WEEK 2: Seizure and Epilepsy [Salonga] Flashcards
when does epilepsy peak?
first peak in children (1-9) second peak (60)
The key to a successful management of seizures and
epilepsy is
Early recognition and correct diagnosis
Pathophysiology of seizure?
1. Decreased inhibition o Defective GABA-A inhibition o Defective GABA-B inhibition o Defective activation of GABA neurons o Defective intracellular buffering of calcium 2. Increased activation o Increased activation of NMDA receptors o Increased synchrony between neurons o Increased synchrony and/or activation due to recurrent excitatory collaterals
GABA is _________ while Glutamate is _________
inhibitory
excitatory
how can epilepsy be diagnosed? (3) Clinical definition
- at least 2 unprovoked seizure occurred greater than 24 hrs apart have been documented or witnessed
- In the presence of one unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after 2 unprovoked seizures, occurring over the next 10 years;
- In cases where diagnosis of an epilepsy syndrome is considered
when is epilepsy considered to be resolved?
if age dependent epilepsy syndrome, are now past the applicable age.
2. seizure free for the last 10 yrs with no seizure meds for the last 5 years.
epileptic disorder characterized by a cluster of signs and symptoms customarily occurring together.
epilepsy syndrome
partial seizure are now termed as?
Focal
major classifications of seizure?
Focal
Generalized
Unknown Onset
what are the classification under the focal onset of seizure?
Impaired awareness vs aware
Motor vs non motor
focal to bilateral tonic clonic
classification of seizure under generalized onset?
motor vs non motor
classification of seizure under unknown onset?
motor, non motor, unclassified
In patients with generalized onset, they should have have impaired awareness. T or F?
T
Described a pseudoseizure
patients who have motor seizures na generalized pero may awareness naman.
Seizure arising from a specific location in one cerebral hemisphere
Focal seizure
What seizure: The first clinical and EEG changes indicate synchronous involvement of all of both hemispheres
Generalized seizure
Post ictal manifestations in generalized seizures
maybe confused, drowsy, sleep for a while or have headache
non motor na absence is under what category of seizure?
generalized
if both motor and non motor symptoms are present, which one predominate?
motor
what are etiology of seizures in neonates?
Hypoglycemia
• Hypocalcemia
• Hypomagnesemia
• Hyponatremia or hypernatremia
among neonates, we always give what drug is given to patients with difficulty in controlling seizures
pyridoxine
cerebrovascular causes of epilepsy?
hypoglycemia Arterial and Venous Ischemic stroke Hypoglycemia • Hypocalcemia • Hypomagnesemia • Hyponatremia or hypernatremia
vitamin B6 aka?
Pyridoxine
CNS infection causes of epilepsy?
Bacterial meningitis
Viral meningoencephalitis
intrauterine “torch” infections
developmental causes of epilepsy
Multiple forms of cerebral dysgenesis • Hypoxic-ischemic encephalopathy • Rare genetic syndromic disorders • Early myoclonic encephalopathy • Benign neonatal familial convulsions
Recommended terminology for etiology of epilepsy are?
Genetic
Structural metabolic
Unknown
It is an epileptic disorder characterized by a cluster of signs
and symptoms customarily occurring together. These include
such items as type of seizure, etiology, anatomy, precipitating
factors, age of onset, severity, chronicity, diurnal and
circadian cycling and sometimes prognosis.
Epilepsy syndrome
Infantile spasms - west syndrome what is the onset?
onset between 3 and 10 months
manifestation of infantile spasm west syndrome?
Spasms of head, neck, trunk, extremities o Flexor spasm o Extensor spasm • Mixed flexor-extensor spasms • Developmental regression
findings of infantile spasm west syndrome on EEG?
hypsarrhtyhmia - abnormal interictal high amplitude
waves and a background of irregular spikes.
DOC for IS west syndrome?
ACTH (but not available in the phil)
abnormal interictal high amplitude
waves and a background of irregular spikes.
hypsarrhtymia
Unlike other epilepsy syndromes, patient with IS does not
normally respond to the common anti-seizure medications. T or F?
T
DOC for Infantile spasm assoc with Tuberous sclerosis?
Vigabatrin
Treatment for Infantile spasm West syndrome which is available in the phil?
Oral Prednisolone (4 mg/kg/day max 60 mg/day)
2 weeks then wean
other anti seizure meds that can be tried with IS west syndrome together with DOC?
Valproic Acid and Topiramate
onset of childhood absence epilepsy
Age at onset between 4 and 10 years, Peak 5-7 years
EEG findings in Childhood absence epilepsy?
