seizures / epilepsy / convulsions Flashcards
WHAT IS STATUS epilepticus ?
seizures lasting for >30min, or repeated seizures without intervening
consciousness. Mortality and the risk of permanent brain damage increase with the
length of attack
time threshold after which a seizure is considered SE differs according to the type of a seizure:
≥ 5 minutes for tonic-clonic seizures
≥ 10 minutes for focal seizures with impaired consciousness
10–15 minutes for absence seizures
what is the difference between seizure , epilepsy and convulsion?
seizure - abnormal electrical discharge in your brain
single seizure doesn’t mean you have epilepsy
Epilepsy is defined as having chronic seizures
characterized by a predisposition to seizures
convulsion - general term that people use to describe uncontrollable muscle contractions
Not all seizures are characterized by convulsions. if you have a seizure you can simply feel confused without a physical reaction
for epilepsy to be diagnosed what needs to be demonstrated ?
Two or more unprovoked or reflex seizures separated by more than 24 hours
or
unprovoked or reflex seizure in an individual with a high risk of subsequent seizures (e.g., after traumatic brain injury, stroke, CNS infections)
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A single seizure or multiple provoked or triggered seizures (e.g., febrile seizures) without an underlying predisposition to seizures do not suffice for the diagnosis of epilepsy.
what is the aetiology of seizures ?
Seizure triggers are stimuli that can precipitate seizures both in people with and without epilepsy.
Excessive physical exertion Alcohol consumption Fever (febrile seizures) Sleep deprivation Flashing lights (e.g., strobe lights, video games) Music Hormonal changes - after menopause
etiology of epilepsy ?
genetic
Genetic mutations affecting ion channels or transmitter receptors
Chromosomal abnormalities (e.g., Angelman syndrome, Prader-Willi syndrome, Rett syndrome)
Genetic metabolic disorders (e.g., PKU !!!!, congenital disorders of glycosylation, lysosomal storage diseases,
Mitochondrial diseases (e.g., MELAS)
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structural - cerebral lesion or abnormality
Perinatal injury, e.g., hypoxic-ischemic injury Brain tumors and metastases Traumatic brain injury (TBI) Hippocampal sclerosis Tuberous sclerosis
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Metabolic
Inborn errors of metabolism - PKU
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Immune: autoimmune encephalitides
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Infectious: chronic CNS infection (e.g., toxoplasmosis, malaria, neurocysticercosis) or complication of acute CNS infection
what is the classification of seizure according to location
1) location of abnormal activity
focal - Originates within the networks of a single hemisphere
Generalized - Originates from both hemispheres
Unknown
Focal to bilateral tonic-clonic: focal progresses to a tonic-clonic pattern (characteristic of bilateral brain involvement)
what are the different types of seizures according to clinical manfestation ?
Simple partial (focal)
no loss of consciousness
seizures or ‘auras’
“rising” feeling in your tummy – like the sensation in your stomach when on a fairground ride
can be motor - jerking movements of a foot, the face, an arm or another part of the body
sensory - hearing problems, hallucinations
unusual smells or tastes
Autonomic : may cause changes in blood pressure, heart rhythm, or bowel or bladder function
psychic
a feeling that events have happened before (déjà vu)
tingling in your arms and legs
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Complex partial (focal) seizures lose your sense of awareness and make random body movements, automatisms such as: smacking your lips rubbing your hands making random noises (grunting shouting) moving your arms around unresponive and have no memory of it
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Tonic-clonic seizures
happen in 2 stages
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Absence
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Myoclonic seizures
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Clonic seizures
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Tonic seizures
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Atonic seizures
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febrile seizures
what are the different types of epilepsy ?
Reflex epilepsy
Epilepsy in which seizures are consistently provoked by a certain trigger (e.g., lights, music, hormonal changes during menstrual cycle). Subtypes can be determined based on the trigger and include:
Photosensitive epilepsy
Musicogenic epilepsy
Catamenial epilepsy
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Drug-resistant epilepsy: epilepsy in which at least two antiepileptic drugs have failed to prevent seizures
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Resolved epilepsy
age‐dependent epilepsy syndrome that has not recurred in individuals who are now past the applicable age.
Under generalised onset seizures what are the common symptoms of all the types of seizures
Symptoms are produced by bilateral cerebral cortex disturbances.
Start with loss of consciousness.
Patients do not recall the seizure.
Aura is uncommon
clinical manifestation of Tonic-clonic seizure (grand mal) ?
