Seizures and Syncope (Cohen)

Question 1

The problem (syncope)

Answer 1

Loss of consciousness is a common reason for a trip to the emergency department or the primary care office
Approximately 50% of people will lose consciousness at least once in their lifetime
It is always viewed as a medical emergency, and demands a medical explanation if at all possible
A first loss of consciousness may be the beginning of a life threatening illness, or part of a more benign disorder
A terrifying experience for family and friends

Question 2

Medical terminology: LOC, Found down, syncope, faint, seizure

Answer 2

LOC: loss of consciousness
Found down: slang term, but accurate sometimes when there is no witness at the time LOC occurred
Syncope: loss of consciousness from a lack of blood flow to the brain
Faint: syncope, most likely vaso-vagal, due to bradycardia and hypotension via the vagus nerve
Seizure: neurological changes due to a sudden electrical discharge in the brain

Question 3

“Can I Get a Witness?”

Answer 3

It is crucial to check for any witnesses to the LOC, since many patients will have limited or no memories of how they blacked-out

Important questions:
Was there a warning, light headedness or dizziness, loss of vision, nausea, sweating, pallor or gray color, shaking or convulsion, open or closed eyes, standing or lying or sitting position, unprotected fall or gradual, duration of unconsciousness, speed of recovery to normal consciousness, has this patient had a previous LOC?

Question 4

Syncope [SING-KA-PEE]

Answer 4

The most common cause of LOC
From Greek words meaning “a cutting short”
Generally meant as a lack of sufficient blood flow to continue the metabolism of brain cells sufficiently to preserve consciousness
Consciousness requires a functioning brain stem and one cerebral hemisphere; loss of the brainstem’s reticular activating system OR part of both cerebral hemispheres will cause LOC
The brain is absolutely dependent on a minimum blood pressure, glucose concentration and partial pressure of oxygen

Question 5

Vaso-vagal syncope (Faint)

Answer 5

Vasovagal syncope is caused by combination of

• sympathetic withdrawal (vasodilatation)
• increased parasympathetic activity (bradycardia)

Precipitated by

• Hot or crowded environment, ETOH, extreme fatigue, severe pain, hunger, prolonged standing, emotional or stressful situation:
• Church services, funerals, military activities, athletic activities
• Blood drawing, insertion of an intravenous line, dental work

Sometimes there is no apparent precipitant at all

Patients may have a long history of vaso-vagal syncope going back to their childhood

Question 6

Vaso-vagal symptoms

Answer 6

The period of unconsciousness is usually less than a minute, and full recovery of consciousness occurs within five minutes

Patients will gradually remember their symptoms, and the fact that they lost consciousness quickly

Upon awakening they may need to move their bowels or urinate

Often the patients feel cold and sweaty

Normally a brief warning of seconds or minutes

Patients feel “light, woozy, dizzy,” and notice their vision dims in both eyes, sounds become muffled or the ears seem to ring, there may be palpitations, difficulty breathing, nausea, increased perspiration, a “clammy feeling”, numbness in the hands

Usually no biting of the tongue or urinary incontinence

May be able to cushion their fall

Question 7

Cardiovascular Syncope

Answer 7

Cardiac Output= Heat Rate x Stroke Volume

Due to decreased/insufficient cardiac output caused by

Cardiac arrhythmias

• bradyarrhythmias
• tachyarrhythmias

Structural cardiac abnormality

• Left ventricular myocardial pathology of various causes causing decreased myocardial motility
• flow obstruction

Question 8

Cardiac causes of syncope

Answer 8

Virtually any serious cardiac disorder can cause syncope when there is inadequate blood flow to the brain

The heart rate itself is very important; only fairly healthy patients can tolerate a pulse less than 40 beats per minute or a pulse greater than 180 bpm

A sudden change in pulse is very common; atrial and ventricular arrhythmias, sick sinus syndrome, the tachycardia bradycardia syndrome

