Bloch: Clinical Epilepsy Flashcards by Megan Foggia

the clinical manifestation of an abnormal, excessive excitation and synchronization of a population of cortical neurons

seizure

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recurrent seizures (two or more) which are not provoked by systemic or acute neurologic insults

epilepsy

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Two main types of seizures

partial

generalized

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Three types of partial seizures

simple partial
complex partial
secondarily generalized (starts on both sides of the brain at the same time)

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Different types of partial seizures?

somatosensory or special sensory symptoms
motor signs
autonomic signs
psychic symptoms

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Hallmark of complex partial seizures

impaired consciousness

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How long do complex partial seizures last?

<2 minutes

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What can happen to partial seizures?

they can secondarily generalized

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How long do secondarily generalized seizures last? How is the patient following the seizure?

1-3 minutes; usu confused, somnolent, with or w/o transient focal deficit

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List the types of generalized seizures

absence
myoclonic
atonic
tonic
tonic-clonic

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Brief staring spells (“petit mal”) with impairment of awareness
3-20 seconds
Sudden onset and sudden resolution
Often provoked by hyperventilation
Onset typically between 4 and 14 years of age
Often resolve by 18 years of age
Normal development and intelligence
EEG: Generalized 3 Hz spike-wave discharges

typical absence seizures

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Brief staring spells with variably reduced responsiveness
5-30 seconds
Gradual (seconds) onset and resolution
Generally NOT provoked by hyperventilation
Onset typically after 6 years of age
**Often in children with global cognitive impairment
EEG: Generalized slow spike-wave complexes (

Atypical absence seizures

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Brief, shock-like jerk of a muscle or group of muscles
Differentiate from benign, nonepileptic myoclonus (e.g., while falling asleep)
EEG: Generalized 4-6 Hz polyspike-wave discharges

myoclonic seizures

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Symmetric, tonic muscle contraction of extremities with tonic flexion of waist and neck

Duration - 2-20 seconds.

tonic seizures

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Sudden loss of postural tone
When severe often results in falls
When milder produces head nods or jaw drops.

Consciousness usually impaired

Duration - usually seconds, rarely more than 1 minute

atonic seizures

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Associated with loss of consciousness and post-ictal confusion/lethargy
Duration 30-120 seconds 
Tonic phase
Stiffening and fall
Often associated with ictal cry
Clonic Phase
Rhythmic extremity jerking

generalized tonic-clonic seizure

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Why do babies and children have seizures?

Prenatal or birth injury
Inborn error of metabolism
Congenital malformation

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Why do kids and adolescents have seizures?

Idiopathic/genetic syndrome
CNS infection (fever can cause seizure)
Trauma

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Why do adolescents and young adults have seizures?

head trauma

drug intoxication and withdrawal*

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Why do older adults have seizures?

stroke
brain tumors
acute metabolic disturbances*
neurodegenerative

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6 labs/things you can do after the first seizure?

H&P
blood tests: look at CBC, electrolytes, glucose, Ca++, Mg++
Lumbar puncture (only if meningitis/encephalitis expected)
Blood/urine screen
EEG
CT or brain scan

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What are some things that can precipitate a seizure?

metabolic/electrolyte imbalance
stimulants or proconvulsant intoxications
sedative or EtOH withdrawal
sleep deprivation
hormones (estrogen)
stress
fever/infection
closed head injuries

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Which metabolic disturbances can lead to seizures?

low blood glucose
low Na+
low Ca++
low Mg++

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What drugs can cause seizures?

IV drugs
cocaine
ephedrine
medication reductions
antidepressants
neuroleptics
etc etc

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Relapse rate of seizure after first seizure depends on the following four factors:

abnormal imaging abnormal neuro exam abnormal EEG family history

What percentage of unprovoked seizures will recurr w/i 5 years?

16-62%

What things should you consider when choosing an antiepileptic drug?

``` seizure type epilepsy syndrome efficacy cost adverse effects pt's medical conditions ```

What does choice of anti-epileptic drug for partial epilepsy depend on?

the drug side-effects and the pt's preference/concerns

What does choice of anti-epileptic drug for generalized epilepsy depend on?

predominant seizure type drug side-effects patient's preference/concerns

T/F: Monotherapy is best for partial seizures

True

Which AEDs have the best evidence and FDA indication for partial seizures?

carbamazepine oxcarbazepine phenytoin topiramate

Which AEDs have the best evidence and FDA indication for generalized tonic-clonic seizures?

valproate topiramate **topiramate makes you dopey, and also decreases your appetite

What is the gold standard drug for generalized tonic clonic seizures? What's one side effect to think about?

valproate; makes people eat more

Which AEDs should be used for absence seizures?

ethosuximide *absence only | valproate

Which AEDs work the best for myoclonic seizures?

valproate levetiracetam clonazepam

Drugs for Lennox-Gastaut Syndrome?

