General Epilepsy

Question 1

Incidence

Answer 1

3.1% of population (9 million people) suffer from epilepsy

Question 2

Risk of epilepsy

Answer 2

5% of US population (15 million) will have a seizure at sometime in their lives
~1/2 of those will progress into epilepsy

Question 3

Incidence rate of epilepsy

Answer 3

44/100,000 people in US
-61 for first time unprovoked seizures
39 for acute symptomatic seizures
100 for all seizures

Question 4

Age with highest risk of epilepsy

Answer 4

> 75yo

Question 5

Common etiology for epilepsy

Answer 5

• Stroke ~11%

- CP ~8%

Question 6

First lifetime unprovoked seizure work up

Answer 6

Class B evidence:
EEG
MRI (pref 3 Tesla)

Question 7

Types of abnormalities found on MRI after first unprovoked seizure

Answer 7

Tumors > developmental anomalies > hippocampal patholies > vascular malformations

Seen in ~14-23%

Question 8

Recurrence rate for seizures

Answer 8

After 1st unprovoked sz: 40% within the first 2 years
After 2nd: 73%
After 3rdL 76%
After treated first unprovoked 15%

Question 9

Seizure Recurrence after first unprovoked seizure according to Etiology and EEG findings

Answer 9

Etiology:
Idiopathic 32%
Symptomatic 57%

EEG
normal 27%
Epileptiform 58%

Etiology + EEG
Idiopathic +Normal 24%
Symptomatic + abnormal EEG 65%

Berg + Shinnar et all

Question 10

Factors for seizure reucrrence

Answer 10

Focal >generalized
Nocturnal seizures > daytime seizure
Status epilepticus 
Abnormal interictal neuro exam
Abnormal brain imaging
Multiple or clustered seizures 
Strong family history of seizures

Question 11

Percentage of seizure freedom

Answer 11

70% of epilepsy patients will eventually achieve seizure freedom
~11-41% will relapse after AED
-Less in children 20%
-Higher in adults 40%

Question 12

Risk of relapse of epilepsy

Answer 12

Most within 1st year or AED withdrawal

More at risk if:
Severe and long lasting epilepsy before remission
JME 85%
Structural lesion

Question 13

Risk from Epilepsy vs Surgery

Answer 13

1. Injury
2. SUDEP
3. Quality of Life
4. Side effects of medications

Question 14

Temporal Lobe Epilepsy

Answer 14

Aura: epigastric, olfactory, gustatory sensation, emotional changes, sense of familiarity or strangeness, hallucinations, staring, automatisms

Abdominal aura 52% sensitivity and 90% specificitivity

Basal temporal lobe epilepsy presents with behavioral arrest or motor changes

Question 15

Frontal lobe seizure semiology

Superior or Interhemispheric onset

Answer 15

Superior or Interhemispheric -> contralateral eye, head or body turning with tonic/dystonic posturing

Question 16

Orbital frontal seizure semiology

Answer 16

unusual behaviors, hypermotor activity, rapid leg kicking/bicycling, autonomic findings, behavioral arrest, automatisms.
-Frequently in sleep, and are brief

Question 17

Inferior frontal lobe seizures semiology

Answer 17

Referrable to face or to speech

Question 18

Dorsolateral or dorsomedial frontal seizures

Answer 18

Contralateral motor findings

Question 19

Premotor seizures semiology

Answer 19

Tonic version

Question 20

Supplementary motor areas

Answer 20

Speech arrest
Fencer posturing
Bilateral hand motor findings
Head version

Question 21

Insular seizure semiology

Answer 21

Visceral, gustatory, somatosensory symptoms (laryngeal constriction or paresthesias)

Question 22

Parietal lobe seizure semiology

Answer 22

Somatosensory phenomena (pain/dysethesias)
Can be silent until propagated
-Can look like superior frontal lobe seizures or sensorimotor symptoms

Question 23

Occipital lobe semiology

Answer 23

Visual auras and phenomena

Can be silent until propagation

Question 24

Restrictions for Patients with Epilepsy

Answer 24

No working at unprotected heights (roofs, ladders)
No working around heavy machinery with moving parts
No construction equipment
No use of manufacturing equipment including fork lifts, heavy presses, conveyor belt systems
Avoid environmental triggers
Shower/bathe
Swim when supervised by someone and capable of helping
No cooking or working around open flames
No driving

Question 25

Driving comercial Truck and Epilepsy

Answer 25

If seizure free on and off of meds 10 years can get license One time event that is thought to be non-epileptic requiring no anti-seizure medication. Needs to be seizure free x 6mo Single unprovoked seizure with no recurrence - 5 years off of medication Acute symptomatic seizures with low risk of recurrence No restriction if no seizures for 2+ years off of AED Any one that has a procedure that penetrates the dura should not be considered eligible

Question 26

Merchant Mariners and Epilepsy

Answer 26

If low risk recurrence and seizure free off of medication for at least 1 year Seizures with high risk of recurrence - must be seizure free for 8 years on or off meds. If on meds, dose must be stable for 2 years. If off of meds, must be seizure free for 8 years from when stopping meds

Question 27

Aircraft Pilots and Epilepsy

Answer 27

Disturbance of conciousness without satifsactory medical explanation - must report Rolandic seizure - may be eligible if seizure free >4 years with normal EEG Febrile seizure - without recurrence and off of meds for 3 years Transient loss of neurologic function - required to report; FAA decision Unexplained syncope, single siezure - denied Special considerations: childhood epilepsy, but seizure free for number of years

Question 28

Common seizure triggers

Answer 28

``` Stress Fatigue Medication compliance Excessive EtoH use Sleep deprivation ```

Question 29

Accomodations in work setting for epilepsy

Answer 29

Minimize excessive stress Limited work hours to 8-10hr/day No third or midnight shift No working at unprotected heights No working around heaving moving and machinery Avoided environmental situations that are known triggers Providing assistive technology

Question 30

Accomodations in school

Answer 30

Leniency on attendance If seizures are active, they may need to rely on others for transportation Can result in assignments not being completed or late All night study sessions not possible Avoidance of multiple exams on same day Short term memory loss - no pop quizzes Assitnace with reading, taking notes, or recording lectures. Single room in college Dogs/pets, single level home, access for rides, use of wheelchair

Question 31

Disability and Epilepsy | What needs to be documented

Answer 31

EEG corroborating nature and frequency of seizures Seizure semiology - observed by 3rd party or provider History of treatment, response, recent changes Compliance Absorption or metabolism AED levels - if low then explain,