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Flashcards in 5. Seizures Deck (29):
1

A 25 year-old woman is referred for episodes of altered behavior. These episodes last for 2 minutes, and are associated with lip-smacking movements and repetitive behavior. The patient does not remember these events, but says that she feels “butterflies in my stomach” and a sense of fear before they occur. Sometimes she says she smells burning rubber as well. What is the most likely diagnosis?

Complex partial seizure

2

Most focal epilepsies arise from which location?

Mesial temporal areas/hippocampus

3

An otherwise healthy 65 year-old man has the first seizure of his life. You suspect...

A brain tumor

The rate of epilepsy is high in early childhood (Ages 0-14).

Causes of most seizures in children:

  • Genetic factors
  • Congenital malformations
  • Trauma
  • Neoplasms

The risk of epilepsy declines significantly until age 60.

Causes of most seizures in old people:

  • Vascular disease (>50%)
  • Neoplasms
  • Trauma
  • Infection
  • Neurodegenerative disorders

4

After a seizure, a patient is noted to be weak on the left side of her body, primarily her leg. This helps you determine...

The location of the epileptic focus in her brain

 

5

A patient is observed to suddenly lose consciousness and have tonic- clonic movements of their extremities with urinary incontinence and tongue-biting. The best term for this would be... 

Primary generalized seizure

  • A seizure that affects the whole brain at the same time
  • Consciousness is lost
  • Examples:
    • Absence seizures, atonic seizures, and tonic-clonic seizures

*Often focal seizures can generalize almost instantly, making them indistinguishable from primary generalized seizures!

6

A 7 year-old boy is noted by his teacher to be day-dreaming numerous times during the day. His grades start to suffer, though the child has no recollection of these events.

  1. If this is a seizure, this is most typical of...
  2. The EEG would show...

  1. Absence seizures
    • A type of primary generalized seizure
    • Hyperventilation can bring out such seizures
  2. Spike and wave activity at 3 cycles per second (3-Hz spike/wave pattern)

7

In what way are absence seizures different from complex partial seizures?

There is no post-ictal state with absence seizures.

8

A 15 year-old boy has been teased by his family for being clumsy, especially early in the morning when he is noted to drop his utensils on the floor. The teasing stops when he has a seizure after staying out late for a party. An MRI and neurological exam are normal, but an EEG shows a normal background with frequent generalized polyspike and wave discharges diffusely throughout at 4-6Hz.

  1. This is consistent with...
  2. Suggested treatment...

  1. Juvenile myoclonic epilepsy
  2. Starting valproic acid (Depakote)
    1. Levetiracetam (Keppra) works as well

Juvenile myoclonc epilepsy

  • Characterized by myoclonic jerks, typically upon wakening
  • Triggered by sleep deprivation
    • Classically, a teenager seizes after pulling an all-nighter
  • Seizures do not remit, and treatment is needed

9

A patient with a known brain tumor in the left frontal lobe experiences shaking of her right hand that progresses up to her right arm and shoulder before terminating. The patient is wide awake and alert throughout this event. What is this called?

Simple partial seizure

Simple partial seizure

  • A seizure that begins in a definitive area in the brain and does NOT affect consciousness
  • May manifest with motor, sensory, autonomic, or psychiatric symptoms
  • Often comes with a sense of overwhelming fear or depersonalization

Complex partial seizure

  • A seizure that begins in a definitive area in the brain and DOES affect consciousness
  • An aura is always a sign of a focal seizure

10

A patient with a known brain tumor in the left frontal lobe experiences shaking of her right hand that progresses up to her right arm and shoulder. This continues until the patient loses consciousness and has tonic-clonic movements of their entire body. What is this called?

Secondary generalized seizure

  • A seizure that affects a single area of the brain initially, and then spreads to include the rest of the brain
  • Jacksonian March
    • Pattern of seizure progressing up someone's body before generalizing

11

What is Todd's paralysis?

A focal neurological deficit, usually weakness, that persists for up to 24 hours after a seizure.

12

A five year old child is brought to you by his concerned mother – she has noticed a severe decline in his ability to comprehend and produce speech.

