Neurological Conditions

What is a Seizure? : Disruption in electrical brain function

Define Seizure: Electrical dysfunction in the brain. Affects the following

• Consciousness

• Motor

• Sensation

What is a convulsion?  : Violent contraction of muscles. Specifically refers to the physical S/S

What is an Epilepsy? Chronic; unprovoked seizure and recurrent. Two or more seizures occurring more than 24 hours a part without identifiable cause

Assessing Seizure Disorders

EEG (nodes into scalp, for abnormal brain waves

CT scan (detailed images of brain)

MRI (soft tissue imaging of brain

Skull Radiography (X-ray imaging of bone structure)

Medical History (triggers, symptoms, family hx, medication related)

What is the difference? What do each look like? S/S

There are many different types of seizures to know

Focal Aware Seizure

• Patient remains awake and alert

• limbs start switching

• weird sensations or strange emotions

Focal Impaired Awareness Seizure

• Patient stares blankly and their consciousness is altered

• Automatisms means repetitive movements

  • I.e. lip- smacking, chewing, hand-rubbing

Absence Seizure

• Brief blank stare 5-30 seconds

• Eyelid fluttering

• No movement, falling or jerking (able to stand)

Tonic-Clonic Seizure

• Loss of consciousness

• Tonic: Body stiffens

• Clonic: Limbs jerk rhythmically

Atonic Seizure

• Sudden loss of muscle tone

• patient limp, drops or falls

Convulsion = physical manifestation; what you SEE and TOUCH

Convulsion S/S

• Violent, involuntary jerking or stiffening of muscles

• Rhythmic limb movements

• Teeth clenching

• Loss of bladder/bowel control may happen

Epilepsy

Pattern of seizures over time

• Patient history of seizures “I’ve had several seizures over the past year

• Recurring episodes

• Without obvious trigger

• Patient appears normal in between

i.e. A child with absence seizures occurring 10-20 times per day

i.e. An adult with tonic-clonic seizures happening monthly

i.e. Patient with a mix of focal and generalized seizures over months/years

Focal Seizures Slide

What is a focal seizure?

• AKA partial seizures

• Origin: specific area/group of cells on ONE side of brain

• S/S vary depending on region of brain that’s affected

Different types of Focal Seizures

• Focal Aware Seizure

  • Awake and Aware; conscious

  • Unusual sensations, sudden localized twitching, strange emotions

• Focal Impaired Awareness Seizures

  • Confusion or partial loss of awareness; altered consciousness

  • Blank stare, automatisms

• Focal to Bilateral Seizures

  • One side of brain then spread to both hemispheres

  • Generalized seizure, initial focal S/S

Partial Simple Seizure Slide

• Localized, fully aware not altered consciousness

• Because consciousness is there, pt can describe S/S, use this as assessment documentation

• Motor Manifestations

  • Rhythmic jerking of one limb or face

  • Tonic stiffening of extremity

  • Jacksonian march (idk)

  • Todd’s paralysis (idk)

• Sensory/Autonomic Manifestations

  • Tingling, numbness, burning sensation

  • Visually disturbed from flashing lights, spots

  • Auditory or olfactory aura

    • Means they hear sounds that aren’t there, pt can describe what they’re hearing “Do you hear that?” “What’s that noise?”

    • Ringing, buzzing, humming, roaring, clicking, popping, voices

    • Olfactory: burning smell (most common)

  • Flushing, pallor, piloerection (hairs stand up)

Generalized Seizures Slide

Both hemisphere of brain simultaneously abnormal electrical. Widespread effect of consciousness and motor function. Both sides of body

Tonic-Clonic Seizure

• Loss of consciousness

• Tonic: Body stiffens

• Clonic: Limbs jerky rhythmically

• Falls

Absence Seizures

• Person stops moving

• Blank stare (5-30 seconds), don’t hear their name

• Last a few seconds; common children, rare in adults

Atonic Seizures (Drop attack)

