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Clinical Medicine III > Seizures and Epilepsy > Flashcards

Seizures and Epilepsy Flashcards

1
Q

Define seizure

A
  • Sudden paroxysmal excessive discharge of cerebral neurons resulting in transient sensory, motor, cognitive impairment
  • Can happen in normal brains or secondary to acute conditions
  • Finite event, has a beginning & end
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2
Q

Define epilepsy

A
  • A chronic neurological disorder, a condition characterized by sudden recurrent episodes of seizures associated with abnormal electrical activity in the brain that manifest as sensory disturbance, motor impairments, loss of consciousness, or convulsions
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3
Q

Describe a seizure

A
  • Can be induced in any normal brain be a variety of different electrical & chemical stimuli
  • Can also occur as a physiological reaction of the brain to physiologic stress, sleep deprivation, fever, alcohol, sedative drug withdrawal
  • May occur in many medical illnesses if brain function is temporarily impaired or can occur w/o any discernible reason in otherwise healthy people
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4
Q

Describe epilepsy

A
  • A syndrome of recurrent seizures & observed by a set of clinical & electroencephalographic (EEG) features
  • Many have age of onset
  • Responds to particular treatments
  • May have specific prognostic outcomes depending on the type of epileptic syndrome
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5
Q

What is epilepsy characterized as

A
  • Electroclinical syndromes
  • Non-syndromic epilepsies
  • Epilepsies of unknown cause (idiopathic)
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6
Q

Incidence of epilepsy

A
  • After headache, epilepsies are the most frequent chronic neurologic condition seen by GP’s worldwide
  • Highest incidence among children & elderly and in men slightly more than women
  • 3rd most common serious neurologic disease of old age after dementia & stroke
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7
Q

Etiology & risk factors of epilepsy

A
  • Underlying cause typically unknown
  • Causes can be genetic or acquired
  • Genetics is believed to be involved in the majority of cases (directly or indirectly)
  • Most are due to the interaction of multiple genes along with environmental factors
  • Acquired cases occur as a result of brain injury, stroke, brain tumors, infections of the brain, & developmental malformations through a process known as epileptogenesis
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8
Q

Common causes of epilepsies in younger people and older people

A
  • Genetic, congenital, or developmental conditions are more common causes in younger people
  • Brain tumors & strokes are more common causes in older people
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9
Q

Genetic causes of epilepsy

A
  • Single or combination of genetic defects presumed to be the cause
  • Individual defects can have additive effects along with environmental factors to predispose to epilepsy
  • Genetic defect may cause inherited biochemical, membrane, or neurotransmitter defects resulting in abnormal excitability in involved circuits or neurons
  • Common features: family Hx, onset in childhood/adolescence
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10
Q

Acquired causes of epilepsy

A
  • Can be linked to a causative factor (seizure is one of the symptoms)
  • Symptom can be transient or can persist
  • Causes can be structural or metabolic impairments from malformations, lesions or injuries, or chemical insults
  • Hormonal changes trigger seizures, increase in estrogen during ovulation/menstruation (can trigger gestational epilepsy)
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11
Q

Pre-/Peri-/Post- natal causes of seizures

A
  • Eclampsia (gestational hypertensive encephalopathy) canc ause seizures
  • May occur within 24-72 hrs during neonatal period, cannot spread to become generalized due to immaturity of hemispheres/corpus callous limiting movement
  • Hypoxia-ischemia insult is most common cause of neonatal seizures with convulsion
  • Neonatal hypoglycemia
  • Hyper/hypocalcemia and hyper/hyponatremia can also cause seizures within a few days after birth
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12
Q

Seizures can develop as a result of

A
  • All seizure activity is a result of chaotic synchronous electrical discharge in CNS: sudden burst in neural firing
  • Overactivation of the NMDA glutamate receptors
  • Alterations in neurotransmitter activity in afferents from brainstem to cortex
  • Pathologic attempt by the CNS to compensate by sprouting of excitatory mossy fibers
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13
Q