  1. What is this disorder called?
  2. What is the most common finding of this disorder on EEG?

  1. Landau-Kleffner syndrome
  2. Bilateral spike-and-wave discharges during non-REM sleep

Landau-Kleffner syndrome

  • Characterized by progressive aphasia in children, affecting both Broca's and Wernicke's areas
  • Onset is between 3-7 years old
  • 80-85% of children will demonstrate epileptiform activity during non-REM sleep

 

13

A parent brings in her 2 month- old baby to the pediatrician because of colic pain. The baby cries a lot in pain and often bends himself forward at the level of the trunk. It is noted that there are 3 hypopigmented lesion on the baby’s skin that are more apparent with UV light.

  1. What is the diagnosis?
  2. What would be the most appropriate treatment after confirming the diagnosis?

  1. Tuberous sclersois (TS)
  2. ACTH

Tuberous sclerosis

  • Signs
    • Infantile spasms
    • Cortical tubers
    • Ash-leaf macules
    • GERD
  • Treatment = ACTH
    • Prevents infantile spasms associated with TS by reducing the corticotropin releasing hormone (CRH)
      • CRH normally causes excess excitability

14

What is West syndrome?

A syndrome of infants that consists of the triad of:

  1. Infantile spasms
  2. Hypsarrhythmia = EEG pattern of high amplitude waves and background of irregular spikes
  3. Mental retardation

Treatment = ACTH

15

What is Lennox-Gastaut syndrome?

Epilepsy syndrome that occurs in children age 2-6.

Multiple seizure types:

  • Tonic - stiffening of the body, upward deviation of the eyes
  • Atonic - brief loss of muscle tone and consciousness
  • Atypical absence
  • Myoclonic - sudden muscle jerks

Seizures are very difficult to control

16

What is Benign Rolandic Epilepsy/epilepsy with centrotemporal spikes?

The most common epilepsy syndrome in children

  • Characterized by nocturnal seizures
  • has characteristic centrotemporal spikes
  • Rarely needs treatment
    • Always remits by age 16

17

A 10 year-old child has seizures characterized by laughing fits. His MRI is below. These are most characteristic of seizures due to a neoplasm of the...

Hypothalamus

  • These are known as gelastic seizures
    • Symptoms of seizure depend on what part of the brain it originates from

18

A 35 year-old man falls while riding his bike hitting his head on the ground. He got up immediately, clearly shaken, but otherwise normal. 30 minutes later, when telling the story to his friends, he “turned as white as a ghost,” fell to the ground and had some shaking movements of his arms and legs. He got back up within minutes and seemed fine again. The most likely diagnosis is...

Vasovagal syncope

  • Recurrent episodes of loss of consciousness in the absence of an emotional cue would suggest a cardiac etiology of the syncope
  • Convulsive syncope = convulsive movements during syncope

19

A patient presents with bilateral, asynchronous ballistic movements of her arms and legs. The patient is conscious during these events that last between 30-120 seconds This is consistent with...

Non-epileptic seizures (pseudo-seizures)

  • Characterized by DIFFERENT movements, lasting DIFFERENT amounts of time
  • Epileptic seizures are "sterotypic"
    • They tend to be identical for the same patient in terms of duration and clinical presentation
  • Convulsion in doctor's office or waiting room...ಠ_ಠ
  • Can co-exist in same patient with epileptic seizures!

20

What is necessary in the diagnosis of epilepsy?

  • Patient's history
  • Neurological exam
  • MRI
  • Electroencephalography (EEG)
    • Non-epileptic vs. epileptic event
    • Focal vs. generalized
    • Characteristic of epilepsy syndrome?
  • Video EEG = most accurate diagnostic tool

21

What are the side effects of valproic acid (Depakote)?

Elevated LFTs, pancreatitis, hirsuitism, leukopenia, weight gain, alopecia

  • Most patients discontinue depakote due to weight gain

22

  1. Which anti-epileptic medication is most strongly associated with neural tube defects when given to pregnant women?
  2. Which anti-epileptic medication is contraindicated in patients with a history of kidney stones?
  3. Which anti-epileptic medication is associated with hyponatremia?
  4. Which anti-epileptic medication is associated with gum enlargement?

