Seziures Flashcards
A one-time event – a single surge of electrical activity in the brain.
Seizure
Multiple seizures. Diagnosis requires at least two “unprovoked” (natural) seizures.
Seizure Disorder
Triggered “provoked” by a disorder, event, or other condition that irritates the brain (febrile, birth trauma, brain tumor, pseudo seizures)
Non-epileptic Seizure
Once a person has a single unprovoked seizure, he/she has what chance of having another seizure and a 2nd seizure?
- 50% for another
- 2nd seizure often occurs within 6 months of first - If had two seizures, ~80% chance of recurrent seizures.
high-risk features that increase seizure recurrence after a 1st unprovoked seizure:
- Epileptiform abnormalities on EEG.
- Remote symptomatic cause, as identified by clinical history or neuroimaging (eg, brain tumor, brain malformation). Acute symptomatic seizures have a lower risk for subsequent epilepsy.
- Abnml neuro exam, including focal findings and intellectual disability.
risk factors for seizures
7
- age - very young or old (>60)
- some children will outgrow them - brain infections/tumors
- dementia
- FHx
- vascular dz
- other: head injuries/brain trauma, inadequate O2 to the brain, cerebral edema
- chronic diseases: metabolic, autoimmune, kidney or liver failure, hypoPTH, vit B6 def
no real correlation with ethnicity or gender - caucasians MC generalized epilepsy; certain genders may be more likely to develop certain subtypes of epilepsy.
possible drugs that can cause seizures
- Buspirone (Wellbutrin)
- Camphor (hydrocarbon)
- Chlorpromazine (Thorazine)
- Ciprofloxacin
- Chloroquine
- Clozaril (clozapine)
- Cyclosporine
- Imipenem (Primaxin)
- Indomethacin
- Meperidine (Demerol)
- Phenytoin (Dilantin)
- Theophylline
- Tramadol (Ultram)
- Tricyclics (OD)
recreational drugs that can cause seizures
Amphetamines
Cocaine (OD)
Drug Withdrawal after heavy use
toxins that can cause seizures
Lead
Strychnine
precipitating factors of seizures
- fatigue
- decreased physical health
- alc
- emotional stress
- flashing lights
- menstrual cycle
- hypoglycemia
- sleep deprivation
- stimulants
- withdrawal
- substance abuse
- high fever
- lyte disturbances
- hypoxia
stages of seizure activity
- prodromal
- pre-ictal or aura - Actually, a focal onset seizure
- ictal - During the seizure (the part of the seizure outsiders can witness)
- post-ictal
s/s of pre-ictal
Precedes the seizure by sec to min - may alert onset
Vary depending on type of seizure and area of the brain affected. Most people who have auras have the same type each time
presentation of post-ictal
- AFTER the active part of the seizure
- The body begins to rest, and after-effects may set in
- The type and length vary from person-to-person
- Numbness, HA, Fatigue, Focal weakness (Todd’s paralysis), Stupor, Confusion and Agitation, LOC or Unresponsiveness, Loss of bowel or bladder control
Two Primary Types of seizures
- focal
- generalized
- unknown
types of focal seizures
- Focal seizure w/ retained awareness (previously simple partial seizure) - Typically cause few symptoms, often overlooked or mistaken for another condition. No LOC. No memory loss
- Focal seizure w/ impaired awareness (previously complex partial seizure) - Like simple but they HAVE alter consciousness or awareness; unaware of what occurred; Unusual, repetitive movements (hand rubbing, chewing, swallowing or walking in circles)
Abnormal activity generated affects only one area of brain – the whole hemisphere or part of a lobe
focal seizure
Seizures that involve all areas of the brain. With the exception of myoclonic, all involve LOC. Because they spread quickly, it can be impossible to tell point of origin.
