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Neurology= Clinical Medicine > Seizures & Epilepsy > Flashcards

Seizures & Epilepsy Flashcards

1
Q

What is a tonic seizure?

A

Muscle stiffening frequently in a decerebrate posture

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2
Q

What is a clonic seizure

A

rhythmic synchronous limb movements (pseudoseizures are freq. asynchronous)

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3
Q

What is an absent seizure

A

type of generalized epilepsy with staring (3 hz spike and wave on EEG) but often (and wrongly) used to refer to a focal seizure with staring

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4
Q

what is status epilepticus

A

5+ min of seizure or multi seizures over 5 min without return to awareness

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5
Q

what are drug resistent seizure

A

1/3 of patients who have seizures in spite of full medication trials :. Therefore 2/3 will gain control with meds

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6
Q

What is epilepsy surgery

A

Surgical excision of an area of abnormal brain tissue usually reserved for pts with refractory seizures. (ie. Microgyria, Heterotopic cortex)

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7
Q

Neurostimulation

A

Vagal nerve stimulator FDA approved for refractory epilepsy

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8
Q

SUDEP sudden unexpected death in epilepsy

A

death from no identifiable cause in an epileptic person (appx) 1/1000-higher risk in refractory epileptics

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9
Q

Aura

A

a memory of sensations before seizure: smell, taste, nausea, fear, twitch

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10
Q

What is epilepsy?

A

“Epilepsy is a central nervous system disorder (neurological disorder) in which the nerve cell activity in your brain is disturbed, causing a seizure during which you experience abnormal behavior, symptoms and sensations, including loss of consciousness.

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11
Q

Epidemiology of Epilepsy/ seizures

A

Epilepsy Incidence: about 1/100 world wide

Single Seizure incidence: 1/20 over a life time

70% are idiopathic

30% have secondary causes

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12
Q

3 types of focal onset seizures

A
  1. Simple Focal: without impaired consciousness
    2. Complex Focal: with impaired consciousness
    3. Secondarily Generalized
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13
Q

6 types of generalized onset seizures

A
  1. Absence
    2. Tonic
    3. Clonic
    4. Tonic clonic
    5. Atonic
    6. Myoclonic
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14
Q

simple focal onset seizures

A

Preserved consciousness
Many kinds: sensory, motor, autonomic, psychic
Any discrete experience
Dx: based on repeated occurrence of same experience with focal EEG changes

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15
Q

Complex focal onset seizures

A 
Have an aura
An aura is a simple focal seizure
Consciousness impaired
In practice it is hard to assess
Ask pt if they remember event
Dx: recurrent auras leading to a complex focal onset seizure or 2nd generalized seizure with EEG changes
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16
Q

Complex focal onset seizures usually present by?

A 
Aura followed by 	
Behavioral arrest followed by
Staring, automatisms followed by
Postictal confusion
Automatisms: chewing, lip smacking, mumbling and fumbling with the hands
Bicycling  
Fencing postures
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17
Q

How long does a complex focal onset seizure last?

A

Typically lasts 60-90 seconds
If frontal lobe site may present with bizarre motor behaviors
Many demonstrate postictal correlate on EEG

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18
Q

Secondarily Generalized Seizures

A

Often begin with aura
Evolves into complex focal seizure
Following into generalized tonic-clonic seizure
Prominent amnesia of aura, correlates with severity of secondarily generalized seizure.

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19
Q

Specifics of focal seizures (5)

A

Begins in one anatomic location
That location may have symptomatology referral to location
Sensory or motor cortex: Jacksonian March
Amygdala: ictal fear
Temporal lobe: de ja vu, jamais vu

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20
Q

Generalized Onset Seizures do not have what?

A

Generalized Onset Seizures do not have a warning

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21
Q

The 6 types of generalized onset seizures are classified by what?

A

classified by clinical and EEG

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22
Q

Absent Seizures (5)

A 
(petite mal)
Brief episodes (seconds) of impaired consciousness, can happen many times per day 
No aura
No postictal confusion
Usually last less than 20 seconds
May or may not have repetitive blinking
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23
Q

When do absent seizures usually occur?

A

Typically begin in childhood or adolescence may persist into adulthood
Often unrecognized
Child is unaware
Signs are subtle
1st clue may be decline school performance or unexplained daydreaming

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24
Q

How do you diagnose the absent seizure?