Pathogenesis of seizures

A
  • Normally spread of neuronal bursting activity is prevented by inhibitory mechanisms (hyperpolarizations of inhibitory interneurons)
  • GABA is main inhibitory NT in CNS
  • GABA agonists (gabapentin, pregabalin) can stop seizures
  • Bursting pattern depends on type of seizure
    -Generalized tonic-clonic seizures (grand Mal seizure) have a sustained high frequency discharge, followed by interruptions of continuous firing, followed by restoration of membrane potential
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14
Q

Describe focal seizures

A
  • Abnormal discharge remain confined to a redistricted area in cortex
  • Hippocampal sclerosis (aka medial temporal sclerosis) is characterized by neuronal loss & gliosis (most common cause of focal epilepsy in adolescents & adults)
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15
Q

Describe kindling

A
  • A neuropathic phenomenon: experimental explanation for seizure activity in epilepsy
  • Repeated exposure to low intensity electrical or chemical stimuli results in facilitation/potentiation of connections
  • Has been used to induce seizure & epilepsy in animal models
  • Can explain onset of epilepsy from initial brain injury
  • Can explain how distant areas of brain become susceptible to seizures
  • Can explain why surgical ablation of focal areas don’t always stop seizures
  • Cannot explain why some epilepsies came to an end even after years of repeated seizures
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16
Q

Clinical manifestations of seizures

A
  • In most individuals seizures occur unpredictably w/o any warning signs
  • In others seizures are provoked by specific stimuli such as flashing light or a flickering television (triggers)
  • In some there are some prodromal symptoms (Aruas) that indicate an impending seizure
17
Q

Events that may trigger seizure

A
  • Stress
  • Poor nutrition
  • Missed medication
  • Skipping meals
  • Flickering lights
  • Illness
  • Fever and allergies
  • Lack of sleep
  • Emotions such as anger, worry, fear
  • Heat and humidity
18
Q

Clinical manifestations of generalized tonic-clonic seizure

A
  • Classic type/grand mal seizure
  • Involve both hemispheres
  • Loss of consciousness
  • Starts with general rigidity, sustained contractions of limb extensors, arching of back lasting 10-30 sec (tonic phase),may hear a cry or see them turn blue (cyanosis)
  • Followed by general rapid jerky movements of limbs (clonic phase)
  • Followed by recovery period (post-ictal phase), can last minutes to hours, may feel tired/headache/confusion/difficulty speaking, may fall into deep sleep with salivary frothing
  • Can cause bowel/bladder incontinence
  • Sometimes causes oral trauma, vertebral Fx, shoulder dislocation, aspiration pneumonia, or death
19
Q

Clinical manifestations of absence seizures

A
  • Petit mal seizures
    -Generalized seizure type
  • Loss of conscious control, but person is unaware of it
  • Sudden cessation of ongoing conscious activity (stares into space)
  • Not preceded by aura and immediately followed by return to normal activity
  • Occur mostly in children & disappear with adolescence
20
Q

Clinical manifestations of focal/partial seizures

A
  • Characterized by locus of onset, neuronal activity restricted to a local structure or with networks limited to one hemisphere
  • EEG shows activity in a focal area
  • Symptoms will depend on the lobe the focus is present
  • Sensory symptoms depend on the sensory area involved in seizure: localized parenthesis, numbness, tingling, vertigo, auditory, or visual hallucinations
  • Classified into simply partial and complex partial seizures
21
Q

Symptoms of focal/partial seizures based on lobe affected

A
  • Frontal lobe: bizarre movements, thrashing of arms, pelvic thrusting, pedaling or legs
  • Temporal lobe: feeling of deja-vu, jamais-vu
  • Parietal lobe: numbness or tingling, agnosia, spatial perceptual distortion
  • Occipital lobe: visual distortions or hallucinations
22
Q

Clinical manifestations of simple partial seizures

A
  • Individual retains consciousness
  • Typically last 60-120 secs
  • Subjective unusual sensations/feelings: feelings of fear, anger, sadness, happiness or nausea, sensations of falling or movement
  • Altered sense of hearing, smelling, tasting, seeing, tactile perception or involuntary movements
  • Space or time distortions
  • Deja-vu/Jamais-vu
  • Labored speech or inability to speak at all
  • If somatosensory or motor area involved tingling or clonic jerks can progress or march from distal to proximal parts known as Jacksonian March
  • Can occur during sleep, typically REM sleep
23
Q