ICTAL
Prodromal symptoms
sleep disturbances, lightheadedness, mood changes, anxiety/irritability, impaired concentration
Loss of consciousness (sudden and without warning)
Motor symptoms
1) Tonic phase
Generalized muscle contraction: muscles go stiff
!! ROTATED EYES, APNEA, LATERAL TONGUE BITING !!
pooled oral secretions, cyanosis,
Increased sympathetic tone: dilated, unresponsive pupils,
↑ heart rate,
↑ blood pressure
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Clonic phase: rhythmic muscle twitching
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Bladder or bowel incontinence
Usually lasts 1–3 minutes
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POST - ICTAL
Unresponsiveness - last a few seconds or up to an hour
Confusion Amnesia of the event Aphasia Fatigue Muscular flaccidity and muscle pain
clinical manifestation of clonic seizure ?
ICTAL
Loss of consciousness - if general
Bilateral rhythmic jerking (of the entire body or only a part)
typically lasts a few minutes
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post - ictal
Amnesia of the event
Under generalised motor seizures, what are the clinical manifestation of tonic seizure ?
ICTAL
Often occurs when the patient is drowsy, asleep, or after waking
Loss of consciousness
Muscle stiffening (extension or flexion of the head, trunk, and/or extremities)
can be bilateral or unilateral
Can be accompanied by
autonomic symptoms (e.g., tachycardia, flushing)
This might mean you lose balance and fall over
Can be followed by atypical absence seizure
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POST ICTAL
Amnesia of the event
Drowsiness or confusion may occur
Under generalised motor seizures, what are the clinical manifestation of myoclonic seizure ?
Positive myoclonus: sudden jerk-like muscle twitching
Negative myoclonus: a brief loss of muscle activity during tonic contraction of a muscle
can affect the entire body or only a part.
Myoclonic seizures
often happen soon after waking up.
normally remain awake during them
only last a fraction of a second, but several can sometimes occur in a short space of time.
are nonrhythmic (i.e., jerks occur at different intervals) and irregular (i.e., jerks are asymmetric and may change laterality)
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post ictal
amnesia
Under generalised motor seizures, what are the clinical manifestation of
1) myoclonic - atonic seizure ?
2) Myoclonic-tonic seizure?
3) Atonic seizure (also known as “drop seizure” or “drop attack”?
ICTAL
1) Myoclonus followed by a brief loss of tone
2) Myoclonus followed by a brief increase in tone
3) Sudden loss of muscle tone: sudden head drop or collapse (lasts < 15 seconds)
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post ictal
amnesia
clinical manifestation of Typical Generalized nonmotor seizure (absence seizure)
Sudden onset and stop
They mainly affect children
you lose awareness of your surroundings for a short time.
stare blankly into space
look like they’re “daydreaming”
blank stare, unresponsiveness
with sudden stop in motion
Subtle automatisms (often go unnoticed): lip-smacking, eye fluttering, or head nodding are common.
may fall to the ground.
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Can occur several hundred times a day and usually lasts < 10 seconds
tend to be very brief and They can happen several times a day.
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post ictal
awareness returns rapidly, without any impairment
Amnesia is common
clinical manifestation of ATypical Generalized nonmotor seizure (absence seizure)
Gradual onset and stop
Interrupted motion or activity, blank stare
Patients may be responsive
Automatisms: lip-smacking, eye fluttering, chewing
Small hand movements (e.g., rubbing of the fingers)
Longer than typical form (10–30 seconds)
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post ictal
awareness returns rapidly, without any impairment
Amnesia is common
what is the diagnosis of seizures ?
important to distinguish between focal/bilateral tonic-clonic seizures and generalized tonic-clonic seizures, as they manifest similarly but are managed differently.
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CONFIRMATION OF SEIZURE
History
description of the event by the patient (aware seizure) and/or witnesses (seizure with impaired awareness)
Potential triggers (e.g., sleep deprivation, excessive alcohol intake)
Prodromal symptoms (e.g., aura)
Ictal symptoms
Postictal symptoms
Past medical history
History of epilepsy
History of other potential underlying conditions (e.g., head trauma, stroke, tumor, CNS infection)
Physical examination: attention should be paid to visual inspection e.g., for bruises from falls, tongue bites, phakomatosis-specific skin manifestations and evaluation for cardiovascular disorders
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EEG
Performed in individuals who present with first seizure, with insufficient information for seizure classification
During the seizure (ictal) Epileptiform discharges (e.g., spikes, sharp waves, spike waves) are usually detected.
3 Hz spike-and-wave in typical absence seizures
- After a seizure or between seizures (postictal or interictal)
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Video-EEG telemetry in hospitalized patients
Continuous EEG in ambulatory patients
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Evaluation for underlying conditions
ECG: Rule out cardiogenic causes (e.g., cardiac arrhythmias resulting in cerebral hypoxia)
MRI: Modality of choice for investigating potential underlying structural abnormalities.
