Seizures

Question 1

Seizures that occur in infants (<2 years) tend to be from

Answer 1

Febrile, perinatal injury, infection, metabolic, or genetic

Question 2

For febrile seizures, a good medication to provide the child is ….

Answer 2

Acetaminophen

Question 3

Seizures that occur in children (2 to 10 years) tend to be from

Answer 3

Idiopathic (cryptogenic), infection, trauma, febrile

Question 4

Seizures that occur in adolescents (10 to 18 years) tend to be from

Answer 4

Idiopathic (cryptogenic), trauma, drug withdrawal, AVMs

Question 5

Seizures that occur in adults (18 to 35 years) tend to be from

Answer 5

trauma, EtOH, tumor

Question 6

Seizures that occur in adults (>35 years) tend to be from

Answer 6

trauma, stroke, metabolic, EtOH, tumor

Question 7

What are the two major ways epilepsy is acquired?

Answer 7

Structural brain lesions (tumor, stroke, hemorrhage, AVM)

Non-neurologic etiologies

Question 8

In terms of seizures, these [Below] all cause _______ types of seizures

Hypoglycemia, hyponatremia, hypocalcemia, hyperosmolar states, hepatic encephalopathy, uremia, porphyria, drug overdose (cocaine, antidepressants, neuroleptics, methylxanthines, lidocaine), drug withdrawal (alcohol and other sedatives), eclampsia, hyperthermia, hypertensive encephalopathy, head trauma, and cerebral hypoperfusion.

Answer 8

Non-neurologic seizures

Question 9

In what two ways are seizures classified?

Answer 9

Focal vs Generalized

Question 10

Structural brain lesions tend to cause ______ seizures

Answer 10

focal

Question 11

How are focal seizures divided?

Answer 11

Loss of consciousness: “Impaired Awareness” (Complex Partial)

Maintains consciousness: “Aware” (Simple Partial)

Nuances:
-Both simple and complex partial (focal) seizures may evolve into secondary generalized sezuire.

-Focal seizures can change into bilateral tonic-clonic and have associated loss of consciousness and postictal confusion.

-A patient presents with lip smacking with an impaired level of consciousness and this is followed by confusion, think Complex partial seizure.

-A patient presents with uncontrollable twitching of their thumb and is fully aware of their symptoms, think Simple partial seizure.

Question 12

What describes the abnormal electrical activity arising from a discrete region (or multiple discrete regions) of the brain that can have motor, sensory, autonomic, or psychic (eg, fear, déjà vu, hallucinations) features?

Answer 12

Partial (Focal) Seizure

Common features:
- Aura (auditory, visual, olfactory, or tactile hallucinations)
- Automatisms often (lip smacking, picking, swallowing)
- Autonomic activity (sweating)
- Postictal focal neurologic deficits such as hemiplegia, hemiparesis, or Todd paralysis, usually resolve in 24-hrs.

Question 13

What is the type of seizure that involves both cerebral hemispheres resulting in impaired level of consciousness?

Answer 13

Generalized seizures:

Tonic-clonic (Grand-Mal): alternating stiffening and movement (can develop from focal seizures)
Myoclonic: Quick repetative jerks
Tonic: stiffening
Atonic: loss of motor tone
Absence: blanking out

Question 14

What type of seizure is marked by a sudden loss of consciousness with extension of the back and contraction of muscles (chest and extremities), repetitive, and symmetric movements seen where there’s an alternation between muscle contraction and relaxation?

Answer 14

Tonic-clonic (Grand-Mal), a type of Generalized seizure

Etiology often idiopathic

Simple and complex partial seizures may evolve into secondary generalized tonic-clonic seizures

Marked by incontinence and tongue biting, appearance of cyanosis during the ictal period, and postictal confusion and drowsiness. Muscle aches and headaches may also be present.

Diagnosed with 10 Hz activity during the tonic stage and slow waves during the clonic phase (if EEG is normal consider psuedosezuires and cognitive behavioral therapy)

Question 15

What is the best first step in Dx a seizure?

Answer 15

EEG

CT or MRI for evaluation of a focal seizure in search for an epileptogenic focus.

Question 16

What lab analyte can be elevated in the immediate period of generalized and complex-partial seizures?

Answer 16

PRL is elevated in the immediate period of generalized and complex-partial seizures.

Can help distinguish psuedoseizures.

Other labs that might be able to determine etiologies of seizures: CBC, Lytes, Ca, Glu, LFTs, Renal Panel, ESR, Tox.

