Seizures - Bloch Flashcards
1
Q
seizures are (hyper/dys)synchronous discharge
A
hypersynchronous
2
Q
seizures arise from (cortical/deep) neurons
A
cortical
3
Q
How many unprovoked seizures are necessary to have epilepsy?
A
two more more
4
Q
What fraction of all seizures are febrile convulsions
A
1/3
5
Q
What is the lifetime incidence of seizures?
A
9%
6
Q
what percent of patients with new onset seizures will have epilepsy?
A
60%
7
Q
to have epilepsy, your seizures cannot be caused by…
A
EtOH or sedative withdrawal
metabolic disorders
nonketotic hyperglycemia
8
Q
What are the types of partial seizures?
A
simple partial
complex partial
secondarily generalized
9
Q
what are the types of generalized seizures?
A
Absence myoclonic Atonic Tonic Tonic-clonic
10
Q
Dx of a type of epilepsy is based off of….
A
clinical history and seizure type
11
Q
in what type of partial seizure is consciousness preserved?
A
simple partial
12
Q
in what type of partial seizure is the person able to pay attention, and respond to questions and commands?
A
simple partial
13
Q
In what type of partial seizure is consciousness lost?
A
complex partial
14
Q
in what type of partial seizure is the memory of the seizure lost?
A
complex partial
15
Q
in what type of partial seizure must driving be reistricted?
A
complex partial
16
Q
partial onset seizures may progress to what?
A
secondarily generalized
17
Q
Secondarily generalized seizures involve motor activity on (blank) sides of the body
A
both sides; makes it hard to tell if it is pimarily generalized
18
Q
What are some of the clinical features of simple partial seizures?
A
- somatosensory or special Sx
- with motor signs
- with autonomic Sx or signs
- with psychic or experiential Sx
19
Q
Presence and nature of aura, automatisms, and motor activity vary with what factors in complex partial seizures?
A
site of origin
degree of spread
20
Q
what is the duration of a complex partial seizure?
A
less than two minutes
21
Q
where do most complex partial seizures start/
A
temporal lobe
22
Q
T/F: complex partial seizures can affect consciousness while still remaining focal
A
true
23
Q
what is the first thing patients tend to do in a complex partial seizure?
A
stare off
24
Q
what are automatisms?
A
commonly involve the mouth
lip smacking, chewing, swallowing, fumbling, picking, vocalizations, complex acts; done automatically
25
how long does post-ictal confusion last in complex partial?
less than 15 minutes
26
how long may fatigue and other Sx last after a complex partial seizure?
hours
27
T/f: Secondarily generalized seizures may begin with or without focal neurologic symptoms
true
28
Describe the tonic and clonic phases of secondarily generalized/
variable symmetry, intensity, and duration of the phases
29
How long does a secondarily generalized last?
1-3 minutes
30
what are the after effects of a secondarily generalized?
postictal confusion
somnolence
with or without transient focal deficit
31
what three things can distinguish a secondarily generalized from primary?
1. history
2. EEG
3. neuro exam
4. CT or MRI
32
(1ry/2ry) generalized will have an aura prior to convulsing
2ry
33
What is Todd's paralysis?
focal weakness on the side contralteral to 2ry generalized seizure onset
34
Describe the EEG in simple partial seizures?
localized or lateralized abnormal rhythmic activity
35
the EEG in complex partial seizures is rhythmic and (uni/bi)lateral
bilateral
36
Describe the EEG in 2ry generalized seizures?
1. rhythmic activity
2. high amplitude
3. bilateral and diffuse
4. can be obscured by artifact from abundant muscle activity
37
what does an EEG look like immediately post-ictal?
FLATLINE; the neurons have spent all of their energy and neurotransmitter
38
what type of seizure affects both hemispheres from the beginning?
generalized
39
T/F: all generalized seizures result in some loss of consciousness
true
40
What type of seizure has a petit mal staring spell and impairment of awareness?
absence seizures
41
how long do absence seizures last?
3-20 seconds
42
Absence seizures have (sudden/prolonged) onset and resolution
sudden
43
What provokes absence seizures?
hyperventilation
44
What is the age that absence seizures typically onset?
between 4 and 14
45
By what age do absence seizures normally resolve?
