Epilepsy and Seizure Disorders

Seizure

Seizure

A transient occurrence of signs and/or symptoms due to an abnormal excessive of synchronous neuronal activity in the brain.

Acute Symptomatic seizure (provoked or triggered seizures)

A seizure caused by a new, transient generalized abnormality of brain function.

• If you make the problem go away, the seizures go away.

Epilepsy

Recurrent, unprovoked afebrile seizures

Electroencephalography (EEG)

-A recording of the electrical activity of the brain

-Supports diagnosis of a seizure and may assist in classifying type of seizure or epilesy

1.) Where seizures begin in the brain

2.) Level of awareness during a seizure

3.) Other features of seizures.

What are the three key features of a seizure based on the International League Against Epilepsy (ILAE)

Focal Seizures

-Presumed to be the result of an underlying brain abnormality

-Most common location is the medial aspect of the temporal lobe.

• Most common seizure type in adults and children

-Seizure involves just one area of the brain.

Focal (simple) seizure

-Focal seizure Without impairment of awareness or consciousness

• Patient remains awake and alert

• Motor areas consist of jerking motions

Primary Sensory Cortex

Where is the seizure located if the patient is experiencing Contralateral tingling with focal seizures?

Piriform Cortex

Where is the seizure located if the patient is experiencing Hallucinations of unpleasant smells with focal seizures?

Primary auditory cortex

Where is the seizure located if the patient is experiencing hallucinations of sounds with a focal seizure?

Temporal lobe epilepsy

Where is the seizure located if the patient is experiencing Deja vu or J’amais vu with focal seizures?

Visual cortex.

Where is the seizure located if the patient is experiencing Hallucinations or flashes of light with focal seizures?

Focal (complex) seizures

-Focal seizures with impairment of consciousness, awareness or cognitive function.

• Patient typically does not completely lose consciousness, but it is impaired.

• Unable to response properly to the environment or recall events during the episode.

Secondary Generalized seizures

-Focal seizures evolving to a bilateral tonic-clonic seizures

-the abnormal activity can sometimes spread to the neurons throughout the entire cortex, leading to a generalized seizure.

-Most of following will be present:

• Stiffening

• Jerking

• Loss of consciousness

• Loss of Urinary continence

• some bite tongue/vomit/drool.

-Roll person on side and DO NOT stick finger in mouth.

Aura

Definition: what a patient experiences as a result of the focal seizure that precedes his/her generalized seizure.

Todd’s paralysis

Following a motor seizure activity, a patient can have weakness of the involved body part which will resolve within several hours of the seizure.

Post-ictal state

Immediately following a seizure with impaired consciousness or generalized seizure, the patient may be confused, agitated, aggressive, or sleepy; will not usually remember the event.

Primary Generalized seizures

-Neurons throughout the entire cortex spontaneously and synchronously generate action potential.

-Why? → usually unknown

-Classified by what type of motor activity is expressed.

Absence seizure

-Sudden arrest of behavior w/ staring

-Loss of awareness

-No post-ictal period

Myoclonic seizure

-Bilateral, very brief symmetric jerking of groups of muscles

-Usually no impaired consciousness.

-No post-ictal period

Clonic seizure

-Bilateral jerking movements of face and all extremities

-Will fall to the ground

-Post-ictal period present

Tonic Seizure

-Stiffening and breath holding

-Will fall to the ground

-Post-ictal phase present

Tonic-Clonic seizure

-Stiffening and breath-holding followed by jerking

-Will fall to the ground

-Post-ictal phase present

Atonic seizure

-Sudden loss of all muscle tone

-Sometimes falls to the ground

-No post-ictal phase.

Epilepsy syndromes

Usually involves a specific type of generalized seizure seen in a specific population of patients along with specific EEG findings and a fairly consistent prognosis.

Child Absence Epilepsy

-Frequent absence seizures starting between the ages of 2-12

• characteristic 3Hz generalized spike/wave activity.

-up to 80% outgrow

-Strong genetic component

-Treat until patient is seizure-free for 2 years AND EEG is normal, then taper off medications.