• Sudden loss of muscle strength; limp

• Falls

Myoclonic Seizures

• Brief, shock-like muscle jerk or twitches in specific muscle group

Clonic Seizures

• Limbs jerky rhythmically

Tonic Seizures

• Body stiffens

• Falls

Absence Seizures S/S Slide

Form of generalized seizure common w/ children, 5-30 seconds

Commonly mistaken for not paying attention/daydreaming

No aura No postictal phase

• Aura

  • Warning sign BEFORE seizure

• Postictal

  • period AFTER seizure ends

Classic S/S of Absence Seizure

• Suddenly stops activity

• Blank, fixed stare

• Eyelid fluttering (3 Hz)

• No falling or convulsions

During Absence Seizure

• Unresponsive verbally

• Automatisms

• May happen multiple times a day

• Abrupt onset and offset

  • Happens without warning (onset)

  • Stops suddenly like nothing happened (offset)

After Absence Seizure

• No postictal confusion

• Patient unaware they just had a seizure

• Immediately able to return to activity

EEG Hallmark of Absence Seizure

• 3 Hz spike-and-wave discharges— diagnostic for absence seizure. First-line treatment: Ethosuximide

Treatment for Generalized Seizures

Treatment selection depends on seizure type, patient age, and comorbid conditions

Tonic-Clonic Seizures

Loss of consciousness, muscle rigid, rhythmic jerking movements

• Carbamazepine (Tegretol)

  • Blocks sodium channels

  • Common Side effects

    • Dizziness, drowsiness, and nausea

  • Monitor

    • CBC and liver function

    • Risk of aplastic anemia

• Phenytoin (Dilantin)

  • Stabilizes neuro membranes

  • Monitor

    • drug levels closely; narrow therapeutic range

  • S/S of toxicity

    • Nystagmus (rapid eye movement; involuntary)

    • Ataxia (“drunk” loss of coordination)

    • Gingival Hyperplasia (inflamed gums, swollen)

• Valproic Acid (Depakene)

  • Increases GABA activity

  • Monitor

    • Liver Function Tests (LFTs)

    • Amylase/Lipase

  • Common Side Effects

    • GI upset

    • Tremors

    • Weight gain

  • S/S of toxicity

    • Hepatotoxicity & Pancreatitis

Myoclonic Seizures

Brief jerks of muscle groups, occurs in clusters

• Valproic Acid (Depakene)

  • First-line for myoclonic seizures

  • Enhances inhibitory neurotransmission

    • increases the activity of chemicals that SLOW DOWN brain activity

  • S/S of toxicity

    • Hepatotoxicity & Pancreatitis

Treatment for Status Epilepticus Slide

Life threatening. More than 5 minute seizure or recurrent seizures without recovery in between. Can lead to permanent brain damage, respiratory failure, death

• Immediate Assessment (1)

  • Airway & administer oxygen

  • Establish IV access

  • Monitor Vital Signs

• First-line treatment (2)

  • Administer Benzodiazepines (Lorazepam or Diazepam IV)

    • to stop seizure

• Second-line treatment (3)

  • If seizure continues even after benzodiazepines

  • Phenytoin or Fosphenytoin IV loading dose under cardiac monitoring

• Ongoing Management (4)

  • ICU admission; continue to monitor EEG

  • Identify and treat underlying cause and prevent complications

AEDs (Antiepileptic Drugs) Key Side Effects Slide

High risk drugs with significant side effects. Monitor closely and educate patient. Routine labs required. Following are side effects of each drug

Nurse Priority: Teach patient never to abruptly discontinue AEDs — can lead to status epilepticus (seizure that doesn’t stop)

• Phenytoin (Dilatin)

  • Gingival Hyperplasia (swollen, inflammation of gums)

  • Ataxia (“drunk” loss of coordination)

  • Nystagmus (rapid eye movement; involuntary)

  • Diplopia (you see two images of the same object)

  • Steven-Johnson syndrome (rare) (red patches of skin)

  • Monitor: Serum levels, CBC, LFTs

• Carbamazepine (Tegretol)

  • Aplastic Anemia (bone marrow stops making RBCs)’