18
46
T/f: children with absence seizures show developmental delays in langauge
false; normal development and intelligence
47
What is the hallmark EEG in absence seizures?
3hz spike-wave discharge
48
Do absence seizures have a postictal period?
nope
49
How do you distinguish between absence seizure and complex partial seizures?
absence does not have a post ictal period
50
If an absence seizure lasts more than ten seconds, what tends to also happen/
motor phenomena (eye blinks, automatic movements, changes in muscle tone)
51
What are the different characteristics of an atypical absence seizure?
generally not provoked by hyperventilation
onset after 6 years old
IN KIDS WITH GLOBAL COGNITIVE IMPAIRMENT
GRADUAL onset over seconds
52
describe the EEG in aytpical Absence seizures?
slow spike-wave complexes at less than 2.5hz
53
Pts with atypical absence seizures also have what two types of seizures?
atonic and tonic seizures
54
What is the EEG like in myloclonic seizures?
4-6 hz polyspike-wave and slow wave discharges
55
describe the presentation of a myoclonic seizure?
bilateral, synchronous jerks of the neck, shoulders, upper arms, body, and upper legs
56
is consciousness impaired in myclonic seizures?
no
57
how long does a myoclonic seizure last?
less than 1 second
58
if myoclonic seizures happen in succession, they are called....
clonic seizures
59
is there altered awareness in clonic seizures?
yes
60
describe the presentation of tonic seizures?
symmetric, tonic muscle contraction of extremities with tonic flexion of waist and neck
61
how long do tonic seizures last?
2-20 seconds
62
Describe the EEG in tonic seizures?
sudden attenuation with generalized, low voltage fast activity (most common)
OR
generalzed polyspike-wave
63
Describe the presentation of atonic seizures?
sudden loss of postural tone
severe = falls
mild = head nods or jaw drops
64
Atonic or tonic seizures and atypical absence are most common in people with....
other neurologic abnormalities
65
In contrast to partial motor seizures, tonic seizures are generalized and involve (blank) musculature
bilateral musculature in a symmetric or near symmetric manner
66
when do tonic seizures normally occur?
during sleep
67
how long do atonic seizures normally last?
several seconds, not longer than a minute
68
What does the EEG look like in an atonic seizure?
electrodecremental response; sudden diffuse attenuation or generalized polyspike wave
69
Epileptic drop attacks occur with what other seizures besides atonic?
myoclonic or tonic if the legs are involved
70
is consciousness impaired in atonic seizures?
yes
71
what type of seizures are grand mal?
primary generalized tonic-clonic
72
How long do grand mal last?
30-120 seconds
73
Does the tonic or clonic seizure happen first?
tonic phase
74
What happens in the tonic phase of grand mal?
stiffening and fall
| ictal cry
75
What happens in the clonic phase of grand mal?
rhythmic extremity jerking; slows before stopping
76
what are some of the other things that happen in grand mal?
drooling
foaming at the mouth
incontinence
biting of tongue/bleeding
77
Describe the postictal period in grand mal?
lasts from minutes to hours; confusion and lethargy, may be agitated
78
describe the EEG in grand mal seizures/
generalized polyspikes, can be obscured by muscle artifact
79
Describe the EEG in the postictal period of grand mal?
background suppression then diffuse slowing
80
what are the causes of seizures in infancy and childhood?
prenatal and birth injury
inborn error of metabolism
congenital malformations
81
what are causes of seizures in childhood and adolescence
idiopathic/genetic syndrome
CNS infx
trauma
82
what are the causes of seizures in adolescents and young adults?
DRUG INTOX AND WITHDRAWAL
| head trauma
83
What are the causes of seizure in older adults?
stroke
brain tumor
ACUTE METABOLIC DISTURBANCE
neurodegenerative
84
what should be done in the initial seizure workup?
1. determine if it actually was a seizure
2. search for evidence of partial onset
3. search for evidence of underlying CNS dysfunction
4. look for systemic or metabolic disorders
5. classify seizure
6. determine studies
7. determine drugs
85
What blood tests should be ordered after the first seizure?
