Neurology I: Seizure and Epilepsy

-focal aware

-focal impaired awareness

what are the two types of focal seizures?

Motor: twitching, jerking in one limb/face

Sensory: tingling, visual flashes, auditory phenomena

Autonomic: flushing, nausea, epigastric rising sensation

Psychic: déjà vu, fear, jamais vu

presentation of focal aware seizure

Altered awareness/responsiveness

Automatisms: lip smacking, picking at clothes, chewing

Aura may precede (odd smell, taste, rising epigastric sensation)

Post-ictal confusion common

presentation of focal impaired awareness seizure

-absence

-tonic clonic

-tonic

-clonic

-myotonic

-atonic

name the types of generalized seizures

Sudden loss of consciousness

Tonic phase: rigidity, cry, apnea, cyanosis

Clonic phase: rhythmic jerking of limbs

Post-ictal confusion, fatigue, headache

presentation of tonic-clonic seizure

Sudden stiffening, sustained posturing

Often during sleep

presentation of tonic seizure

Repetitive, rhythmic jerking movements

presentation of clonic seizure

Sudden, brief, shock-like muscle jerks

Often bilateral and symmetric (e.g., juvenile myoclonic epilepsy)

presentation of myoclonic seizure

Sudden loss of tone → collapse, injury risk

Usually brief, may need helmet for protection

presentation of atonic seizure

foca lonset

hx of aura before seizure suggests this type of seizure

CT head non contrast

-rule out acute bleed, stroke, mass lesion (esp. if focal deficit, new-onset seizure, or trauma).

emergent imaging for seizures

MRI brain (preferred long-term) → more sensitive for structural lesions (tumor, cortical dysplasia, mesial temporal sclerosis)

preferred long term imaging in work up of seizure

ideally within 24 hours of event

how soon should you get EEG post seizure event?

Status epilepticus.

Abnormal neuro exam or persistent altered mental status.

First seizure with structural lesion on imaging.

Metabolic derangement requiring correction.

indications to hospitalize seizure pt

carbamazepine, lamotrigine, levetiracetam.

first line therapy for focal seizure if recurrence risk is high

valproate, levetiracetam., lamotrigine

first line therapy for generalized tonic-clonic seizure if recurrence risk is high

Usually continued for 2-5 years seizure-free before tapering

after first seizure, if recurrence rate is high, continue anti-seizure meds for how long?

Abnormal EEG (epileptiform discharges).

Abnormal neuroimaging (structural lesion: tumor, stroke, cortical malformation).

Prior CNS insult (TBI, stroke, meningitis).

Seizure occurred during sleep (nocturnal seizure).

first time seizure pts who have a high risk of recurrence:

About 30-40% of adults will never recur after a first seizure.

Long-term remission rates are similar whether treatment starts after the first or second seizure.

Side effects of ASMs: cognitive impairment, sedation, mood changes, teratogenicity, drug interactions.

arguments against treating after first seizure

valproate, levetiracetam.

first line treatment for myoclonic seizures

seizure >5 min, or ≥2 seizures without return to baseline

define status epilepticus

1. stabililze ABCs (0-5 min)

2. IV benzo (lorazepam preferred) (5-10 min)

3. IV antiseizure drug (10-30 min)

4. continuous IV anesthetic infusion (30-60 min)

management of status epilepticus

vasovagal syncope

what type of neurally mediated syncope?

Triggers: emotional stress, pain, prolonged standing, sight of blood.

Prodrome: nausea, warmth, diaphoresis, lightheadedness, vision changes.

carotid sinus hypersensitivity

Condition in which pressure over the carotid sinus leads to a decreased heart rate, decreased BP, and cerebral ischemia with syncope. May occur in older adults with hypertension or occlusion of the carotid artery

failure of autonomic reflelxes---> inadequate BP response to standing

causes: hypovolemia, autonomic dysfunction, medication

what causes orthostatic syncope

orthostatic syncope

what type of syncope?

Occurs within seconds to minutes of standing, improves with lying down.

Bradyarrhythmias (sinus node dysfunction, AV block).

