Seizures and Epilepsy Flashcards
Recurrent, unprovoked seizures
Epilepsy
Abnormal electrical actvity in the brain
Seizure
Clinical manifestatons: range from sensory symptoms, autonomic changes, psychic experiences, and brief confusion to full-blown convulsions
Semiology
Top 4 primary causes of epilepsy in children
- Unknown (67%)
- Congenital (20%)
- Trauma (5%)
- Vascular (5%)
Failure of greater than/equal to 2 anti-epileptic medications to control seizures
Intractability
When should an epileptic patient be evaluated for surgery?
- If the patient is intractable (Failure of greater than/equal to 2 anti-epileptic medications to control seizures)
- The patient has focal epilepsy (not GENERALIZABLE)
True or false? Generalized seizures involve the entire cortex as shown by imaging and neurophysiological studies
FALSE; they DO NOT
- Seizures originating at some point within, and rapidly engaging, bilaterally distributed networks.
- These networks can include cortical and subcortical structures, but do not necessarily involve the entire cortex
- Can be asymmetric
Generalized Seizures
True or false?
Generalized seizures must be symmetric
False
Generalized seizures can be asymmetric
Define Generalized seizures
- Seizures originating at some point within, and rapidly engaging, bilaterally distributed networks.
- These networks can include cortical and subcortical structures, but do not necessarily involve the entire cortex
- Can be asymmetric
True or false?
Generalized seizures must involve the entire cortex
False;
networks can include cortical and subcortical structures, but do not necessarily involve the entire cortex
6 types of generalized seizures
- Absence seizures
- Myoclonic seizures
- Tonic-clonic seizures
- Tonic
- Atonic
- Clonic
________
myoclonic: sudden, involuntary jerking of a muscle or group of muscles
tonic: In a tonic seizure, the body, arms, or legs may be suddenly stiff or tense. STIFFENING.
clonic: sustained rhythmical jerking
tonic-clonic: tonic first (stiffening), then clonic (rapid, rhythmic jerking)
atonic: type of seizure where. a person suddenly loses muscle tone (also called “drop attack”)
- Seizures originating within networks limited to one hemisphere, discretely localized or more widely distributed.
- For each seizure type, ictal onset is consistent from one seizure to another, with preferential propagation paberns that can involve the contralateral hemisphere
Focal Seizures
What are the sub-categories of Focal Seizures?
- Focal dyscognitive/with impaired awareness
- Focal without impairment of consciousness or awareness
EEG: 3 Hz Spike-Wave / HV sensitive
Absence Seizures/GENERALIZED SEIZURE
When do absence seizures tend to onset?
Childhood or teenage
Describe key characteristics of an absence seizure
GENERALIZED SEIZURE
- Sudden onset, without aura, prompt offset
- Momentary loss of consciousness
- Eyelid fluber/minor automatisms
- 3-15 seconds duration
- Family history as indicator
______
EEG: 3 Hz Spike-Wave / HV sensitive
EEG: Flattening/high frequency discharge
Tonic Seizure/GENERALIZED SEIZURE
Patient presents with:
- Sudden onset, without aura, prompt offset
- Momentary loss of consciousness
- Eyelid fluber/minor automatisms
- 3-15 seconds duration
GENERALIZED SEIZURE
___________
Absence seizure
__________
EEG: 3 Hz Spike-Wave / HV sensitive
Describe key characteristics of tonic seizures
GENERALIZED SEIZURE
____
- Sudden stiffening
- Extension maximal in arms
- A few seconds in duration
- Patient may fall or have injury
- Extra-temporal origin
- Tend to be refractory to therapy
_____
EEG: Flattening/high frequency discharge
Patient presents with:
- Sudden stiffening
- Extension maximal in arms
- A few seconds in duration
- Patient may fall or have injury
GENERALIZED SEIZURE
_________
Tonic seizure
_________
EEG: Flattening/high frequency discharge
In general, where do Tonic Seizures originate in the brain?
Extra-temporal origin
In general, how do tonic seizures respond to therapy?
In general, refractory to therapy (GENERALIZED SEIZURE)
EEG: Slow spike-wave/flattening
Atonic Seizures/GENERALIZED SEIZURE
Describe key characteristics of an atonic seizure
GENERALIZED SEIZURE
____
- Abrupt onset
- Sudden loss of tone
- Head drop/falls/injuries
- A second or two in duration
- Poor response to AEDs
- Poor prognosis
_____
EEG: Slow spike-wave/flattening
Patient presents with:
- Abrupt onset
- Sudden loss of tone
- Head drop/falls/injuries
- A second or two in duration
GENERALIZED SEIZURE
____
Atonic Seizure
_____
EEG: Slow spike-wave/flattening
Which type of seizure has a poor overall prognosis and poor response to AEDs?
Atonic Seizures
EEG: generalized polyspike-wave burst
Myoclonic Seizure/GENERALIZED
Describe key characteristics of Myoclonic Seizures
GENERALIZED
_____
- Sudden jerks
- Usually bilateral, maximal in arms
- One second in duration
- Often multiple
- May be photic or sensory triggered
- Often maximal on awakening
_____
EEG: generalized polyspike-wave burst
Patient presents with:
- Sudden jerks
- Usually bilateral, maximal in arms
- One second in duration
- Often multiple
- May be photic or sensory triggered
- Often maximal on awakening
GENERALIZED
_____
Myoclonic Seizures
_____
EEG: generalized polyspike-wave burst
Which type of seizure may be photic or sensory triggered?