EEG: High amplitude spike and wave discharges – 3 Hz
BENIGN FOCAL EPILEPSY WITH CENTROTEMPORAL SPIKES
(BECTS) aka?
benign rolandic epilepsy
BENIGN FOCAL EPILEPSY WITH CENTROTEMPORAL SPIKES
(BECTS) age of onset? predominance? remission?
Age of onset between 1-14 years, 75% between 7-10 years
• Male predominance – 1.5:1
• Remission usually before age 16 years
manif of BECTS?
unilateral facial sensorimotor
symptoms, oropharyngeal manifestations, speech arrest,
hypersalivation
EEG Finding in BECTS?
Centrotemporal spikes – usually bilateral, activated in
sleep
2 types of Benign Occipital Epilepsy
Panayiotopoulous Type
Gastaut Type
Benign susceptibility to autonomic seizures and autonomic status epilepticus
• Onset from age 1-14 years, 76% between 3-6 years (Mean: 5 years)
• Seizures characterized as: autonomic (pallor, flushing, cyanosis), vomiting, behavior changes, deviation of the eyes
- Remission within 1-2 yrs, Seizures after age 15 years rare
Panayiotopoulous Type (benign occipital epilepsy)
EEG findings in Panayiotopoulous Type (benign occipital epilepsy)
EEG: focal spikes – usually in the posterior regions but may appear anywhere
Purely occipital seizures
• Mean age at onset: 8 years
• Seizures characterized as: elementary visual hallucinations, blindness, deviation of the eyes
• Post-ictal headache
• Prognosis not as predictable
• 50-60% experience remission within 2-4 years from onset
Gastaut Type of benign occipital epilepsy
Age at onset between 8-26 years, 75% between 12-18 years
• Myoclonic jerks occur sooner in girls (12-14 y) than in boys (14-16y)
• GTCS occur later
• Seizures: Myoclonic jerks, GTCS, Typical Absences, perioral reflex myoclonias (talking)
• Photosensitivity
JUVENILE MYOCLONIC EPILEPSY
EEG Findings in JUVENILE MYOCLONIC EPILEPSY?
EEG: Polyspike and wave discharges
Drugs for myoclonic seizure?
***Valproate
Levetiracitem (FDA Indication as adjunctive Rx in JME)
Clonazepam (FDA indication)
Possibly effective: Zonisamide, Topiramate
in level of Evidence and Classification of recommendation, what does Level A B and C mean?
LOE A Data derived from multiple randomized clinical trials or meta-analyses
LOE B Data derived from a single randomized trial or nonrandomized studies
LOE C Only consensus opinion of experts, case studies, or standard-of-care
in level of Evidence and Classification of recommendation, what does CLASS 1, 2, 3 mean?
Class I Conditions for which there is evidence for and/or general agreement that a procedure or treatment is beneficial, useful, and effective
Class II Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment
Class IIa Weight of evidence/opinion is in favor of usefulness/efficacy
Class IIb Usefulness/efficacy is less well established by evidence/opinion
Class III Conditions for which there is evidence and/or general agreement that a procedure/treatment is not useful/effective and in some cases may be harmful
antiepileptic drug that we dont give to female because of its teratogenic effect?
Valproate
For children with partial onset seizures:
o Based on available efficacy and effectiveness evidence alone, this drug should be considered a candidate for initial monotherapy
Oxcarbazepine;
CBZ, PB, PHT, TPM, and VPA are possibly efficacious or effective as well (level C).
carbamazepine, phenobarbital, phenytoin, topiramate, valproic acid
An epileptic encephalopathy, and is something progressive
• Onset before age 8 years, peak between 3 and 5 years
• 1/3 of patients have a history of infantile spasm
LENNOX-GASTAUT SYNDROME
These are not benign causes or syndromes of epilepsy. You may have read about this because of the controversy with the use of marijuana. This is one of the most difficult to treat type of epilepsy and that’s why they have tried, and with some success, to use marijuana in this type of seizure.
LENNOX-GASTAUT SYNDROME
Triad (form of diagnosis) of Lennox-Gastaut Syndrome?
- Multiple seizure types: axial tonic, atonic, atypical absence
- EEG:
▪ Diffuse slow spike and wave discharges – 1-2 Hz (awake)
▪ Generalized polyspikes (sleep) - Cognitive impairment
Best evidence/ FDA indication for Lennox-Gastaut Syndrome?
