Seizure Disorders - Exam 3 Flashcards
Define a seizure. After a single seizure, a pt has a _____ of having another. If a pt has had 2 seizures → _____ of future seizures
Transient disturbance of brain function due to abnormal neuronal activity
50% chance after a single one
2 seizures, 80% chance of future seizure
What 3 things increase your risk of a recurrent seizure?
Epileptiform abnormalities on EEG
Remote symptomatic cause identified by hx or imaging (brain tumor, TBI, brain malformation)
abnormal neuro exam
What is a non-epileptic seizure? What is epilepsy?
triggered by a disorder, event, or other condition that irritates the brain
“Seizure Disorder” - a condition characterized by recurrent seizures due to a chronic, underlying process
How are neurons transmitted?
via electrical impulses that are transmitted into chemical messages
What are the two different types of neurotransmitters? briefly describe each
Excitatory and inhibitory
excitatory: increases neurotransmission by increasing the likelihood that postsynaptic cells will “fire” express into action potential
inhibitory: decreases neurotransmission by decreasing likelihood that postsynaptic cell will “fire” express an action potential
What process makes excitatory neurons more likely to fire?
Open cation channels (mainly Na+, some Ca2+), letting them into the neuron and then the neuron depolarizes (becomes more positive) the affected neuron
Where is the majority Na found? Where is the majority of K found?
found mostly outside of the cell
found mostly inside of the cell
What process makes inhibitory neurons less likely to fire?
May open K+ channels, allowing potassium ions to flow out of the neuron
May open Cl- channels, allowing chloride ions to flow into the neuron
so they hyperpolarize (makes them more negative) the affected neuron
______ is the major excitatory neurotransmitter. What is it strongly linked to?
glutamate
strongly linked to memory
______ is the major inhibitory neurotransmitter. What is the nickname?
GABA
“nature’s valium”
________ major functions include attention and wakefulness, memory, skeletal muscle, ANS target organs. What are the 2 major receptors?
Acetylcholine
nicotinic and muscarinic
What are the glutamate major receptors?
NMDA and AMPA
______ major functions include mood, memory, sleep, muscle contraction, GI motility, organ development and growth hormones, appetite
Serotonin
______ major functions include movement control, reward system, emotional regulation,
motivation, attention and wakefulness, memory, sexual arousal
dopamine
Which two major neurotransmitters are considered catecholamines?
dopamine and epi/norepi
What are the 2 major receptors for epi/norepi? What are the major functions?
Major receptors - ⍺-adrenergic and β-adrenergic receptors
Major functions - “fight or flight response,” memory, attention, BP, HR, sleep, alertness
What are the 6 broad categories of the causes of epilepsy?
What does “idiopathic” mean in terms of epilepsy?
means unknown GENETIC problem
What does “cryptogenic” mean in terms of epilepsy?
means the doctors have no idea!!
What are the risk factors for epilepsy?
age: early childhood or late adulthood (older than 60)
family hx
males
ethnicity: MC and severe in Blacks, less common in hispanic pts
brain inflammation or damage
chronic disease
medications
What is going on during a “febrile seizure?”
inflammatory cytokines → increased neuroexcitability
aka fever that spikes very rapidly is more like to have a seizure
What are some chronic diseases that increase your risk for epilepsy?
hyperglycemia, hypoglycemia, hypoparathyroidism, high or low sodium, low calcium, low magnesium, lupus (SLE), kidney failure, liver failure, Vit B6 deficiency (especially in newborns and infants)
What medications are risk factors for epilepsy?
alcohol, bupropion, ADHD stimulants, diphenhydramine and BZD withdrawal
_______ is very safe to give empirically if you do not know the underlying cause of the seizure?
Vit B6
When are seizures more likely to occur? What is the pattern? What is the pattern of activity?
most seizures are unpredictable and may occur at any time.
Seizures are often stereotyped–each one is like the previous one.
Pattern of activity: Prodrome (+/-) → Pre-Ictal (Aura) (+/-) → Ictal → Post-Ictal
What are some common s/s of the prodome stage?
Mood changes, sleep changes, lightheadedness, irritability, poor concentration that usually happen hours to days before a seizure
What can the pre-ictal stage be considered? How long before it progresses to a seizure?
focal-onset seizure
precedes seizure by seconds to minutes but does NOT always occur and may NOT progress to a prolonged seizure
What are some examples of aura symptoms? What do the symptoms tell you?
