Seizures- MJ Flashcards
(71 cards)
1
Q
What is epilepsy? (Defined as 4 different things)
A
Not a single entity or disease but a family of syndromes
Defined as:
- 2+ unprovoked seizures > 24 hours part
- 1 seizure with risk of recurrent seizures
- Diagnosis of an epilepsy syndrome
- Tendency to unprovoked recurring seizures, not caused by any known medical condition
2
Q
1 in ___ people will develop epilepsy during their lifetime
A
26
3
Q
Seizures do not respond to medical tx in what percent of people?
A
30-40%
(60% of people w/ new onset epilepsy respond to the first few AEDs)
4
Q
What is drug resistant epilepsy?
A
- continued seizures despite at least 2 medication trials
- drug resistance can’t be determined until dx of epilepsy and type is confirmed, other factors that may affect seizure control assessed, and appropriate medication trials assessed
5
Q
What is the most common cause of death in people with epilepsy?
A
SUDEP
(Sudden Unexplained Death in Epilepsy)
6
Q
What are the 2 largest age groups affected by epilepsy?
A
Neonates and >65y/o
7
Q
What is a seizure
A
A sudden surge of abnormal electrical discharges from complex chemical changes in brain cells
8
Q
What are the 3 different types of seizures?
A
- Focal (partial)
- Generalized
- Unknown onset, unclassified
9
Q
Which type of seizure?
- Onset within a network or group of neurons in one hemisphere or side of the brain
- May spread to affect networks on both sides, called bilateral (secondary generalized)
A
Focal (partial)
10
Q
Which type of seizure?
•Affects large networks throughout both sides of the brain
A
Generalized
11
Q
What are 3 examples of motor clinical features of focal seizures?
A
- Loss of movement
- Excess movement (shaking)
- Automatisms (repetitive)
12
Q
What are the 4 most common epilepsy syndromes in adults?
A
- Temporal lobe epilepsy
- Frontal lobe epilepsy
- Juvenile Myoclonic epilepsy
- Lennox-Gastaut syndrome
13
Q
Which type of epilepsy is the MC focal epilepsy, amenable to sx and w/ good outcome
A
Temporal lobe epilepsy
14
Q
Which type of seizure is often mistaken for psychiatric conditions, some are amenable to sx but has a less favorable outcome?
A
Frontal lobe epilepsy
15
Q
Which type of epilepsy is lifelong, genetic, and the choice of drugs is critical?
A
Juvenile myoclonic epilepsy
16
Q
Which type of epilepsy is described as:
- Drug resistant seizures
- progressive cognitive/behavioral decline
- Pt is often developmentally delayed
- May have hx of Cerebral Palsy
A
Lennox-Gastaut Syndrome
17
Q
What are the 6 most common causes of epilepsy in adults?
A
- Genetic (brain malformations)
- Structural (stroke, head trauma, tumors)
- Metabolic
- Immune
- Infectious (encephalitis, abscess, neurocysticercosis)
- Unknown (60% of new cases have no obvious cause
18
Q
What are the following examples of?
- Neurologic (MS, migraines)
- Somatic (osteoporosis, COPD, asthma, sleep disorders)
- Mental health (depression, anxiety)
- Cognitive disorders (learning disorders, developmental delay, dementias, autism)
- Injuries (burns, lacerations, trauma)
A
Comorbidities of epilepsy
19
Q
When is a CT scan or an MRI needed in the diagnosis of epilepsy?
A
- Any adult w/ new onset seizures needs MRI
- CT may be done urgently but this does not replace MRI
20
Q
What are the goals of CT/MRI in the diagnosis of epilepsy?
A
- Look for structural causes, treatable lesions
- Assess for changes or focal lesions/onset in person with history of seizures
21
Q
What are the 3 roles of EEG testing?
A
- To look for abnormal electrical discharges (epileptiform) that can occur between seizures
- To confirm if an event is an epileptic seizure
- To evaluate for ongoing seizures, e.g. status epilepticus
22
Q
T/F: If a patient has a normal EEG, you can rule out seizures/epilepsy?
A
FALSE
Normal EEG does not rule out seizures/epilepsy
23
Q
What is the role of other forms of EEG if symptoms do not respond to tx?
A
- to provoke seizures and record events.
- To confirm diagnose seizures/epilepsy
- Characterize types of seizures
- Localize where seizures start and eligibility for other treatments
24
Q
The following is describing what cause of nonepileptic event/seizure? What is the treatment (2)?