```
CBC
electrolytes
glucose
calcium
magnesium
phosphate
hepatic and renal function
blood/urine drug screen
EEG
CT or **MR*** brain scan
```
86
When should you do an LP after a seizure?
if you suspect meningitis, encephalitis and potential for brain herniation is excluded
87
what postictal findings suggest lateralization?
weakness, aphasia, or sensory dysfunction
88
What is an important sign of upper-motor involvement postictally?
babinski sign
89
Signs that are non-transient may indicate a preexisting structural issue like....
tumor, or a stroke
90
when would you use a CT over an MRI in initial assessment of a seizure?
if you suspect an acute process (intracerebral hemorrhage)
91
Can CT rule out small tumors, vascular malformations, hippocampal atrophy, and cortical dsyplasia?
no, you need an MRI
92
what are some seizure precipitants?
```
Metabolic and Electrolyte Imbalance
Stimulant/other proconvulsant intoxication
Sedative or ethanol withdrawal
Sleep deprivation
Antiepileptic medication reduction or inadequate
AED treatment
Hormonal variations
Stress
Fever or systemic infection
Concussion and/or closed head injury
```
93
what particular metabolic disturbances can lead to a seizure/
```
low blood glucose
high blood glucose w/ hyperosmolar state
low sodium
low calcium
low magnesum
```
94
Which antidepressants can lower your seizure threshold?
bupropion
| Tricyclics
95
what drugs can lower your seizure threshold?
```
bupropion
TCAs
Neuroleptics
Phenothiazines
Clozapine
Theophylline
Isoniazid
PCN
Cyclosporins
Meperidine
```
96
what percent of uprovoked seizures will recur in 5 years?
16-62%
97
relapse rate may be reduced by the use of....
AED
98
What things increase the risk of relapse rate?
abnl imaging
abnl neuro exam
abnl EEG
FHx
99
does treatment with an AED eliminate the risk of a recurrence of seizure?
no but it does decrease it by 50%
100
what is the determining factor in choosing an AED for partial epilepsy?
side effects profile and patient concerns
101
What is the determining factor in choosing an AED for generalized epilepsy
predominant seizure type
| and also SE profile and patient chocie
102
what are the broad spectrum AEDs?
```
Valproate
Felbamate
Lamotrigine
Topiramate
Zonisamide
Levetiracetam
Rufinamide
Vigabatrin
```
103
What are the AEDs for partial onset seizures?
```
Phenytoin
Carbamazepine
Oxcarbazepine
Gabapentin
pregabalin
Tiagabine
Lacosamide
```
104
What is the only drug you can use for absence seizures?
Ethosuximide
105
Which drugs have the best FDA evidence for partial seizure monotherapy?
Carbamazepine
Oxcarbazepine
Phenytoin
Topiramate
106
Which drugs have similar efficacy to first choice drugs but are better tolerated for partial seizure monotherapy?
Lamotrigine
Gabapentin
levetiracetam
107
What are non-firstline drugs that have been shown to be effective in partial seizure monotherapy?
Valproate
phenobarbitol
felbamate
lacosamide
108
Which drugs have limited data but are commonly used in monotherapy for partial seizures?
Zonisamide
| Pregabalin
109
What are the two best drugs for monotherapy of generalized onset tonic-clonic seizures?
Valproate
| Topiramate
110
Phenytoin and carbamazepine may exacerbate which two types of seizures?
absence and myoclonic seizures
111
Lamotrigine may exacerbate which type of seizure?
myloclonic sz of symptomatic generalized epilepsy
112
what drug is used in photosensitive epilepsy?
valproate
113
Clonazepam and phenobarbitol are useful in generalized seizures but have what greater SEs?
sedation and behavioral effects
114
which two drugs can be used for absence seizures?
ethosuximide
| valproate
115
Which three drugs have the best evidence of working for myoclonic seizures?
Valproate
levetiracetam (FDA indicated as adjunctive Tx)
Clonazepam (FDA indicated)
116
What drugs can you use to treat Lennox-Gastaut?