Question 17

What is the condition that involve epileptic spasms where the onset is usually within the first year of life, and is typically accompanied by a global developmental delay, and is commonly due to structural brain anomalies (tuberous sclerosis), Down syndrome, or genetic defects (ARX, CDKL5 mutations)?

Answer 17

Infantile spasms (West syndrome)

Most commonly in males and presents between 3 to 5 years old.

Question 18

What is the first-line treatment for West Syndrome?

Answer 18

Vigabatrin

An antiepileptic medication that reduces excitability in the brain by inhibiting the catabolism of GABA. Primarily used to treat infantile spasms and refractory complex partial seizures.

Question 19

What are the major adverse effects of Vigabatrin?

Answer 19

Vigabatrin is teratogenic and can cause neural tube defects and vision loss. Vigabatrin is contraindicated in epilepsy syndromes that are associated with absence seizures because it can precipitate them.

Question 20

What type of seizure can be triggered by hyperventilation in children?

Answer 20

Absence seizures

Question 21

What is the most common childhood epilepsy syndrome that is characterized by multiple episodes involve the child appearing to be daydreaming?

What is the characteristic EEG pattern?

What is the Treatment?

What is the prognosis?

Answer 21

Absence seizures (pyknolepsy), a form of generalized seizure, is often familial.

These types of seizure occur in children between the ages of 2–12 years (peak incidence: 5–6 years) and females are more commonly affected.

Episodes usually involve their eyes open/fluttering while they are staring off into space (amnestic) for several seconds at a time, multiple times per day, along with smacking, nod heading, or chewing.

EEG:
3 Hz spikes and waves in all regions of the brain is used to diagnose this condition

Treatment:
* 1st line: ethosuximide
* 2nd line: sodium valproate
* 3rd line: lamotrigine

Prognosis:
80% of children are seizure-free with treatment
Usually subsides before adulthood

Question 22

What are the major adverse reactions from Ethosuximide?

Answer 22

• Gastrointestinal symptoms
• Allergic skin reactions (urticaria, Stevens-Johnson syndrome)
• Pancytopenia
• Fatigue
• Headache
• Myopia
• Sedation
• Dizziness

Question 23

What is the first line treatment for absence seizures?

Answer 23

ethosuximide

Question 24

Do absence seizures have a postictal period?

Answer 24

No

Absence seizures are generalized (ie, originating from both cerebral hemispheres) and present with staring spells, with or without automatisms, lasting only 10-20 seconds. In contrast to focal seizures, absence seizures are characteristically easily provoked by hyperventilation, however, not associated with a postictal period.

Question 25

Lennox-Gastaut syndrome

Typically is Dx by the age of ___ years old

Caused by:

Presents with :

Special characteristics of the EEG are:

Answer 25

Age:
5 years (males more common)

Caused by:
Most commonly due to structural abnormalities from tuberous sclerosis, meningitis, hypoxic-ischemic injuries, and head injuries, but 40% of cases are cryptogenic (idiopathic) but have a genetic predisposition.

Presentation:
Intellectual disability/delayed cognitive development & severe seizures of varying types (atypical absence, tonic).

EEG:
Interictal EEG with a slow spike-and-wave pattern with a frequency < 2.5-Hz.

Treatment:
Lamotrigine
An antiepileptic drug that reduces the excitability of neurons by inhibiting voltage-gated sodium channels and glutamate release in the brain. Lamotrigine is not only used for seizure prophylaxis in patients with Lennox-Gastaut syndrome, but also patients with either focal (partial) seizures or generalized tonic-clonic seizures.

Question 26

What is the major adverse effect of Lamotrigine?

Answer 26

SJS (must be titrated slowly)
Blurred vision
Gl upset with N/V
hemophagocytic lymphohistiocytosis (black box warning)

Question 27

A 13 year old male wakes up and has a tonic-clonic seizure, with a history of absence seizures, what is this most likely?

Answer 27

Juvenile absence epilepsy

EEG:
3–4 Hz spikes and waves in all regions of the brain

Treatment and prognosis:
60% are seizure-free under treatment (valproic acid), but there is possibility for a transition to juvenile myoclonic epilepsy.

Question 28

What is a genetic form of epilepsy syndrome characterized by recurrent myoclonic seizures, generalized tonic-clonic seizures, or absence seizures, where the onset of seizures occurs between the ages of 8 and 25, and seizures characteristically occur immediately after waking up or following sleep deprivation?

