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Flashcards in Seizure Disorders Deck (98):
1

Seizure Types

Not all seizures = epilepsy

Symptomatic Seizure
Cryptogenic Seizure

Acute vs Remote

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Prevalence of Seizures

1 in 10 adults will have had a seizure

3

Seizure where cause is identified

Symptomatic Seizure

4

No cause of seizure is identified

Cryptogenic Seizure

5

Pathophysiology of Seizure

Basis for neuronal excitation is the action potential

Seizure results from increased frequency burst of action potentials- spikes

Glutamate- excitatory neurotransmitter- allows Ca++ influx which keeps Na+ voltage gated channels open (perpetuates depolarization)

Depolarization activates NMDA channels open which allows further Ca++ influx

GABA- inhibitory neurotransmitter

Old theory: loss of inhibitory neurons (GABA)

New theories:
-loss of excitatory neurons (that stimulate the inhibitory neurons)
-Injury leads to axonal “sprouting” to other excitatory neurons

6

Causes of Non-epileptic Seizure

> 70-80% Idiopathic

Neurogenic: Brain tumor, CVA, trauma

Electrolyte/Metabolic imbalances

Hypoglycemia, hyponatremia, hypocalcemia

Hyperthyroidism

Acute renal or hepatic failure

Medication overdoses

Antidepressants, antipsychotics, cyclosporine, interferon, INH, Lithium, Demerol, tramadol (Ultram), quinolone atbs

Drug withdrawal

Drugs: Cocain, m-amphetamine, nitrous oxide, IV contrast dye, lead or mercury poisoning, acetylcholinesterase inhibitors

Infection and/or fever

7

Common seizure causes <10 yo

Idiopathic
congenital
birth injury
metabolic disorders

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Common seizure causes 10-40 yo

Idiopathic, congenital, birth injury, metabolic disorders

9

Common seizure causes 40-60 yo

Brain Tumor
Head Trauma

10

Common seizure causes >60 yo

CVA
brain tumor
subdural hematoma
CNS infection
Alzheimers
metabolic disturbance

11

Age of Febrile Seizure Occurance

6 mo - 5 yo
Peak age 2 yo

12

Prevalence of Febrile Seizures

66% male

3-5% children <5

13

First Febrile Seizure Risk Factors

Fever >38 (100.4)
Day care attendance
Developmental delay
Neonatal nursery >30 days
FH (sibling- 10% risk)
Viral infections (HHV6, influenza, others)
Vaccinations (influenza, DTP, MMR (fever))

14

Common Viral pathogen for Febrile Seizures

HH6
Influenza

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Recurrent Febrile Seizure Risk Factors

30-50% will experience subsequent szs

Age <104F)
First degree relative with febrile

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Simple Febrile Seizure

last less than 15 min; no underlying neuro problems, ie. Cerebral palsy

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Evaluation of Febrile Seizure

History & Physical:
FH
PMH
HPI
Recent vaccines
Meningeal irritation - If yes, LP

Imaging?
Most do not require. MRI preferred (due to less radiation)

18

Management of Febrile Seizures

Antipyretics Tylenol/ibuprofen
-For comfort
-Do NOT prevent seizure
Recurrence likely
No increased morbidity/mortality
No behavioral/developmental disorders
No prophylaxis required- adverse effects, lack of efficacy

19

Febrile Seizure Prognosis

By age 5 - 98% seizure free

20

Risk of developing later seizures after febrile seizure:

Underlying neuro disease (cerebral palsy)
FH epilepsy
Complex seizures

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Types of Seizures

Partial
Generalized

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Partial Seizures

Simple
Complex

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Generalized Seizures

Absence (“Petit Mal”)
Generalized tonic-clonic (“Grand Mal”)
Myoclonic
Atonic

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Causes of Absence Seizures

Inherited idiopathic disorder
Secondary disorder: AVM, neoplasm, ID

25

Absence seizures vs Partial-complex seizures

AGE is critical.

In adult, with similar symptoms, think partial-complex seizures.

Tx different!

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Age of onset of Absence Seizures

age 5-18

Rare under age 2 or beyond adolescense

27

Signs and Symptoms of Absence Seizures

NO AURA!!!