Generally NOT preceded by an aura. Categorized as Motor onset or Non-motor onset.
generalized seizures
types of generalized seizures
- Absence
- Myoclonic
- Atonic
- Tonic
- Clonic
- Tonic-Clonic
- Only non-motor onset, all other generalized seizures are motor onset
- staring and subtle body movement with impairment of consciousness. (ex. lip smacking); “spacey”
absence seizures
If lasting >45 sec or pt has a post-ictal phase = focal seizure instead
- sudden, irregular, brief jerks or twitches (myoclonic jerks) of the arms and legs, jaw, or generalized throughout the body, milliseconds in duration but ongoing for >30 min w/ partial retained awareness.
- jumps inside the body that may affect the limbs, jaw, or other body parts.
myoclonic seizures
- a rare condition characterized by non-epileptic spasms. The spells begin before age 1 yr and are self-limited. The EEG is invariably normal, and neurologic development is not affected.
- commonly mistaken with myoclonic seizures
benign myoclonus of infancy
- Sudden loss of muscle control w/o myoclonic or tonic features for < 2 sec
- Head, neck, or limbs.
- slumping or nodding briefly before recovering to sudden fall or collapse.
- pt is unaware of what happened.
- Usually associated w/ intellectual impairment.
Atonic Seizures (Drop Attacks)
- Cause muscles - often of the bilateral arms, legs, and back - to tighten and stiffen. Lasts seconds-minutes.
- Most fall to the ground bc of muscle rigidity.
- May turn blue if breathing is impaired.
- associated w/ intellectual impairment.
Tonic Seizures
- Convulsive movements - associated with bilateral rhythmic, jerking muscle movements; usually affecting the neck, face and arms.
Clonic Seizures
how to differentiate clonic from myoclonic
clonic - rhythmic jerking (vs. irregular jerking) as well as altered consciousness.
- Sometimes associated with loss of bladder/bowel incontinence, tongue biting, loss of body secretions (foaming of the mouth).
- Can last from several minutes up to 20 min. After the shaking stops, it may take 10-30 min for the person to return to normal (post-ictal phase)
- Characterized by LOC, violent shaking, and body stiffening.
- Bilateral, symmetrical generalized motor involvement.
Tonic Clonic Seizures
what is West syndrome
- infantile spasms - Reflect abnormal interactions between cortex and brainstem; may be related to an immature CNS
- Age-specific epileptic disorder of infancy and early childhood - 90% dx under a year of age - (MC 4 - 7 mo)
how are infantile spasms diagnosed
hypsarrhythmia on EEG (very high voltage, random, slow waves and spikes in all cortical areas)
Common features of infantile spasms:
Symmetric, synchronous
Sudden, brief contractions of one or more muscle groups
80% occur in clusters
Average duration of spasm 4 - 6 sec
A physical manifestation of a psychological disturbance - frequently occur in conversion disorder.
A non-epileptic seizure, but superficially resemble an epileptic seizure. Nothing physically wrong.
Pseudo seizures (PNES or NEAD)
Not false, fraudulent, or produced under any sort of pretense (vs. factitious disorder)
Pseudo seizures are MC in who
women
tx for Pseudo seizures
psychotherapy
common features of pseudo seizures
- Severe tongue biting
- Last >2 min
- Gradual onset
- Closed eyes during the seizure (and resist opening)
- Side-to-side head movements.
- They will stop their hands from hitting their face.
- no incontinence
how to test is a pt is faking a seizure?
Draw a prolactin level 10-20 min after event and compare to baseline level 6 hrs later.
The relative rise of 2x from baseline is considered positive.
PRL can be elevated for a multitude of reasons including ?
syncope, neuroleptic drugs, stress
labs for seizures
- CBC
- CMP
- prolactin (?) - Elevated 3-4-fold after tonic-clonic activity
- Serum anticonvulsant lvls - Determine baseline levels, Potential toxicity, Lack of efficacy, Treatment noncompliance
- UA
- toxicity
- LP, blood cx (?)
- Electrodes sense and record the electrical activity taking place in the brain.
- This test can identify epilepsy even when the patient is not having a seizure.
Electroencephalogram (EEG)
When are Epilepsy monitoring typically done for:
indications
- To distinguish epileptic seizures from other types of spells, such as PNES, syncope, subcortical movement disorders and migraine variants.
