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. spacing out. psychic experience. epigastric discomfort. deja and jamais vu . or an unpleasant smell ‡ I like: foot stomping. ‡ symptom depends on which part of the cortex is disrupted ‡ most common: jerking of an extremity. fear.

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. lip smacking ‡ last 3 minutes or less ‡ post-ictal: somnolence. gesturing. confusion. chewing. headache for up to several hours .

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

violent. bladder control . salivation ‡ loss of bowel.Generalized tonic-clonic seizure ‡ Clonic phase x 90 seconds: ‡ brief. generalized flexor contractions alternating with progressively longer muscle relaxation ‡ cyanosis ‡ cheek or tongue biting.

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 .

lab and even EEG are way less important than history .How to work up first seizure in an adult ‡ A good time to point out that ‡ history rules!!! ‡ Physical exam.

Diagnosis is clarified by overnight sleep testing . often aggressive. behaviors for which the patient is amnestic.How to work up first seizure in an adult ‡ REM behavior disorder ² REM behavior disorder is a parasomnia that consists of sudden arousals from REM sleep immediately followed by complicated.

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. ‡ deficit of short-term memory that begins abruptly and persists for minutes to hours. . Episodes are usually not recurrent. without other cognitive or motor impairment. ‡ occurs after the age of 50.

. 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 ‡ Migraine ² Migraine auras such as visual illusions and basilar migraine symptoms. including altered consciousness.

How to work up first seizure in an adult ‡ ‡ ‡ ‡ ‡ ‡ Is it a seizure? If it¶s not REM behavior disorder Transient ischemic attack Transient global amnesia. or Migraine it¶s 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 anticonvulsant therapy .

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

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

Is it epilepsy? ‡ Physiologic seizures caused by: ‡ Precipitous falls in serum sodiumhigh mortality ‡ Hypocalcemia--neonates ‡ Renal failure and uremia .

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

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

Is it epilepsy? ‡ ‡ ‡ ‡ ‡ PMH--head injury stroke alzheimer¶s disease history intracranial infection alcohol/drug abuse .

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

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 .

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

How to order an eeg ‡ Looking for seizure focus ‡ substantiates epilepsy if positive ‡ can indicate generalized vs partial seizure disorder .

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

also obtained eeg p sleep deprivation . if normal.How to order an eeg ‡ Study of 157 adult pts with untreated first idiopathic seizure ‡ obtained single awake eeg.

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%) .

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? ‡ In general.

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 ‡ Don¶t give meds unless you¶re 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 .

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

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