Answer 28

Juvenile myoclonic epilepsy, Janz syndrome

Triad of seizures :
- Bilateral symmetrical myoclonic jerks, primarily after awakening, without impaired consciousness
- Generalized tonic-clonic seizures
- Absence seizures with impaired consciousness

Triggers: sleep deprivation, alcohol consumption, flickering lights

EEG:
Irregular 3–5 Hz polyspikes and waves with frontocentral predominance

Treatement and prognosis:
Responds well to antiseizure drug therapy (valproic acid along with trigger avoidance); seizures become less frequent in adulthood but life-long treatment usually required (high risk of recurrence with an increased risk of psychiatric comorbidities.

Question 29

What is the first-line drug for seizure prophylaxis in older patients with partial-onset seizures?

Answer 29

Lamotrigine

Blocks sodium and glutamate release

Question 30

What medications are known to be efficacious as a monotherapy for chronic partial and/or tonic-clonic seizures?

Answer 30

Levetiracetam
Phenytoin
Carbamazepine
Valproic Acid

Question 31

What medication is used as a first-line medication for children?

Answer 31

Levetiracetam

The mechanism of levetiracetam is not well understood, but it is believed to alter synaptic vesicle binding and indirectly alter GABA activity.

Levetiracetam is currently not a first-line drug for seizure prophylaxis in patients with absence seizures.

AMBOSS:
Currently, levetiracetam is only licensed for adjunctive seizure prophylaxis in adolescents (> 16 years old) and/or adults with myoclonic seizures (especially juvenile myoclonic epilepsy), focal seizures, and/or generalized tonic-clonic seizures.

Question 32

What is the major adverse affects for Levetiracetam?

Answer 32

Neuropsych changes such as personality changes, fatigue, drowsiness, and headache

Question 33

What is the first-line medication for focal seizures?

Answer 33

Carbamazepine
(also used as a second line med for tonic-clonic seizures)

Inactivates Sodium channels

Question 34

What are the adverse effects of Carbamazepine?

Answer 34

Diplopia
Ataxia
blood dyscrasias (agranulocytosis, aplastic anemia)
Liver toxicity
Teratogenesis (cleft lip/palate, spina bifida) during the first trimester of pregnancy
Induction of cytochrome P-450
Hyponatremia via SIADH
Derm issues like SJS and DRESS

Question 35

What is the first-line medication for long-term tonic-clonic seizures?

Answer 35

Valproate
(also used for focal seizures and second-line for absence seizures)

Inhibits GABA transaminase → ↑ GABA → ↓ neuronal excitability Inactivates Na+ channels and Ca2+ channels

Question 36

What are the adverse effects for Valproate?

Answer 36

VALPPROaTTES:
Vomiting
Alopecia
Liver damage
Pancreatitis
p-450 inhibition
Rash
Obesity (weight gain)
Agranulocytosis
Tremor
Teratogenesis (neural tube defects)
Epigastric pain (GI distress)
SIADH

Question 37

What medication is instead used for seizure prophylaxis in patients with focal seizures and/or generalized tonic-clonic seizures, and as a second-line drug to treat status epilepticus, particularly for prophylaxis?

Answer 37

Phenytoin

An antiepileptic drug that inhibits voltage-gated sodium channels in the brain, which reduces the excitability of neurons. Used primarily for tonic-clonic and focal seizure prophylaxis. Can also be used as a second-line drug to treat status epilepticus. Adverse effects include Stevens-Johnson syndrome, gingival hyperplasia, hypertrichosis, and fetal hydantoin syndrome.

Question 38

What are the main adverse effects to Phenytoin?

Answer 38

PPHENYTOIN:
P-450 induction
Pseudolymphoma
Hirsutism
Enlarged gums
Nystagmus
Yellow-brown skin
Teratogenicity (fetal hydantoin syndrome, IUGR, Intellectual disability, cleft palate, congenital heart defects)
Osteopenia
Neuropathy
Inhibited folate absorption (megaloblastic anemia)
Neutropenia (agranulocytosis)

Toxicity leads to diplopia, ataxia, and sedation.

Rarely what can occur: SJS, DRESS syndrome, drug-induced lupus.

Question 39

Which anti-epileptic is not only used for Focal and generalized tonic-clonic epileptic seizures but also Migraine prophylaxis and Idiopathic intracranial hypertension?

Answer 39

Topiramate

Enhances Na+ channel inactivation and and increases GABA action

Question 40

What are the adverse affects of Topiramate?

Answer 40

Sedation
Slow cognition
Stones (kidney)
Skinny (weight loss)
Sight issues (glaucoma)
Speech and word finding difficulties