- To characterize / classify seizures for the purposes of treatment
- To localize the region of brain from which a seizure originates for workup of possible seizure surgery
- To provide a guide to prognosis
pt prep for seizure/EEG monitoring
- Wash hair night before but don’t use products other than shampoo
- Avoid caffeine day of test
- Take usual medications
types of brain scans for seizure pts?
-
MRI
- to look for possible causes (cysts, tumors, bleeding)
- to look for areas with decreased blood flow around the time of a seizure, which may indicate which areas in the brain are causing seizures.
- Performed on any progressive disorder or new onset of seizures in a patient over age 20. - fMRI (functional MRI) - to see how blood flows through the brain, helping to identify what areas of the brain are involved during a seizure.
-
PET scan - to measure blood flow and glucose uptake
- MC increased blood flow and glucose metabolism during a seizure in the cerebral cortex.
- between seizures - lower-than-normal glucose uptake and blood flow.
tx for seizures
- refer
- Antiepileptic Drugs (AEDs)
- Non-epileptic seizures - AED after 1 PROVOKED seizure is not usually indicated
- AED after 1 UNPROVOKED seizure deferred depending on RF and pt preference. need >2 unprovoked seizures.
- AED tx for those with abnormal EEGs.
AED Therapy Guidelines
- Treat initially with AED monotherapy and when possible, maintain monotherapy.
- When to start treatment and with what agent is individualized in order to optimize both efficacy and tolerability.
- Renal and hepatic disease impacts choice of AED
- Start with one drug and gradually increase until seizure controlled or SE. If max dose and seizure not controlled or SE, add second drug and increase while the first is gradually withdrawn.
common SE of AED
drowsiness, dizziness, diplopia, imbalance, N/V
which AEDs are the most problematic for drug interactions with warfarin, OCDs, and certain anticancer / anti-infective drugs.
enzyme-inducing AEDs
- phenytoin
- carbamazepine
- phenobarbital
- oxcarbazepine
- topiramate
what med can increase the metabolism of lamotrigine (Lamictal), thereby reducing the plasma drug concentration.
OCD
what AEDs are known teratogenic agents
older 1st-generation AEDs (phenytoin, carbamazepine, phenobarbital, valproic acid)
Gingival hyperplasia associated with use of which AED
phenytonin
which AED must you check levels for often?
carbamazepine
Prior to starting AED therapy, what labs/screening must you get?
- CBC, CMP (LFTs / BUN / Cr / Electrolytes), albumin levels (for AEDs that are highly protein bound).
- Screen for depression at time of dx of epilepsy then annual f/u
monitoring during AED therapy
- Regular f/u visits to check drug concentrations, blood counts, hepatic and renal function, address concerns and possible side effects, address psychosocial aspects
- Check drug levels at least yearly in patients who are not having seizures and are not undergoing medication dose changes.
- Ask patients to keep a “seizure journal”
1st line monotherapy for focal seizures
Lamotrigine (Lamictal)
1st line monotherapy for generalized seizures
Valproate (Depakote)
Not given to pregnant women
what is the preferred AED for pregnant pt with generalized seizures
Levetiracetam (Keppra)
what specific etiologies may impact tx choice?
Post-stroke epilepsy
brain tumors
AIDS
when to DC AEDs?
After at least 2-yr seizure free interval
No data that indicate an optimal tapering regimen. The following considerations may be helpful:
- Rapid changes in tx increase the risk of provoking seizures (esp carbamazepine and oxcarbazepine).
- Slow rates of AED taper (6 mo) = moderate rates (2-3 months) - Exceptions are benzos and barbiturates - very gradually
- In patients on combo therapy, taper one drug at a time
guidelines for driving after AED cessation
There are no guidelines or consensus regarding driving restrictions during and after AED withdrawal.