Best evidence/ FDA indication:
o Topiramate, Felbamate, Clonazepam, Lamotrigine, Rufinamide
These are new drugs, we call as Designer drugs
o (FDA approval is for adjunctive treatment for all except clonazepam)
• Also effective:
o Valproate
• Some evidence of efficacy:
o Zonisamide, Levetiracetam
Annual prevalence of epilepsy
0.5-1%.
The occurrence of a single seizure or of febrile seizures does not necessarily imply the diagnosis of epilepsy. T or F?
T
laboratory tests for first unprovoked seizure?
CBC with differential • Blood glucose • Electrolytes • Calcium, magnesium, phosphorous • Urine drug/toxicology screen • Urine HCG (age dependent)
when is lumbar puncture indicated as a diagnostic test for epilepsy?
only indicated if there are other symptoms that suggest a diagnosis of meningitis
FEATURES FAVORING EPILEPTIC SEIZURES?
Presence of an aura • Brief duration (1-2 minutes) • Postictal confusion • Abnormal posturing • Amnesia for the event • Incontinence • Events arising from sleep - self injury (lateral tongue biting) - Eyes open at the onset of event
Lateral tongue bite is very highly suggestive of seizure, but if the tongue bite you see is at the tip of the tongue that’s usually not related to seizure. That might be
psychogenic seizures
Occur between the age of 6 and 60 months
• With a temperature of 38°C or higher
• NOT the result of central nervous system infection or any metabolic imbalance
• Occur in the absence of a history of prior afebrile seizures
Febrile Seizures
2 types of febrile seizures?
Simple and complex
a febrile seizure that
Do NOT have an increased risk of mortality even though they are concerning to the parents.
o There are no long-term adverse effects of having ≥1 of this
simple febrile seizure
a febrile seizure that May have an approximately 2-fold long-term increase in mortality, as compared to the general population over the subsequent 2 yr., probably secondary to coexisting pathology.
More worrisome, because it is also associated with increased mortality and developmental problems
complex febrile seizure
Primarily generalized(usually tonic-clonic)
Attack associated w/ Fever
Lasting for a maximum of 15min
NOT recurrent within a 24-hr period
Simple Febril seizure
When you make a diagnosis of SIMPLE Febrile Seizures, these elements should ALL be present.
Focal
Attack associated w/ Fever
Lasting greater than 15min
Recurs within a 24-hr period
Complex febrile seizure
When you make a diagnosis of COMPLEX Febrile Seizures, presence of ANY ONE of these elements would suffice to make a diagnosis of Complex Febrile Seizures
Febrile seizure lasting > 30mins
Febrile status epilepticus
Risk Factor for occurrence of subsequent epilepsy is HIGHEST when you have
neurodevelopmental abnormalities and focal complex febrile seizures
first aid drugs for acute febrile seizure?
midazolam, diazepam
Defined as continuous seizure activity or recurrent seizure activity WITHOUT regaining of consciousness lasting for more than 5min
status epilepticus
defined as a “a condition characterized by an epileptic seizure that is sufficiently prolonged or repeated at sufficiently brief intervals so as to produce an unvarying and enduring epileptic condition
status epilepticus
determines the time at which treatment should be considered or started,
time point of operational dimension (t1)
determines how aggressively treatment should be implemented to prevent long-term consequences.
time point of operational dimension (t2)
what is T1 in tonic clonic seizure? t2?
5 mins; 30 mins
in Focal SE w/ Impaired Consciousness what is t1 and t2?
10 mins; 60 mins
For Absence Status Epilepticus, what is t1 and t2?
10 -15 mins; unknown
initial therapy of choice that will give you the immediate effect for seizure control
Benzodiazepine
We either give MIDAZOLAM, LORAZEPAM, or DIAZEPAM. Pero wala tayong lorazepam. So we either have a choice of Midazolam or Diazepam.
MIDAZOLAM ADVANTAGE – it can be given via IM, because sometimes it is very difficult to put in a line
DIAZEPAM DISADVANTAGE – It cannot be given IM, it will take a long time to have a therapeutic level
dose of benzodiazepine for children?
for patients weighing >40kg, they should be given 10mg of Midazolam IM, and for 13-40kg only 5mg single dose.
If the seizure is still not controlled, even after second line drugs, what should we do
put the patient in general anesthesia.
mortality rate of status epilepticus?
10 % but in children 6%
complications of status epilepticus
- Hypoxemia
- Acidemia
- Glucose alterations
- Blood Pressure Disturbances
- Increased intracranial pressure
- Morbidity