New onset of arrhthymias are common causes of syncope, especially ventricular tachycardia and ventricular fibrillation, both of which can cause sudden death

Disorders which limit the stroke volume due to obstruction are also important to consider

1. Aortic stenosis, especially in the elderly
2. Idiopathic subaortic hypertrophic cardiomyopathy; this may cause syncope or sudden death in high school and college athletes
3. Mitral valve prolapse, very common in young women, may cause syncope

Question 9

“Situational syncope”

Answer 9

Certain conditions can cause syncope, especially in elderly patients

COUGH SYNCOPE: repeated coughing, especially in patients with chronic lung disease, may increase thoracic pressure and lower venous return to the right atrium; usually a brief period of LOC

MICTURITION SYNCOPE: elderly patients, almost always men who stand to urinate late at night, LOC due to the vagal response needed to urinate in patients who are sleepy; clinicians like to call this “Pee Syncope”

Question 10

Other disorders that may resemble syncope

Answer 10

Hypoglycemia
Anemia 
Hypoxia
Diminished carbon dioxide due to hyperventilation
Anxiety attacks
Hysterical fainting
Seizure

Question 11

SEIZURES

Answer 11

Seizure definition: A widespread electrical discharge originating in the neurons of the cerebral cortex, causing an abrupt loss or decline in consciousness, new movements, altered bodily sensation, or unusual psychic feeling; perhaps in some cases by sub-cortical neurons

The patient is suddenly affected, or “seized”

An apparent widespread synchronized depolarization of many neurons which would normally be without such synchrony

Mediated by changes in ion channels, such as sodium, potassium and calcium, and by neurotransmitters, such as glutamate, and gamma amino butyric acid

Question 12

(John) Hughlings Jackson, MD

Answer 12

The English physician used recent discoveries that the brain had electrical currents, and applied them to epilepsy, writing in 1873 that:

“Epilepsy is the name for sudden, occasional, excessive and rapid discharge of grey matter.”

Question 13

Definitions of Epilepsy

Answer 13

Epilepsy is the condition of two or more spontaneous (UNPROVOKED) seizures

Epilepsy suggests a disease of brain function, either hereditary or acquired

Epilepsy comes from Greek words meaning “seized by forces from without”

An ancient disease, described by the Babylonians, and well known to Greek and Roman physicians, including Hippocrates, one of the first to suspect that seizures came from the brain

Question 14

Epilepsy over the centuries

Answer 14

By the Middle Ages, epilepsy came to be seen in a much less sympathetic light

Epilepsy was renamed The Falling Evil or The Falling Sickness

Patients were thought to be evil, or agents of the devil, or witches

Masturbation thought to be a common cause

Lunatic: someone who has a seizure once a month

Patients were ostracized, tortured, or placed in asylums, which were run by psychiatrists until the late 19th century

Question 15

Seizure Disorders

Answer 15

In the 21th century, epilepsy is still a useful term, but continues to carry some negative connotations

Some people still don’t know it is a medical disorder

Patients seldom want to be called “epileptics”

The preferred term now is SEIZURE DISORDER

Seizures are still often called “FITS” in the United Kingdom, but this term is considered politically incorrect in the United States

Question 16

Provoked, or Secondary Seizures

Answer 16

The majority of patients with a first seizure or even multiple seizures, will be found to have a cause, or provocation for this

Therefore, these patients are not truly epileptics, especially if the cause is temporary or can be reversed

There is a long list of causes of these provoked, seizures

Two of the most common causes of provoked seizures:

 1. Hypoglycemia, which may also cause syncope
 2. Alcohol withdrawal: patients have one or a few seizures after being intoxicated, within the range of 7 – 72 hours, but typically less than 48 hours after they stopped drinking

Question 17

Other common causes of provoked seizures:

Answer 17

Metabolic: hyponatremia, hypomagnesemia, hypocalcemia, hypoxia

Fever in young children “febrile seizures”

