures do they have confused afterwards?
yes
Complex partial seizures may progress to ?
generalized tonic-clonic
Complex partial seizures resemble generalized absence seizures (“Petit mal”) but the different is that ?
but complex partial can happen in kid and adults but generalized absence happen only in kids
Complex partial seizures Treatment ?
Carbamazepine (Tegretol)
Phenytoin (Dilantin) - older
Valproic acid (Depakote)
Others!
Complex partial seizures: surgeries ?
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
Main 3 first line seizure medicines ?
- Carbamazepine (Tegretol)
- Phenytoin (Dilantin) - older
- Valproic acid (Depakote)
Simple Partial seizures facts ?
No LOC
Focal area ( may spread to other areas)
Simple Partial seizures sensory sxs. ?
visual
auditory
olfactory
gustatory
Simple Partial seizures autonomic sxs. ?
GI sxs
Flushing
Simple Partial seizures motor sxs. ?
Jerking limbs
Paresthesias
Simple Partial seizures other sxs. ?
hallucinations
déjà vu
jamais vu
Simple Partial seizures treatment ?
Carbamazepine (Tegretol)
Phenytoin (Dilantin) - older
Valproic acid (Depakote)
Temporal lobe resection
-Failed medical treatment after 1-2 years
Vagal nerve stimulator
ABSENCE SEIZURES onset ?
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 **
ABSENCE SEIZURES causes ?
Inherited idiopathic disorder
Secondary disorder
AVM, neoplasm, ID
AGE is critical.
In adult, with similar symptoms, think _________________.
Tx different!
partial-complex seizures
ABSENCE SEIZURES facts ?
NO AURA !
Vacant, dazed expression
Staring
Pallor
Usually no automatisms
ABSENCE SEIZURES ofte escape detection and are mistaken for what ?
ADHD
day dreaming
ABSENCE SEIZURES duration ?
10 seconds max (20 if complex)
ABSENCE SEIZURES frequency ?
Multiple times throughout day (50-100x)
ABSENCE SEIZURES other sxs. ?
eye blinking, head movements, picking clothes, pursing lips
ABSENCE SEIZURES my have ?
urinary incontinence
ABSENCE SEIZURES: EEG results ?
diffuse 3Hz spike pattern
ABSENCE SEIZURES usually cease by what age ?
20
ABSENCE SEIZURES con progress to ?
generalized tonic-clonic seizures in 33%
ABSENCE SEIZURES: Treatment ?
Ethosuximide (Zarontin)
Valproic acid (Depakote)- used less often due to hepatotoxicity
Lamotrigine (Lamictal)- usually adjunct
GENERALIZED TONIC- CLONIC: History and Physical ?
“Grand Mal”
Aura (often precedes)
Sudden LOC
Tonic- muscular rigidity (adduction and flexion of arms; extension of legs)
Clonic- jerking
Incontinence
Tongue biting
GENERALIZED TONIC- CLONIC: Aura sxs. ?
Irritability
Apathy
HA
Scintillating scotoma
nausea, choking sensation, paresthesias
GENERALIZED TONIC CLONIC: treatment ?
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…
GENERALIZED TONIC CLONIC: treatment-others ?
Primidone (Mysoline)
Lamotrigine (Lamictal) - tremor
Topiramate (Topamax) - migrane headaches -prevention
Zonsisamide (Zonegran)
Levetiracetam (Keppra)
Tend to be adjunct therapies…
Myoclonic seizures sxs ?
Sudden, single or multiple jerks of trunk/limbs
Myoclonic seizures duration ?
Last only a second or two
Myoclonic seizures often associated with ?
other seizure disorders/syndromes
Myoclonic seizures own notes ?
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 **
Infantile spasms aka ?
West’s Syndrome
Infantile spasms (“West’s Syndrome”) prevalence ?
rare
Infantile spasms (“West’s Syndrome”) onset ?
Start around 3-8 mos of age; stop around age 2-4
Infantile spasms (“West’s Syndrome”) characteristics ?
arms fling out
knees draw up to body
bend forward
Infantile spasms (“West’s Syndrome”) often occur around what times ?
around sleep-
waking up or falling asleep
Infantile spasms (“West’s Syndrome”) Treatment ?
steroid therapy or sz medications
ATONIC/AKINETIC siezure sxs. ?
LOC
Head drops, loss of posture
“drop attack”
Falls = Injury
**BIZARRE
sudden head drop and LOC**
ATONIC/AKINETIC treatment ?
resistant to drug therapy - unfortunately
Rolandic Epilepsy is a type of what ?
partial seizure
no LOC
**not really a total zebra cause it is sorta common in children, get drooling or cheek twitches **
Rolandic Epilepsy only occur in?
ONLY occur in children (account for 15%)
Usually outgrow by age 15
Rolandic Epilepsy originate from where ?
