Neuro unit 2

what are the two different seizure activity

• acute

• chronic like epilepsy

when do acute symotomatic seizures occur

occurs at the time of a systemic insult or in close temporal assocition with a documented brain insult

unpoked seizure

relation to prexisting brain lesions or progressive nervous system disorder

what is epilepsy

•At least two unprovoked seizures occurring more than 24 hours apart.

•One unprovoked seizure and a probability of further seizures. More so the case with remote structural lesions such as stroke, central nervous system infection, or certain types of traumatic brain injury.

•Diagnosis of an epilepsy syndrome (genetic)

what are things that can provoke a seizure

Alcohol & drug withdrawal ​

Drug intoxication ​

Hyponatremia, hypernatremia ​

Hypomagnesaemia  ​

Hypocalcemia ​

Hypoglycemia ​

Nonketotic hyperglycemia /Hyperosmolar Hyperglycemic State

DKA

Uremia ​

Hypoxia ​

Hyperthyroidism ​

Dialysis disequilibrium syndrome ​

Porphyria ​- liver disorders with build up of porphyrins 

focal partial seizure

abnormal neuronal discharge from one discrete focus of one hemisphere

focal partial seizure 2 different types of awareness

• retained awareness (simple) consciouses fully maintained

• imapired awareness (complex) conciousness impaired

motor component of focal seizures

• jerky rhythmic movements

• jackson march is followed by todd paralysis

jackson march

when a focal seizure starts in one area and spreads to other parts of the body

todd parylsis

paralysis of one side 30-60 min sometimes makes in hard to tall from stroke

sensory components of a seizure

•Paresthesia

•Numbness

•Pain

•Heat

•Cold

•Sensation of Movement

•Olfactory

•Flashing Lights

what can autonomic sx of focal seizure

• abdominal pain

• cardiovascualr sinus tachy

• flustions in BP

• bronchoconstriction

can aura be present in focal seizure

prior and after event

psychological componenets of focal seizure

• fear

• agition

• deja vu

• hallucination

what are the complex types of focal seizure

• behvarioal arrest and staring

• automatism

• post ictal phase

behavioral arrest and starting time frame

less than 3 min

awareness in behavioral arrest

unaware and unresponsive - type of complex focal

automatism

repitive behvarios (lips smacking, facial grimicing, chewing, manual picking, patting, or repeating words)

post itcal phase

somnolence, confusion, agition, HA, generally lasting minutes to hours

inital w/u for seizure

•CBC, CMP (electrolytes, liver and renal function), tox screen, pregnancy test, RPR (rapid plasma reagin, syphillis)

•MRI is preferred; CT if emergent

Video EEG is gold standard. 

A normal EEG after an event does not exclude

Epilepsy

what is the gold standard for focal seizure

EEG

Epilepsy Monitoring Unit (EMU

receive continuous video-electroencephalography (video-EEG) monitoring to diagnose, classify, or manage seizure disorders

EEG findings of focal seizure for simple

focal discharge at onset

EEG findings of focal seizure for complex

interictal spikes or slow waves in the temporal or frontotemporal areas

absence seizure

generalized seizure (in both hemispheres) most common in children (4-10) like a child is daydreaming

how often do petit mal seizures occur

aka absence seizure can occur ten of times a day

cinical manifestation of absence seizure

• sudden amrked inmpairment of consciousness & loss of awarness w/o loss of body tone

• blank spare

• promt return to baseline w/o post ical state or aura

how long do abcence seizure last

5-10 sec

what can be a trigger for abcence siezure

hyperventilation/ emtional like fear and anger

main diagnostic tool of EEG findings for abcence seizure

b/l synchronous & symmetrical 3 hertz (3 cyles per sec) spike and waves discharge that start and end abruptly

what is first line for absence seizure

ethosuximide (Blocks T-type voltage-gated calcium channels in thalamocortical neurons, calming overactive nerve signals in the brain that trigger brief lapses of consciousness)

second line for petit mal seizure and gtc

valprocic acid if gtc= manotrigine or tropiramate

medications to aviod

some sodium channel blockers (Carbamazepine, Gabapentin, Phenytoin, Pregabalin) -- can exacerbate

why do sodium channel blocker exacerbate

•Some gene mutations associated with absence seizures cause a loss of function of the sodium channel that leads to increased seizure activity.  The result of this mutation leads to a decrease in the amount of inhibitory neurotransmitter that should balance the excitatory neurotransmitters. This makes a seizure more likely to occur.  In this situation, the problem with the balance of excitation and inhibition in the brain is not too much excitation, it is too little inhibition.

