Seizures And Syncope (Hon)

Question 1

What are some paroxysmal (episodic) disorders in neurology?

Answer 1

Migraine
Syncope
Dizziness
Seizure

Question 2

What is epilepsy?

Answer 2

Generally defined as 2 or more unprovoked seizures
4th most common neurological disorder (behind migraine, Alzheimer’s, stroke)
1/26 people will develop epilepsy in their lifetime

Question 3

Describe percent positive findings for epilepsy on a single EEG? With 3 sleep-deprived EEGs?

Answer 3

Singe:
All types: 40%
Generalized tonic-clonic: 20%
Petit mal (with HV): 90%
Parital: 30%

for all types with 3 EEGs: 85%

Question 4

What is the single most important information for diagnosing epilepsy?

Answer 4

Although EEG is an important tool, history of events (preferably by witnesses) is most important

• normal EEG does not exclude presence of epilepsy
• minor abnormalities on EEG does not necessarily indicate a pt will have seizures

Question 5

What are the seizure classifications?

Answer 5

Partial seizures (activity begins on one side of brain)

• simple partial
• complex partial
• secondarily generalized (partial onset)

Generalized seizures

• absence (petit mal)
• tonic-clonic
• myoclonic
• tonic
• clonic
• atonic
• clonic-tonic-clonic

Question 6

Describe simple partial seizures

Answer 6

Focal motor or sensory activity
No loss of consciousness
Lasts seconds
No post-ictal state

Question 7

Describe complex partial seizures

Answer 7

Nonresponsive staring
Possible preceding aura
Automatisms
Loss of consciousness
Lasts 1-3 min
Post-ictal state

Question 8

Describe secondary generalized (partial onset) seizures

Answer 8

Bilateral tonic-clonic activity
Loss of consciousness
Lasts 1-3 min
Post-ictal state

Question 9

Describe absence (petit mal) generalized seizures

Answer 9

Nonresponsive staring
Rapid blinking
Chewing
Clonic hand motions
Loss of consciousness
Lasts 10-30 seconds
No post-ictal state

Question 10

Describe tonic-clonic generalized seizures

Answer 10

Bilateral extension followed by symmetrical jerking off of extremities
Loss of consciousness
Lasts 1-3 min
Post-ictal state

Question 11

Describe atonic generalized seizures

Answer 11

Sudden loss of muscle tone
Head drops or pt collapses
Loss of consciousness
Variable duration
Post-ictal stat

Question 12

Describe myoclonic generalized seizures

Answer 12

Brief, rapid symmetrical jerking of extremities and/or torso
Loss of consciousness
Lasts

Question 13

What drugs treat partial/secondary generalized seizures?

Answer 13

Phenytoin, carbamazepine, valproic acid, phenobarbital, gabapentin, lamotrigine, topiramate, gabatril, felbamate, oxcarbamazepine, leviteracetam, zonisamide, lacosamide, perampanel, vigabatrin

Question 14

What drugs treat primary generalized seizures?

Answer 14

Ethosuxamide (absence only)
Valproic acid*
Lamotrigine*
Leviteracetam*
Zonisamide*
Perampanel*

*also treat partial/secondary generalized

Question 15

What is status epilepticus?

Answer 15

Condition characterized by prolonged seizure (generally greater than 10 mintues) or repeated seizures without recovery in between

Question 16

What is the treatment for status epilepticus?

Answer 16

ABC’s, establish IV
History
Labs: Accuchek, CBS, Chemistry panel, drug levels
Noncontrast CT head
Benzodiazepine (buys time but must give longer lasting AED)
Fosphenytoin
Phenobarbital (intubate first to anticipate respiratory depression)
Valproic acid
Lacosamdie (watch for cardiac conduction abnormalities)
If unsuccessful, midazolam or propofol (intubated)
Last resort: pentobarbital coma
In some cases, pt may only respond to one oral AED (carbamazepine). Consider NG tube

Question 17

What are the general principles in treatment of pts with epilepsy?

Answer 17

Try to use monotherapy
Consider drug interactions (oral contraceptives with carbamazepine)
Consider long term side effects (bone loss with carbamazepine or phenytoin)

Question 18

Describe women with epilepsy

Answer 18

All women of child-bearing age should be on a MVI with 1 mg folic acid. Particularly important in women with epilepsy, as many of AEDs are folate-depleting
Avoid valproic acid in pregnancy
In general, newer AEDs (lamotrigine, leviteracetam) are probably safer in pregnancy than older ones (phenytoin or valproic acid), but the drug of choice for a woman is the drug which best controls her seizures

Question 19

Compare/contrast syncope vs seizure

Answer 19

Syncope:
Pallor
Sweating
Abnormal head sensation
Lightheadedness
Positionally related
Slow onset
Brief unconsciousness

Seizure:
Urinary or bowel incontinence
Tongue injury
Tonic/clonic movements
Postictal state