Clinical manifestations of myoclonic seizures

A
  • Sudden brief single or repetitive muscle contractions involving one body part or entire body
  • Myoclonic jerks range from small movements of the face and hands to massive bilateral spasms
  • Repeated myoclonic jerks may get severe & turn into generalized tonic-clonic seizures with convulsions
  • Can happen anytime but often observed shortly after waking up or while falling asleep
24
Q

Clinical manifestations of dyscognitive seizures

A
  • Complex partial seizure
  • Loss of consciousness or impairment of awareness or responsiveness
  • Often preceded by aura
  • Once consciousness lost may show automatisms like lip smacking, chewing, swallowing
  • Most commonly arise in medial temporal lobe & consciousness is lost when discharge spreads to hippocampus & amygdala
  • May show amnesia about the details surrounding the seizure event
25
Q

Clinical manifestations of atonic seizures

A
  • AKA drop attacks
  • Brief loss of consciousness & postural control
  • Most often in children
  • Characterized by sudden loss of muscle tone that may result in falls with injury
  • Sometimes loss of muscle tone happens in neck muscles causing head drop
26
Q

Clinical manifestations of status epilepticus

A
  • When person has generalized tonic-clonic seizures that are so long or so repeated that there is nor recovery or return of consciousness
  • Medical emergency, can cause death
  • Often occurs due to tumor, CNS infection, or drug abuse
  • Febrile seizures in children under 3 yrs are also a common cause
27
Q

Describe electroclinical diagnosis of seizures

A
  • Electroencephalography (EEG): central role, inter-octal activity provides strong evidence that the event was a seizure
  • Best way to diagnose & classify seizure event: observe patient & EEG
  • Normal reading does not rule out seizure event
  • Other indicators: age of onset, status of client after the episode, responses to medications
28
Q

Describe magnetocephalography diagnosis of seizures

A
  • Differential diagnosis
  • Loss of postural control/consciousness due to seizure versus syncope, OH, cariogenic arrhythmia, sometimes may be difficult to distinguish
29
Q

Describe the treatment for seizures

A
  • Control of seizure is most important
  • Antiepileptic drugs can be used depending on the type of seizure
  • Commonly used drugs: Carbamazepine, Levetiracetam, Phenytoin, Pregabalin, Gabapentin
  • Antiepileptic drugs have adverse side effects: dizziness, diplopia, blurred vision, ataxia, hepatic failure, anemia, lupus like syndrome, Steven-Johnson syndrome
  • Ketogenic diet (high fats) helpful in reducing convulsions
  • Surgical treatment like lobectomies, sectioning of corpus callous indicated if drug therapy does not control seizures
  • Vagus nerve stimulation found to reduce seizures by 50%
30
Q

Pharmacologic effects of different anti epileptic drugs in modulating GABA activity

A
  • Act by either by mimicking GABA neurotransmitter or by inhibiting metabolic breakdown of GABA or preventing re-uptake
31
Q

Describe the prognosis of epilepsy

A
  • Those with epilepsy have increased mortality rates
  • Death can happen from asphyxia (when seizure occurs during eating), drowning, or sudden unexplained death
  • For children diagnosed of unknown cause, remission is defined as 5 yrs w/o seizures
  • 75% remission rate for those diagnosed before 10 yrs
  • Children seizure free for more than 4 yrs while taking anti epileptic drugs have 70% chance of permeant remission when drugs are withdrawn
  • If period of uncontrolled seizures extend to 4yrs, the chances of ever achieving control is 10%
32
Q

Implications for the therapist

A
  • Understanding the facts about the type of epilepsy
  • Seizure event recognition
  • Patient needs protection from injury during seizure not restraint
  • Make sure patient is lying on a surface to prevent falls
  • Rolling the patient to sidelying position may help airway to keep clear
  • Observation/documentation of physical symptoms, duration of seizure, cognitive status
  • Knowledge of triggers
  • Evaluation of home, school environments for safety recommendations
  • Patients can be encouraged to participate in activities with adequate supervision provided seizures are controlled by medications
    -Adequate knowledge of medication side effects

Clinical Medicine III (20 decks)

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