Visual - flashing lights, spots, or other unusual patterns
Auditory - buzzing, ringing, or other strange sounds
Olfactory - smelling strange odors
Gustatory - tasting unusual tastes
Somatosensory - numbness, tingling, nausea, headache
Psychocognitive - Deja vu, Jamais vu, panic, confusion
where in the brain the abnormal activity is occuring
What are the different observable symptoms that can be seen throughout the ictal phase? Give a brief description of each
Tonic - muscles become stiff, rigid, tense
Atonic - sudden, unexpected loss of muscle strength or tone
Myoclonic - short, lightning-quick, jerking movements
Clonic - periods of rhythmic shaking or jerking movements
Epileptic Spasms - body flexes and extends
repeatedly
Hyperkinetic - intense, irregular, complex
movements - pedaling, rocking, thrashing,
pelvic thrusting
Automatisms - clapping, rubbing hands,
lip smacking
What are the two types of ictal phase that lack major motor symptoms?
Absence - usually used to describe a seizure with altered neurologic function but no major motor movements
Behavior arrest - describes a seizure wherein a patient is “frozen” and unable to initiate normal behavior
**Most ictal phases last between _____ and ______ and stop on their own.
30 seconds to 2 minutes
**An ictal phase lasting over _____ is a medical emergency (________) and can lead to brain damage or death.
5 minutes
status epilepticus)
How long is the typical post-ictal phase? What are some common s/s of the post-ictal phase?
Most commonly 5-30 minutes in length
Loss of consciousness or unresponsiveness
Numbness or focal weakness (Todd’s paralysis)
Headache
Fatigue
Confusion, agitation, or stupor
Loss of bowel or bladder control
What are some important hx questions to ask regarding seizures?
What is the difference between a focal and generalized seizure?
focal: involves only ONE AREA of the brain
generalized: involves ALL of the brain
What is Psychogenic Nonepileptic Seizure (PNES)?
Superficially resemble an epileptic seizure, but no true epileptic activity
physical manifestation of psych disease: think conversion disorder that are NOT intentionally produced
What are some common features of a pseudoseizure? What is the tx?
Gradual onset, last >2 minutes
Often have closed eyes (and resist opening) during seizure
Side-to-side head movements and severe tongue biting are common
Will stop their hands from hitting their face
Typically, no incontinence
tx: psychotherapy
What is the first step to identifying the seizure type? What do you do next?
verify the seizure type is epileptic
next: determine how the abnormal brain activity began
Which type of seizure is more common? How prevalent are they?
focal onset
Over 50% of all seizures are focal seizures and s/s vary on what part of the brain is impaired
What are the different variations of a focal onset seizure?
Focal Seizure with Retained Awareness
Focal Seizure with Impaired Awareness
both are further classified as motor onset or nonmotor onset depending on s/s
Focal to Bilateral Tonic-Clonic Seizures
What are Focal to Bilateral Tonic-Clonic Seizures? What were they previously called?
a special category of focal seizures, usually with impaired awareness, that consistently progress to bilateral tonic-clonic seizures
Previously called “secondary generalization seizures”
What are 3 important things to note about focal seizure with RETAINED awareness onset seizures?
< 15% of seizures
Fewer symptoms than general
No LOC or memory loss -> but can have abnormal sensation
What are 3 important things to note about focal seizures with IMPAIRED awareness?
> 33% of seizures
Similar to focal seizure with retained awareness, but with altered consciousness; unaware of what occurred after
Unusual, repetitive movements are common (hand rubbing, chewing, walking in circles)
What are the types of generalized seizures?What is important to note about the types of generalized seizures? What is the prevalence?
Non-Motor: Absence
Motor Onset:
Myoclonic
Atonic
Tonic
Clonic
Tonic-Clonic
Other than myoclonic, all involve LOC!! and are often NOT preceded by an aura
Over 30% of patients with epilepsy have generalized seizures
_______ is characterized by staring and subtle body movement with impaired consciousness. What is important to note about the timing?
Nonmotor - Absence
start and stop suddenly and can occur numerous times a day
if a generalized nonmotor- absense seizure is longer than 45 seconds or a postictal phase is present, what do you need to consider?
need to consider focal seizure
What pt population is Generalized Nonmotor - Absence seizure more common in?
more common in kids
consider if the kid is spacey or cannot pay attention well
________ is characterized by sudden, irregular, brief jerks or twitches of the muscles. What parts of the body are commonly affected? How long do they last? When do pts often experience these types of seizures? **What is SUPER important to remember?
myoclonic
Arms, legs, jaw often affected
very short duration: millisecond in duration, but can occur in back-to-back prolonged periods
Often experienced when falling asleep or waking up
**typically no LOC
What is Benign Myoclonus of Infancy? What is the tx?
are condition characterized by non-epileptic spasms. The spells begin before age 1 yr and are self-limited. The EEG is invariably normal, and neurologic development is not affected.
