Flashcards in CN LANGE - Seizures & Syncope II Deck (73):
Risk factors for seizure recurrence include:
Slowing or spikes (max risk with both present) on EEG.
Recurrence of seizures has been reported in approx. ...?
20% of children.
40% of adults.
after medication withdrawal.
Side effects of anticonvulsants - Nearly ALL anticonvulsant drugs may lead to ...?
Blood dyscrasias and some have hepatic toxicity.
Phenytoin - Dose-related side effects:
4. Coarse facial features.
7. Megaloblastic anemia.
Phenytoin - Side effects - Idiosyncratic:
1. Skin rash.
3. Lymphoid hyperplasia.
4. Hepatic dysfunction.
5. Blood dyscrasia.
7. Gingival hyperplasia.
Carbamazepine - Side effects - Dose related:
Carbamazepine - Side effects - Idiosyncratic:
1. Skin rash.
2. Blood dyscrasia.
3. Hepatic dysfunction.
Oxcarbazepine - Side effects - Dose related:
Oxcarbazepine - Side effects - Idiosyncratic:
Phenobarbital - Side effects - Dose related:
3. Behavioral disturbance.
Phenobarbital - Side effects - Idiosyncratic:
1. Skin rash.
Valproic acid - Side effects - Dose related:
1. GI distress.
4. Weight gain.
5. Hair loss.
Valproic acid - Side effects - Idiosyncratic:
1. Hepatic dysfunction.
2. Peripheral edema.
Ethosuximide - Side effects - Dose related:
1. GI distress.
Ethosuximide - Side effects - Idiosyncratic:
1. Skin rash.
2. Blood dyscrasia.
Clonazepam - Side effects - Dose related:
4. Behavioral disturbance.
Gabapentin and pregabalin - Side effects - Dose related:
3. Drugged sensation.
4. Weight gain.
Lamotrigine - Side effects - Dose related:
Lamotrigine - Side effects - Idiosyncratic:
1. Skin rash in 1%-2% (frequency increased by concomitant valproic acid therapy and reduced by gradual build-up dose).
Vigabatrin - Side effects - Dose related:
Vigabatrin - Side effects - Idiosyncratic:
Peripheral visual constriction (IRreversible).
Topiramate - Side effects - Dose related:
2. Mental slowing.
Topiramate - Side effects - Idiosyncratic:
1. Renal stones.
Tiagabine - Side effects - Dose related:
Tiagabine - Side effects - Idiosyncratic:
Zonisamide - Side effects - Dose related:
Zonisamide - Side effects - Idiosyncratic:
2. Skin rash.
Ezogabine - Side effects - Dose related:
Lacosamide - Side effects - Dose related:
Lacosamide - Side effects - Idiosyncratic:
Perampanel - Side effects - Dose related:
Perampanel - Side effects - Idiosyncratic:
2. Behavioral disturbances.
Lamotrigine hase a ... incidence of SJS.
1/1.000 in the first 8 weeks.
Teratogenic effects of epilepsy:
The incidence of stillbirth, microcephaly, mental retardation, and seizure disorders is increased in children born to EPILEPTIC mothers.
Based on current data, the safest anticonvulsant in pregnancy is ...?
Levetiracetam also appears safe.
Status epilepticus in a pregnant woman?
Treated as described for the nonpregnant patient.
Anticonvulsant levels in pregnancy:
Plasma levels of anticonvulsant drugs may DECREASE during pregnancy because of the patient's enhanced drug metabolism, and higher doses may be required to maintain control of seizures.
--> Particularly important with lamotrigine --> The dose often needs to be doubled or tripled during a pregnancy to maintain adequate blood levels.
Prognosis - After a single unprovoked seizure, only about ... of patients will have recurrence over 3 to 5 years (ie develop epilepsy).
--> If a second seizure occurs, however, the subsequent recurrence rate approaches 75%, and anticonvulsants therefore should be started.
Syncope - Common causes of syncope and their prevalence:
Vasovagal --> 8-41%.
Situational --> 1-8%.
Carotid sinus syncope --> 0.45%.
Orthostatic hypotension --> 4-10%.
Decr. CO --> 1-8%.
Arrhythmias --> 4-38%.
Neurologic and psychiatric diseases --> 3-32%.
Unknown --> 13-41%.
Vasovagal syncope - Precipitating factors:
1. Emotional stimulation.
3. The sight of blood.
5. Medical instrumentation.
6. Blood loss.
7. Prolonged motionless standing.
Vasovagal episodes generally begin while the patient is ...?
In a standing or seated position and only rarely in a horizontal position (eg with phlebotomy or intrauterine device insertion).
Vasovagal syncope - A prodrome ...?
Lasting 30-60seconds usually precedes syncope and can include:
8. Blurred vision.
Vasovagal syncope - The patient, who then loses consciousness and falls to the ground, is ...?