A

EEG hallmark: 3-Hz generalized spike and slow wave complexes.
Usually shows more waves than was expected clinically
Hyperventilation or photic stimulation often provokes the EEG changes and even the seizure

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25
Tonic- Clonic Seizure (grand mal)
10% of all epilepsy types Usual type if secondary to metabolic issues (check: lytes, renal, glucose…) Begins abruptly Tonic Phase (about 10-20 seconds) Initial phase tonic contraction of muscles with possible ictal cry Impaired respirations
26
What are signs that will be found with Tonic- Clonic Seizures during the tonic phase?
Increased oral secretions Cyanosis May bite tongue Increase in pulse, blood pressure
27
What are signs that will be found with Tonic- Clonic Seizures during the clonic phase?
(about 1 minute) Periods of muscle relaxation on the tonic muscle contractions Periods of relaxation increase with time until the end of the ictal (seizure) phase
28
What are signs that will be found with Tonic Clonic Seizures during the postctal phase?
``` Unresponsiveness Muscle flaccidity Excessive salivation: watch airway Bladder or bowel incontinence Minutes to hours of postictal confusion ```
29
What will be seen on the EEG for a Tonic- Clonic Seizure
Increase in general low voltage fast activity  High amplitude polyspikes  In the clonic phase, spike and wave pattern Postictal phase shows diffuse slowing that gradually recovers
30
What is a myoclonic Seizure
Brief (< 1 second), arrhythmic, sudden, jerking motor movements Associated with: metabolic disorders, degenerative CNS diseases, anoxia If clustered may progress to Tonic-Clonic seizure Normal myoclonus can happen when falling asleep
31
What is a clonic seizure?
Rhythmic motor jerking May start focally with or without impaired consciousness Typically involves upper and lower extremities EEG shows spike and wave which may be obscured with movement artifact
32
What is a Tonic Seizure
Sudden flexion or extension of the head, trunk or extremities Usually occur with drowsiness EEG shows high beta frequency AKA “beta buzz” low amplitude, may turn into spike and wave
33
What is a atonic seizure?
Loss of postural tone for 1-2 seconds Consciousness briefly impaired No postictal phase May present as a quick head drop to collapse resulting in injuries EEG shows spike and wave immediately followed by diffuse slow waves correlating with the atonia
34
Juvenile Myoclonic Epilepsy
``` Family history of epilepsy Bilateral myoclonus jerks Provoked by sleep deprivation Can be seen upon awakening Upto 1/3 have absence seizures age 12-16 bilateral myoclonic jerks upon awaking up May evolve to generalized tonic clonic seizures– EEG specific 5 hz polyspike discharge ```
35
Lennox-Gastaut Syndrome
In children, severe form of epilepsy Triad of : Multiple seizure types, 3 Hz spike and wave on EEG, impaired cognitive function Does not respond well to medications Poor prognosis
36
Mesial Temporal Lobe Epilepsy Syndrome
``` Most common syndrome Focal seizures EEG specific changes MRI specific changes (hippocampal) Tx: surgery. Does not respond to medications ```
37
Seizures are caused by what?
Seizures are caused by abnormal electrical currents in neurons (Gray matter) The abnormal electrical current creates a DIPOLE which is frequently surface negative
38
Epileptogenesis
the CNS network becomes chronically hyperexcitable from an insult or injury Severe penetrating head trauma, has 45% risk Stroke Infections Abnormal CNS development
39
What are some causes of a provokes seizure?
``` Alcohol withdrawal 72 hrs Hypoglycemia from excess insulin Hyponatremia Cocaine Trauma Hypoxia/ischemic arrest Medications: Welbutrin, Ultram Sleep deprivation in youth ```
40
What are some causes of unprovoked?
``` Family history important here Upto 50% the cause is unknown Any structural abnormality than involves gray matter can cause seizures: Tumor CVA (especially bleeding) Abscess, Meningitis MS, Lupus Tuberous Sclerosis ```
41
Generalized Tonic clonic versus (syncope)?
``` Syncope Brought on by stress, orthostatic hypotension, arrhythmia Rare tongue injury Pallor of face 15s or less duration Seconds of unconsciousness No incontinence eyes closed ```
42
(Generalized Tonic clonic) versus syncope?
No precipitating factor ``` Biting of tongue Cyanosis of face 30-60 s duration Minutes of unconsciousness Incontinence eyes open ```
43
Syncope Physiology