Originate in rolandic area of brain
Rolandic Epilepsy EEG pattern ?
centrotemporal spikes
Rolandic Epilepsy sxs. ?
Face/cheek twitching
Drooling
Difficulty speaking
Rolandic Epilepsy often occur when ?
at night so may not require tx
Rolandic Epilepsy tx ?
none
Gelastic or Dacrystic seizures occur in ?
children
Gelastic or Dacrystic seizures sxs. ?
Falling asleep
emotional stress
Gelastic = ?
laughing
Dacrystic= ?
crying
Gelastic or Dacrystic seizures facts ?
May generalize
Difficult to treat
Partial (focal
**BIZARRE!
another type of partial seizure
tend to occur under stress or around sleep **)
Lennox seizures aka ?
Lennox-Gastaut
Lennox seizures etiology and RF ?
Developmental delay
- *ass. with developmental delay secondarily
- *
Lennox seizures secondary causes (80%) ?
Encephalopathy
Meningitis
Birth injuries- hypoxia ( cerebral palsy)
Lennox seizures often occur when ?
nocturnal
Lennox seizures frequency ?
frequent szs-daily
Lennox seizures EEG result ?
interictal spikes
Lennox seizures tx ?
difficult
- *tx. never cure just minimizing seizures
- *
Lennox seizures own notes ?
very frequent seizure - hence helmet for protection
more of a seizure syndrome
Common Seizure Triggers ?
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
POST ICTAL PERIOD what sxs. typically last 5-30 min ?
Headache
Exhaustion
Confusion, drowsiness
POST ICTAL PERIOD: rare sxs. ?
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
STATUS EPILEPTICUS patho ?
2 or more seizures without recovery period
STATUS EPILEPTICUS risk factors ?
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 **
MANAGEMENT OF STATUS EPILEPTICUS ?
Check glucose
Lorazepam (long acting) or diazepam (short acting) … +/- midalzolam
Fosphenytoin or phenytoin - BBW for cardiac
Phenobarbital
Propofol, Depakote, Keppra
**Benzos main stay **
Phenytoin (Dilantin) side effects ?
Gingival hyperplasia, blood dyscrasias, SJS, Black box warning for rapid infusion and cardiac arrhythmias
Carbamazepine (Tegretol) side effects ?
Black Box- Asians SJS/TEN,
BM suppression in all
Valproic Acid (Depakote) side effects ?
Black Box warning: hepatotoxicity;
associated with neural tube defects - never give to pregnant women
Primidone (Mysoline) side effects ?
Related to phenobarbital
Lamotrigine (Lamictal) side effects ?
Black box warning: SJS
Topiramate (Topamax) side effects ?
Associated with narrow angle glaucoma
Safest seizure medications for pregnancy ?
Lamictal or Keppra may be safest
SPECIAL POPULATIONS: PREGNANCY notes ?
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
Avoid what seizure medications if pregnant ?
valproate
phenytoin
Catemenial seizures onset due to what ?
Onset due to progesterone withdrawal
Mid-cycle/ovulation due to estrogen surge ( mid cycle)
Catemenial seizures prevalence ?
50% of women with epilepsy
Drugs that do not affect the efficacy of OCs ?
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 **
Polycystic ovary disease : ___ women with epilepsy
40%
Subset related valproate (Depakote)
PSYCHOGENIC NONEPILEPTIC SEIZURE aka ?
“Pseudoseizures”
PSYCHOGENIC NONEPILEPTIC SEIZURE causes ?
Anxiety attacks/PTSD
PSYCHOGENIC NONEPILEPTIC SEIZURE facts ?
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
**
Atypical seizure activity so catch people faking it ( PSYCHOGENIC NONEPILEPTIC SEIZURE ) ?
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
Labs to evaluate for a new onset seizure ?
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
Evaluation of seizure: LP ?
only if infectious etiology suspected
Evaluation of seizure: Imaging ?
Head CT if acute bleed suspected
MRI preferred
Approaching patients with recurrent seizures: favorable prognosis factors ?
Provocative condition
EEG NL
No seizure within first year
Approaching patients with recurrent seizures: negative prognosis factors ?
Abnormal EEG
Underlying neuro condition
Remote condition- CVA
Seizure prophylaxis ?
Structural abnormality: neoplasm, AVM, infection
Head trauma (guys) , CVA
Sibling with epilepsy
Hx prior seizure
Abnormal EEG
Status epilepticus
Todd’s paresis
+/- Unprovoked seizure
When do you not want to treat seizures prophylaxitly ?
Febrile
Electrolyte abnormality
Secondary to stimulant abuse
Sleep deprivation
Alcohol/drug withdrawal
When can you discontinue seizure medications ? What two things ?
Seizure free fro 2 years
Normal EEG
**then consider tapering medication **
Patient education if seizures ?
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
