Lecture 8: Seizures/Syncope

Question 1

Epilespsy is generally defined as?

Answer 1

2 or more unprovoked seizures

Question 2

What continues to be a problem worldwide for patients with epilepsy based on longstanding stigma?

Stricter laws when compared to?

Answer 2

• Unemployment and underemployment of these pt’s continues to be a problem
• Driving restrictions - in most states stricter laws for pt who has had a seizure when compared to persons w/ DUI convictions!

Question 3

Which type of seizure is nearly always picked up (90%) as a positive finding on a single EEG?

Answer 3

Petit mal (with Hyperventilation)

Question 4

How many sleep-deprived EEG’s are necessary for positive findings in 85% of all types of epilepsy?

Answer 4

3 sleep-deprived EEG’s

Question 5

What is the single most important piece of information alongside EEG in the diagnosis of epilepsy? (this is going to be a test Q)

Answer 5

HISTORY of the event(s) - preferably by witness

Question 6

Where does the seizure activity begin with Partial Seizures?

Answer 6

Activity begins on one side of the brain

Question 7

What are 3 types of Parial Seizures and how does each manifest?

Answer 7

1. Simple partial: pt is aware (conscious)
2. Complex partial: pt loses consciousness
3. Secondarily generalized (partial onset): symptoms that are initially associated with a preservation of consciousness that then evolves into a loss of consciousness and convulsions

Question 8

What parts of the brain involved with generalized seiures?

Answer 8

Both sides of the brain

Question 9

What are the 7 types of generalized seizures?

Answer 9

1. Absence (petit mal)
2. Tonic-clonic (grand mal)
3. Myoclonic
4. Tonic
5. Clonic
6. Atonic
7. Clonic-tonic-clonic

Question 10

What is the difference between a tonic and a clonic seizure?

Answer 10

• Tonic = Muscle stiffness, rigidity (think increased tone)
• Clonic = Repetitive, jerking movements

Question 11

Which type of seizure is characterized by focal motor or sensory activity, no LOC, lasting only seconds and no post-ictal state?

Answer 11

Simple partial seizure

Question 12

What are the characteristic of a complex partial seizure (i.e., signs/symptoms, time-line, consciousness post-ictal)?

Answer 12

• Nonresponsive staring, possible preceding aura
• Automatisms (action performed unconsciously or involuntarily)
• Loss of consciousness
• Last 1-3 mins
• Post-ictal state

Question 13

What is a secondary generalized (partial onset) seizure (symptoms, consciousness, timeline, post-ictal)?

Answer 13

• Starts on one side of brain and then progresses to bilateral tonic-clonic activity
• Loss of consciousness
• Lasts 1-3 mins
• Post-ictal state

Question 14

What is seen with an Absence (petit mal) seizure, how long does it last, how does the patient feel after?

Answer 14

• Nonresponsive staring, rapid blinking, chewing, clonic hand motions
• Loss of consciousness
• Lasts 10-30 sec
• No post-ictal state

*Abrupt onset and abrupt end

Question 15

What is seen with a tonic-clonic seizure, how long does it last, and how does the patient feel afterwards?

Answer 15

• Bilateral extension followed by symmetrical jerking of extremities
• Loss of consciousness
• Lasts 1-3 mins
• Post-ictal state

Question 16

What is seen with an Atonic seizure, duration, and how does patient feel after?

Answer 16

• Sudden loss of muscle tone –> head drops or patient collapses
• Loss of consciousness
• Variable duration
• Post-ictal state

Question 17

What is seen with a Myoclonic Seizure, duration, and how does patient feel after?

Answer 17

• Brief, rapid symmetrical jerking of extremities and/or torso
• Loss of consciousness
• Lasts < few seconds
• Minimal post-ictal state

Question 18

Which drug is used to treat Absence (petit mal) seizures, if this is the only type of seizure the person has experienced?

Answer 18

Ethosuxamide (absence only)

Question 19

Which combination of AED’s has been shown to be synergistic in treatment of epilepsy (especially for primary generalized seizures)?

Answer 19

Valproic acid and Lamotrigine

Question 20

What is Status Epilepticus?

Answer 20

Condition characterized by prolonged seizure (generally >10 minutes) or repeated seizures w/o recovery in between

Question 21

What is the general treatment for Status Epilepticus?

Answer 21

• A, B, C’s; establish IV
• Try to gain history; seizure previously, allergies to seizure meds
• Labs: accucheck, CBC, chemistry panel, drug levels
• Non-contrast CT head
• Give benzodiazepine

Question 22

What type of imaging should be taken with Status Epilepticus?

Answer 22

Non-contrast CT head

Question 23

Which drug should be given for initial treatment of Status Epilepticus?

What is the purpose?

Answer 23

• Benzodiazepine (i.e., lorazepam 2-4 mg IV)
• This buys time, but must give longer lasting AED

Question 24

What are 3 general principles/considerations in the treatment of patients with epilepsy?

Answer 24

1. Try to use monotherapy
2. Consider drug interactions, i.e., OC’s w/ carbamazepine
3. Consider long-term side effects, i.e., bone loss with carbamazepine or phenytoin

Question 25

All woman of child-bearing age with epilepsy should be on what? Which drug should be avoided?

Answer 25

- Should be on a **multivitamin** w/ **1 mg Folic acid**; many of the AED's are folate-depleting - Avoid valproic acid in pregnancy

Question 26

What is the drug of choice for a woman with epilepsy?

Answer 26

Whichever drug BEST controls her seizures (no one size fits all)

Question 27

What are common associated signs with Syncope?

Answer 27

- Pallor - Sweating - Abnormal head sensation - Lightheadedness - Positionally related - Slow onset - Brief unconsciousness

Question 28

What are 4 common signs/symptoms seen with a seizure that are distinct from syncope?

Answer 28

- Urinary or bowel incontinence - Tongue injury - Tonic/clonic movements - Post-ictal state

Question 29

What is Transient Global Amnesia? Typical patient presentation and how long do they episodes last? Recurrence?

Answer 29

- Sudden, temporary, **isolated episode** of loss of memory (amnesia) - No other neurologic symptoms or signs - Patient **knows self and close family friends**, but may not recognize others - Usually **lasts a few hours**, then resolves - Usually doesn't recur