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Flashcards in epilepsy Deck (55):
1

questions to ask

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

2

seizure old def

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

3

seizure new def

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

4

epiplepsy



prevalence?

causes??

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

5

what is NOT considered epilepsy

etOH, metabolic derangements (PROVOKED)

6

seizure initiation phase

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

7

if gets better w. prednisone

reduces vasogenic edema from brain mass

8

seizure propagation phase

can go all over from initial location

9

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

PCN (dangerous!)


GABA

10

structural/metabolic causes

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

11

hypoglycemic seizures are

reversible, give sucrose

12

assess for meningitis

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

13

partial seizure: simple

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

14

partial seizure: complex

loss of consciousness
Frequently begins with aura

Automatisms:
Chewing, lip smacking, picking

EEG will be abnormal during seizure

15

partial with secondary generalization

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

16

primarily generalized seizures: absence (petit mal)

"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?

17

primarily generalized seizures: tonic clonic (grand mal)

~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

18

other primarily generalized seizures:

tonic: stiffening
atonic: limp
myoclonic: shaking

19

unclassified:

neonatal
infantile

20

simple partial seizure symptoms

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

21

generalized seizure arise from..

both hemispheres simultaneously

22

Juvenile Myoclonic Epilepsy

Bilateral myoclonic jerks single or repetitive

Most frequent in AM, worse with sleep deprivation

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

23

Lennox-Gastaut Syndrome (triad)

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

24

a normal brain is...

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

25

a variety of conditions have high chance of chronic seizure disorder

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

26

seizures are ??

episodic
May go months to years between episodes

27

things to exclude

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

28

how to dx pseudoseizure??

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

29

ddx syncope from seizure

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

30

hit ground fast with no prodrome

cardiac arrhythmia

31

if hx of epilepsy

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

32

no hx epilepsy

same labs + serum glucose, Ca, Mg, UA

33

do what first?

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

34

+ metab. screen

metab/inf disorder

35

no hx epilepsy, neg metab. screen

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

36

ddx seizure

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

37

check ?? level after seizure
why ??

CK
rhabdomyalgia (tightened musc.)

38

chance my child will have it again?

It is possible, but unlikely

39

childhood febrile seizure

Simple febrile – brief, symmetric

Complex febrile - >15 minutes, focal features

1/3-1/2 of children will have another seizure, but

40

evaluation

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

41

lab studies

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

42

EEG

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

43

brain imaging

Almost all patients, except children may not need this

*MRI better than CT to detect any anatomical abnormalities

44

status epilepticus





how does it wreak havoc?

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

45

seizure tx

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

46

status epilepticus tx

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

47

first line tx: tonic-clonic

*valproic acid*
lamotrigine

48

FLD: partial

carbamazepine
phenytoin (dilantin)
lamotrigine
*valproic acid*

49

FLD: absence

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

50

FLD: atypical absence, myoclonic, atonic

*valproic acid*

51

phenytoin (dilantin) OD SEs

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

52

carbamazepine (tegretol, carbatrol) OD SEs

leukopenia, aplastic anemia

53

valproic acid OD SEs

thrombocytopenia, hepatic toxicity

54

can you ever stop the medicine?

it depends
after 2 yrs seizure free

55

Lamictal SEs OD

SJS, skin rash