Benzodiazepine withdrawal (lorazepam, alprazolam)

Illicit drugs: cocaine, methamphetamine

Prescription dugs: antidepressants (bupropion), antipsychotics, amphetamine (stimulants)

Head trauma, especially severe trauma causing LOC

Brain tumors, primary or metastatic

Brain hemorrhages

Strokes, especially embolic strokes

Question 18

Idiopathic, or Probably Idiopathic Epilepsies

Answer 18

These are patients who have seizures for no known cause, most likely due to genetic conditions, or acquired disorders that can’t be determined, even with neuroimaging, lumbar punctures, and blood tests

Every patient with a first seizure, especially an adult, should be evaluated with a full history, physical examination and neurological examination, an MRI of the brain and full blood tests

Not every child needs an MRI scan

An electroencephalogram is often very helpful

Rarely is a lumbar puncture essential

Question 19

Diagnosis of a Seizure Disorder

Answer 19

Do NOT diagnose patients unless there is strong evidence from the history, due to reliable witnesses, of two or more unprovoked seizures

If the history is limited, or doubtful, wait for more evidence before diagnosing

An electroencephalogram EEG may be helpful but:

1. A few patients who do indeed have seizures may have a normal EEG
2. At least 5 -15 % of patients who DO NOT have seizures will have some mild epileptic findings on an EEG
3. The EEG may not be as important the reports of reliable witnesses, and other clinical information

Question 20

The role of electroencephalograms (EEG)

Answer 20

An EEG is helpful but seldom diagnostic with epilepsy, with perhaps the exception of absence seizures
Strong amplifiers show electric potential differences between pairs of electrodes on the scalp, resulting from many post synaptic excitatory and inhibitory potentials (EPSPs, IPSPs)
Most (but not all!) patients with epilepsy will eventually show spikes or sharp waves on an EEG, but some normal patients show abnormalities on this test
A normal EEG does NOT mean a patient cannot be having seizures

Question 21

abnormal EEGs

Answer 21

Spikes (everything going up at the same time)

Sharp waves (crazy town)

Question 22

Major Types of Seizures

Answer 22

Focal (one hemisphere)

Generalized (2 hemispheres)

Question 23

Generalized Tonic Clonic Seizures

Answer 23

Sometimes called “grand mal,” presumably French for “big and bad”

Extremely common cause of seizures for which patients and their families seek immediate medical attention

Often start in adolescence and the twenties, seemingly never in infants under five months or so of age

Can be idiopathic, presumably genetic, or from any of the secondary causes

Question 24

Tonic Clonic Seizures

Answer 24

Patients may get a brief warning, or “aura” which is actually the beginning of the seizure

First have a tonic phase, with clenching or tightening of the muscles in a fixed position, arms may be flexed, legs are extended, breathing muscles may be locked, and the mouth may close quickly causing biting of the tongue or lip and loss of urinary and rarely bowel continence

The eyes often roll upward and should be OPEN at the stat of the seizure

Followed in approximately 10 – 30 seconds by the clonic phase, with repetitive synchronous movements of the arms and or legs

The seizure usually ends within two minutes with a gradual slowing of the frequency of repetitive movements

Respiration resumes

Patient remains unresponsive for 5 minutes or more, typically, and only slowly gains some orientation after that

Patients have no memory of the seizure, other than how they felt immediately before, or the aura

Often awaken in an ambulance or emergency department without any idea of what happened to them; may be combative or “agitated” at that time

Patients may be somewhat confused (POST ICTAL ) for hours, or even days in elderly patients

The heart rate will increase immediately

The oxygen saturation of the blood, if measured, will drop

Blood pressure will increase

The pupils often dilate widely for a while and will not react to light

Blood tests may reveal a metabolic acidosis with a decline in serum bicarbonate ion

Occasionally patients will remain weak on one side for another day due to the seizure focus itself: Todd’s Paralysis

