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PHAR 358 > Seizures > Flashcards

Seizures Flashcards

1
Q

what is a seizure?

A

a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain

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2
Q

what is epilepsy?

A

disorder of the brain characterised by an enduring predisposition to general epileptic seizures

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3
Q

what is the current diagnostic definition of epilepsy?

A

patient has minimum of 2 unprovoked seizures 24 hours apart
OR
patients with only 1 unprovoked seizure but at significant risk of seizure recurrence (EEG with epileptiform abnormalities, brain injury, structural brain abnormalities, nocturnal seizures)

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4
Q

what is an unprovoked seizure?

A

seizure which occurs in the absense of an acute brain event (stroke, head trauma, infection, metabolic/toxic insult)

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5
Q

what is the risk of seizure recurrence?

A

if 1 non-provoked seizure: 50%
if 2 non-provoked seizures: 60-90%

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6
Q

what is the etiology of seizures

A

variable causes, largely unknown
- genetics
- structural lesions in brain
- metabolic disorders
- infectious
- immune
anything that disturbs the normal functioning of the cerebral cortex can cause seizure, and if this abnormality is enduring, it can result in epilepsy

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7
Q

what is the pathophysiology of seizures?

A

increase excitatory synaptic neurotransmission
decrease inhibitory synaptic neurotransmission
alteration of voltage gated ion channels
alteration of intra- or extacellular ion concentrations
hypersynchrony

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8
Q

what are s/sx of a seizure

A

tingling of face, body limb
involuntary muscular contractions of a limb or body part
sweating
awareness of surroundings
fear
recollection of events
aphasia
particular automatisms

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9
Q

what are the 3 primarily types of seizure onset?

A

focal
generalised
unknown

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10
Q

what is the difference between focal and generalised seizures?

A

focal seizures originate within networks limited to one hemisphere
generalised originate at some point within and rapidly engage, bilaterally distributed networks

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11
Q

what are the 2 subdivisions of focal onset seizures?

A

aware and impaired awareness

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12
Q

what are some types of generalised seizures?

A

absense
tonic-clonic
myoclonic
atonic

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13
Q

what percent of seizures are focal onset?

A

70%

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14
Q

how are seizures classified?

A

based on location of origin

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15
Q

what are epilepsy syndromes?

A

refers to clusters of features that may occur together, including seizure type, EEG findings, imaging findings, age-dependent features, specific comorbidities

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16
Q

what is status epilepticus?

A

medical emergency
any recurrent or continuous activity lasting 30+ mins in which the patient does not regain baseline mental status
or a cluster of seizures that does not return to baseline for 30+ mins

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17
Q

at what duration of seizure is it treated as impending status epilepticus?

A

any seizure that does not stop within 5 mins

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18
Q

what is the acute treatment of status epilepticus?

A

benzodiazepines

adults: lorazepam 1-2 mg SL
pediatrics: midazolam IN or buccal 0.2-0.3 mg/kg/d (max 10 mg)
infants (<3 mo.): rectal diazepam 0.5 mg/kg/dose (max 10 mg)

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19
Q

what are post ictal symptoms?

A

period when the brain recovers from the seizure
- confusion
- depression
- memory problems
- tiredness
- headaches
- anxiety
- repetitive movements
- cognitive problems
- behaviour changes
- language problems

post ictal migraines are very common

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20
Q

what do you do if someone is having a convulsive seizure?

A

time it - longer than 5 mins = call 911
explain what is going, ask to be given space
cushion head and neck with something soft
roll the person to their side to prevent choking
clear the area of dangers
do NOT put anything in the mouth
no NOT restrain
speak gently, be kind during and after the seizure

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21
Q

what do you do if someone is having a non-convulsive seizure?

A

time it - longer than 5 mins = call 911
explain what is happening
clear the area of dangers
gently guide and protect from hazards
do NOT restrain
speak gently, be kind during and after

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22
Q

what are some medications that can lower seizure threshold

A

analgesics: opioids (esp. meperidine, tramadol)

anticancer drugs

antimicrobials: carbapenems, cephalosporins (4th gen), FQs, isoniazid, penicillin

immunosuppressants: azathioprine, cyclosporin, mycophenolate, tacrolimus

psychiatric medications: antipsychotics (esp. clozapine), atomoxetine, bupropion, buspirone, lithium, MAOIs, SSRIs/SNRIs, TCAs

stimulants: amphetamines, methylphenidate

sympathomimetics and decongestants

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23
Q

why are EEGs done for epilepsy diagnosis?

A

used to determine if focal vs. generalised onset and estimate risk of recurrence

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24
Q

why is brain imaging done in epilepsy diagnosis?

A

used to identify structural abnormalities
NOT to observe seizure activity

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25
Q

what laboratory studies may be done as part of epilepsy diagnosis?

A

blood glucose
CBC with diff
electrolytes (esp. Na)
lumbar pucture

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26
Q

what are some potential differential diagnoses to rule out with seizures?

A

syncope
TIA
panic attack and anxiety
narcolepsy with cataplexy
transient global amnesia
drug intoxication
migraine
psychogenic or nonelectrical seizures

27
Q

what percent of pts with epilepsy achieve seizure control?

A

60-70%

28
Q

what is the approach to treatment of epilepsy?