Vacant, dazed expression
Staring
Pallor
Timing: 10 seconds max
Multiple times throughout day (50-100x)
Other: eye blinking, head movements, autonomic movements (incontinent stool or urine)
Post-ictal: brief recovery, picking clothes, pursing lips
EEG: diffuse 3Hz spike pattern (see later)

28

What are absence seizures mistaken for?

Often escape detection.

Mistaken for ADHD, daydreaming.

29

Treatment of Absence Seizures

Usually cease by age 20

Progress (if untreated) to generalized tonic-clonic seizures in 33%

Treatment:
Ethosuximide (Zarontin)
Valproic acid (Depakote)
+/- clonazepam (historically)

30

Pharmacologic Treatment of Absence Seizures

Ethosuximide (Zarontin)
Valproic acid (Depakote)
+/- clonazepam (historically)

31

Tonic Clonic Seizures AKA

Grand Mal

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What often proceeds Tonic Clonic seizures?

Aura

33

Aura symptoms

Irritability
Apathy
HA
Scintillating scotoma
nausea
choking sensation
paresthesias

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Signs of Tonic Clonic seizures

Aura (often precedes
Sudden LOC
Tonic- muscular rigidity (adduction and flexion of arms; extension of legs)
Clonic- jerking
Incontinence
Tongue biting

35

Treatment of Tonic Clonic Seizures

Valproic acid (Depakote) (first line)
Phenytoin (Dilantin)
Carbamazepine (Tegretol)
+/- phenobarbital

Others:
Primidone (Mysoline)
Lamotrigine (Lamictal)
Topiramate (Topamax)
Zonsisamide (Zonegran)
Levetiracetam (Keppra)

36

Myoclonic Seizures feel like

Sudden, single or multiple jerks

37

Myoclonic seizures and chidren manfest as

"Infantile spasms"

38

S/S Atonic Seizures

LOC
Head drops, loss of posture
“drop attack”
Falls cause Injury

39

Treatment for Atonic Seizures

Resistant to drug therapy

40

Simple Partial Seizure occurs in a

focal area (may spread to other areas)

41

Sensory manifestations of Simple Partial seizures

visual
auditory
olfactory
gustatory

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Autonomic manifestations of Simple Partial seizures

GI sxs
flushing

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Motor manifestations of Simple Partial Seizure

Jerking limbs
Paresthesias

44

Other manifestations of Simple Partial Seizurs

Hallucinations
Deja vu
Jamais vu

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Treatment of Simple Partial Seizures

Phenytoin (Dilantin)
Carbamazepine (Tegretol)
Valproic acid (Depakote)

+/- others… (phenobarbital, primidone, zonisamide)

46

Most common type of seizure

Complex Partial

47

S/S Complex Partial Seizures

LOC

“Temporal lobe” may travel to frontal

Aura: GI symptoms, Sense of fear

Stare, automatisms-picking/fumbling, facial movements

Last 30 sec – 2min

May progress to generalized tonic-clonic

Resemble petit mal

48

Treatment of a Complex Partial Seizure

Carbamazepine (Tegretol)

Phenytoin (Dilantin)

Surgery: temporal lobe resection

Failed medical treatment after 1-2 years

49

Rolandic Epilepsy are a type of

partial seizure.

50

Rolandic epilepsy only occurs in

children.

51

Rolandic epilepsy originates in

rolandic area of brain but may generalize to tonic-clonic

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Symptoms of Rolandic epilepsy

Face/cheek twitching
Drooling
Difficulty speaking

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Rolandic epilepsy EEG pattern

Centrotemporal Spikes

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Rolandic seizures often occur

during sleep

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Treatment of Rolandic Seizures

Carbamazepine (Tegretol)
Oxcarbazepine (Trileptal)
Gabapentin (Neurontin)

56

Gelastic or Dacrocystic seizures only occur in

children.

Often occur when falling asleep or under emotional stress.

May generalize.

57

Gelastic seizures manifest as

laughing.

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Dacrocystic seizures manifest as

crying.

59

Treatment of Lennox pts

Difficult

60

Lennox seizures occur from...

Lennox-Gastraut

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Also seen with Lennox seizures

Developmental delay

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Lennox seizures occure secondarily to:

Encephalopathy
Meningitis
Birth injuries- hypoxia

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Lennox Seizure Timing

Nocturnal
Frequent seizures daily

Often wear helmet because seizures are SO frequent.