  1. Valproic acid (Depakote)
  2. Topiramate
  3. Carbamazepine, oxcarbazepine
  4. Phenytoin (Dilantin)

*Chronic anti-epileptic therapy can cause cerebellar atrophy.

23

A patient states that he has been feeling moody and irritable since starting levatiracetam (Keppra). His wife made him make an appointment, and he requests a medication switch. The physician recommends a switch to lamotrigine (Lamictal), as this AED may have beneficial effects on mood, but cautions the patient to notify him immediately if he begins to notice new onset of...

Rash

Stevens-Johnson syndrome

  • Life-threatening
  • Hypersensitivity reaction affecting skin and mucous membranes
  • To reduce risk, lamotrigine is titrated slowly to a therapeutic dosage

 

24

A 3 year-old child has a seizure while febrile. This occurs often as an inherited predisposition to have seizures while febrile. It usually occurs in children between the age of 6 months and 6 years. There is usually no cause and it is generally not a risk factor for epilepsy. However, what are the risk factors for the child to develop seizures as an adult?

  1. The seizures last longer than 15 minutes
  2. The seizure is not generalized and there are focal features
  3. There are structure abnormalities on brain imaging

Simple febrile seizure:

  • A generalized tonic-clonic seizure that lasts < 1 min and no seizures occur in the next 24 hours

Complex febrile seizure:

  • A seizure with focal features that lasts > 15 mins or recurs in 24 hours
  • 3% of children with febrile seizures will develop epilepsy

Indications for treatment:

  • Complex febrile seizure
  • Children < 1 year-old
  • Abnormal MRI

 

25

A patient is observed to suddenly lose consciousness and have tonic- clonic movements of their extremities with urinary incontinence and tongue-biting.

  1. You are called to the ward and arrive within 1 minute. If the patient is still seizing at this time, you should treat the patient with...
  2. You are called to the ward and arrive within 15 minutes. If the patient is still seizing at this time, you should treat the patient with...

  1. Observation
  2. IV lorazepam

SUDEP = sudden unexpected death in epilepsy patients

  • Post-mortem exam does not reveal a structural or toxicological cause for death

Status epilepticus (SE):

  • Life-threatening seizure lasting longer than 5-10 mins, or
  • Recurrent seizures without regaining consciousness between seizures for > 30 mins
  • Benzodiazepines = initial treatment due to rapid onset of action
    • IV phenytoin cannot be given quickly due to cardiac arrhythmias

Epilepsia partialis continua:

  • Persistent focal motor seizure, typically involving the hand and foot

26

What are the surgical treatments of epilepsy?

  • Removal of temporal lobe
    • ​Removal from other lobes can occur as well
  • Corpus callosotomy

Removal of temporal lobe:

  • Most common surgical procedure in epilepsy
  • Careful brain mapping of the proposed area of resection is required prior to any epilepsy surgery to ensure the patient is not left with severe language or cognitive deficits

Corpus callosotomy:

  • Lesion is made in the corpus callosum
  • Used in patients with refractory epilepsy to prevent partial seizures from spreading across the brain to become generalized

*Certain conditions (seizures of Sturge-Weber syndrome) or cases of severe cortical dysplasia may require dramatic surgical procedures to control the seizure

27

Electronic stimulation of which cranial nerve is used to help control epilepsy?

Vagus nerve

28

A woman in her 35th week of pregnancy is found to have a blood pressure of 210/120 as well as proteinuria. Which treatment should be started at this time to prevent seizures?

Magnesium sulfate

The patient is suffering from eclampsia. Immediate delivery of the fetus is also indicated at this time.

29

An ER physician has given several patients IV phenytoin to prevent a seizure. Though none of these patients has had a seizure, the physician feels the prophylactic use of this medication is justified. In which situation is he correct?

A patient with severe head trauma

  • In patients with head trauma, prophylactic anticonvulsants decrease the initial seizure rate, but does not impact long-term seizure rates
  • There is NO ROLE for seizure prophylaxis in brain tumors or intracerebral bleeds