seizures Flashcards
Setting: ER
35 year old female
Previously healthy
Right handed
BIBEMS for 1 minute of generalized shaking
Does not recall the event
Woke up in the hospital
Reports pain in her tongue
Witness:
Initially looked confused
Made sounds, pulled at clothing
Looked to her right
Body began to shake
Woke up at hospital
First time this occurred
Preceding déjà vu with smelling burning rubber and taste of iron in her mouth followed by brief confusion from which she needed time to recover
-Vitals:
110/70
HR 75
RR 18/min
Temp 97F
Neuro exam
A&Ox3 now
Normal speech
CN II-XII normal
Motor, sensory, coordination are normal
35 year old woman who presented with 1 minute of generalized shaking preceded by lip smacking and hand picking (automatisms)
Exam significant only for lateral tongue laceration
She was initially confused, and it took time to return to normal mental status
-tonic clonic seizure
-started as a focal -> progressed to bilateral tonic clonic
-focal only has aura
epilepsy
-Recurrence ofseizure
-Chronic disorder
-Unprovoked andunpredictable
-Each type of epilepsy has a distinct formwith its own naturalhistory and response totreatment
seizure
-A sudden change in consciousness, movement or behavior!
-Caused by electrical hyper-synchronization of neuronal networks in the cerebral cortex!
-Transient event
-May occur only during the course of an acute medicalor neurologicillness
epidemiology
-About 4%of peopleliving up to74 years of agehave at least oneunprovoked seizure
-6.5 personsper 1000 population withepilepsy
-1-2% of the population
-Highest ratesamong youngchildren and elderly
-Causecan vary with age
-~60-70%achieve control of their seizures with antiepilepticmedications
-Mortality
-Risk incurred by underlyingdisease
-Sudden unexplained death(SUDEP) is 25xmore likelyinepilepsy patients
transient neurological dysfunction (dont need to know details)
-seizures often present with any of the 4 categories
-motor dysfunction/shaking:
-DDX: syncope, movement disorders, ataxia, panic attacks, transient cerebral ischemia, PNES
-non-motor dysfunction (language, vision, sensory changes)
-DDX: migraine with aura, cerebral ischemia
-movements during sleep:
-DDX- REM sleep behavior
-with acute confusion
-DDX- transient global amnesia, syncope, migraine that affects the RAAS
focal seziures
-AURA
-Experiential phenomena: déjà vu or jamais vu
-Epigastric sensations: stomach butterflies, rising sensation
-Sensory phenomena: abnormal smell or taste
-Automatisms
-ICTUS
-shaking
-Abrupt onset
-Rapid progression over ~10 seconds
-Example: Jacksonian march
-Spontaneous termination
-POST-ICTAL STATE
-confusion, lethargy
-focal neuro deficits
-lateral tongue bites
-Pearl:
Symptoms are often “stereotypic” meaning that it’s the same symptoms in the same person, due to the same neural networks being activated with each seizure
generalized vs focal (partial) seizures
-partial/simple - start in one area -> unilateral shaking and consciousness stays
-complex partial- LOC and shaking
-simple partial- stays in one area
-focal to bilateral tonic-clonic- moves bilaterally -> LOC
-only focal has auras
-tonic clonic- classic seizure
-myoclonic- body jerking
-atonic- no moving
focal onset seizures
-May or may not have impaired awareness
-Motor symptoms
-Automatisms:
-Semi purposeful hand and finger movements
-Picking at clothes
-Lip smacking
-Cycling legs in babies
-Jacksonian march
-Common form: Seizure spreads from the hand, up the arm, to the face, and down the leg; or
-From the foot, the seizure marches up the leg, down the arm, and to the face, usually in a matter of 20-30s
-The first symptom correlates to the focus of the seizure. The focus can progress to generalized no matter where it is!
-Non-motor symptoms
-Intense smells
-Emotions
-Behavioral arrest
-Sensory disturbance
simple partial seizures
-Electrical discharge occurs in limited and circumscribed area of cortex
-Patients interact normally with environment during simple partial seizure
-Symptoms widely range depending on foci location
-Subjective (“Aura”)
-Déjà vu, jamais vu, epigastric rising sensation, fear, feeling of unreality or detachment, olfactory hallucination, unilateral sensory disturbance
-Physical (observable) manifestation
-Motor movement
-“Jacksonian march” (sometimes):
-Common form: Seizure spreads from the hand, up the arm, to the face, and down the leg; or
-From the foot, the seizure marches up the leg, down the arm, and to the face, usually in a matter of 20 to 30 s.
focal seizures with impaired awareness
-Previously called “complex” focal seizures
-Impaired consciousness!
