epilepsy

Question 1

questions to ask

Answer 1

prodrome?
loss of urine/BM?
tongue biting?
describe seizure (witnesses?)
occupation?

Question 2

seizure old def

Answer 2

paroxysmal event due to abnormal, excessive, hypersynchronous discharges from aggregate of CNS neurons

Question 3

seizure new def

Answer 3

transient disturbance of cerebral function due to an abnormal paroxysmal neuronal discharge in the brain

Question 4

epiplepsy

prevalence?

causes??

Answer 4

Recurrent seizure due to genetically or acquired brain disorder

0.5 to 1 % of pop

50% have a cause:
Head trauma, brain tumor, stroke, infection in brain, congenital

Question 5

what is NOT considered epilepsy

Answer 5

etOH, metabolic derangements (PROVOKED)

Question 6

seizure initiation phase

Answer 6

High frequency APs and hypersynchronization (all at same time)
Long lasting depol. of membrane due to influx of calcium which opens voltage dependent sodium channels–>repetitive action potentials
(abnormal e- activity)

location of activity determines type

Question 7

if gets better w. prednisone

Answer 7

reduces vasogenic edema from brain mass

Question 8

seizure propagation phase

Answer 8

can go all over from initial location

Question 9

??? can lower seizure threshold by inhibiting (antagonizing) the effects of ??? at the receptors

Answer 9

PCN (dangerous!)

GABA

Question 10

structural/metabolic causes

Answer 10

Pediatric – congenital
Metabolic – withdrawal alcohol, drugs, hypoglycemia
Trauma – post trauma, may not imply future seizure
Tumors – all patients > age 30 with seizure must have head imaging, focal seizures
Vascular – usually advanced age, >60
Infectious – AIDS, meningitis, encephalitis, syphilis, cysticercosis

Question 11

hypoglycemic seizures are

Answer 11

reversible, give sucrose

Question 12

assess for meningitis

Answer 12

nuchal rigidity
Kernig: flex knee and hip
Bruzinski: flex neck
stretching meninges

Question 13

partial seizure: simple

Answer 13

motor, sensory, autonomic, or psychic signs
-preservation of consciousness
Jacksonian march: spread over larger regions of motor cortex
Todd’s paralysis: loc. paresis after seizure

Question 14

partial seizure: complex

Answer 14

loss of consciousness
Frequently begins with aura

Automatisms:
Chewing, lip smacking, picking

EEG will be abnormal during seizure

Question 15

partial with secondary generalization

Answer 15

Focal onset may not be clinically evident, but EEG would capture spikes/waves
Difficult to distinguish from generalized tonic clonic seizure

Question 16

primarily generalized seizures: absence (petit mal)

Answer 16

“staring off into space”
Brief lapse of consciousness without loss of postural control

Frequently lasts seconds
Usually begins in childhood, ages 4-8
Can occur hundreds of times a day
Decline in school performance? Daydreaming?

Question 17

primarily generalized seizures: tonic clonic (grand mal)

Answer 17

~10% of patients with epilepsy have this type

Most frequent type from metabolic derangements

Tonic contraction of muscles of expiration and larynx cause “ictal cry”

EEG will be abnormal during seizure

what worry about: airway, aspiration, most dangerous

Question 18

other primarily generalized seizures:

Answer 18

tonic: stiffening
atonic: limp
myoclonic: shaking

Question 19

unclassified:

Answer 19

neonatal

infantile

Question 20

simple partial seizure symptoms

Answer 20

paresthesia, flashing lights, vertigo, flushing, altered smell/hearing

EEG will be abnormal during seizure, but hard to classify unless actually having seizure- use 24 hr EEG
how to provoke? sleep deprivation

Question 21

generalized seizure arise from..

Answer 21

both hemispheres simultaneously

Question 22

Juvenile Myoclonic Epilepsy

Answer 22

Bilateral myoclonic jerks single or repetitive

Most frequent in AM, worse with sleep deprivation

Respond well to anti convulsive therapy
-roll on side
hypoglycemic?

Question 23

Lennox-Gastaut Syndrome (triad)

Answer 23

1) multiple seizure types (ie: generalized tonic clonic, atonic, atypical)
2) an EEG showing slow spike and wave discharges
3) impaired cognitive function

Question 24

a normal brain is…

Answer 24

capable of having a seizure, there are differences in the threshold or susceptibility
i.e. 2 kids w/ fevers, 1 gets seizure, other doesn’t

Question 25

a variety of conditions have high chance of chronic seizure disorder

Answer 25

i. e. penetrating brain trauma, 50% chance of epilepsy | - ppx anticonvulsants

Question 26

seizures are ??

