Seizures

Question 1

____% of first time seizures occur before age 20

Answer 1

75%

Question 2

Patho

Answer 2

Increased cell membrane excitability due to failure of normal inhibitory mechanisms - GABA

Leads to intense, prolonged neuronal discharges

May remain localized or may spread to involve entire cortex

Question 3

Etiology

Answer 3

Idiopathic

EtOH withdrawal (very common)

Metabolic (hypoglycemia, hepatic failure, hyper/hyponatremia)

Infectious (meningitis, abscess, neurosyphilis)

Degenerative (i.e. MS, senile dementia)

Neoplastic (esp. in elderly with new onset seizures)

Toxic (theophylline)

Head trauma (epidural/subdural hematomas)

Vascular (stroke, AVM, subarachnoid hemorrhage)

Perinatal (infx, metabolic disorders)

Eclampsia

Question 4

Classification of Seizures

Answer 4

Generalized szs

• Grand mal
• Petit Mal (Absence)
• Myoclonic

Partial/Focal szs

• Simple partial
• Complex partial

Question 5

Generalized Seizures

(general)

Answer 5

Cause abrupt LOC because entire cerebral cortex is activated

Question 6

Grand Mal Seizure

Answer 6

AKA tonic-clonic seizures

Begin with LOC, usually without warning

Tonic phase: pt falls to ground with trunk/extremities extended

Clonic phase: rhythmic jerking of trunk and extremities

• Often, apnea, cyanosis, tongue-biting, urinary incontinence
• Typically last 60-90 seconds

Post-ictal phase: after attack, pt remains unconscious, flaccid, confused, usually for many minutes before slowly regaining consciousness (20-60min)

Todd’s Paralysis: occassionally may have transient postictal focal paresis

Question 7

Petit Mal (Absence) Seizures

Answer 7

Typically very brief - only a few seconds

Abrupt LOC, no response to voice

Blanke stare, eyelids may twitch

No falls, involuntary movement, no incontinence

No post-ictal phase; attacks cease abruptly; pt unaware that anything has happened

May be frequent (>100/day)

Typically seen in school-aged kids, resolving as they grow up; very rare to see in a

Question 8

Myoclonic Seizures

Answer 8

LOC associated with extremity jerking

Usually has post-ictal phase

Question 9

Partial (Focal) Seizures

general

Answer 9

Due to electrical discharged beginning in localized region of brain

May remain localized or may spread, becoming more generalized

Often due to focal structural brain lesion - tumor, AVM, scar tissue, CVA, head injury

Question 10

Simple Partial Seizures

Answer 10

No alteration of consciousness

Manifestations may be:

• Motor: tonic or clonic movements, often unilateral, often limited to one extremity
• Sensory: paresthesias/numbness, flashing lights, olfactory/gustatory hallucinations

Question 11

Complex Partial Seizures

Answer 11

AKA psychomotor sz or temporal lobe sz

Involves changes in LOC or mentation - pt not thinking clearly, but are conscious

Usually bizarre sx with psychic features

• visceral sxs (nausea, butteflies in stomach)
• hallucinations (visual, olfactory, auditory, olfactory)
• memory disturbances (deja vu, jamais vu)
• dream-like states
• automatisms: repetitive, purposeless movements (lip smacking/playing with clothes)
• affective disorders (paranoia, depression, elation)

Question 12

Consequences of being diagnosed with seizure disorder

Answer 12

Employment

Insurability

Driving

Long-term meds

Question 13

Psychogenic Seizure

Answer 13

aka pseudoseizure

Often occur in repsonse to emotional upset

Often occur only when witnesses present

Bizarre features - pts protect themselves from noxious stimuli, no incontinence or injury during episode, no post-ictal confusion, normal EEG

Question 14

Physical Exam

Answer 14

Look for systemic illness that may have precipitated the attack

• v/s
• detailed neuro and mental status exam

Look for injuries resulting from seizure

• fxs, bruises
• tongue lac, broken teeth
• aspiration
• head/neck injury

Question 15

Labs

Answer 15

Depends on suspected etiology and sz hx

Always check a glucose

Possibly: lytes, BUN/Cr, Ca, Mg, PO4

LP if suspect meningitis

Tox screen if ingestion suspected

Anticonvulsant levels in pt with known sz hx

Question 16

Imaing

Answer 16

CT

• appropriate for first time sz
• look for structural lesions, head bleed
• generally not indicated in pt with known sz disorder who sustains typical sz

MRI

• more sensitive for sublt abnormalities
• may be study of choice for first time sz if acutely available

EEG

• Identifies and locates abnormal electrical findings
• abnormal EEG supports dx of true sz
• A normal inter-ictal EEG does not r/o epilepsy

Question 17

Treatment of Acute Seizure

Answer 17

protect pt from injury, prevent falls with gentle restrain

place on side to reduce aspiration

DO NOT try to force open tonic jaw - bite block not necessary

assure airway patency after sz subsides

if lasts longer than 5 minutes consider benzodiazepine

tx underlying illness, if present

if known sz disorder, check anticonvulsant levels

Question 18

Warn all pts with first time seizures to refrain from….

Answer 18

No driving

No operating dangerous machinery

No heights

No unsupervised swimming

Question 19

Status Epilepticus

Answer 19

Continuous seizure activity lasting >30min (sometimes classified as less) OR two or more seizures without return of consciousness in between

50% have no sz history; MC’ly tonic clonic, but can be any kind

Demands urgent treatment

• hypoxia > 30-60 minutes lead to permanent neuro injury

Causes - same as acute

Treatment

• ABC’s - O2 by facemask, consider intubation + large bore IV
• Check stat glucose
• Anticonvulsants - first line are benzo’s
• Search for underlying cause and tx
• Look for injuries resulting from sz
• CT head after seizures controlled