Driving cessation for 6 mo following an unprovoked seizure is appropriate but follow state legislated guidelines.
when to consider surgery for seizures
- If seizures continue w/ 2+ AEDs or if they can’t tolerate side effects of AEDs
- imaging detects area of brain affected, and it’s small and well-defined (esp temporal lobe)
- may be performed to prevent seizures from spreading to other areas of the brain
Surgically cutting the _____ may help people who have seizures that originate in several areas of the brain or that spread to all parts of the brain very quickly
corpus callosum
Even if surgery reduces frequency and severity of seizures, many people need to do what?
continue to take AEDs, but usually in lower doses/fewer drugs.
a newer option for those who are not optimal surgical candidates
Chronic vagal nerve stimulation
what diet has some evidence to help seizures
keto
- for intractable epilepsy, esp childhood
- mechanism is unknown
- monitor urinary ketones daily in hospital and several times a week at home
- avoid excessive stimulants and energy drinks
A state of continuous seizure activity lasting longer than 5-10 min or several seizures occurring during a 30 min time frame, or when patient does not completely regain consciousness between two or more seizures.
Status epilepticus - A neurological emergency
tx for Status epilepticus
Large doses of +1 AEDs, lorazepam 4 mg given IV push to stop the seizure.
- 2 mg/min and repeated once after 10 min if necessary
- Diazepam alternative as a gel (0.2 mg/kg)
- Fosphenytoin or phenytoin is given IV to initiate long term seizure control regardless of response to benzos above
All patients with epilepsy should be given a Rx of?
diazepam
Diastat rectal gel
Valtoco nasal spray
Only 2 to 18% of people with epilepsy die from SUDEP. Cause is unknown, but one theory suggests what?
heart and respiratory issues may contribute to the death
- First-time seizure (no medical ID and no known h/o seizures)
- Repeated seizures without regaining consciousness
- More seizures than usual or change in type
- Person is injured
- Seizure during pregnancy
- Person has DM
- Seizure occurs in water
- Normal breathing does not resume
precautions during a seizure
- maintain airway - Protective headgear when bicycling, skiing, etc
- prevent injury - Good prenatal care to protect baby against epilepsy.
- pay attention to length of the seizure
- be vaccinated - Childhood vaccinations can guard against diseases that might lead to epilepsy
- padded side rails on the bed
- do not hold down the person
- do not put anything in their mouth
- if lasting >5min: call 911
- Document length of seizure, preceding aura, LOC, precipitating factors, incontinence, resp difficulty
complications of seizures
- car accidents
- Many states do not issue driver’s licenses until patient is seizure-free for a specified period of time.
- The seizure-free interval (time since last seizure) is an important factor in assessing risk of MVA - personal injury
- 15-19x more likely to drown; never swim alone.
- Falls - pregnancy related
- Women w/ epilepsy can get pregnant and have healthy pregnancies and babies, but extra precaution is needed.
- Some AED can cause birth defects. - psychosocial issues
- depression, anxiety, suicidal thoughts / actions.
- Employment negatively impacted, even when seizures are infrequent.
- Loss of independence (driving)
- Problems obtaining insurance
seizures increase what type of comorbidties?
- Increased prevalence of cardiovascular, respiratory, inflammatory, and pain disorders than adults without epilepsy.
- Sleep-related breathing disorders
- Cognitive impairment
Recognition of medical comorbidities can facilitate treatment of epilepsy and is particularly important when selecting AED therapy.
which AED are hepatic enzyme inducers
- phenytoin
- carbamazepine
- barbiturates
- oxcarbazepine
- topiramte
which AED can concomitant a migraine?
- valproate
- gabapentin
- topiramate
what AED have parenteral available?
- phenytoin/fosphenytoin
- valproate
- barbiturates
- benzos
which AEDs are high protein binding?
6
- phenytoin
- valproate
- tiagabine
- carbamazepine
- clobamazepine/clonazepam
- phenobarbital
what AEDs to avoid in young women and why?
- valproate - higher teratogenic risk
- phenytoin - cosmetic effects, hirutism
which AEDS are mainly renally excreted
- gabapentin
- levetiracetam
- topiramate
which AEDs are associated with weight loss?
- topiramate
- zonisamide
which AEDs are QD (increasing compliance)
- phenytoin
- zonisamide
- valproate
- phenobarbital
which AEDs can manage cluster seizures?
- lorazepam perorally
- rectal diazepam gel