```
Topiramate
***Felbamate***
Clonazepam
Lamotrigine
Rufinimide
Valproate
```
117
When converting to monotherapy what two things should you do?
eliminate sedative drugs first and withdraw the AEDs slowly over several months
118
Which AEDs may INDUCE the metabolism of other drugs?
Carbamazepine
phenytoin
phenobarbitol
primidone
119
Which AEDs may INHIBIT the metabolism of other drugs?
valproate
| felbamate
120
Which AEDs are protein bound?
***Valproate, phenytoin tiagabine***
Carbamazepine, Oxcarbamazepine
Topiramate
121
which drug classes may alter metabolism and protein binding of AEDs?
Abx
chemotherapy
antidepressants
ASA, warfarin, and phenothiazines (protein bound)
122
when is monitoring serum concn of AEDs useful?
```
when the patient is taking other high protien bound drugs, or in pts with renal disease or hypoalbuminemia
OR:
optimizing therapy
assessing compliance
monitoring during pregnancy
testing drug-drug intrxnsvs
```
123
Which AEDs decrease the effect of oral contraceptives?
```
Phenytoin
carbamazepine
Phenobarbitol
Topiramate
Oxcarbazepine
Felbamate
so that means you give you high dose birth control pills
```
124
The pill can decrease which AED levels by 50%
lamotrigine; it can be toxic during the placebo week
125
lamotrigine can decrease the level of which hormone?
progesterone; need shorter intervals between Depo shots
126
T/F: therapeutic and toxic ranges on AEDs are the same for all patients
false; they are set by the patients themselves!!
127
T/F: SE of AEDs are not dose related
false; usually dose related
128
What SE are common to all AEDs?
dizziness, fatigue, ataxia, diplopia
129
Which drug causes irritability?
levetiracetam
130
which drug causes word finding problems?
topiramate
131
which AEDs cause wt. loss and anorexia?
topiramate
zonisamide
felbamate
132
which AEDs cause weight gain?
valproate (also causes PCOS)
| carbamazepine, gabapentin, pregaballin
133
Which drugs give you renal stones?
topiramate
| zonisamide
134
Which drugs cause anhydrosis and heat stroke?
topiramate
135
Which drugs cause acute closed-angle glaucoma?
topiramate
136
Which drugs cause hyponatremia?
carbamazepine
| oxcarbazepine
137
which drugs cause aplastic anemia?
felbamate
zonisamide
valproate
carbamazepine
138
Which drugs cause hepatic failure?
valproate
felbamate
lamotrigine
phenobarbitol
139
which drug causes peripheral vision loss
vigabatrin
140
which drug causes rash?
phenytoin
lamotrigine
zonisamide
carbamazepine
141
What are the predictors of developing a rash with AED use?
occurrence of another AED-rash
| more common in asian populations
142
Stevens-Johnson syndrome and toxic Epidermal necrolysis (TENS) are characterized by....
blisters and erosions of the skin, particularly palms and soles and mucous membraines
fever and malaise
143
Which drugs have the highest risk of SJS or TENS?
rapid titration of lamotrigine, esepcially in combo with valproate
144
which comorbidities are worsened by AEDs?
Osteoporosis
Migraine
Depression
145
osteoporosis is worsened by AED enzyme (inducers/inhibitors)
enzyme inducers
146
Which drugs worsen osteoporosis?
Phenytoin
Phenobarbitol
Primidone
147
Which drugs should you put your pts on if they have migraine?
topiramate
| valproate
148
Which AED worsens depression?
levetiracetam
149
Which AEDs help depression?
lamotrigine
gabapentin
pregabaline
vagus nerve stimulator
150
T/F: you can have interictal depression
true; along with prodromal and peri-ictal
151
how many times higher is the the suicide rate in pts with depression and epilepsy?
5x higher
152
T/F: AEDs slightly increase the risk of suicide
true
153
how long must you be seizure free to discontinue AED use?
>2 years; implies 60% chance of successful withdrawal from AED
154
What are factors favoring discontinuing AEDS?