64

Lennox EEG pattern

interictal spikes

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Management of Status Epilepticus

Check glucose

Lorazepam or diazepam… +/- midalzolam

Lorazepam 0.1mg/kg IV max 4 mg (duration 12-24h)

Diazepam 0.1-0.3mg/kg IV max 10mg (short acting)

66

Biggest risk factor for status epilepticus

Medication Withdrawal!

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Status epilepticus is...

LIFE THREATENING!!!

68

Status epilepticus seizures last

>30 minutes

2 or more seizures without recovery period.

69

Risk factors for status epilepticus

MEDICATION!
Alcohol withdrawal
Drug overdose
Intracranial infections (meningitis, encephalitis)
Neoplasms

70

What occurs after seizure?

Post Ictal Period

71

How long is the post ictal period?

5-30 minutes

72

S/S Post Ictal period

Headache
Exhaustion
Confusion
Drownsiness

73

Rare manifestations of the Post Ictal Period

Todd’s paresis: (6% of grand mal)-paralysis 15h-36h

Postictal psychosis: lucid phase 2-6h, psychosis 9-10d

Postictal bliss: euphoric

74

Medication Treatment for Seizures

LOOK IN CURRENT

LOOK OVER SIDE EFFECTS - fatigue, drowsiness, sedation, ataxia

KNOW A FEW FOR EACH DRUG

75

Medications to avoid during pregnancy

Valproate
Carbamazepine

76

Supplementation for pregnancy

Folic Acid
Vitamin K

77

Lactation for women with seizures

Breast feeding still recommended

78

What to monitor for breast feeding women

Irritation
Altered Sleep
Poor weight gain

79

Anovulatory Cycles

Have to do with seizures and pregnancy - look up.

80

Anti-seizure medications may effect

Hormones.

May increase risk of miscarriage

Birth defects 2-3% risk v 4-8%

81

How should medications be prescribed for pregnant women?

Lowest possible dose but dilution factor.

82

Seizures onset due to progesterone withdrawal

Catemenial Seizures

83

Pathophysiology of Catemenial Seizures

Mid-cycle ovulation due to estrogen surge.

84

Common occurence in women with seizures

Polycystic Ovary Disease
40% women with epilepsy

Subset related to valproate - Depakote

85

Drugs that do not affect the eficacy of OCs

Gabapentin (Neurontin)
Levetiracetam (Keppra)
Lamotrigine (Lamictal)
Valproate (Depakote)
Zonisamide (Zonegran)

86

Atypical Seizure Activity

Nonfocal: opposite arm/leg

Pelvic thrusting

Head turning side to side

Eyes closed, tight

Tongue biting limited tip

Postictal crying

Memory of the event

May be triggered by emotional/stressful situations

87

Causes of Psychogenic Nonepileptic Seizures

Anxiety attacks/ PTSD
Conversion Disorder

88

Pseudoseizures

Psychogenic Nonepileptic Seizures

89

Who may experience pseudoseizures?

Epilepsy patients
Women

90

Labs to order for new onset seizures

CBC
CMP
Ammonia (cirrhosis)
Tox screen
+/- ESR
+/- prolactin- 40-60% within 20min sz

LP if you suspect infection.

91

Imaging for Seizures

Head CT if acute bleed suspected
MRI preferred

92

Favorable Factors for pts with seizures

Provocative condition
EEG NL
No seizure within first year

93

Negative Factors for pts with seizures

Abnormal EEG
Underlying neuro condition
Remote condition- CVA

94

Approach to pt with seizures:

Recurrent?
Favorable factors?
Negative factors?

95

Seizure Prophylaxis

Structural abnormality: neoplasm, AVM, infection
Head trauma, CVA
Sibling with epilepsy
Hx prior seizure
Abnormal EEG
Status epilepticus
Todd’s paresis
+/- Unprovoked seizure

96

Do not attempt prophylaxis for pateints with

Febrile
Electrolyte abnormality
Secondary to stimulant abuse
Sleep deprivation
Alcohol/drug withdrawal

97

Stop/Tapering Medication

Seizure Free x 2 Years

AND

Normal EEG

98

Patient Education: Driving

No driving 6 months from last seizure.