•This makes sodium channel blocking anti-epileptics a poor choice for treatment.  Giving sodium channel blocking drugs to patients with a loss of function mutation will further decrease the amount of inhibitory neurotransmitters in the brain, making the balance scale tip more toward excitement and more seizure activity.

generalized seaizure =

GRAND mal

what defines grand mal seizure

simultanous neural discharge of both hemisphere (diffuse brain invovement)

what are the two clinical manifestions of generalized seizure

• mycolonic

• atonic

• tonic/ clonic

• clonic

• tonic

myoclonic

sudden, breif, sporadic involuntary twiching of one muscle or a group of muscle usally w/o loss of consciousness

atonic

sudden partial or complete loss of muscle and postural tone= drops attach may can cause injury

tonic

Loss of consciousness followed by rigidity

clonic gran mal

•repetitive, rhythmic, symmetric jerking (usually 1-2min)

•Post-ictal phase

tonic-clonic grand mal

•Sudden loss of consciousness with tonic activity (contraction & rigidity)

•May have respiratory arrest followed by 1-2min of clonic activity (repetitive, rhythmic, symmetric jerking) <3min

•Followed by post ictal phase

•Cyanosis, tongue-biting & urinary incontinence can occur

inital w/u for grand mal

CBC, CMP (electrolytes, liver and renal function), tox screen, pregnancy test, RPR (rapid plasma reagin, syphillis to r/o reversiable causes

what to check after seiazure to r/o psychogenic nonepileptic seiseizure

prolactin or lattic acid immediately after

what to order to r/o brain lesion or mass after seizure

MRI

what does tonic-clonic siezure show on eeg

generilized high amplitude rapid spiking during active events

how to tx generalized seizure

treat the cause

•Alcohol withdrawal: benzodiazepines;  AEDs such as phenytoin are not effective.  Why??

•Eclampsia: magnesium sulfate. (Works in multiple ways, but specifically for seizures -- raises the seizure threshold by blocking glutamate receptors, which are responsible for excitatory signaling in neurons)

•Hypoglycemia, hyponatremia, hypocalcemia: correct the abnormality.

•Isoniazid (TB treatment): pyridoxine antidote (through depletion of vitamin B6).

Seizure-threshold drugs: bupropion, tramadol, theophylline.  (excess will lower seizure threshold

what antiseizure meds are safest in pregancy

Levetiracetam & Lamotrigine

myoclonic tx with

valporic acid

what defines staus epilepticus

five min or more of convulsion or two or more convulsion in 5 min interval w/o returning toward preconvulsive neurological baseline

status epilepticus is

neurological emergancy

what can cause status eptiliptical

structural abrnoamilites, infx, metabolic abnorm, toxins

status epilepticus should get

CT than MRI

tx of status eplepticu first line

Benzodiazepines (lorazepam/midazolam), IM/IV/nasal

tx status eplicpticus 2nd line

Levetiracetam, Fosphenytoin, Phenytoin or Valproate

tx status eplicpticus 3rd line

•Lacosamide or Phenobarbital (refractory)

anasthesia for status epilepticus.. and what is super refractory

•Midazolam or Propofol Infusion. (airway secured)

•Ketamine infusion/IV (super refractory)

complications of status epilepticus

hypoxia, aspiration, respiratory failure, cardiac arrhythmias

•First line benzodiazepines are frequently under-dosed. 

•Initiate a complete workup of the underlying etiology for status epilepticus. Seizures will be difficult to control with antiseizure drugs if they are caused by an underlying uncorrected metabolic problem. 