Myoclonic Seizures/GENERALIZED
EEG: Variable, often obscured.
Tonic-Clonic Seizure/MAY BE GENERALIZED OR FOCAL ONSET
What are the key characteristics of Tonic-Clonic Seizures?
MAY BE GENERALIZED OR FOCAL ONSET
______
- Loss of consciousness
- May have focal or generalized onset
- Tonic extension of limbs (about 20-40 secs)
- Evolves to rhythmic clonic jerking of extremities (about 30-50 sec)
- Cessation of breathing, tongue biting, incontinence
- Post-ictal sleep (altered state of consciousness after a seizure)
____
EEG: Variable, often obscured
Patient presents with:
- Loss of consciousness
- Tonic extension of limbs (about 20-40 secs)
- Evolves to rhythmic clonic jerking of extremities (about 30-50 sec)
- Cessation of breathing, tongue biting, incontinence
- Post-ictal sleep (altered state of consciousness after a seizure)
MAY BE GENERALIZED OR FOCAL ONSET
______
Tonic-clonic seizures
____
EEG: Variable, often obscured
EEG: Interictal-focal sharp or slow; ictal- rhythmic discharge or often normal
Focal seizures without impairment of consciousness/FOCAL
Describe key characteristics of Focal Seizures without impairment of consciousness?
FOCAL SEIZURE
____
- Motor, sensory, psychic or autonomic signs or symptoms
- Preservation of consciousness & awareness
- May progress to dyscognitive seizures or tonic-clonic seizures
____
EEG: EEG: Interictal-focal sharp or slow; ictal- rhythmic discharge or often normal
Patient presents with:
- Motor, sensory, psychic or autonomic signs or symptoms
- Preservation of consciousness & awareness
FOCAL SEIZURE
____
Focal Seizures without Impairment of Consciousness
____
EEG: EEG: Interictal-focal sharp or slow; ictal- rhythmic discharge or often normal
Focal seizures without impairment of consciousness may progress to what?
May progress to dyscognitive seizures or tonic-clonic seizures
EEG: Interictal- sharp waves or spikes; Ictal- focal or bilateral rhythmic sharp
Focal dyscognitive seizures/FOCAL
Describe key characteristics of focal dyscognitive seizures
FOCAL
_________
- Altered consciousness/awareness
- Duration 30 sec to 3 min
- Purposeless autmatisms (arms, oral)
- Amnesia
- Semiology can vary with site of origin
______
EEG: Interictal- sharp waves or spikes; Ictal- focal or bilateral rhythmic sharp
Patient presents with:
- Altered consciousness/awareness
- Duration 30 sec to 3 min
- Purposeless autmatisms (arms, oral)
- Amnesia
- Semiology can vary with site of origin
FOCAL
_________
focal dyscognitive seizures
______
EEG: Interictal- sharp waves or spikes; Ictal- focal or bilateral rhythmic sharp
Describe the differential diagnosis for Generalized Tonic-Clonic Seizures for Primary Generalized v. Secondarily Generalized?
Describe epileptic v. nonepileptic seizures with regard to:
- Age at onset
- sex
- previous psych history
- motor
- vocalation at onset
- incontinence
- duration of seizure
- injury
- amnesia
- suggestion provokes seizure
Describe epileptic v. PNES status with regard to:
- Onset
- Seizure course
- Motor manifestations
- Consciousness
- Duration
- Cyanosis
- Eyes
- Pupillary light response
- Plantar response
- Response to noxious stimuli
- Response to benzodiazepines
a neurological emergency defined as 30 or more minutes of either continuous seizure activity or repetitive seizures with no intervening recovery of consciousness.
status epilepticus
define status epilepticus
a neurological emergency defined as 30 or more minutes of either continuous seizure activity or repetitive seizures with no intervening recovery of consciousness.
How is status epilepticus clinically determined?
It is clinically determined by the presence or absence of motor activity (generalized or focal) and the presence or absence of intact consciousness.
Patients can exhibit paroxysmal or continuous tonic or clonic motor activity that may be symmetrical or asymmetrical. This type of SE includes primary and secondary generalized seizures and is further subdivided into:
(1) overt; or
(2) subtle
Generalized convulsive status epilepticus (SE)
4 ways of treating epilepsy
- Anti-seizure medications (44% acheive seizure freedom with 1st anti-seizure monotherapy, additional 9% acheive seizure freedom with 2nd anti-seizure monotherapy)
- Epilepsy surgery
- Resection
- Transection
- Neuromodulation
- Vagal Nerve stimulation
- Responsive neurostimulation
- Diet therapies
- Ketogenic
- Modified atkins
Per the epilepsy foundation, what is the goal of treatment?
No seizures and no side effects
What clinical history is important to diagnose epilepsy? Which additional tests should be ordered for diagnosing epilepsy?
History:
- Auras/warning signs
- Report of witnesses
- Postictal symptoms/experiences that follow seizures
Additional tests:
- EEG
- MRI
How does mortality relate to epilepsy? What about comorbidities?
Patients with epilepsy have approximately 2-3 x higher rates of premature mortaility than those seen in general population