Question 25

Complex Partial Seizures

Answer 25

“Partial,” because they stay within one cerebral hemisphere

“Complex” because unlike partial motor or partial sensory seizures, the level of consciousness is partly reduced

Very common, but not as easily diagnosed as tonic clonic seizures, even if there are witnesses

Patients may get an aura more commonly than with tonic clonic seizures:

Déjà vu: surroundings look strangely familiar
Jamais vu: familiar surroundings look unfamiliar

Bad sensations such as an irritating smell or taste, a sense of dizziness, or an abdominal discomfort which rises to the head quickly
Can occur at any age, including the very elderly
Often occur when patients are alone, or if witnessed, assumed to be transient ischemic attacks or other “spells”
May be due to trauma, often seemingly mild head trauma
Last one or two minutes, typically, and the patients seldom know they are having a seizure, and there is a post ictal period usually shorter than for a tonic clonic seizure
May begin with a sudden loss of speech, a blank look on the face, and AUTOMATISMS:
1. repetitive blinking, chewing movements of the mouth, simple motioning with the hands, odd fumbling with clothes or even undressing, repetition of very simple spoken phrases or words

TEMPORAL LOBE

Question 26

Absence Seizures

Answer 26

A very common cause of seizures in CHILDREN
Formerly known as Petit Mal seizures, a term best avoided at this time
Brief episodes, mostly less than 10 seconds in duration, always less than 60 seconds, of inability to speak or respond in any way
Patients do not fall down, except in atypical absence
Occasionally blink or have repetitive movements of the face, eyes or arms
Patients quickly recover a normal level of consciousness and do not even known they have had a seizure

Question 27

Absence Epilepsy

Answer 27

These are generally very healthy children, who never have brain lesions, and are assumed to be victims of a genetic disorder
However, they may have HUNDREDS of these seizures per day, and do poorly in social situations or in their school work
Often diagnosed by an observant kindergarten or early elementary school teacher who notices the child staring or day dreaming quite often
Parents are often frustrated when these children don’t seem to listen or respond to questions

Question 28

Absence seizures- prognosis

Answer 28

The prognosis is very good, unless atypical seizures develop, and then there is usually evidence of loss of developmental milestones
The vast majority of children are neurologically normal, and two thirds of children will stop having seizures during their teenage years
Some of them will develop generalized seizures

Question 29

Absence seizures: EEG shows

Answer 29

Three per second spike/wave complexes

Question 30

Absence Epilepsy Treatment

Answer 30

Patients usually respond to a small dose of valproic acid
Ethosuximide is equally effective for absence, but it is not effective for tonic clonic seizures, and not as readily available as valproic acid, so it is not used much anymore
And, valproic acid is a highly prescribed drug, for bipolar disorder and migraines as well as epilepsy, so all pharmacies keep it in stock

Question 31

Management of Seizure Disorders

Answer 31

Antiepileptic drug (AED) is usually not indicated after  a first seizure with normal EEG and no risk factors 
Multiple studies have been done to determine what per cent of healthy patients with one unprovoked seizure will go on to have a second seizure:
   1. A wide range of results,  @29% - @61% but most are under 50%

May consider initiation of AED after a first seizure with normal EEG if risk factors are present: abnormal MRI scan, a type of seizure which is known to recur, brain hemorrhage or tumor, even after surgical removal, etc.
Electroencephalograms (EEGs) may be helpful, but can be normal in patients with epilepsy, and abnormal in patients who do NOT have epilepsy

Question 32

Managing a seizure disorder- after 2nd seizure

Answer 32

However, other studies show that once a healthy patient has had a SECOND UNPROVOKED SEIZURE, approximately 80% or more of these patients WILL go on to have more seizures
So, this meets our definition of epilepsy, and patients should take a medication
The latest surveys show that ultimately 3% of Americans will develop epilepsy, including the very elderly who are probably underdiagnosed
Roughly three times this number of people have one or more provoked seizures
Discuss safety measures when a seizure does occur

