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CMT-uno > Seizures/Epilepsy > Flashcards

Seizures/Epilepsy Flashcards

1
Q

Seizure

definition

A

clinical manifestation of abnormal & excessive excitation & synchronization of population of cortical neurons

the event

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2
Q

Epilepsy

definition

A

: ≥ 2 seizures unprovoked by systemic or acute neurologic insults (or when 1 unprovoked seizure occurs in setting of predisposing cause (focal cortical injury, evidence of genetic predisposition)

the disease

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3
Q

Epilepsy

Essentials of Dx

A

Recurrent unprovoked seizures.
Characteristic EEG changes accompany seizures.
Mental status abnormalities or focal neurologic symptoms may persist for hours postictally.

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4
Q

Seizure Type

Focal ( formerly called partial)

A

Restricted to part of one cerebral hemisphere

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5
Q

seizure type

Generalized

A

Electrical disruption involves entire brain

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6
Q

Focal Seizures

Motor

A

Usually clonic jerking or automatisms

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7
Q

Focal seizures

Nonmotor
Sensory/ cognitive/ emotional/ autonomic

A

Sensory sx: paresthesias/tingling, gustatory, olfactory, visual, auditory
Cognitive sx: speech arrest, deja vue, jamais vue
Emotional sx: fear
Autonomic sx: epigastric sensations, sweating, flushing, pupillary dilation

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8
Q

Focal seizures

can evolve..

A

Can evolve to bilateral tonic-clonic seizures (‘secondary generalization’)

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9
Q

A 5 year old child has seizures with stiffening of the right arm and leg, during which responsiveness and awareness are retained.

A

Focal Seizures Motor Tonic Aware Example

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10
Q

A 22 year-old man has seizures during which he remains fully aware, with the “hair on my arms standing on edge” and a feeling of being flushed

A

Focal Seizures Nonmotor Autonomic Aware Example

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11
Q

A 25 year old woman describes seizures beginning with 30 seconds of an intense feeling that“familiar music is playing.” She can hear other people talking, but afterwards realizes that she could not determine what they were saying. After an episode, she is mildly confused, and has to“reorient herself”

A

Focal Seizures Nonmotor Sensory with Impaired Awareness Example

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12
Q
A
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13
Q
A
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14
Q

Generalized Seizures Tonic-Clonic (“grand mal”)

A

Sudden LOC, rigidity, pt falls to ground, respiration is arrested
Clonic phase (convulsions)
Tongue or lips bitten, urinary/fecal incontinence, injury
HA, disorientation/confusion, drowsiness, nausea, muscle soreness common postictally.
Atonic seizures: very brief loss of muscle tone, falls (epileptic drop attacks)

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15
Q

A 35 year-old man with a history of juvenile epilepsy has seizures beginning with a few regularly-spaced jerks, followed by stiffening of all limbs and then rhythmic jerking of all limbs.

A

Generalized Seizure Tonic-Clonic Example

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16
Q

Generalized Absence Seizures (“petit mal”)

A

Lapses in awareness; staring.
Begin and end abruptly, very brief; can be so brief they are mistaken for daydreaming, may delay Dx.
More common in children.

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17
Q

 5 y/o female is brought to your office because of episodic “ blanking out” which began 1 month ago. Episodes in which she abruptly stops all activity for ~10 seconds, followed by rapid return to full consciousness. Eyes are open during episodes and she remains almost motionless.
After the episodes she resumes whatever activity in which she was previously engaged with no awareness that anything has occurred
~30 episodes per day
No convulsions
Hyperventilation replicates the episodes

A

Absence Seizures

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18
Q

Seizure triggers

A

Medication non-adherence
Sleep deprivation
Metabolic/Electrolyte Imbalance
Intoxication or withdrawal
Hormonal fluctuation
Stress
Fever/systemic infection
Head injury

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19
Q

Syncope

general

A

Characteristic warning, usually gradual (except cardiac arrhythmia)
Typical precipitants (except cardiac arrhythmia)
Minimal to no postictal confusion/somnolence