Typically resolves on its own without treatment.
______ is characterized by sudden loss of muscle control without myoclonic or tonic features for < 2 seconds. What will happen normally in these patients? Often associated with ________
generalized motor - Atonic
Severe - sudden fall or collapse and the pt will not be aware of what just happened
intellectual impairment
_______ is characterized by tightening and stiffening of the muscles. These patients will often ______. What is a huge concern? How long do they last? Often associated with ______
Generalized Motor - Tonic
Many pts fall to the ground because of muscle rigidity
Pt may become cyanotic if respiration is impaired
last seconds to minutes
Often associated with intellectual impairment
_____ is characterized by rhythmic convulsive jerking movements of the muscles. How long do they last? associated with ________
generalized motor-clonic-> More rhythmic jerking than myoclonic seizures. usually neck, face and arms often affected
lasts seconds to minutes
Associated with altered consciousness
aka constant rhythmic jerks with altered consciousness
______ are characterized by LOC, violent shaking, body stiffening that is usually bilateral, symmetric, generalized. How long do they last? How long does the post-ictal phase usually last?
Generalized Motor - Tonic-Clonic. “Grand mal” seizure
often last for several minutes
Commonly takes 10-30 min to see a more normal baseline (these have the longest post-ictal phase)
aka move move stiffen then move move
How do you classify the type of epilepsy? How do you determine the epilepsy type?
based on the type of seizure the patient most often experiences
focal or generalized or generalized and focal (they have both types) or unknown
EEG tracing: focal and generalized seizures usually have different patterns
What is an epilepsy syndrome? What are the defining criteria?
A disorder with epilepsy as a predominant feature, and enough diagnostic evidence to suggest a common underlying condition
Seizure types
EEG findings
Imaging features
Genetic testing
Age at onset
Other medical comorbidities
What are the 4 epilepsy syndromes we learned in lecture?
Juvenile Myoclonic Epilepsy (JME)
Lennox-Gastaut Syndrome
West Syndrome (Infantile Spasms)
Mesial Temporal Lobe Epilepsy (MTLE)
_____ is characterized by bilateral myoclonic jerks, single or repetitive that is most common in the AM and appears in early adolescence. What type of seizures do they have? What is the prognosis?
Juvenile Myoclonic Epilepsy (JME)
patients may also have tonic-clonic seizures and 1/3 may have absence seizures
this type responds well to medications
________ is thought to be polygenetic and generally have NO LOC!
Juvenile Myoclonic Epilepsy (JME)
_________ is most often diagnosed in children and is a nonspecific response of the brain to ________. What are the 3 major characteristics?
Lennox-Gastaut Syndrome
diffuse neuronal dysfunction
- Multiple seizure types (generalized tonic-clonic, atonic, absence)
- Slow spike-and-wave EEG pattern, along with other abnormalities
- Impaired cognitive function (most, but not all cases)
What is the prognosis for Lennox-Gastaut?
Many patients have poor prognosis due to underlying CNS disease and their severe epilepsy
_______ is most often diagnosed in infants and is thought to be due to _______
West Syndrome
Abnormal cortex-brainstem interactions and may be due to CNS Immaturity
aka nervous system is not communicating but some pts may grow out of it
75% of patients with West syndrome have ______. Describe them. What does their EEG look like?
symptomatic epilepsy
Symmetric, sudden, brief contractions of 1+ muscle groups. Spasms last 4-6 seconds; 80% occur in clusters
Hypsarrythmia on EEG (high voltage, random, slow waves and spikes in all cortical areas)
What is the tx for West syndrome?
Anticonvulsants, B6, ACTH, and prednisone may help treat
_______ is the MC focal epileptic syndrome in adults. What is it associated with? What is it characterized by?
Mesial Temporal Lobe Epilepsy (MTLE)
severe hippocampal neuronal loss
Characterized by cognitive impairment, poor verbal memory, and abnormal sensory experiences
aka hearing, smelling and tasting weird things
What is the tx for Mesial Temporal Lobe Epilepsy (MTLE)?