Question 33

MOST SEIZURES END WITHOUT HARM TO THE PATIENT

Answer 33

Well over 90% of seizures end in two minutes or less, and no damage is done to the brain
The most common “damage” from seizures is trauma from falling, including fractures, or aspiration of gastric or oral contents, or biting the tongue or cheek
Do NOT give intravenous benzodiazepines (lorazepam, diazepam or others) unless there is status epilepticus which we will discuss later
1. These drugs have a much greater chance of causing respiratory arrest (perhaps over 5%) than the seizures do

Question 34

“Pseudoseizures”

Answer 34

Some patients may unconsciously or deliberately have episodes which may appear to be seizures

Now more often referred to as Psychologic Nonepileptic Seizures, or PNES

Most of these patients have serious psychiatric illnesses, from conversion disorders to malingering, borderline personality disorders, history of physical and sexual abuse

Look like generalized seizures, usually but with atypical features:

Asynchronous limb movements, eyes are often closed, involve pelvic thrusting or odd movements of the trunk, go on for more than 2 minutes, come on more slowly than typical seizures, do NOT respond to epilepsy drugs

Question 35

Drug treatment of a Seizure Disorder

Answer 35

If at all possible, use a single dug, pushing it to as high a dose as the patient can be comfortable with

Laboratory “drug levels” can help this process, but should NOT be used too rigidly

Some patients will need to gradually switch to a second drug, or take two drugs simultaneously, which may cause significant drug to drug interactions

If a patient continues to have seizures after the use of three different anticonvulsants, at high doses, the physician needs to reevaluate:

1. Does the patient truly have epilepsy?
2. Is the patient noncompliant with the medication?
3. Is the medication wrong for the apparent type of seizure?

Question 36

Drug treatment- control

Answer 36

Most patients will have good control of their seizure frequency with a medication, especially patients with the generalized epilepsies

But what the physician considers “good control” may still be difficult for patients to cope with

Patients with partial epilepsies tend to be more difficult to control

Choose an anticonvulsant drug appropriate for the type of seizure your patient has, and also consider the patient’s other illnesses or symptoms

Also be aware of the possible adverse effects of these drugs

Question 37

Surgery for seizures

Answer 37

Requires extensive study of patients who have failed drugs, and who do NOT have pseudoseizures

Multiple EEGs, including continuous video-EEGs for days in an Epilepsy Monitoring Unit

If a definite focal source of the electrical discharges can be found, commonly in one of the temporal lobes, surgical excision is often safe and highly effective

The majority of well-chosen patients for epilepsy surgery will no longer have to take anticonvulsants

The Vagal Nerve Stimulator is one of perhaps many devices that will detect and try to stop seizures at their onset with strong electrical shocks

Question 38

STATUS EPILEPTICUS

Answer 38

A true medical emergency which can be fatal if not treated
A prolonged generalized seizure may cause permanent brain damage or the lack of respiration may cause death immediately
Defined as either multiple seizures without regaining of a normal level of consciousness between each one
OR:
One prolonged generalized seizure for at least 10 minutes
(partial seizures lasting this long are NOT dangerous)

Treatment involves the usual “ABCs,” checking glucose and oxygen levels, and sometimes urine for toxicology studies

Administer small doses of lorazepam or diazepam, ONLY for status epilepticus, and not for a single seizure, and give a loading dose of phenytoin or another anticonvulsant(s)

** TWO DRUGS **

Question 39

Treating status epilepticus

Answer 39

1. Be certain that the patient actually HAS status epilepticus, and not something else, including psychogenic seizures, or a movement disorder such as dystonia, tremors, chorea, etc.

Stabilize in the usual manner: Airway, Breathing, Circulation

An intravenous line is almost always necessary, except for the use of intramuscular phosphenytoin and diazepam (Valium)

Give intravenous glucose if there is ANY chance of hypoglycemia, and oxygen if there is ANY chance of hypoxia