Pale + diaphoretic and has DILATED pupils.
--> Breathing continues.
--> Eyes remain open and there is an upward turning of the globes.
--> Bradycardia replaces tachycardia as consciousness is lost.
Vasovagal syncope - The patient recovers consciousness very rapidly (20-30seconds) after assuming the horizontal position, but ...?
7. Urge to defecate.
may be noted.
Vasovagal syncope may RECUR, especially if the patient ...?
Stands within the next 30min.
Recurrent vasovagal syncope (also termed neurally mediated or neurocardiogenic syncope) can be diagnosed by ...?
Inducing syncope during head-up tilt-testing.
Postural tachycardia syndrome (POTS):
1. Predominantly in young women.
2. Incr. in heart rate of 30 or more beats per min.
3. Generally without significant change in BP.
4. Occurs on standing from the supine position.
5. Accompanied by presyncopal and other symptoms.
Cerebrovascular syncope - Basilar artery insufficiency:
1. Basilar artery TIAs usually occur after the 6th decade.
2. Attacks are typically sudden in onset and brief in duration (seconds to minutes), but when consciousness is lost... recovery is frequently PROLONGED (30-60minutes or longer).
The subclavian steal syndrome results from ...?
Subclavian or innominate artery stenosis that causes retrograde blood flow in the vertebral artery, diverting flow from the brainstem and producing hypoperfusion.
Subclavian steal syndrome - The degree of subclavian artery stenosis that produces symptoms is variable, but ...?
Even minor (-40%) stenosis may sometimes do so.
Migraine - Syncope occurs in ...% of patients with migraine during the headache.
Migraine syncope - The syncope often occurs on ...?
Rapid rising to a standing position, suggesting that loss of consciousness is due to orthostatic hypotension.
--> Autonomic neuropathy may coexist.
Syncopal migraine has both ...?
More prolonged unconsciousness + More prolonged recovery than syncope alone.
In some patients, basilar migraine produces ...?
Symptoms similar to those of basilar artery TIAs.
Takayasu disease - Syncope - Precipitating factors:
3. Head movement.
Carotid sinus syncope:
2. Men twice as often as women.
3. Most are >60.
Drugs known to predispose to carotid sinus syncope:
Carotid sinus syncope is diagnosed when ...?
Carotid sinus massage for 10seconds results in bradycardia/hypotension (carotid sinus hypersensitivity).
--> Reproduces spontaneous syncope.
Carotid sinus hypersensitivity ...?
Is COMMON in older men - BUT without syncope.
Carotid sinus syncope may be mistakenly diagnosed when ...?
Symptoms result from compression of a normal carotid artery contralateral to an occluded internal carotid artery.
Carotid sinus massage should NOT be performed in ...?
Patients with recent TIA or stroke or with carotid bruit.
1. Occurs more often in men than in women.
2. MC in the 50-70 - It may appear in teenagers.
Orthostatic hypotension - Loss of consciousness usually occurs upon ...?
1. Rapidly rising to a standing position.
2. Standing motionless for a prolonged period (especially after exercise).
3. Standing after prolonged recumbency (especially in the elderly).
Causes of orthostatic hypotension:
1. Hypovolemia or hemorrhage.
2. Adrenal insufficiency.
5. Other neurologic disorders.
6. Cardiac pump failure.
7. Prolonged bed rest.
Orthostatic hypotension may be a feature of neurodegenerative disorders - Idiopathic orthostatic hypotension is associated with ...?
Isolated degeneration of post ganglionic sympathetic neurons.
--> In MSA (Shy-Drager syndrome), degeneration of preganglionic SNS neurons occurs in combination with:
3. Cerebellar, or LMN signs.
The diagnosis of classic orthostatic hypotension is established ...?
By demonstrating a decline in BP of at least 20mmHg systolic or 10mmHg within 3 minutes of the patient standing from a lying position.
Severe orthostatic intolerance associated with heart rate increases (>120/min) without significant hypotension or syncope is termed ...?
Postural orthostatic tachycardia syndrome (POTS) and is MC in young women.
1. Middle-aged men with COPD.
2. Has also been reported in children.
3. Coughing, which need not be prolonged, immediately precedes unconsciousness.
Cough syncope - The cause may be ...?
A decrease in cerebral blood flow from incr. ICP --> Results from transmission of cough-induced increased intrathoracic pressure to the intracranial compartment via the spinal fluid or venous connections.
Cerebral hypoperfusion event occurring almost exclusively in MEN --> Probably because of the standing position for urination, and is due to peripheral pooling of blood + vagally induced bradycardia.
Micturition syncope - Episodes can occur ...?
Immediately before, during, or after micturition.
--> More likely to occur at night after the prolonged recumbency of sleep.
Rare syndrome characterized by intermittent, agonizing, paroxysmal pain localized to the tonsillar pillar or occasionally to the external auditory meatus.