- Events often atypical
- Not associated with epileptiform brain activity
- Often not at conscious level
- Associated with history of trauma or abuse
A
- Psychogenic
- Treatment options: cognitive behavioral therapy, treatment of psychological/behavioral problems
25
How do you diagnose a nonepileptic event?
•Video EEG telemetry in an epilepsy monitoring unit is the gold standard
26
What is the clinical trajectory of seizure treatment?
27
**Are the following describing _old or new_ antiepileptic drugs?**
## Footnote
* Hepatic influence on pharmacokinetcs, dosing, drug interactions
* Should monitor serum drug levels
* More short and long term side effects
* Less costly
Old
28
Are the following describing **old or new** antiepileptic drugs?
## Footnote
**•Hepatic influence less likely**
**•Less drug interactions**
* More predictable pharmacokinetics
* Serum drug levels usually not needed
* **Less side effects**
* **More costl**y when still under patent
Newer
29
What are the 7 times you would want to treat the first seizure?
1. **Unprovoked seizures with a high recurrence rate**
* Prior brain lesion (stroke) or insult (head trauma)
2. Epileptiform EEG abnormality (88% risk of another sz)
3. significant brain abnormality by imaging
4. Nocturnal seizures
5. Older age
6. Social factors - driving, employment
30
What is the general advice for dosage of many AEDs? What are 2 examples of meds where this is the case?
"Start low, go slow"
Examples: Lamotrigine, Topiramate
31
After how many seizures should you ALWAYS start meds?
After 2 unprovoked seizures
32
**The following are examples of what?**
1. Other illness or infection
2. Medication nonadherence
3. Sleep deprivation
4. Stress
5. Other prescription or OTC meds/products
6. Alcohol/ilicit drugs
7. Menses
Potential triggers of breakthrough seizures
33
What AED causes weight gain (1)?
Valproic acid/valproate
34
Which 2 AEDs cause weight loss and **kidney stones?**
1. Topiramate
2. Zonisamide
35
What 3 AEDs cause hyponatremia?
1. Carbamaepine
2. Oxcarbazepine
3. Zonisamide
36
Which 2 AEDs cause osteopenia, osteoporosis?
Enzyme inducers
Valproate
37
Which 5 AEDs have effects on cognition?
1. phenytoin
2. phenobarbital
3. valproate
4. carbamazepine
5. topiramate
38
What 7 AEDs cause mood/behavior issues?
1. phenobarbital
2. phenytoin
3. tiagabine
4. zonisamide
5. levetiracetam
6. perampanel
7. ezogabine
39
Which 3 types of medications can cause an **increase risk of seizures** in a person w/ epilepsy?
1. **Abx** (ex: Ciprofloxacin)
2. **Antidepressants** (ex: Clomipramine, bupropione, amoxapine, maprotiline)
3**. Narcotics (**ex: Demerol
40
Which ADE has the greatest risk of **major birth defect**s and impact on child development
VPA (valproate)
41
What 3 ADEs have the **greatest risk** for major birth malformations?
Which 2 have less risk or malformations?
* greatest risk= VPA, phenobarbital, topiramate
* Less risk= lamotrigine, levetiracetam
42
Which AED's level can be lowered by oral contraceptives resulting in breakthrough seizures and side effects?
Lamotrigine
43
What AEDs lower efficacy of oral contraceptives? (9)
1. Carbamazepine, phenytoin,
2. Phenobarbital, primidone
3. Clobazam
4. Eslicarbazepine
5. Felbamate
6. Lamotrigine (300 mg daily or more)
7. Oxcarbazepine
8. Rufinamide
9. Topiramate
44
What are the 6 reasons you should consider AED withdrawal?
1. Seizure free for 2 years or more
2. If seizure control is easily achieved on low dose of one AED
3. No prior unsuccessful attempts at withdrawal of meds
4. Normal neurological exam and EEG (except JME)
5. With benign syndromes (e.g. benign rolandic epilepsy)
6. Patient/family readiness for AED withdrawal
45
How should you properly change a patient to a different AED? (4 steps)
* Usually start new drug 1st
* Build to effective dose before removing first drug
* Consider use of rescue therapy for breakthrough events
* Educate families about potential drug interactions and actions to take
46
How do you treat a patient with persistent seizures?
**•Consult an epilepsy specialist** to confirm diagnosis and consider other options
* More than 1 drug, additional meds, investigational
* Surgery, devices, diet
•Consider use of **rescue therapy** for seizure clusters or periods of increased seizures
47
When are the 2 times epilepsy is considered resolved?
* If person has an **age-dependent epilepsy** syndrome and they are now **past the relevant age range**
* If **seizure free for 10 years** and has been **off AEDs for 5 years.**
48
What are the 4 times specialized epilepsy care is needed?
