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Neurology > Seizures and Epilepsy > Flashcards

Seizures and Epilepsy Flashcards

1
Q

Tonic vs clonic

A

Tonic - stiffening

Clonic - movement

Tonic-Clonic (grand mal) - alternating stiffening and movement

Myoclonus - quick, repetitive movements

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2
Q

Atonic vs Absence

A

Abscence (petit mal) - 3Hz, no postictal confusion, blank stare

Atonic - drop seizures (falls to floor) - commonly mistaken for fainting

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3
Q

Seizure vs epilepsy

A

Seizure is paroxysmal event caused by abnormal, excessive electrical discharge from an aggregate of CNS neurons

Epilepsy is when there is a syndrome of recurrent seizures. Use term with caution and don’t apply to patients who have periodic seizures provoked by secondary causes like diabetics with hypoglycemic episodes

HOWEVER, consider a patient with a brain tumor and recurrent seizures. This IS epilepsy. You can’t explain why patient had seizure on Tuesday but not on Wednesday.

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4
Q

Generalized vs partial seizures

A

If abnormal activity arises from both hemispheres at once (generalized - always with LOC) or from a focal area of cortez (partial).

Partial seizures can occasionally spread to involve the whole cerebral cortex - secondary generalization. It’s important to get good history to know if something started out as partial since partial and generalized have different differentials.

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5
Q

Generalized seizures

A

Cortical discharge - entire cortex

Consciousness - Lost

Common causes - metabolic**, fever, genetic epilepsy syndromes, sleep deprivation, idiopathic

Initial work up - systemic labs, EEG and MRI

Examples - Generalized tonic-clonic, absence, tonic, myoclonic

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6
Q

Partial seizures

A

Cortical discharge - regional

Consciousness - preserved (simple) or altered (complex)

Common causes - stroke, neoplasm, head trauma, infection, mesial temporal sclerosis

Initial workup - Neuroimaging

Examples: Simple - motor (classical Jacksonian march), sensory, psychic (deja-vu), autonomic (rising epigastric sensation). Complex - temporal lobe seizures, frontal lobe seizures

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7
Q

Clean MRI and EEG following first generalized tonic clonic seizure

A

Risk of seizure in next year is very low so no need for AEDs

No driving for 6m

Don’t operate alone

If EEG or MRI are abnormal then you get AEDs

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8
Q

Systemic abnormalities associated with seizures (6)

A

1) Electrolytes - hypoNa, hypoCa, hypoMg
2) Blood glucose - hypoglycemia
3) Organ failure - uremia, hepatic failure, TTP, sepsis
4) Drug intox - Penicillins, local anesthetics, TCAs, Li, theophylline, amphetamine, cocaine, phenycyclidine, wellbutrin
5) Drug withdrawal - alcohol, benzos, barbs
6) Endocrinopathies - hypoparathyroidism

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9
Q

Absence seizures

A

Duration - seconds

Automatisms (motor) - Rare

Post-ictal state - None

EEG pattern - 3 cycles/second in all leads (generalized)

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10
Q

Complex partial seizures

A

Duration - minutes

Automatisms (motor activity) - Frequent (lip smacking)

Post-ictal state - Frequent

EEG pattern - Focal area of abnormal spikes and waves

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11
Q

GTC vs Syncope

A

1) Precipitating factor - None (seizure) vs emotional stress, valsalva (syncope)
2) Premonitory symptoms - None or vague (seizure) vs tunneling vision, lethargy, nausea, diaphoresis (syncope)
3) Posture at onset - Any posture (seizure) vs generally standing (syncope)
4) Transition to unconsciousness - immediate (seizure) vs gradual over seconds in vasodepressor form (syncope)
5) Duration of tonic and/or clonic movements - 30-60s (seizures) vs always less than 15s if present (syncope)
6) Facial appearance - cyanotic (seizure) vs pallid (syncope)
7) Post-event confusion/lethargy - minutes to hours (seizure) vs less than 5 minutes if present (syncope)
8) tongue biting - occasionally (seizure) vs rarely (syncope)
9) Incontinence - occasionally (seizure) vs sometimes (syncope)
10) Elevated CPK, myalgias - frequent (seizures) vs sometimes (syncope)

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12
Q

Phenytoin kinetics

A

zero order - rate is independent of reactant concentrations. Rate is constant in rate vs time graph

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13
Q

Phenytoin half life

A

24h, but this is dose-dependent

Effective level 10-20 mcg/ml

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14
Q

Phenytoin uses

A

1) GTC*

2) Partial

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15
Q

Phenytoin mechanism

A

Increasing Na channel inactivation

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16
Q

Phenytoin side effects

A

Ataxia, confusion, cerebellar degeneration, gum hyperplasia, LAD, osteomalacia, rash, SJS, SLE-like syndrome, induction of P450

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17
Q

Carbamazepine uses, mechanism and half life

A

1) Partial*
2) GTC*
3) Trigeminal neuralgia*

Mechanism - Increased Na channel inactivation

Thalf- 15h

Level 4-12

18
Q

Carbamazepine side effects

A

Self-inducer

Ataxia, vertigo, aplastic anemia, leukopenia, hepatotoxic, GI upset, SIADH, SJS

Heme stuff! Check CBC

19
Q

Valproic Acid uses, mechanism, and half life

A

1) GTC
2) Partial
3) Myoclonic*
4) Atonic*
5) Bipolar

Mech - Increased Na channel inactivation and increased GABA concentration by blocking GABA transaminase

Half - 15h

Level 50-100

20
Q

Valproic acid side effects

A

Ataxia, tremor, lethargy, hepatotoxic, thrombocytopenia, alopecia, weight gain, PCOS

Teratogen!