A

epilepsy diagnosis –> classification +/- syndrome disorder –> creation of patient centered management plan

29
Q

T or F
pts with acute seizures due to metabolic, toxic or infectious causes require long term treatment

A

false
may require short term treatment but dont generally require long term treatment

30
Q

what is the general approach for initiating ASM therapy?

A

start with monotherapy
titrate slowly

31
Q

what is the usual dose titration to target dosing of ASM?

A

start at 1/4 to 1/3 of initial dose and increase q1-2 weeks to minimise s/e

32
Q

what is the approach if somebody was inadequate response to initial ASM therapy?

A

assess adherence

if at a mod dose with few a/e titrate to max dose

if breakthrough seizures at max tolerable dose consider switching or augmenting

33
Q

what is the most common reason for treatment failure with ASM?

A

non adherence

34
Q

what is the benefit of poly ASM therapy?

A

may have fewer side effects with lower doses of 2 concomitant medications

35
Q

when is polytherapy reserved for in epilepsy?

A

failed monotherapy with 2-3 drugs

36
Q

T or F
all patients with epilepsy require life long treatment

A

false

37
Q

what are some factors that favour successful d/c of ASM?

A

seizure free (2 years for children; 2-5 years for adults)
normal neurologic exam
normalised EEG with treatment
history of single type of focal seizure of generalised tonic-clonic seizures

38
Q

how do you d/c ASM?

A

if non emergency situation: slow and gradual taper
- taper over at least 6 weeks seems to be safe
if on >1 ASM, each one should be withdrawn separately

39
Q

what is the risk of abrupt d/c of ASM?

A

can precipitate a seizure

40
Q

which diet may have efficacy in reducing seizure frequency?

A

keto

41
Q

when is surgery an option for epilepsy?

A

some patients with refractory focal onset epilepsy resistant to multiple ASMs

42
Q

what is VNS?

A

vagus nerve stimulation
involves a surgical procedure to implant an electrical pulse generator in the chest and attach electrodes to the vagus nerve in the neck
pulse generator stimulates the vagus nerve on a regularly scheduled basis

43
Q

what are some nonpharm options in epilepsy?

A

diet: keto
surgery
vagus nerve stimulation
general measures
- adequate sleep/nutrition
- decrease stress/anxiety
- decrease alcohol
- avoid triggers

44
Q

what are some common ADEs associated with ASM?

A

sedation, dizziness, blurred or double vision, ataxia, difficultly concentration
nausea, vomiting

45
Q

which ASM are associated with SJS?

A

phenytoin
carbamazepine
lamotrigine
lacosamide ?

46
Q

which ASMs should be avoided if you develop a rash on another ASM?

A

any with aromatic hydrocarbon ring
carbamazepine
oxcarbamazepine
eslicarbazepine
phenobarbital
primidone
phenytoin
lamotrigine
? lacosamide

47
Q

why is there cross sensitivity between some ASM?

A

aromatic hydrocarbon ring

48
Q

which ASM should be avoided in pregnancy?

A

valproic acid

49
Q

what ASM are potentially preferred in pregnancy?

A

lamotrigine
levetiracetam

50
Q

which ASMs are strong CYP inducers?

A

phenytoin
carbamazepine
phenobarbital

51
Q

which ASMs are CYP inhibitors?

A

valproic acid
stiripentol

52
Q

what is the preferred contraceptive method when on ASM?

A

LNG-IUD or copper IUD or progesterone implant

depo
COC with >30 mcg EE taken continuously

53
Q

when are drug levels of ASM taken?

A

once the desired clinical response has bee achieved
to assist clinician in determining the magnitude of a dose increase
ASM toxicity
when seizures persist
alteration to PKs
change in drug formulation
change in clinical response
poor compliance suspected

54
Q

how are ASMs usually classified?

A
  1. conventional vs new
  2. cellular MOA
  3. spectrum of activity
55
Q

what are the “conventional” ASM?

A

carbamazepine
barbiturates
BZDs
phenytoin
valproate

56
Q

which types of seizures are narrow spectrum ASMs used in?

A

generally effective for focal seizures

57
Q

what are the narrow spectrum ASM?

A

carbamazepine
gabapentin
oxcarbamazepine
phenytoin
phenobarbital
pregabalin
tiagabine
vigabatrin

58
Q

what are the broad spectrum ASM?

A

brivaracetam
felbamate
lamotrigine
levetiracetem
perampanel
topiramate
rulfinamide
valproate
zonisamide

59
Q

what are the agents used for focal seizures?

A

1st line: carbamazepine, lamotrigine

2nd line: levetiracetem, valproate, oxcarbazepine, zonisamide

4th line: gabapentin, topiramate, phenytoin

60
Q

what agents are used in generalised tonic-clonic seizures?

A

carbamazepine
lamotrigine
valproate
topiramate
levetiracetem

61
Q

which agents should be avoided in myoclonic seizures?

A

carbamazepine
gabapentin
oxcarbazepine
phenytoin
pregabalin
tiagabine
vigabatrin

62
Q

which medications are used for absent seizures?

A

1st line: ethosuximide, valproate
2nd line: lamotrigine

63
Q

what is the most common MOA of ASM?

A

sodium channel blockage

64
Q
A

PHAR 358 (10 decks)

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