  • Agranulocytosis (bone marrow stops making WBCs, specifically neutrophils)

  • SIADH (Too much ADH hormone; retain too much water)

  • Hyponatremia (too much water; blood too diluted)

    • (Mild) N&V, headache, confusion, weakness → (severe) seizure, coma, cerebral edema, death

  • Diplopia (you see two images of the same object)

  • Dizziness

  • Monitor: Serum levels, CBC, sodium

• Valproic Acid (Depakote)

  • Hepatotoxicity (toxic to liver) — monitor LFTs

  • Thrombocytopenia (low platelet count; can’t clot properly)

  • Teratogenic (cause birth defects)

  • Weight gain, hair loss, tremors

• Levetiracetam (Keppra)

  • Behavioral changes; irritability, aggression

  • Somnolence, dizziness

  • Mood disorders / depression

  • Relatively favorable safety profile

Brain & Cerebellar Disorders

Different parts of brain affected affects different things

• Cerebellum

  • motor control

  • Balance

  • Posture

• Cerebral cortex

  • Cognition

  • Planning

  • Voluntary movement

• Clinical Signs (Cerebellum & Cerebral cortex)

  • Abnormal movement

  • Cognitively challenged

  • Autonomic issues (things body does w/o thinking)

    • Breathing, sweating, digesting, etc.

Parkinson’s Disease

Movement disease. Brain cells that make dopamine DIE. Progressive and degenerative. NOT curable but treatable

4 Main Symptoms

• Resting Tremor

  • W/O dopamine, muscles twitch and shake

  • Being still makes hand shake looks like you’re rolling a small pill — usually starts in one hand

• Bradykinesia

  • Brady = slow

  • Kinesia = movement

  • Hard to START moving (biggest problem) & moving slower

• Rigidity

  • Muscles tight all the time

• Postural Instability

  • Not upright, cannot balance well, wobbly, high fall risk

Neurotransmitter Balance Theory Slide

Imbalance between Dopamine & Acetylcholine

Dopamine ↓ Acetylcholine ↑

• Dopaminergic loss (neurons that make dopamine die) (1)

• Reduced Dopamine (2)

• Relative Acetylcholine Excess (3)

• Treatment implications (4)

Treatment Options for Parkinson’s Disease

• Levodopa (L-dopa)

  • Converted to dopamine by dopadcarboxylase. Dietary protein can affect absorption

  • Crosses Blood Brain barrier

  • GOLD STANDARD

    • Increased functional independence

    • Motor symptoms increases

    • Enhanced quality of life

    • Effective across all stages

  • Cons

    • Delayed Therapeutic Response (6 months)

    • High rate of dyskinesias (involuntary movement) (80% of people)

• Amantadine (Symmetrel)

  • Promotes release of dopamine that’s already stored

  • Anticholinergic (blocks acetylcholine) & Antiviral properties

  • Uses

    • Mild PD S/S

    • Drug induced Parkinsonism

      • Side effect of a medication that causes Parkinson’s-like symptoms but not actually having Parkinson’s disease

        • I.e. tremors (resting), bradykinesia, rigidity (muscle stiffness)

Pharmacokinetics of Levodopa

L-Dopa is absorbed so fast in small intestine that it is converted to dopamine before it reaches the brain.

Dopamine can’t cross the blood brain barrier. less than 1% of L-dopa actually reaches CNS.Reaminer is metabolized and excreted by kidneys

• Oral absorption (very fast in small intestine)

• Peripheral metabolism (enzymes break down L-dopa too before crossing BBB)

  • Dopamine in blood stream leads to adverse effects → nausea & orthostatic hypotension

• BBB transfer ( less than 1% is actually absorbed)

• Renal Excretion (remaining 99% excreted)

Carbidopa (Lodosyn)

Prescribed along side Levodopa

• Mechanism

  • Blocks the enzyme (decarboxylase) that converts L-dopa to dopamine prematurely

  • Carbidopa (lodosyn) cannot cross BBB so it doesn’t interfere with L-dopa effects

• Advantages

  • L-dopa availability to CNS 10 fold → reduces l-dopa dose by 75%

  • Decreases side effects

  • Faster therapeutic effect

What is a stroke?