•Consider toxins that can cause seizures: tricyclic antidepressants (look for QRS widening on the EKG, treat with sodium bicarbonate); theophylline; cocaine / sympathomimetic; alcohol withdrawal (rarely causes SE, treat with accelerating doses of a benzodiazepine)

•almost any agent in overdose may cause a seizure indirectly if they cause hypoxia, hypotension, or electrolyte (including hypoglycemia) abnormalities 

when is the onset of alc withdraw

4-6 hrs after you stop drinking to reduce the amount significantly

what kind os seaizures does alc withdraw cause

tonic clonic can be single or in clusters

what are risk factors for seizure in alc withdraw

concurrent withdraw from benzo, low potassium and low platlets

how to tx seizure from alc withdraw

• iv benzo with taper

• iv fluids, iv thiamine, mg, multivitamin (b12 and folate), electrolyte replacement

what are the benzo names

diazepam, lorazepam, chlordiazepoxide, and oxazepam

moa of benzo

they potentiate GABA mediated CNS inhibition, alc mimics GABA so in withdraw there is increase CNS activity

why is iv thiamine given in alc withdraw

prior to glucose to prevent wernike encephalopathy

how to tx febrile seaizure

tx fever with antipyretics, use rescue meds for active seiazure and admit if unstable

what are the two type of febrile seaizure

complex and simple

difference between complex and simnple febrile seizures

complex last over 15 min if docal , reccures or has postictal deficits

tx different between compllex and simple febrile seizures

• complex: EEG, LP, teach seizure aid to parents as there is an increase risk of epilepsy. neuro f/u within 2 wks

• simple no imaging needed is discharge

first line for infants seizures

ACTH(ACTH signals the adrenal glands to produce cortisol and other glucocorticoid) or high dose steriods or vigabtrin if tuberous sclerosis

childhood 4-10 tx of seizure

ethosuximide this is for abcence seizures

ask someone what slide 38 means

carbamazepine moa

blocks sodium channels

when to use carbamazepine

• epilepsy

• generalized tonic clonic

• focal

• mood stabilization

carbamazepine AE

SJS

worsen HF

can worsen abscence seiazure

ethosuximide MOA

blocks Ca channels

ethosuximide AE

SJS, GI upset w

what is CI in abscent siezures

carbampizine

what is the drug of choice for petitee mal seizures

ethosuximide

what can ethosuximide worsen

renal and hepatic failure

phenytonin moa

blocks voltage gated Na

when to use phenytoin

GTC, focal seizures, prophylasis

ADE of phenytonin

P - 450 inducer = can induce lupus-like syndrome

H yperplasia of the gums & Hirsutism

E rythema Multiform, Stevens-Johnson

N europathies: vertigo, ataxia & headache

Y ield = Give Slow. Hypotension/Arrythmia

T eratogenicity: Cleft lip/palate, microcephaly

O steopenia

I nhibits Folic Acid absorption (megaloblastic anemia)

N ystagmus

phenobarbital moa

barbituarate that binds GABA receptrs and potentiates GABA mediated CNS inhibition

is phenobarbital safe in pregancy

yes also safe for children

phenobarbital indications

focal of generalizes. second line after phenytonin for status seaizures (lasting over 5 min) also good with alc withdraw seiazures

phenobarbital AE

depression, SJS, osteoproosis

names of the benzos

loprazepam, diazepam, midazolam

moa of benzo

POTENTIATES GABA CNS inhibitions

which benzo is the most effective for seizures

lorazepam have shorter half life means faster peak

when are benzo used

FIRST LINE to all acute seizures

what to give in a benzo

first line for all acute seizures

what to give in benzo overdose

flumazenil

what is flumaxzenil

antagonizes benzo receptors

valproic acid (divalproex sodium) moa

•GABA, inhibits glutamate & NMDA receptors, increases refractory period of voltage-gated sodium channels

when to used valproic acid (divalproex sodium)

myoclonic seizures

ae for valproic acid (divalproex sodium)

pancreatitis, hepatotoxic, inhibition of drug metab

what is the black box warning for valproic acid (divalproex sodium)

highest risk of birth defects (mainly in the neural tube like spina bifida)