``` topiramate felbamate clonazepam lamotrigine rufinamide ```

Why is monotherapy best?

simplifies treatment, increases compliance | reduces adverse effects

These AEDs can induce metabolism of other drugs

carbamazepine phenytoin phenobarbital primidone

Which AEDs inhibit metabolism of other drugs?

valproate (if you're on phenytoin and you add valproate, your phenytoin level in the blood may increase) felbamate

Which AEDs decrease the efficacy of oral contraceptive pills?

``` phenytoin carbamazepine phenobarbital topiramate oxcarbazepine felbamate ``` **ex: phenytoin can decrease BC concentration and can increase risk of pregnancy - recommend IUD or other form of BC

This AED is used frequently in women

lamotrigine **may need higher doses of lamotrigine if you are on BC though

When do we check blood levels when pts are on AEDs?

levels can be used to see if a pt is compliant (taking the drug) or to monitor drug levels during pregnancy, etc

What symptoms do all AEDs cause?

dizzy, fatigue, ataxia, diplopia

Levetiracetam causes (blank)

irritability

Can cause word-finding difficulty, weight loss, renal stones, anhydrosis or heat stroke, glaucoma

topiramate

(blank) is the most common side effect of AEDs that causes people to be taken off their meds

rash

These populations have a higher incidence of rash than other pts taking AEDs

Asian pts

This is the worst case scenario in patients who experience rash on AEDs

Stevens Johnson syndrome

Which two AEDs are most likely to increase risk of SJS?

lamotrigine titrated in combo with valproate

Comorbidities to consider in pts with long term AED use

osteoporosis (esp phenytoin) migraine depression

20-60% of pts on epileptic meds are (blank)

depressed **these pts more likely to commit suicide, feel stigma, less likely to get married

Antiepileptic drugs increase the risk of (blank)

suicide

When to discontinue AEDs?

``` seizure free for >2years and are younger control with one drug at low dose no previous unsuccessful attempts at withdrawal normal neuro exam or EEG benign syndrome ``` **always think about the risks of taking the pt off, like driving and pregnancy

What things should you consider if a seizure recurrs?

some avoidable precipitant? if not on AED, start therapy? if on AED, are they compliant? do you need to increase dose or change meds?

What lifestyle modifications can be made to decrease seizures?

adequate sleep!! avoid alcohol and stimulants reduce stress

This type of diet can be therapeutic for patients, especially children, with multiple seizure types

ketogenic diet **low carbs, high fat

Other diets that can be somewhat helpful?

modified Atkins | low-glycemic index treatment (our brains run on glucose, so this decreases seizures of hyperactive neurons)

When might you consider surgery for patients with epilepsy?

not responding to medical management | partial seizures

This type of treatment can be used to stimulate the left vagus nerve and decrease seizures

Vagus nerve stimulator

More than 10 minutes of continuous seizure activity or Two or more sequential seizures without full recovery between seizures

status epilepticus

What are some potential consequences of status epilepticus?

``` hypoxia hypotension acidosis hyperthermia neuronal injury ``` **this is a medical emergency, because neuronal death will destroy brain tissue

Steps to treating status epilepticus?

``` check ABCs Give O2 get IV access monitor EKG check glucose (make sure they are not hypoglycemic) do a tox screen draw blood ```

This is usu given IV as soon as possible for status epilepticus?

lorazepam or diazepam if you can't go IV thiamine unless you know their blood glucose is OK

If seizures persist for 10-20 minutes, what should you give?

fosphenytoin

Different choices if the seizures last 10-60 minutes?

continuous IV midazolam continuous IV propofol IV valproate IV phenobarbital

This is a huge every day consideration for patients with epilepsy

driving

How long must patients go w/o having a seizure to get their license back?

3 months

Bloch: Clinical Epilepsy Flashcards

(67 cards)