-Automatism
-Repetitive, complex, purposeless motor activity
-Lip-smacking, repeated swallowing, chewing, picking motions with hands (temporal lobe epilepsy)
-Hypermotor, frenetic activity (Frontal lobe epilepsy)
-Staring
-70-80% of complex partial seizures arise from temporal lobes
-Remainder arise from frontal and occipital lobes
generalized onset motor seizures (tonic-clonic) (grand-mal)
-Abrupt loss of consciousness with little to no warning
-Fall to the floor that often results in facial/bodily injuries
-Loud vocalization as air forced across contracted vocal cords (ictal cry)
-May bite the lateral margin of the tongue
-Bilateral tonic extension of trunk and limbs (tonic)
-Synchronous muscle jerking (clonic)
-Often apneic during this phase, may turn a light blue/purple
-Pupils often dilated and unresponsive to light
-Bladder incontinence can occur during the seizure or post-ictally
-Post-ictally
-Unarousable, then lethargic / confused / bewildered / possibly agitated
-Prefer to sleep, wont remember anything said in the post-ictal time
generalized onset motor seizures (tonic-clonic) (grand-mal)- EEG tracing
-Initially movement artifact obscures tracing
-dont need to KNOW
-May seen early spike-wave discharges lasting a few seconds followed by 10s period of 10Hz spikes
-Clonic phase: spikes mix with slow waves then assumes a polyspike and wave pattern
-As movements cease: isoelectric then resumes pre-seizure pattern
general onset non-motor seizures (absence) (petit mal)
-Brief, rapid onset, rapid cessation, without warning
-KIDS
-Momentary lapses in awareness lasting 2-10s
-stop what they are doing and zone out
-To an onlooker:
-Motionless staring with behavioral arrest
-May have fine myoclonic movements of eyelids, facial muscles,
-May have minor automatisms—in the form of lip-smacking, chewing, and fumbling movements of the fingers
-No postictal period!!!!!!!!!
-Seizure can be induced with hyperventilation
-May have several hundred episodes in a day
-Most often occur in children between 4yo-puberty
general onset non-motor seizures (absence) (petit mal)- EEG and tx
-Characteristic EEG finding during seizure -> 3 Hz generalized spike-and- wave!!!!!
-Treatment: Ethosuximide!!!! is 1st line! Then Valproate!, lamotrigine, divalproex (PANCE)
-Attacks tend to diminish in adolescence then disappear
-Some children will be at increased risk of generalized motor seizure later on
myoclonic seizures
-Rapid brief (50-100ms) muscle jerk
-Variations:
-Bilaterally, synchronously
-Unilaterally, asynchronously
-can or can not have post ictal
-Myoclonic jerks range from isolated small movements of face, arm or leg to massive bilateral jerks
atonic seizure
-drop attacks
-sudden loss of muscle tone resulting in fails
febrile seizure
-Specific to infants and children between 6 months – 5 years old
-Benign condition and uncomplicated~!
-Single, generalized motor seizure during the peak of a fever
-Lasts no more than a few minutes
-Seizure should not recur during the same episode of fever
-Return to baseline
-Risk of developing epilepsy later in life is almost zero above gen pop
-Do not miss: acute encephalitis, meningitis, complex febrile convulsions
localization of seizures:
35 year old woman
Prior déjà vu with burnt smell and metallic taste
Followed lip smacking and hand picking
Followed by looking to her right side
Followed by generalized shaking
-LOOK TOWARDS LESION FOR STROKE
-LOOK AWAY FROM LESION FOR SEIZURES
-Began in TEMPORAL lobe
-LEFT SIDE
- FOCAL THAT Spread to bilateral tonic clonic
estimate risk of seizure recurrence
-Unprovoked seizure
-Whatever lesion or network that caused the first seizure.. Is likely to happen again!!
