Seizures and Epilepsy Flashcards
Classification of seizures
Partial (or focal) seizures
Simple partial seizures
With motor signs
Without impairment of consciousness.
With motor signs. With or without march. Versive. Postural. Phonation.
Classification of seizures
Partial (or focal) seizures
Simple partial seizures
With sensory symptoms
Somatic. Visual. Auditory. Olfactory. Gustatory. Vertiginous.
Classification of seizures
Partial (or focal) seizures
Simple partial seizures
With autonomic signs or sx
Epigastric sensations. Pallor. Sweating. Flushing. Piloerection. Pupillary dilation.
Classification of seizures
Partial (or focal) seizures
Simple partial seizures
With psychic sx
disturbance of higher cerebral function).
i. Dysphasic.
ii. Deja vu.
iii. Cognitive.
iv. Affective.
v. Illusions.
vi. Hallucinations.
Complex partial seizures
With automatisms
With automatisms – seizure involves a period of altered behavior for which patient is amnestic and during which patient appears to respond in a limited fashion to his environment, as if partially conscious and able to carry out coordinated motor acts.
Complex partial seizures
Clinical features
i. May have lip smacking, chewing, grimacing, swallowing. May pick at clothes; permit himself to be led; strike out if restrained but in a nondirected way; speak in jumbled or repetitive phrases; perform stereotyped behavior which is repeated with each attack; walk about in a dazed state; etc.
ii. Duration may be brief or up to five minutes long.
iii. Usually followed by several minutes of postictal confusion.
iv. May follow any of the subjective phenomena listed above for simple partial seizures.
v. Automatisms may occur in the postictal period following any severe seizure and are usually associated with confusion.
Types of partial seizures
Partial (focal) seizures
Complex partial seizures
Partial seizures evolving to secondarily generalized seizures (tonic, clonic, or tonic-clonic)
Generalized seizures
types
Absence seizures Generalized tonic-clonic seizures (“grand mal”) Generalized tonic seizures Generalized clonic seizures Myoclonic seizures Atonic seizures
Causes of seizures by age groups
Infancy (0-2 years old)
Congenital maldevelopment. Birth injury. Metabolic (hypocalcemia, hypoglycemia). Vitamin B6 deficiency. Phenylketonuria.
Causes of seizures by age groups
Childhood (2-10 yo)
Birth injury. Trauma. Infection. Thrombosis of cerebral artery or vein. Beginning of idiopathic epilepsy.
Causes of seizures by age groups
Adolescence (10-18yo)
Idiopathic epilepsy.
Trauma.
Congenital defects.
Causes of seizures by age groups
Early adulthood (18-35 yo)
Trauma. Neoplasm. Idiopathic epilepsy. Alcoholism. Drug addiction.
Causes of seizures by age groups
Middle Age (35-60 yo)
Neoplasm. Trauma. Vascular disease. Alcoholism. Drug addiction.
Causes of seizures by age groups
Late life
Vascular disease
degenerative disease
neoplasm
Seizure hx protocol
General historical questions
onset
i. When did the first attack occur?
ii. Was it precipitated by an accident or associated with an acute illness (fever)?
iii. How soon was it followed by a second
attack?
Seizure hx protocol
General historical questions
Frequency
i. What is the usual interval between attacks?
ii. Are they increasing in frequency?
iii. Do the attacks occur in clusters?
iv. Have you had a series of attacks without recovering consciousness (status epilepticus)?
Seizure hx protocol
General historical questions
Precipitating factors
i. Do the attacks occur at any special time of the day?
ii. Do they occur only at night?
iii. Are they related to menstrual periods?
iv. Is there any factor known to precipitate attacks (e.g., coughing, eating, drinking, alcohol, photic stimuli, sound, reading, stress, etc.)?
Seizure hx protocol
General historical questions
Prodrome (premonitory sx)
Symptoms exhibited by patient preceding an attack (for hours to days) which enable him to recognize that a seizure is likely to occur.