* When diagnosis is unclear
* When **seizures are not controlled after 2 or more trials** with appropriate AEDs
* When **surgery or other therapie**s are being considered
* For **consultation** (AED withdrawal, switching from old to new generation AED, pregnancy counseling/management
49
What are 5 non-pharmacologic treatment options for everyone with epilepsy?
1. Trigger management
2. Lifestyle modifications
3. **Cognitive behavioral therapy**
4. Educational approaches
5. Wellness- **nutrition, fitness, stress management**
50
When should a patient be evaluated for surgery as a tx option of epilepsy?
* Indicated for **drug resistant epilepsy** (if fail 2 drugs)
51
What is the most common surgery performed on epileptic patients?
Resection of temporal lobe for mesial temporal sclerosis
52
What should you do before performing surgery on a patient with drug resistent epilepsy? (presurgical evaluation)
* localize seizure onset/spread
* determine language/memory location
* potential risks of surgery
53
What are the 3 dietary therapies for epilepsy?
**1. Ketogenic**
**2. Modified atkins**
**3. Low glycemic**
\* all should be monitored by medical professionals
54
What are the 3 indication for use of devices in the treatment of epilepsy?
1. Drug resistant epilepsy (mostly for focal epilepsy)
2. When surgery doesnt work
3. When the pt is not a surgical candidate
55
What 4 presurgical evaluation steps should you do before inserting a device as tx for epilepsy?
* Confirm seizure type, frequency, location
* MRI
* Functional status
* Education/psychosocial
56
What are the 3 types of devices used for tx of epilepsy?
1. VNS therapy
2. Responsive neurostimulation
3. Deep brain stimulation
57
What is considered **status epilepticus?**
* Continuous seizures \>5 minutes
* Recurrent seizures w/o return to baseline
\*\*\*this is a medical emergency\*\*\*
58
Up to 90% of seizures in critically ill patient in the ICU are what type of seizures?
non-convulsive
59
**Clinical features of focal seizures in the ICU:**
What are considered "positive" symptoms?
•Twitching and automatisms to agitation, eye deviation, and blinking
60
**Clinical features of focal seizures in the ICU:**
What are considered "negative" symptoms?
Coma, aphasia, and weakness to confusion, staring, amnesia
61
**Clinical features of focal seizures in the ICU:**
Up to 90% of seizures experienced by critically ill patients are non-convulsive. What are the 4 most common sxs?
* Fluctuation in mental status
* Sudden decline in neurological status
* Unexplained stupor
* Agitation
subtle signs (ex: eye deviation, facial twitching) is seen in 50%
62
The following are **_relative_** risk factors for what type of seizure?
## Footnote
* Clinical seizure
* Severe sepsis
* Acute brain injury
* Drug intoxication/withdrawal
* AED non-compliance
Non-convulsive seizures
63
The following are **_remote_** risk factors for what type of seizure?
## Footnote
* Epilepsy
* Intracranial tumor
* CNS infection
* Stroke
* Neurosurgery
Non-convulsive
64
**The following are clinical findings that are considered risk factors for what type of seizure?**
## Footnote
* Clinical findings
* Coma exam
* Nystagmus, hippus, eye deviation
* Face/limb twitching, automatisms
Non-convulsive
65
What are the steps in treating a seizure emergency?
1. First 30 min- tx w/ **Benzodiazepines**
2. 30-120 min- tx w/ **IV antiepileptic drug**
3. \>120 min- tx w/ **general anesthesia**
66
What is the pathophys behind early status epilepticus?
•GABA receptor trafficking intensifies and SE is sensitive to GABA
67
What is the pathophys behind refractory status epilepticus?
•GABA receptors are internalized leading to less responsiveness to GABA agents
68
What is the pathophys behind super refractory status epilepticus? (4 things happen)
* NMDA receptors are over expressed and NMDA antagonists become more important
* Neuronal death
* Inflammatory processes
* Mitochondrial failure
69
Which AED is a good option for a patient wanting to become pregnant?
Lamotrigine
70
What are the clinical features of focal seizures?
* **Motor** (loss of movement, excess movement/shaking, automatisms)
* Sensory
* cognitive/emotional
* Autonomic
* **Level of awareness** (aware, unaware or unknown)
71
How do you classify seizures? (table from pharm)
* If a person is aware during seizure is it focal or generalized?
* If a patient has an absence ("staring") seizure, is this focal or generalized?
* If a person is aware during seizure is it focal or generalized? **_Focal_**
* If a patient has an absence ("staring") seizure, is this focal or generalized? **_Generalized_**