Tachyarrhythmias (VT, SVT, WPW, long QT, Brugada).

arrhythmias that can cause syncope

Aortic stenosis (exertional syncope).

Hypertrophic obstructive cardiomyopathy (HOCM).

Pulmonary embolism.

Acute MI or ischemia.

Cardiac tamponade.

structural causes of cardiac syncope

sudden, no prodrome, exertional or while supine, family history of SCD.

historical features pointing to cardiac syncope

Prodrome (nausea, diaphoresis), triggers like pain/stress

prodrome associated with vasovagal syncope

vertigo

true spinning sensation

BPPV (most common cause), vestibular neuritis, Ménière's disease, labyrinthitis.

common causes of peripheral vertigo

stroke (posterior circulation), multiple sclerosis, cerebellar tumor.

causes of central vertigo

Benign Paroxysmal Positional Vertigo (BPPV)

most common cause of vertigo in adults (esp. >50 yrs).

Reassurance (benign in most).

Avoid triggers (prolonged standing, dehydration).

Physical counterpressure maneuvers (leg crossing, handgrip).

Severe recurrent cases: medications (fludrocortisone, midodrine).

treatment of neurally mediated syncope

Hydration, salt/fluid intake.

Compression stockings.

Review/adjust medications.

Pharmacologic: midodrine, fludrocortisone.

tx of orthostatic hypotension causing syncope

epley maneuver

Series of head movements to relieve symptoms of benign positional vertigo

low-salt diet, diuretics

tx of Menieres disease

benign paroxysmal positional vertigo

Brief, recurrent episodes of vertigo (seconds-minutes).

Triggered by head position changes (rolling over in bed, looking up).

No hearing loss or tinnitus.

Dix-Hallpike maneuver

Rapidly moving the pt from a sitting position to the supine position with the head turned 45 degrees to the Right. After waiting apx. 20-30 sec, the pt is returned to the sitting position. If no Nystagmus is observed, the procedure is then repeated on the Left side.

-+ nystagmus indicates BPPV

Otoliths displaced into semicircular canals → transient vertigo.

what causes BPPV

vestibular neuronitis

Acute onset of severe, continuous vertigo lasting days.

Often follows viral upper respiratory infection.

No hearing loss or tinnitus.

Unidirectional, horizontal nystagmus (away from affected side).

Positive head impulse test (catch-up saccade when turning head toward lesion).

physical exam findings associated with vestibular neuronitis

Isolated inflammation of vestibular nerve.

cause of vestibular neuritis

labyrinthitis

Similar to vestibular neuronitis (acute, prolonged vertigo).

Associated with hearing loss and tinnitus (distinguishes from neuronitis).

Often post-viral or bacterial infection.

Nystagmus (unidirectional, horizontal).

Sensorineural Hearing deficit on exam (audiometry confirms).

physical exam findings associatedd with labyrinthitis

Inflammation involves both vestibular and cochlear portions of labyrinth → vertigo + hearing loss.

pathophys of labyrinthitis

RINNE:

SNHL: still AC > BC (test remains "positive"), but hearing is diminished overall.

Helps differentiate from conductive hearing loss, where BC > AC (negative Rinne).

WEBER:

SNHL: sound lateralizes to the normal (unaffected) ear.

Conductive loss: sound lateralizes to the affected ear.

how do you distinguish between sensorineural and conductive hearing losss

vestibular rehabilitation therapy

Core treatment for persistent dizziness and imbalance due to vestibular dysfunction.

Supervised physical therapy program focusing on:

Habituation exercises: repeated exposure to movements that provoke dizziness (reduces sensitivity).

Gaze stabilization: improves visual focus during head movements.

Balance training: improves posture and reduces fall risk.

physical therapy components off vestibulalr rehabililtation therapy

chronic vestibular neuritis, labyrinthitis recovery, bilateral vestibular loss, central compensation after vestibular damage.

indications for vestibular rehab

Avoid alcohol, caffeine, nicotine (can worsen vestibular symptoms).

avoid these substancess in pts with chronic dizziness

meclizine, benzodiazepines, antihistamines

vestibular suppressants useful in short term tx of vertigo