Change in mental status (irritability, depression), funny feeling in head, giddy, myoclonus.
Seizure hx protocol
General historical questions
Aura
i. Symptoms produced by the beginning of the seizure and perceived by the patient before consciousness is lost.
ii. Symptoms of aura may reflect the exact area of the brain in which the seizure begins. For example, complex mental states (feeling of unreality – “jamais vu”; of familiarity – “deja vu”), emotions, special or somatic sensory symptoms, illusions/hallucinations (olfactory, visual, auditory, vertigo; numbness, tingling, pain), abnormal visceral sensations, motor symptoms (urge to speak, chewing, lip smacking, myoclonus, adversive movement of head/eyes), etc.
iii. Does patient have any warning?
iv. If so, what and by how long does it precede attack?
Seizure hx protocol
General historical questions
The ictus or seizure
i. How does the attack begin?
ii. Is its onset local or general, gradual or sudden?
iii. Do convulsive movements occur during attack?
iv. If so, are they symmetrical or asymmetrical?
v. What parts of the body are involved and in what order?
vi. How long do attacks last?
vii. Is consciousness lost?
viii. Has patient injured himself during attack (tongue biting, head injury, falling)?
ix. Urinary/fecal incontinence?
Seizure hx protocol
General historical questions
Postictal state
What is patient’s condition after an attack?
Are attacks followed by headache, sleepiness, confusion and disorientation, muscle aching, paralysis (Todd’s), memory deficit, aphasia, automatisms?
Seizure hx protocol
General historical questions
Previous tx or tests
What treatment has the patient had and how has he responded to it?
Has the patient had an EEG, MRI scan, CT scan, arteriogram, skull xrays, blood tests?
Seizure hx protocol
General historical questions
PMH and family hx
i. If attacks did not begin in infancy, did the patient suffer from febrile convulsions?
ii. Has the patient had a head injury at any time?
iii. Any history of CNS infection?
iv. Product of a normal pregnancy, labor, and delivery?
v. Normal neonatal development? Normal progress in school?
vi. Prior history of status epilepticus?
vii. Is there a family history of epilepsy, seizures, neurological disorder
Seizure
Lab and auxillary studies
Blood work – CBC, chemistry panel (for electrolytes, glucose, calcium, magnesium, uremia, hepatic encephalopathy), toxicology screen, antiepileptic drug levels.
EEG.
MRI scan or CT scan.
Formal visual fields (for complex partial seizures).
Video EEG monitoring.
Neuropsychological testing.
Simple Partial, complex partial, generalized tonic-clonic
DOC
Phenytoin
Carbamazepine
Levetieacetam
Simple Partial, complex partial, generalized tonic-clonic
Alternatives
Valproic acid
Phenobarbital
Absence, myoclonic, atonic
DOC
ethosuximide
Absence, myoclonic, atonic
Alternatives
Clonazepam
Status epilepticus
def
A state of continuing or recurring series of seizures in which recovery between attacks is incomplete (i.e., a series of seizures without regaining consciousness between attacks).
Status Epilepticus
Occurs with what seizure types
Can occur with any seizure type: generalized tonic-clonic, absence (absence status), complex partial (complex partial or temporal lobe status) or simple partial (simple partial or focal status).
- The only true emergency among these is generalized tonic-clonic status.
- If you treat any of the other types of status as an emergency, more damage may be done by your treatment than by the recurring seizures.
Status epilepticus
Approach to patient in generalized tonic-clonic status
- Observe seizures briefly to ascertain that patient is really in status.
- Place I.V., draw baseline blood work (CBC, chemistry panel, antiepileptic drug levels–send STAT), draw ABGs (for pO2 and pH), draw toxicology screen, obtain vital signs.
- Quickly assess patient for signs of respiratory compromise, hyperpyrexia, focal neurologic signs, head trauma, CNS infection, etc.
- Always have CPR equipment at bedside of a patient in status.
Status epilepticus
Drug therapy
Pg. 477
