seizures

Joseph Breuner, MD 6/24/03

Goals
How to work up first seizure in an adult how to order an eeg which drugs for which seizures status

How to work up first seizure in an adult

Objectives 1. Was it a seizure? What kind? 2. Does the patient have epilepsy

How to work up first seizure in an adult

Is it a seizure? A seizure is a sudden change in behavior that is the consequence of brain dysfunction. Learn the following 3 typical and most common seizures

Auras =simple partial seizures

Affect enough of the brain to cause symptoms does not impair consciousness--simple does not affect the whole brain--partial

Auras =simple partial seizures

Can precede complex partial seizure can evolve to secondarily generalized seizure implies epilepsy as opposed to physiologic nonepileptic seizures--more on this later

Auras =simple partial seizures

Long list(50) of typical symptoms, symptom depends on which part of the cortex is disrupted most common: jerking of an extremity, epigastric discomfort, fear, or an unpleasant smell I like: foot stomping, spacing out, psychic experience, deja and jamais vu

Complex partial seizure

Most common type in epileptic adults appear to be awake consciousness is impaired

Complex partial seizures

stare into space/engage in automatisms, such as grimacing, gesturing, chewing, lip smacking last 3 minutes or less post-ictal: somnolence, confusion, headache for up to several hours

Generalized tonic-clonic seizure

No aura tonic phase x 10-20 seconds: sudden LOC, loss of posture, arms flex, eyes deviate upward extension of back, neck, arms, legs involuntary crying out ends with tremors which merge c clonic phase

Generalized tonic-clonic seizure

Clonic phase x 90 seconds: brief, violent, generalized flexor contractions alternating with progressively longer muscle relaxation cyanosis cheek or tongue biting, salivation loss of bowel, bladder control

Generalized tonic-clonic seizure

Post ictal phase x minutes to hours headache mild confusion sore muscles may sleep and feel refreshed

How to work up first seizure in an adult

Is it a seizure? 4 conditions can mimic a seizure and are worth knowing about: REM behavior disorder

Transient ischemic attack

Transient global amnesia Migraine

How to work up first seizure in an adult

A good time to point out that

history rules!!!
Physical exam, lab and even EEG are way less important than history

How to work up first seizure in an adult

REM behavior disorder REM behavior disorder is a parasomnia that consists of sudden arousals from REM sleep immediately followed by complicated, often aggressive, behaviors for which the patient is amnestic. Diagnosis is clarified by overnight sleep testing

How to work up first seizure in an adult

Transient ischemic attack (TIAs) may last seconds to minutes.

characterized by "negative" symptoms and signs (such as weakness or visual loss)

postictal state may include lateralizing "negative" symptoms such as weakness;

How to work up first seizure in an adult

Transient global amnesia is a condition of vascular etiology,

occurs after the age of 50.

deficit of short-term memory that begins abruptly and persists for minutes to hours, without other cognitive or motor impairment. Episodes are usually not recurrent.

How to work up first seizure in an adult

Migraine Migraine auras such as visual illusions and basilar migraine symptoms, including altered consciousness, can mimic complex partial seizures the headache that follows complex partial and generalized tonic-clonic seizures is migrainous in quality and duration.

How to work up first seizure in an adult

Is it a seizure? If its not REM behavior disorder Transient ischemic attack Transient global amnesia, or Migraine its probably a seizure

Is it epilepsy?
Question 2: is it epilepsy? Differentiate physiological and psychogenic seizures from epileptic seizures

Is it epilepsy?
Why do I care about this? Epilepsy treated with anticonvulsants Physiologic/psychogenic seizures you treat the disorder This evaluation will determine the likelihood that a patient will have additional seizures and assist in the decision whether to begin

Is it epilepsy?
Is it epilepsy? In epileptic seizures the EEG is abnormal

Is it epilepsy?
Physiologic seizures are caused by hyper- and hypothyroidism Hypoglycemia Nonketotic hyperglycemia -focal motor seizures