-Provoked seizure = low risk
-Drug-induced- Antibiotics, illicit drugs
-Cerebrovascular - Acute strokes
-Toxic or metabolic disorders- Hyponatremia
-Traumatic brain injury
-CNS infections- Meningitis, encephalitis
etiology and pathophysiology
-Vascular
-Acute ischemic stroke
-Intracerebral hemorrhage
-Subarachnoid hemorrhage
-Hypertensive encephalopathy (PRES)
-Anoxic brain injury
-Infectious causes
-Encephalitis
-Meningitis
-Abscess
-Traumatic causes
-Epidural hematoma
-Subdural hematoma
-Autoimmune causes
-Systemic lupus erythematous (SLE)
-Paraneoplastic syndromes
-Metabolic causes
-B1 (Thiamine) deficiency! - ALCOHOL
-Hypoglycemia
-Hyponatremia (sometimes hyper-)
-Hypocalcemia
-Hypomagnesemia
-Hypophosphatemia
-Uremia (BUN)
-Hyperammonemia (liver damage)
-Hyperthyroidism (T3 T4)
-Idiopathic causes- Epilepsy
-Neoplastic causes
-Drug causes (see next slide)
-Eclampsia
-Everything else - Fevers can trigger esp. in children
-Genetic diseases- Phenylketonuria (PKU)
-Is it a provoked or unprovoked seizure?
No reported meds
Negative urine tox
Non-contrast CT head negative
CBC, CNP, UA is normal
No evidence or history suggestive of brain injury or head trauma
No fever or evidence of CNS infection
Likely had an unprovoked seizure!
first unprovoked seizure: risk factors for developing epilepsy
-Prior neurological insult, such as neurological deficits from birth (e.g. Mental Retardation Cerebral Palsy) = most powerful and consistent predictor of recurrence!
-Partial (focal) seizure- means you already has some lesion or scar in the brain -> likely to happen again
-Abnormal EEG
-Febrile seizures- minor
-Status Epilepticus
-Postictal (Todd’s) paralysis- seizure that occurs and takes out half the body
Evaluation of first seizure: AAN guidelines
-Neuroimaging (CT, MRI)
-Yield cause in about 10%
-Always perform for focal seizures -> there has to be something there to cause seizure (lesions)
-May lead to the diagnosis of brain tumor, stroke, cysticercosis (parasitic infection of central nervous system), or other structural lesions.
-Lumbar puncture
-Helpful in certain clinical circumstances, such as febrile patients or afebrile immunocompromised patients
-Toxicology screening
-About 3% of all seizures in the ER are due to drug intoxication (e.g., cocaine, other stimulants)
-photo shows neurocysticercosis
anti-seizure drug levels labs
-recommended for any pt with known epilepsy/seizure disorder who has a change in their seizure pattern
-Factors that affect drug levels and dictate target drug levels include:
-Their usual target drug level
-Drug compliance
-Any new meds that may interact with the anti-seizure medication (eg antibiotics, Wellbutrin)
-Change in frequency, duration or features of the seizure
-Intercurrent illness that may lower the the seizure threshold
-Anti-seizure drug concentration assays available to most EDs include: phenytoin, valproate, phenobarbital and carbamazepine.
-Drug levels that are not immediately available in the ED but may be useful for our neurology colleagues in follow-up include: lamotrigine, levetiracetam (Keppra) and clobazam
-breakthrough seizures
-left side hippocampal sclerosis
-MC finding in unprovoked seizures- medial temporal lobe affected hippo
major categories of epileptogenic lesions
monitoring brain waves
-Electroencephalography (EEG)
-24 hour continuous EEG monitoring is the best for detecting epileptiform patterns
-Sensitivity 80%
-Specificity 90%
-epileptiform discharges
-3 hertz spike- absance seizure !!! -> this is all you need to know
temporal lobe epilepsy
-“Mesial temporal sclerosis”
-Age of onset: 7-20
-± History of febrile seizure as infant
-Seizure types:
-Simple partial (“aura”)- one part moving w/o loss of consciousness
-Complex partial- one part moving with LOC
-Secondarily generalized tonic clonic
-Characteristic EEG finding - Focal interictal spikes over temporal lobe- just know its over temporal lobe
-MC structural abnormality on MRI: mesial temporal lobe sclerosis
-Often refractory to medication
identifiable causes of epilepsy as a function of age
what to do if somenoes having a seizure
-Don’t panic!
-dont restrain
-Keep them safe
-Time the seizure
-Turn on side for recovery position -> after the seizure
-glutamate is excitatory -> inhibit this presynaptically
-increase GABA
adverse effects of anti-seizure meds
syncope vs seizure
-absance has no post ictal
-vitals arnt helpful
psychogenic non-epileptic seizures (PNES)