Does NOT respond well to anticonvulsant medication
Often improved with surger
______ is the most useful for diagnosing epilepsy. ______ can help clarify a patient’s experiences
the patient
seizure diary
_____ are elevated 3-4x after a tonic-clonic seizure activity
Prolactin levels
Give 4 reasons EEG monitoring is typically done
To distinguish epileptic seizures from other differential diagnoses
To characterize/classify seizures
To locate the site of origin for seizure activity (especially if surgery is being considered)
To provide a guide to prognosis
What is the pt education for prep the night before their EKG?
wash hair the night before (shampoo only)
avoid caffeine at least 12 hours before test
take usual medications
**What are the indications to order an MRI for epilepsy? What is an fMRI?
for any new onset or progression of seizures in a pt over 20 yrs old
monitors blood flow through the brain
What would a PET scan show on a pt with epilepsy?
80% of pts - increased blood flow and glucose metabolism during seizure, decreased between seizures
measure blood flow and glucose uptake
What are the 7 things you should do during an acute seizure?
- maintain airway
- prevent injury by rolling the pt on their side, cushion head, move away from furniture or anything that can hurt them
- note the seizure length
- do NOT hold the pt down
- do NOT put anything in the pt’s mouth
- seizure longer than 5 minutes, call 911
- document seizure details
What are the 8 red flags for seizures?
What is sudden unexplained death in epilepsy (SUDEP)?
Up to 20% of people with epilepsy die from SUDEP
Cause is unknown, but one theory suggests heart and respiratory issues may contribute
What are 4 lifestyle precautions for seizures?
protective headgear
prenatal care
vaccinations
safe environments: never swim alone!
driving precautions
seizure service dogs
______ is used for intractable epilepsy, especially in childhood. What do you need to monitor?
Ketogenic Diet
Urine ketones should be monitored
Pt with epilepsy are more likely to have _______. Why does this matter?
other comorbidities
need to consider other comorbidities when choosing the appropriate medication for the pt
What are the ILAE guidelines for screening for depression?
screen for anxiety depression and SI at time of diagnosis and regular follow-ups
Recommend starting treatment sooner rather than later (SSRIs preferred)
When is sx considered as a tx for epilepsy? When is sx the most helpful?
Typically considered if seizures are refractory
Continue despite 2+ AEDs
Intolerable side effects of AEDs
Most helpful if imaging/EEG identify a small, well-defined area where seizures originate-> focal laser resection of the affected area
If the causative area cannot be removed,________ surgery may help at least reduce the spread of seizures to other parts of the brain. What is it?
Corpus Callosotomy
severs connection between hemispheres
______ may still be needed after sx. Describe the difference when compared to before surgery.
medication
Usually fewer drugs and smaller doses
_____ is often utilized in patients with refractory epilepsy who are not good surgical candidates. Describe it and how it works
Neurostimulation
electrical impulses delivered to key target areas in the brain to reduce the frequency and severity of seizure activity
_______ implanted in chest, delivers electrical pulses to the _____ nerve
vagus nerve stimulation
vagus
________ closed-loop intracranial stimulation unit that monitors and detects seizures and sends impulses when abnormal activity is detected. What is important to note about this one?
responsive neurostimulation
only fires during active seizures
_______ extracranial unit with leads that go into the deep brain areas and deliver impulses to limit seizures
deep brain stimulation
When are AED usually started?
2 or more unprovoked seizures
Abnormal EEG findings
What labs do you need to order before starting AEDs? What is the highlighted one?
CBC, CMP, depression screening
Baseline hematologic profile
Liver and renal function
Electrolyte status
Albumin levels (some AEDs are highly protein bound)
How often do you need to monitor AED serum levels?
at least once a year!!
need to keep a seizure journal!!
What are the generalized AED guidelines?
start with one drug and max it out before starting an additional medication
add second drug first before stopping first AED and may choose to withdrawal first drug after second one is on board
always consider individual patient comorbities!!
**______ is first-line monotherapy for focal seizure
lamotrigine (Lamictal)
______ is first-line monotherapy for generalized seizures. What is important to note about this medication?
valproate (Depakote)
NOT safe in pregnancy!!!
**________ is first-line therapy for seizures in preg and pediatric patients
Levetiracetam (Keppra)
What are the common AED side effects?
drowsy
dizzy
diplopia
imbalance
N/V
hyponatremia
**_______ SE is associated with phenytoin
gingival hyperplasia
What 4 older AEDs are known teratogenic agents?
phenytoin
carbamazepine
phenobarbital
valproic acid
When is the highest risk of systemic toxicity and neurotoxicity with AEDs?
within the first 6 months of treatment!!!
so need to follow up more frequently in the first few months after starting treatment
When can you start considering to d/c AED?