All patients with first-time focal seizures
Angiography: if vascular cause (e.g., cerebral arteriovenous malformation) is suspected
laboratory screening: to identify metabolic disorders and infectious diseases, if suspected Blood CBC Glucose! Electrolytes! Prolactin Toxicology screening!
In adults, an isolated unprovoked focal or focal to bilateral tonic-clonic seizure typically indicates a structural or metabolic origin and should receive further evaluation
dd
patient be pregnant - If so, eclampsia check the urine and BP: call a senior obstetrician—immediate delivery
may be needed
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Psychogenic nonepileptic seizures
Female sex
Psychiatric disorders (e.g., obsessive-compulsive disorder, posttraumatic stress disorder)
History of physical or sexual maltreatment
Substance use
Usually occur in presence of eyewitnesses
Generalized asynchronous motor activity
Forced eye closure
Tongue-biting and other types of self-injury are rare.
Awareness is usually unimpaired
Individuals with PNES can recall the event
Typically > 5 minutes
diagnostics - Video-EEG monitoring
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Panic attack
due to Genetic predisposition
Anxiety disorders
Stress
Palpitations
Chest pain
Sweating
Dyspnea
Seconds to hours
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Syncope
trigger - Emotional stress
Pain
Sudden changes in body position
Dehydration
Transient loss of consciousness and muscle tone Prodromal symptoms Dizziness Palpitations Pallor Sweating
1–2 minutes
what is the management of seizures?
to terminate seizures lasting more than a few minutes as soon as possible (<20min) because brain damage increases
Seizures are usually self-limiting and may not require administration of antiseizure drugs.
Long-term therapy with antiepileptic drugs is required for individuals who meet the criteria for epilepsy
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Acute management
A-E
chin lift head thrust - look for airway obstruction - suction or finger sweep
adjuncts as necessary
Oropharyngeal airway
Nasopharyngeal airway
Place the patient in the recovery position to prevent injury.
call for help early using an appropriate SBARR handover structure.
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B - give 100 percent oxygen and suction as required
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C - IV access
take blood: U&E, LFT, FBC, glucose, Ca2+ Toxicology screen if indicated
check glucose levels !!!
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Remove cause or provoking factors (e.g., cessation of recreational drug use, treatment of underlying disorders)
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Acute seizures are usually self-limiting and do not require pharmacological treatment.
If a seizure has not ceased after 5 minutes (indicating status epilepticus), the patient should receive antiseizure medications, starting with benzodiazepines
(lorazepam 4mg) as a slow bolus into a large vein, midazolam, or clonazepam)
IV route is preferred.
if not rectal route
if not Buccal midazolam
Give 2nd dose of lorazepam if no response after 10–20min
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Stage 2
40 minutes after the onset of a seizure or after stage 1 treatment failed: a single dose of IV phenytoin or valproic acid
WITH MONITORING OF BP and ECG
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Stage 3
60-90 minutes after the onset of seizures or after stage 1 and 2 treatment failed): induction of coma with IV propofol, midazolam, thiopental,
BUT WITH EXPERT HELP
and ventilation with continuous EEG monitoring in ICU. NB: never spend longer than 20min on someone with status epilepticus without having help at the bedside from an anaesthetist
what are the first line and second line treatment for Focal seizures ?
LAMOTRIGINE
LEVETIRACETAM
PHENYTOIN
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second line
gabapentin
valproate
what are the first line treatment for generalised seizures ?
TONIC-CLONIC
Lamotrigine
Valproate
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MYOCLONIC
ATONIC
ATYPICAL ABSENCE
Valproate
Lamotrigine
Topiramate
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TYPICAL ABSENCE
Ethosuximide
Valproate
how is drug resistant epilepsy managed ?
nonpharmacological methods (e.g., with surgery, neurostimulation, ketogenic diet).
how is termination of a seizure concluded ?
evaluated on a case‑by‑case basis
considered if the patient has < 2 seizures/year, an inconspicuous provocation
EEG, normal psychological findings, and no hereditary predisposition
Generally possible after 2–5 seizure‑free years with normal EEG results
complication of epilepsy?
acute
Hyperthermia,
cardiorespiratory deficits, and excitatory toxicity potentially causing irreversible tissue damage (especially to the CNS; e.g., cortical laminar necrosis) and, in turn, increase the risk of further seizures.
Tongue biting
Posterior dislocation of the glenohumeral joint from falling
Long‑term
Psychiatric
Anxiety
Depression and risk of suicide
Sleep disturbances and insomnia
Sudden unexpected death in epilepsy
difference between myoclonic and clonic seizure
clonic seizures are rapid rhythmically recurrent events, whereas myoclonic seizures are single or irregularly recurrent events
if alcohol or malnourishment suspected cause for seizure ?
thiamine 250mg IV over 30min