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20
Q

Psychogenic Nonepileptic Seizures

general and Dx

A

Psychiatric disease
50% respond well to specific psychiatric tx
Epileptic and nonepileptic seizures may co-exist
Video-EEG monitoring may be required for diagnosis

21
Q

Dx Evaluation of a First Seizure

A

 H & P
 Labs: CBC, electrolytes, glucose, calcium, magnesium, phosphate, hepatic and renal function
 LP if meningitis/encephalitis suspected
 Blood/urine drug screen
 EEG
 CT or MRI brain

22
Q

Medical Treatment of First Seizure

A

Whether to treat first seizure is controversial
 16-62% will recur within 5 years
 Relapse rate might be reduced by AED tx
 Abnormal imaging, abnormal neurological exam, abnormal EEG or FH increase relapse risk
 Quality of life issues are important

23
Q

Seizures

Sodium channel blockers

A

Phenytoin
Carbamazepine
Lamotrigine
Oxcarbazepine
Divalproex

24
Q

Phenytoin

MOA and use

A

MOA: stabilizes neuronal membranes and decrease seizure activity by blocking sodium channels in the motor cortex during generation of neve impulse

Used in treatment complex partial (now called focal) seizures and generalized tonic-clonic seizures

25
Q

phentytoin

BB warning

A

Black box warning – IV administration should not exceed a specific rate in adults and children or can lead to hypotension and severe cardiac arrhythmias and purple glove

26
Q

Carbamazepine

MOA and use

A

MOA: Epilepsy Foundation: Carbamazepine blocks frequency-, use- and voltage-dependent neuronal sodium channelsand therefore limits repetitive firing of action potentials

Use in the same seizure disorders as phenytoin,
Is chemically related to tricyclic antidepressants, so can also be used in bipolar disorder

27
Q

Carbamazepine (Tegretol)

BB warning

A

2 black boxed warning:
Increased risk of anemia, agranulocytosis, and other hematological effects. Must closely monitor hematological labs
Toxic epidermal necrolysis and Stevens-Johnson syndrome can occur which is severe and sometimes fatal
Increased risk in patients with the variant HLA-B*1502 allele, found most often in patients of Asian ancestry
Not to be used with or within 14 days of MAO inhibitors

28
Q

Lamotrigine (Lamictal)

MOA and use

A

MOA: inhibits release of glutamate (an excitatory amino acid) and inhibits voltage-sensitive sodium channels, which stabilizes neuronal membranes.

Used in bipolar disorder, partial generalized tonic-clonic seizures (adjunctive only), and partial onset seizures

29
Q

Oxcarbazepine (Trileptal)

MOA and use

A

MOA: structurally similar to carbamazepine but differs in metabolic pathway
Metabolism: extensively metabolized in the liver to active metabolite, MHD
Can be used in children, unlike carbamazepine
Used in partial seizures, not bipolar disorder
no black boxed warning

30
Q

Divalproex (Depakote)

MOA and use

A

Used for bipolar disorder, partial onset and generalized onset seizures, migraine prevention

MOA: causes increased availability of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter, may also enhance action of GABA at postsynaptic receptors. Also blocks voltage dependent sodium channels, leading to suppression of repetitive neuronal firing

31
Q

Gabapentin (Neurontin)

MOA and use

A

used more in neuropathy

MOA: structurally related to GABA, may modulate the release of excitatory neurotransmitters which participate in epilepsy

Can be used in adults and children over the age of 1 month old
Side effects: ataxia, drowsiness, weight gain, CNS and respiratory depression
Use with caution in patients with history of substance abuse – has been increasingly used as a drug of absue

32
Q

Divalproex

MOA and use

A

Used for bipolar disorder, partial onset and generalized onset seizures, migraine prevention
MOA: causes increased availability of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter, may also enhance action of GABA at postsynaptic receptors. Also blocks voltage dependent sodium channels, leading to suppression of repetitive neuronal firing

33
Q

Ethosuximide (Zarontin)

MOA and use

A

MOA: not fully understood; increases seizure threshold and suppresses paroxysmal spike and wave pattern in absence seizures; may decrease nerve transmission in the motor cortex

Only used in absence seizures

34
Q

Levetiracetam (Keppra

MOA and use

A

MOA: exact mechanism is unknown: inhibits the voltage-dependent N-type calcium channels; facilitates GABA through displacement of negative modulators; reduction of delayed rectifier potassium current

Used in generalized tonic-clonic seizures and partial onset seizures in adults and children >1 month old

35
Q

AED reproductive risks
(Anti epileptic drugs?)