After at LEAST 2 years seizure-free, consider discontinuing AEDs
We must weigh the risk of seizure recurrence against the possible benefits of drug withdrawal.
_____ of patients will be able to stop using their anti-epileptic medicines after being seizure-free for about ____ years
50%
2-5 years
What are the different anticonvulsant classes? What is the safest way to d/c drugs in this class?
Drugs Affecting Sodium Channels
Drugs Affecting GABA Activity
Drugs with Other/Multiple MOA
Drugs Affecting Calcium Channels
need to taper when d/c
What 4 AED drugs affect sodium channels? Which ones need serum drug level drawn? Where else are these drugs also used?
carbamazepine (Tegretol)**
oxcarbazepine (Trileptal)
phenytoin (Dilantin)**
lamotrigine (Lamictal)
also used in bipolar disorder
What 2 AED drugs affect GABA activity? Which one need serum drug level drawn?
phenobarbital (Luminal)**
benzodiazepines (BZDs)
What 3 AED drugs affect other/multiple MOA? Which one need serum drug level drawn?
valproic acid/valproate/divalproex (Depakene, Depakote)**
topiramate (Topamax, Trokendi XR)
levetiracetam (Keppra)
What 2 AED drugs affect calcium channels?
gabapentin (Neurontin, Gralise)
pregabalin (Lyrica)
What is the MOA of Anticonvulsants Affecting Sodium Channels? What are the severe SE?
drug blocks the opening of the sodium channel so the cell does not have enough to depolarize and the signal does not go through all the way
Stevens-Johnson Syndrome, multiorgan hypersensitivity
What drug that affects the sodium channel also inhibits the release of excitatory neurotransmitters?
Lamotrigine
do not use ______ if hypersensitivity to tricyclic antidepressants, _______ or use with MAOIs
Carbamazepine
bone marrow suppression: also oxcarbazepine can cause bone marrow suppression
do not use _____ with delavirdine or the IV form in bradycardia or heart block
Phenytoin
What do you need to monitor when prescribing Carbamazepine and Oxcarbazepine?
thyroid function
What is the severe SE of phenytoin?
cardiac arrhythmia
What is the highlighted SE of lamotrigine? What is the severe SE?
regular: nausea
severe: aseptic meningitis
What is the MOA of AED that work on GABA?
GABA binds to cell to make it more negative, more fluoride (negative) cells enter and neuron is less likely to fire
What is the MOA of phenobarbital? **What did Jensen say to remember about phenobarbital?
works on GABA receptors to make the cell even more negative
It is a scheduled IV drug- controlled substance
What is the MOA of Valproate? ** What is the BBW?
Blocks voltage-dependent sodium channels
and also works on GABA
**BBW: for pancreatitis and liver failure, DO NOT USE IN PREGNANCY
What is the MOA for topiramate? **What are the 2 SE?
blocks glutamate
encourages GABA to work better
blocks sodium channels
weight loss
**SE: weight loss and impaired cognition
What is the SE of Levetiracetam? What pt population is it used MC in?
irritability
used in pregnant and kids
What is the MOA of AED that affect calcium channels? What 2 drugs?
binds to calcium channels
inhibiting nerve transmission; also attenuates release of excitatory neurotransmitters
Gabapentin / Pregabalin
What schedule is pregabalin? What is the SE of gabapentin?
Pregabalin is a schedule V drug
gabapentin: sedation
What is status epilepticus? Give all three versions
Continuous seizure activity, as constituted by:
A single seizure episode that lasts > 5 minutes
Multiple seizures within a 30-minute time frame
Inability to fully regain consciousness between 2 or more seizures
What is the MC cause of status epilepticus? What makes it an emergency?
poor adherence to antiepileptic tx
Potential for permanent neurological damage, cardiac arrhythmia and respiratory failure
Can be fatal if not treated
aka they just never fully wake back up after the prolonged seizure
What is the emergency treatment protocol for status epilepticus?
stabilize airway, 100% oxygen, IV access, continuous cardiorespiratory monitoring (mechanical ventilation and/or vasopressors)
IV BZD is preferred (lorazepam) may repeat again if necessary
long-term AED: fosphenytoin (Cerebyx), levetiracetam (Keppra), or valproate (Depakote
What rx should all pts with epilepsy have on hand?
diazepam
either diazepam in rectal gel (Diastat) or Valtoco nasal spray