Common Sequence of events: emotional event (Phlebotomy) Vasodilatation Venous pooling Cardiac hypercontractile state Brain misinterprets info as hypertension Sympathetic withdrawal—bradycardia results Bp lowers further- below mean arterial pressure 50 which is lower end of autoregulation
44
Diagnostic testing for seizures and syncope
EEG Laboratory MRI CT CSF
45
What is the gold standard for ordering a EEG
with In-Patient Video EEG (days) gold standard
46
What is the hallmark of seizure activity on an EEG?
The hallmark of seizure activity is the spike and wave discharge which is “paroxysmal”=sudden and may be repetitive
47
Why would an MRI be done?
Lesions of the frontal and temporal lobes have a higher incidence of epilepsy Lesions will involve cortex Named entities with are frequently encountered include: Mesial temporal sclerosis, tumors, strokes, brain infectio
48
A single, provoked seizure Tx
avoid precipitating factor (alcohol, sleep deprivation) No AEDs
49
Recurrent unprovoked seizure Tx: Goals for treatment:
AEDs. Achieve seizure free status without adverse effects 60% Strive for monotherapy
50
Evaluation of seizure risk based on (3)
History EEG MRI
51
Important aspect for every patient that you think is having seizures (1)
Referral to a neurologist for diagnosis of epilepsy and individualized treatment
52
Anti epileptic drugs (AED) used for? (3)
Focal seizures Generalized seizures Specific epileptic syndromes
53
Enzyme altering AEDs do what?
drugs increase there own metabolism Can decrease the levels of estrogen (birth control) and Vit D (leading to osteopenia) Dilantin = Phenytoin Tegretol=Carbamazepine Frequently require levels to determine appropriate control and toxicity
54
Non enzyme altering AEDs do what?
meds avoid these issues of metabolism Keppra=Levatriacetam Neurontin=Gabapentin
55
Tegretol = Carbamazepine
``` used for focal seizures is most common ,oldest Requires levels CBC to monitor WBC Chemistry to monitor LFT’s Major side effects include drowsiness, diplopia, fogged thinking FDA Pregnancy class D ```
56
Depakote =Valproic Acid
``` used for generalized epilepsy is most common/oldest Requires the same lab evaluation CBC, LFT Major side effects include Tremor Weight gain FDA pregnancy class D ```
57
Keppra = Levetiracetam
``` is a wide spectrum (focal and generalized seizures) medication with no drug interactions – no enzyme associations- no lab required- and FDA pregnancy class C It has irritability as a side effect ```
58
Lamictal=Lamotrigine
is a wide spectrum option used in Pediatrics and Adults with no routine lab FDA pregnancy class C (perhaps the best drug to consider if Teratogenic issues arise) Rash as a major side effect requiring slow upward titration
59
treatment for Juvenile Absence Epilepsy (syndrome)
Rx Ethosuximide=Zarontin which is only used for this syndrome
60
Febrile seizures
``` age 6mo to 6 yrs Associated fever sometimes just after event brief duration (1-2 min max) sometimes family hx - normal lab Value of scan questionable NO AED ```
61
Benign Rolandic Epilepsy
``` age 3-12 occurs with tired child – characteristic EEG with sleep Centro temporal spike may happen a few times in 9 yr span --NO AED ```
62
Treatment for Juvenile Myoclonic Epilepsy
Treatment Valproic Acid-or Levetiracetam (gets worse with Carbamazepine )
63
Juvenile Absence Epilepsy (syndrome)
Characterized by age 3-15 yrs 85% resolve requiring no meds in adulthood EEG 3 hz spike and wave generalized paroxysmal events Clinically patients have only staring spells and no memory of events :
64
Definiton of Status Epilepticus (SE)
Continuous seizures or Repetitive discrete seizures with impaired consciousness in between Generalized Convulsive SE (GCSE) Nonconvulsive SE For 15 to 30 minutes SE is a medical emergency: For GCSE Tx usually started after 5 min
65
complications of Status Epilepticus
Cardiorespiratory dysfunction Hyperthermia Metabolic derangements Irreversible neuronal injury
66
Most common causes of GCSE (SE)
``` AED withdrawal / noncompliance Drug toxicity CNS infection CNS tumors Metabolic disturbances Head trauma Refractory epilepsy ```
67
Status Epilepticus Treatment
Lorazepam (Ativan) 4 mg IV over 2 min, may repeat x1 IF NO RESPONSE and IF able to intubate Then Midazolam (Versed) .2 mg/kg push can repeat q 5 min x10 or start infusion .05mg/kg/hr to .29mg/kg /hr and start Fosphenytoin (Cerebyx) 20 mg PE/kg at 100mg min Or Valproate (Depakote) 40mg/kg IV over 20 min

Neurology= Clinical Medicine (6 decks)

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