-First-Line: Ethosuximide (Zarontin)

-Second-Line: valproate (Depakote)

Juvenile Myoclonic Epilepsy

-Starts in older children/teens but persists throughout adulthood

-Genetic component

-Myoclonic, generalized tonic-clonic, and absence seizures

-Normal intellectual function

-Treatment: valproate (Depakote)

Febrile Seizure

-Generalized Seizure (usually tonic-clonic) associated with fever but without evidence of an intracranial infection or other CNS cause

• 2/3 occur in the first 24 hours of the illness.

Meningitis

Encephalitis

What two conditions should you always be thinking when presented with a febrile seizure?

Age is greater than 18 months

No meningeal signs

Back to baseline in ~10 minutes

Normal Neurologic exam

Seizure occurred on day #1 of the illness

Under what circumstances do you NOT need to perform a work-up for a febrile seizure?

-Meningeal signs/symptoms (regardless of age)

-If child is 6-12 months if immuno. status is unknown

-Patient presents with Status Epilepticus

-If patient is already on antibiotics

-If seizure occurs after day #2 of an illness

What are Work-up indications for a Lumbar puncture?

Simple Febrile seizure

-What is the classification of a single febrile seizure lasting less than 15 minutes? Generalized onset.

-90% are in this category.

Focal onset (seizure started on one side of the body)

OR

Lasts more than 15 minutes

OR

Multiple seizures in a 24 hour period

-What factors must be present (either one or all) in order for a febrile seizure to be classified as complex?

IV benzodiasepines

Buccal midazolam if no IV access

Treat as status epilepticus if seizure does not stop

Acute management for Febrile seizures in the ER is only needed if the seizure persists longer than 5 minutes. What approaches would you use to treat the patient?

Young age of onset

+FH

Brief latency between illness onset and seizure

Seizure at mildly elevated temperature

What are the increased risk factors for future febrile seizures?

Not Recommended

Continuous or intermittent AEDs are ________________ as prophylaxis for children with one or more simple febrile seizures.

True

T/F: With complex febrile seizures, prophylactic treatment decisions are made based on the complete evaluation

• if at high risk for epilepsy then might be treated.

-Epileptiform abnormalities on EEG

-Brain abnormality seen on MRI

-Abnormal neurologic examination.

Under what circumstances should you consider starting AEDs?

If second seizure occurs…..

Should be placed on AED because there is a 75% chance that there will be more seizures.

To control seizures, avoid side effects, and maximize quality of life

What is the goal of Antiepileptic treatment?

1.) ALL of these meds can be associated with increased thoughts of and risk of suicide.

2.) ALL can be associated with neurologic side effects.

What are 2 things to keep in mind when prescribing AEDs?

Carbamazepine

Phenytoin

Lamotrigine

What are the best drug options for Focal seizures?

Valproate

What is the best drug option for generalized seizure types?

ethosuximide

What is the best drug option for absence only seizures?

Epilepsy surgery

Vagus Nerve Stimulators

Cortical or deep brain stimulation

Ketogenic Diet

What are some non AED treatment options?

Status Epilepticus

Continuous seizure activity (5-10 minutes or more) or multiple seizures without gaining consciousness between them

• Generalized tonic-clonic seizure is most common and most dangerous type that results in this.

ABC’s

Continuous EKG and O2 sat. monitoring

Start 2 IVs

• First: Lorazepam = STOP the seizure

• Second: Fosphenytoin = KEEP the seizure stopped.

Draw labs

Give Thiamine and then 50cc of D50 IV

What is the initial management of Status Epilepticus in the ER?

Ohio Laws for driving with seizures.

-No set time the person has to be seizure free

-PCP has to complete medical form for person to drive for 6 months.

• Next one is good for 1 year if there are no problems.

Important things to know.

-NEVER abruptly stop antiepileptic medications

-If a patient is on an AED, make sure it will not cause a significant interaction with another drug you plan to prescribe

Bilateral convulsive seizures.

In clinical practice, what is a common presentation of generalized tonic-clonic seizures? (GTCs)