21
Q

Phenobarbital uses, mech, half life

A

1) GTC
2) Partial onset

Mech - Increased GABA A action

Half - 90h

Level 10-40

1st line in neonates!

22
Q

Phenobarbital side effects

A

Sedation, depression, confusion, ataxia, induces P450

Toxicity is CNS depressant and too much inhibition of neurons

23
Q

Ethosuxamide uses, mech, half life

A

1) Absence***

Mech - Blocks thalamic T type Ca channels

Half - 60h

Level 40-100

24
Q

Ethosuxamide side effects

A

EFGHIJ

Ethosuxamide causes
Fatigue
GI distress
HA
Itching and
SJS*

Cytopenias, ataxia, lethargy

25
Q

Gabapentin uses, mech, half

A

1) Partial
2) Peripheral neuropathy
3) Postherpetic neuralgia

Mech - Mainly inhibits high voltage activated Ca channels designed as GABA analog

half - 5-9h

26
Q

Gabapentin side effects

A

Sedation, ataxia, GI

27
Q

Lamotrigine

A

1) Partial
2) GTC

Blocks voltage gated Na channels

Side effects - SJS** (titrate slow - watch for it with initiation and with every adjustment), sedation, ataxia

Half is 25h (60h with valproate)

28
Q

Topiramate

A

1) Partial
2) GTC
3) migraine prevention

Blocks Na channels, increases GABA action

Side effects - weight loss, sedation, metabolic acidosis, word finding issues, kidney stones

29
Q

Levetiracetam

A

1) Partial
2) GTC

Acts at synaptic vesicle proteins

Side effects - behavioral disturbances. sedation

30
Q

Etiologies of first time seizure

A

VITAMINS

Vascular (stroke)
Infection (meningitis, encephalitis)
Trauma (TBIs, brain bleeds)
Autoimmune (cerebritis, Lupus)
Metabolic (glucose, shock, Ca, Na)
Ingestion/withdrawal (benzo, alcohol withdrawal)
Neoplasm
Sych (pseudoseizure)
31
Q

Seizure algorithm

A

1) history of epilepsy - Epilepsy
- Check med levels. Increase drug/add drugs/change drugs if symptoms are worsening
- Check the VITAMINS - more prone to one of the VITAMINS and this might be reason for worse symptoms (UTI)

2) First time.

2A) Are the currently seizing?

2B) Yes. More than 5 minutes or haven’t returned to baseline after 20 minutes - Status

2C) No. Get EEG, CT(MRI), VITAMINS and fix it

3) Status
- BENZOS BENZOS lorazepam
- if that doesn’t work use IV fosphenytoin
- Then use midazolam and propofol
- Then use phenobarbital drug induced coma

4) Once Status is fixed get EEG, CT(MRI), VITAMINS and fix it

Note: You can have non-convulsive status!

32
Q

Status epilepticus

A

1 prolonged seizure (officially 30 minutes, practically 5 minutes) or 2 consecutive seizures with no full recovery of consciousness between episodes

33
Q

Most common causes of status

A

1) antiepileptic drug noncompliance in an epileptic patient***
2) Brain infections (meningitis or encephalitis)
3) Substance intox or withdrawal
4) Brain tumor
5) Metabolic disturbance (uremia, liver failure, hypoglycemia)

34
Q

Status treatment steps

A

1) Benzo
2) First AED (phenyotin or fosphenytoin)
3) Try first AED again
4) Second AED
5) Intubate
6) Initiate coma with EEG monitoring (pentobarbital, midazolam or propofol bolus then IV infusion)
7) Confirm therapeutic drug levels (bolus IV AED)

35
Q

Child with fever and seizure and nothing else - when is LP indicated?

A

Younger than 12 months - child may not be able to mount the appropriate signs of CNS infection at this time

36
Q

Avg age of febrile seizures

A

18 months

37
Q

Simple febrile seizures

A

1) Patient between 3 months and 5 years old
2) generalized seizure without focal elements
3) Seizure lasting less than 15 minutes
4) Associated with fever (101F, 38.5C) not caused by CNS infection
5) Occurs only once in 24 hr period

Febrile status = longer than 30 minutes. Treated the same as regular status.

38
Q

What entity is most linked to febrile seizures?

A

HHV 6

39
Q

Recurrence risk of febrile seizures

A

overall 30%

If first one is at younger than 12 months - 50%

If first one is older than 3 years - 20%

Half of all occurrences happen within 6 months. 90% within 24m

40
Q

What aspects of a febrile seizures raise your risk of future epilepsy? What are other risk factors for epilepsy development?

A

1) Preexisting neurodevelopmental problem (cerebral palsy, developmental delay)
2) FHx
3) Complex febrile seizures
4) Febrile seizures early in life or associated with more mild fevers

41
Q

Tx for febrile seizures

A

Do not need AEDs. Can treat as benign event.

Daily phenobarb and valproate work but side effects are too much.

During fever, giving oral/rectal diazepam is effective and better tolerated. Antipyretics during these episodes may help too.

Neurology (14 decks)

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