1. control easy on low dose monotherapy
2. no previous unsuccessful attempts
3. nomral neuro exam and EEG
4. pimary generalized seizures exccpet JME
5. "Benign" syndrome with centrotemporal spikes
155
Is mandatory physician reporting to the DMV required in NV?
yes (1 of 6 states)
156
How many exceptions are there to the mandatory license loss in NV w/ seizures?
5
157
What are the 5 exceptions to loss of license?
Breakthru seizure d/t MD-directed med change
Isolated seizure w/ unlikely additional seizures
Seizure related to temporary illness
Est nocturnal seizures
Est simple partial seizures (w/ no risk of generalization)
158
when can pts reapply for a driver's license?
after 3 months being seizure free
159
what are the lifestyle changes that help avoid seizures?
sleep
avoid alcohol and stimulants
avoid known precipitants
stress reduction
160
What is the efficacy of a ketogenic diet as an AED?
50% with a >50% seizure reduction; 30% with >90%; ketosis is anti-seziure
161
What are the SE of a ketogenic diet/
kidney stones
wt. loss
acidosis
dyslipidemia
162
What is "status epilepticus"?
10+ minutes of continuous seizure activity of any type
OR
2+ sequential seizures w/o full recovery btwn seizures
163
How long do most seizures last?
less than 5 min
164
Is status epilepticus an emergency?
YES DUH
165
what are some adverse consequences of status epilepticus?
```
hypoxia
hypotension
acidosis
hyperthermia
rhabdomyolysis
neuronal injury
```
166
what is the goal w/ status epilepticus?
STOP THE SEIZURES
167
what is "kindling" wrt status epilepticus?
abnormal seizing cells convince their neighbors to start seizing > causes more damage & makes seizure worse
168
T/f: vagus nerve stimulator has positive effects in mood and can allow AED reduction
true
169
What are the components of the Atkins diet?
10g/day of carbs, fats encouraged
| No protein, calorie, or fluid restriction
170
how many carbs a day do you get with low glycemic index treatment?
40-60g/day of low glycemic index carbs
| portions are controlled
171
What are the criteria in which a pt is eligible for surgery?
Unacceptable seizure control despite max tolerated doses of 2-3 drugs
172
Which vagus nerve is stimulated?
left nerve
173
what do you do if your pt has been in status for 10-20 min?
fosphenytoin IV w/ BP & EKG monitoring (but you can skip this step, or load fosphenytoin w/ the next step)
174
T/f: vagus nerve stimulator has positive effects in mood and can allow AED reduction
true
175
What are the 7 things you need to do in the first 5 minutes of SE TX?
```
ABCs
Give O2
IV access
EKG monitoring
Glucose
Draw blood
Tox screen
```
176
What drug should you give a SE pt if alcohol withdrawal is suspected?
Thiamine 100mg IV
177
What drug should you give SE pts if you do NOT know their glucose level?
D50 50ml IV
178
What drug should you give a SE pt (generally)?
Lorazepam
4 mg IV over 2 min
if still seizing, repeat in 5 mins
179
what can you give a pt in status if you do NOT have IV access?
diazepam (rectal)
| midazolam (nasal, bucal, or IM)
180
what do you do if your pt has been in status for 10-20 min?
fosphenytoin IV w/ BP & EKG monitoring (but you can skip this step, or load fosphenytoin w/ the next step)
181
if your pt has been seizing for 10-60 min, what are your 4 options?
continuous IV midazolam
continuous IV propofol
IV valproate
IV phenobarbital
***Intubate for all except valproate
182
what is your last resort for a pt in status epilepticus?
attempt to flatline the EEG w/ petrobarbital
183
What percent of pts with a vagus nerve stimulator have a 50% reduction in seizures?
35%
184
vagus nerve stimulator is FDA approved for what types of seizures?
refractory partial onset and refractory depression
185
What is status epilepticus?
more than 10 minutes of continual seizure; or two or more sequential seizures without full recovery between them
186
what are the consequences of status eplepticus
```
hypoxia
hypotension
acidosis
hyperthermia
rhabdomyloysis
neuronal injury
```
187
what should you test for on blood draw in SE?
chem-7, magnesium, calcium, phosphate, CBC, LFT AED level, ABG, troponin
tox screen in urine and blood