Answer 26

episodic | May go months to years between episodes

Question 27

things to exclude

Answer 27

``` syncope TIA (stroke-like, resolves w.in 24 hrs) migraine acute psychosis (pseudo seizure) other causes of episodic cerebral dysfunction ```

Question 28

how to dx pseudoseizure??

Answer 28

dx of exclusion 24 hr EEG HAVE episode, NORMAL EEG trick: "hand drop" doesn't fall on face

Question 29

ddx syncope from seizure

Answer 29

``` (convulsant syncope can pass out and shake gray vision, lightheaded) see slide 21 seizures longer biting of tongue ```

Question 30

hit ground fast with no prodrome

Answer 30

cardiac arrhythmia

Question 31

if hx of epilepsy

Answer 31

``` consider tx, SEs, serum levels e-lytes (hypoNa) CBC (leukocytosis) L/RFTs tox screen (ecstasy: hypothermic, thirsty-->hypoNa) ```

Question 32

no hx epilepsy

Answer 32

same labs + serum glucose, Ca, Mg, UA

Question 33

do what first?

Answer 33

head CT w. w.out contrast contrast better for masses no contrast better for bleeds

Question 34

+ metab. screen

Answer 34

metab/inf disorder

Question 35

no hx epilepsy, neg metab. screen

Answer 35

``` MRI scan or EEG ? if neg: idiopathic seizure if pos: mass, stroke, etc-tx underlying disorder for both: controversial: antiepileptic meds ```

Question 36

ddx seizure

Answer 36

TIA Panic Attack Syncope Psychogenic Nonepileptic Seizure (PNES): Check prolactin, which can be high 15-30 minutes after a tonic-clonic seizure in most patients CK may also be high post convulsion

Question 37

check ?? level after seizure | why ??

Answer 37

``` CK rhabdomyalgia (tightened musc.) ```

Question 38

chance my child will have it again?

Answer 38

It is possible, but unlikely

Question 39

childhood febrile seizure

Answer 39

Simple febrile – brief, symmetric Complex febrile - >15 minutes, focal features 1/3-1/2 of children will have another seizure, but

Question 40

evaluation

Answer 40

``` ABCs Hx/exam (neuro focus) lab studies EEG brain imaging psychogenic seizure prolactin level (rises in seizure) ```

Question 41

lab studies

Answer 41

CMP, Magnesium, UDS LP if meningeal signs on exam HIV patient? Must do LP.

Question 42

EEG

Answer 42

Recording electrodes on scalp, potential differences recorded Normal awake, 8-13Hz alpha rhythm, variable faster >13Hz beta waves Sleep deprivation helps induce seizure, consider 24 hour continuous EEG; may be normal 60% of the time

Question 43

brain imaging

Answer 43

Almost all patients, except children may not need this *MRI better than CT to detect any anatomical abnormalities

Question 44

status epilepticus how does it wreak havoc?

Answer 44

Repeated seizures without recovery between them; a fixed and enduring epileptic condition lasting > or = 30 minutes Medical Emergency: can "fry" brain, airway issues May lead to irreversible neuronal injury

Question 45

seizure tx

Answer 45

Treat underlying cause if metabolic Avoid alcohol if alcoholic Single seizure, started AED is controversial

Question 46

status epilepticus tx

Answer 46

Typically intubation, lorazepam (ativan), and AED (anti-epileptic drugs) all together If no IV, can give rectal diazepam (valium) *resp. depression is issue with lots of benzos*-intubate-->ventilator

Question 47

first line tx: tonic-clonic

Answer 47

*valproic acid* | lamotrigine

Question 48

FLD: partial

Answer 48

carbamazepine phenytoin (dilantin) lamotrigine *valproic acid*

Question 49

FLD: absence

Answer 49

*valproic acid* ethosuximide "sucks to have an absence seizure"

Question 50

FLD: atypical absence, myoclonic, atonic

Answer 50

*valproic acid*

Question 51

phenytoin (dilantin) OD SEs

Answer 51

diplopia, skin rashes (SJS), ataxia, nystagmus, gingival hyperplasia

Question 52

carbamazepine (tegretol, carbatrol) OD SEs

Answer 52

leukopenia, aplastic anemia

Question 53

valproic acid OD SEs

Answer 53

thrombocytopenia, hepatic toxicity

Question 54

can you ever stop the medicine?

Answer 54

it depends | after 2 yrs seizure free

Question 55

Lamictal SEs OD

Answer 55

SJS, skin rash