Seizures, Anticonvulsants & Neuro-degenerative Disorders

Epilepsy: An Overview

• Epilepsy: A chronic neurological disorder characterized by recurrent, unprovoked seizures. Seizures are sudden, transient attacks of altered consciousness, motor activity, or sensory impairment resulting from abnormal, synchronous electrical activity in the brain.

• Treatment strategies for epilepsy are highly individualized, based on the specific type, severity, and underlying cause of seizures.

Generalized Seizures (Tonic–Clonic & Absence)

• Tonic–clonic (formerly “grand-mal”)

  • Tonic phase: Abrupt loss of consciousness (LOC) → patient falls, trunk & extremities extend, body becomes rigid with sustained muscle contraction. This phase typically lasts about 10 ext{–}20 ext{ sec}, often presenting with an ictal cry as air is forced past the vocal cords.

  • Clonic phase: Follows the tonic phase with rhythmic, synchronous contraction and relaxation cycles of the extremities. This phase usually lasts 30 ext{–}60 ext{ sec}.

  • Typical duration of the entire seizure is 2 ext{–}5 ext{ min}.

  • Common sequelae: Post-ictal state characterized by marked drowsiness, confusion, disorientation, headache, generalized muscle soreness, and often complete amnesia for the event. Urinary / fecal incontinence may also occur.

• Absence seizures (formerly “petit-mal”)

  • Sudden, brief LOC without motor collapse; often presents as a blank stare, brief cessation of ongoing activity, or subtle automatisms (e.g., blinking, lip smacking).

  • Duration is typically very short, about 10 ext{–}20 ext{ sec}, with an abrupt start and end, and no post-ictal confusion or memory impairment.

  • Primarily a pediatric presentation, often misdiagnosed as daydreaming or inattention.

Immediate Management of Seizures

• PRIORITY: Prevent injury.

  • Clear environment: Quickly move any potential hazards like desks, cords, sharp objects, and furniture that could cause harm during movements.

  • Cushion or turn head to side: This helps to protect the head from trauma and maintain a patent airway, allowing oral secretions to drain out of the mouth, thereby reducing the risk of aspiration.

  • Loosen tight clothing around neck: This ensures unrestricted breathing.

• What NOT to do

  • Do NOT restrain patient or attempt to stop movements: Restraining can cause musculoskeletal injury (e.g., fractures, dislocations) to the patient or the rescuer.

  • Do NOT attempt to pry mouth open or insert objects (e.g., spoons, fingers): This is a dangerous practice based on the myth of

Anticonvulsants

• Used to reduce the number or severity of severity of seizures in patients with epilepsy. Epilepsy is 2 or more unprovoked seizures. Characterized as sudden attacks of altered consciousness, motor activity, and cause of seizures.

• Different kinds of Primary Generalized Seizures are convulsive and non convulsive

• Partial seizures- no loss of consciousness. Caused by a lesion in the temporal lobe of the brain and limited to one cerebral hemisphere. May be preceded by a subjective but recognized sensation( an aura) that a seizure.

Primary Generalized Seizures

• Tonic Clonic Seizures are characterized by an abrupt loss of consciousness and falling, with tonic extension of trunk and extremities (tonic phase), followed by alternating contractions, relaxation of muscles ( clonic phase) 2-5 min of urinary and fecal incontinence may occur

• Prolonged or frequent that that the patient does not regain consciousness between seizures, the condition is known status epilepticus and is considered to be a true neurologic emergency.

• Absence seizures- brief 10-20 secs and occurs initially in children

• Febrile seizures- resolving the underlying condition is generally sufficient treatment for these types of seizures and daily medication is not necessary

First generation anticonvulsant

• The dosage should be titrated to achieve seizure control or until the maximally tolerated dose is reached.

• Side effects- blurred vision, Steven’s- Johnson syndrome( a severe inflammatory disease affecting children and young adults

• Phenytoin/ Dilantin

• Side effects of Tegretol/ Carbamazepine is ataxia- can cause cardiac complications. Grapefruit juice can potentiates action and increase the risk of serious adverse effects. Do not take grapefruit juice with Carbamazepine

• Oxcarbazepine( Trileptal)- indicated for treatment of partial seizures

• Valprocic acid( Depakote)- broad- spectrum anticonvulsant. Adverse reaction is Thrombocytopenia. Side effects- weight gain

Drug therapy for Febrile Seizures

• Routine treatment of febrile seizures involves searching for the cause of the fever and taking measures to control the fever. Do not require anticonvulsants drugs

Drug therapy for Absence Seizures

• The drug of choice for the management of absence epilepsy is often Ethosuximide (Zarontin), Clonazepam ( Klonopin)

• Side Effects- rash and blood Dyscrasias

Second Generation Anticonvulsant

• They are not currently considered superior in terms of seizure control. Fewer drug interactions than the first- Generation

• The second- generation anticonvulsant should be used with caution in pregnant and lactating women and should not be abruptly Discontinued

• Always taking the medication on time and never omitting dosage( abrupt withdrawal of the medication can lead to status epilepticus)

Antiparkinsonian Drugs

• Usually given for Parkinson’s Disease, a chronic neurological disorder characterized by fine, slowly spreading muscle tremors, rigidity, and generalized slowness of movement call bradykinesia

Dopamine Replacement

• Sinemet ( a combination of Levodopa and carbidopa) is recommended for initial treatment

• Side effects- Dyskinesias ( involuntary movements of many parts of the body)

• Patients receiving sinemet for prolonged periods of times ( 2-5 years) may develop a tolerance, resulting in ineffectiveness of the drug, called wearing off

Dopamine Agonists

• Pramipexole ( Mirapex)

• Ropinirole ( Requip)

• Are comely used in conjunction with levodopa to delay the onset of levodopa- caused motor complications or used alone in early PD or in younger patients as a “ levodopa- sparing”

Selegiline

• Selegiline / Eldepryl

• Prescribed as an adjunctive therapy for PD after Levodopa has been used for several years and begins to wear off

Agents for Restless Legs Syndrome

• Restless legs is a sensorimotor neurological disorder characterized by a distressing urge to move the legs, often accompanied by a marked sense of discomfort in the legs

• Pramipexole/ Mirapex

• 1-3 h before bedtime as a single daily dose

• If other meds give a hangover the next day by they can’t sleep, they’ll sleep. They’ll give Pramipexole

• Rls may be secondary to other causes including iron deficiency

Agents for Alzheimer’s Disease

• Alzheimer’s or dementia of the Alzheimer’s type is the most common type of dementia

NMDA Receptor Antagonist

• Memantine/ Namenda- treatment of moderate to severe dementia of the Alzheimer’s Type

• Donepezil/ Aricept