Cerebrovascular accident (CVA) blood flow in brain interrupted

• Ischemic Stroke (87%)

  • Blood vessels in brain get blocked → ischemic brain, brain cells die

    • due to blood clot or traveling embolus (i.e blood clot from leg → brain)

  • Thrombotic Stroke

    • Most common ischemic stroke

    • Blood clot in the brain artery; typically athersclerotic plaque buildup in brain

  • Embolic Stroke

    • Blood clot forms elsewhere

    • Commonly in heart (atrial fibrillation) → travels to brain artery

• Hemorrhagic Stroke (13%)

  • Blood vessels burst → bleeding into brain tissue → brain cell damaged through compression and toxic effects

  • Higher mortality rate

• Transient Ischemic Attack (TIA)

  • Mini stroke

  • Temporary symptoms less than 24 hours

  • Evaluate immediately to prevent full stroke

Spot a Stroke FAST

• F - Face Drooping

  • smile droops to one side or feel numb, uneven, lopsided

• A - Arm Weakness

  • one arm weaker after goes down after lifted both up

• S - Speech Difficulty

  • slurred speech, difficult to understand, unable to speak

• T - Time to call 911

  • note when S/S began for treatment decision

Stroke Warning Signs

• Sudden

  • Confusion

  • Numbness or weakness (one side of limb weak/numb)

  • Vision problems (Can’t see one or both eyes, blurred, double vision)

  • Trouble walking (loss of balance, coordination, dizziness)

  • Severe headache (worst headache of my life)

Risk Factors of Stroke

• Hypertension

• Sedentary lifestyle

• Obesity

• Smoking

• Poor diet

• Excessive alcohol

• Chronic stress

• High cholesterol

• Atrial fibrillation

• Depression

Cerebrum & Stroke

Two hemispheres, four lobes. each affect different parts

• Frontal

  • Motor function, speech, executive function, personality

• Parietal

  • Sensory, spatial awareness, temperature, pain

• Temporal

  • Hearing, speech comprehension, memories

• Occipital

  • Visual processing and interpretation

Right CVA

Stroke affecting right hemisphere. Right CVA pts often lack awareness of their deficits, close monitoring, fall precautions, frequent reorientation

• Left sided Hemiplegia or Hemiparesis

  • Means left side body weakness/paralysis

    • Left arm, left leg, left face

• Right Hemisphere Stroke → affects LEFT side of body

• Difficulty judging distances, sizes, positions, ignoring left side of environment

• Impulsivity and poor judgment

Left CVA

Stroke affecting left hemisphere. Left CVA often experience language barriers, easily irritated. Provide ample time for communication, use simple sentences, visual aid and expression

• Right sided Hemiplegia or Hemiparesis

  • Means right side body weakness/paralysis

    • right arm, right leg, right face

• Aphasia (language deficit)

  • Speech is hard, forming words, understanding commands

• Slow and cautious behavior

  • Patients may be overly scared, taking risks, slow at actions

Stroke Prevention and Treatment

Distinguish if ischemic or hemorrhagic. Based on type of stroke and timing

• Before Stroke Prevention (1)

  • Antiplatelet Drugs: Aspirin

  • Anticoagulant: Warfarin (Coumadin)

  • Antihypertensives: Blood pressure control (most effective)

• After Ischemic Stroke (Acute Treatment)

  • tPA: clot buster, must be within 3-4.5 hours of stroke symptom onset

  • Verify onset time

    • Contraindications (recent surgery, bleeding disorders), neuro status q15m

• After Hemorrhagic Stroke

  • No FDA-approved targeted therapy

    • Focus on controlling bleeding, blood pressure, intracranial pressure

    • Contraindications: anticoagulants and thrombolytics (worsens bleeding)

Life After Stroke

As soon as medically stable

• Stroke Rehab

• Physical Therapy

• Speech Therapy

• Psychological Support