A

Possible teratogenic effects of AEDs, consider taking supplemental folate to limit risk.
Enzyme-inducing AEDs (phenobarbital, phenytoin, carbamazepine) can limit effectiveness of OCPs; alternative/additional birth control should be considered.

36
Q

D

Discontinuing AEDs

A

If seizure free for  2 years, ~60% chance of successful discontinuation
 Favorable factors
Control achieved easily on one drug at low dose
No previous unsuccessful attempts at withdrawal
Normal neurologic exam and EEG
Primary generalized seizures
 Consider relative risks/benefits (e.g., driving, pregnancy)

Risk of withdrawal seizures
Should be tapered over weeks to months rather than stopped abruptly.

37
Q

Seizure

Lifestyle Modifications

A

 Adequate sleep
 Avoidance of alcohol, stimulants, etc.
 Avoidance of known precipitants
 Stress reduction

38
Q

Epilepsy syndrome not responsive to medical management

A

Potentially curative
Resect epileptogenic region avoiding new neurologic deficit

 Palliative
Partial resection of epileptogenic region
Disconnection procedure to prevent seizure spread — corpus callosotomy

39
Q

Status Epilepticus

definition

A

Seizure that lasts 5 min or more (single or back to back) without return to baseline

40
Q

Status Epilepticus

Medical emergency
Consequences and goals

A

Consequences: hypoxia, hypotension, acidosis and hyperthermia
Goal: stop seizures as soon as possible

41
Q

Status Epilepticus Case

labs to consider

A

CBC
CMP
Blood cultures
ABGs
AED levels
Drug screen
LP
Imaging

42
Q

Status Epilepticus Care

A

Maintain ventilation
IV access
Assess labs
Sequential AED use, IV or rectally
Consider glucose therapeutically
Consider B vitamins therapeutically
EEG monitoring

43
Q

Febrile Seizures

general

A

Seizures occurring in childhood > age 1 month, associated with febrile illness not caused by CNS infection, without previous seizures, and not meeting criteria for other acute symptomatic seizures.*

Fever = greater than 100.4 F (38C)

44
Q

Febrile Seizures

Risk Factors for development of epilepsy:

A

Complex
Neurodevelopmental abnormalities
Afebrile seizures in first-degree relatives
Recurrent
Following brief and low grade fever
Onset in first year

45
Q

Ketogenic Diet

A

 Main experience with children
 Anti-seizure effect of ketosis? (glutamate blocking?)
 Low carbohydrate, low protein, high fat after fasting to initiate ketosis
 Long-term adverse effects unknown

46
Q

Vagus Nerve Stimulator

A

 Electrical/magnetic stimulation of left vagus nerve
 Adverse effects local (hoarseness, throat discomfort, dyspnea)
 Mechanism unknown
 Clinical trials show 26% effective and <10% seizure free
 May improve mood and allow AED reduction

47
Q

Resolved Epilepsy

A

Individuals who had age-dependent epilepsy syndrome but are now past applicable age or those who have remained seizure-free for last 10 years, with no AEDs for last 5 years
does not guarantee that epilepsy will never come back

48
Q

First Aid
Tonic-Clonic Seizure

A

 Turn person on side with face turned toward ground to keep airway clear, protect from nearby hazards
 Transfer to hospital:
Multiple seizures or status epilepticus
Pregnant, injured, diabetic
New onset seizures
 DO NOT put any object in mouth or restrain

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