Is it epilepsy?
Physiologic seizures caused by: Precipitous falls in serum sodiumhigh mortality Hypocalcemia--neonates

Renal failure and uremia

Is it epilepsy?
Physiologic seizures: Acute intermittent porphyria--also includes abdominal pain and behavior changes Cerebral anoxia--including brief syncope, though these patiens wont be post ictal alcohol withdrawal:3-72 hrs post last drink

Is it epilepsy?
Medication history: tricyclic antidepressants can lower seizure threshold

Is it epilepsy?
PMH--head injury stroke alzheimers disease history intracranial infection alcohol/drug abuse

Is it epilepsy?
Family history if positive, highly suggestive of epilepsy especially for absence seizures and myoclonic seizures

Is it epilepsy?
Physical exam/neuro exam rarely helpful except in setting of acute infection or hemorrhage look for lateralizing abnormalities

Is it epilepsy?
Lab eval: epilepsy vs physiologic glucose calcium magnesium BUN/cr tox screen TSH

Is it epilepsy?
Lumbar puncture--only useful if infection or malignant metastasis to the meninges

Is it epilepsy?
Neuroimaging unless obvious physiologic seizure, should obtain MRI. MRI better than CT for infarcts and tumors the older the patient, the more likely you will find a structural cause

How to order an eeg

Looking for seizure focus substantiates epilepsy if positive can indicate generalized vs partial seizure disorder

How to order an eeg

Sleep deprivation hyperventilation intermittent photic stimulation all increase the yield usually okay to begin with awake eeg, sleep deprive if high index of suspicion

How to order an eeg

Study of 157 adult pts with untreated first idiopathic seizure obtained single awake eeg, if normal, also obtained eeg p sleep deprivation

How to order an eeg

Risk of 2nd seizure in 2 years (CI) epileptic discharges: 83% (69-97%) nonepileptic abnormalities 43% (29-53) normal: 12% (3-21%)

Which drugs for which seizures?

In general, recurrence risk at one year after first seizure is 15-30% three year recurrence risk is 30-78% treatment roughly halves recurrence risk

Which drugs for which seizures?

Risk factors for recurrence are head injury A lesion on MRI Focal deficits on neuro exam A record of cognitive impairment A partial seizure as the first seizure An abnormal EEG (particularly epileptiform abnormalities)

Which drugs for which seizures

A record of cognitive impairment A partial seizure as the first seizure An abnormal EEG (particularly epileptiform abnormalities)

Which drugs for which seizures

Absent risk factors, it makes sense to wait for second seizure prior to initiating treatment

Which drugs for which seizures?

Cochrane reviews looked at 4 outcomes: time to withdrawal of treatment 6 month remission rate 12 month remission rate time to first seizure p randomization

Which drugs for which seizures?

Carbamazepine better than phenobarb only in longer time to treatment withdrawal due to side effects--treatment efficacy the same

Which drugs for which seizures?

Carbamazepine equivalent to valproate for both partial and generalized seizures trend for carbamazepine to improved 12 month remission for partial seizures

Which drugs for which seizures?

Phenytoin better than phenobarb solely due to side effects--treatment efficacy the same

Which drugs for which seizures?

Carbamazepine equivalent to phenytoin

Which drugs for which seizures?

Phenytoin equivalent to valproate

Which drugs for which seizures?

Summary of cochrane data: carbamazepine phenytoin valproate are all equivalent in efficacy and tolerability phenobarb also efficacious but more side effects

status
Dont give meds unless youre in a setting where you can control airway ativan 2mg or valium 5mg IVP q 2-4 minutes PRN load fosphenytoin 20 mg/kg iv to icu

References
Up to date evaluation of the first seizure, 12/02/01 treatment of chronic epilepsy van donselaar, CA, value of the eeg in adult patients, arch neurol 1992 cochrane database swedish admit orders for status epilepticus

Take home points

Workup of first seizure--was it a seizure, what kind was it. Aura important physiologic seizures vs. epilepsy anticonvulsant therapy reduces recurrence risk by 1/2