Professional Documents
Culture Documents
Seizure disorders
Juan G. Ochoa, MD
Associate Professor of Neurology
University of South Alabama
Definitions
Seizure: Clinical manifestation of an
abnormal and excessive excitation of a group of
cortical neurons. Seizures have different
phases:
Pre-ictal: the period before the seizure (aura)
Ictal: the period during the seizure
Inter-ictal: the period between occurrences of
seizure activity
Post-ictal: the period immediately after the
seizure
2
Definitions
Epilepsy:
A tendency toward recurrent seizures
unprovoked by systemic or neurologic insults
Epilepsy can be caused by any process that
disrupts the stability of the cell membrane.
Some people have a lower threshold to seizures
as a result of either genetic factors or an
acquired condition such as a structural injury. All
individuals have the capacity to have seizures
given the right circumstances and provocations.
3
Epidemiology
Seizures
Incidence: approximately 80/100,000
per year with a lifetime prevalence of
9% including benign febrile
convulsions.
Epilepsy
Incidence: approximately 45/100,000
per year
4
Seizure Classification:
Based on seizure type
FOCAL
Simple Partial
Complex partial
Secondary
Generalized
PRIMARY
GENERALIZED
Absence
Myoclonic
Atonic
Tonic
Tonic/clonic
Seizure Classification:
Based on Etiology
Regardless of being focal or generalized
the seizures may be:
Idiopathic: Unknown clear etiology but present as a
syndrome (i.e. absence epilepsy). Significant genetic
component.
Focal Seizures:
Simple Partial
With motor signs
With somatosensory or special sensory symptoms
With autonomic symptoms or signs
With psychic symptoms (disturbance of higher
cerebral function)
No
7
Complex Partial
Seizures
Impaired consciousness!!
Clinical manifestations vary with
site of origin and degree of spread
Presence of aura (epigastric
sensation, limb numbness,
vertigo, etc)
Click on
video
Automatisms: complex
involuntary movements (hand
waving, lip smacking, etc)
Other motor activity i.e. tonic
posturing,
Duration (15 sec.3 min.)
8
Is this a focal or a
generalized seizure?
Click any of the answers below
a) Focal
b) Generalized
c) Secondary
generalized
9
Secondarily Generalized
Seizures
Begin as simple and/or
complex partial seizures (aura,
staring, focal twitching, etc)
Variable symmetry, intensity,
and duration of tonic (stiffening)
and clonic (jerking) phases
VIDEO
Yes
no
no
Primarily Generalized
Seizures
Atonic: Sudden loss consciousness and loss of muscle
Primarily Generalized
Seizures
Absence: Day dreaming brief
EEG
Myoclonic
Seizure
13
Epilepsy Syndromes
Partial epilepsies
Idiopathic
Symptomatic
Cryptogenic
14
Epilepsy Syndromes
(cont.)
Generalized epilepsies
Idiopathic
Symptomatic
Cryptogenic
Undetermined epilepsies
Special syndromes
15
Etiology of Seizures
and Epilepsy
Infancy and childhood
Birth injury
Inborn error of metabolism
Congenital malformation
Etiology of Seizures
and Epilepsy (cont.)
Adolescence and young adult
Drug intoxication and withdrawal*
Head trauma
Older adult
Stroke
Brain tumor
Acute metabolic disturbances*
*causes of acute symptomatic seizures, not epilepsy
17
EEG Abnormalities
Background abnormalities: significant
asymmetries and/or degree of slowing
inappropriate for clinical state
Transient abnormalities associated with
seizures and epilepsy
Spikes
Sharp waves
Spike-wave complexes
May be focal, lateralized, generalized
18
19
Diagnosis
20
Medical Treatment of
First Seizure
Whether to treat first seizure is
controversial
16-62% will recur within 5 years
Relapse rate is reduced by antiepileptic drug
treatment
Abnormal imaging, abnormal EEG or family
history increase relapse risk
Quality of life issues are important
21
Choosing Antiepileptic
Drugs
Seizure type
Epilepsy syndrome
Pharmacokinetic profile
Interactions/other medical conditions
Efficacy
Expected adverse effects
Cost
22
Choosing
Antiepileptic
Drugs (cont.)
Partial onset seizures
phenytoin*
gabapentin
carbamazepine*
phenobarbital
valproate
primidone
lamotrigine
felbamate**
oxcarbazepine
topiramate
levetiracetam
tiagabine
zonisamide
* considered by many as drugs of choice
**
associated with aplastic anemia and
hepatic failure
23
Choosing Antiepileptic
Drugs (cont.)
Generalized onset seizures
Absence:
Myoclonic:
Tonic-clonic:
valproate* = ethosuximide
valproate, clonazepam
valproate = phenytoin
Antiepileptic Drug
Monotherapy
Simplifies treatment, reduces
adverse effects
Conversion to monotherapy from
polytherapy
Eliminate sedative drugs first
Withdraw antiepileptic drugs slowly over
several months
25
Antiepileptic Drug
Interactions
Drugs that induce metabolism of other
drugs: carbamazepine, phenytoin,
phenobarbital
Drugs that inhibit metabolism of other
drugs: valproate, felbamate
Drugs that are highly protein bound:
valproate, phenytoin, tiagabine
Other drugs may alter metabolism or
protein binding of antiepileptic drugs
26
AED Serum
Concentrations
In general AED serum concentrations
can be used as a guide for evaluating
the efficacy of medication therapy for
epilepsy. Serum concentrations are
useful when optimizing AED therapy,
assessing compliance, or teasing out
drug-drug interactions. They should be
used to monitor pharmacodynamic and
pharmacokinetic interactions.
27
AED Serum
Concentrations
Serum concentrations are also useful when
documenting positive or negative outcomes
associated with AED therapy. Most often
individual patients define their own therapeutic
range for AEDs. The new AEDs have
potential serum ranges where patients in
clinical trials had optimal seizure control
and minimal side-effects from the
medication. For the new AEDs there is no
clearly defined therapeutic range.
28
Evaluation After
Seizure Recurrence
Progressive pathology?
Avoidable precipitant?
If on AED
Problem with compliance or pharmacokinetic
factor?
Increase dose?
Change medication?
If not on AED
Start therapy?
30
Discontinuing AEDs
Seizure freedom for 2 years
implies overall >60% chance of successful
withdrawal in some epilepsy syndromes
Favorable factors
31
Non-Drug Treatment/
Lifestyle Modifications
Adequate sleep
Avoidance of alcohol, stimulants, etc.
Avoidance of non-precipitants
Stress reduction specific techniques
Adequate diet
Exercise
32
Ketogenic Diet
Anti-seizure effect of ketosis, acidosis
Low carbohydrate, low protein, high fat
after fasting to initiate ketosis
Main experience with children,
especially with multiple seizure types
Long-term effects unknown
33
Surgical Treatment
Potentially curative
Resection of epileptogenic region (focus)
without causing significant new neurologic
deficit
Palliative
Partial resection of epileptogenic region
Disconnection procedure to prevent seizure
spread corpus callosotomy
Vagal nerve stimulation
37
Epilepsy Surgery
Outcomes
Temporal
Extra
Lesional Hemispheric Callosotomy
Temporal
Seizure Free
68
45
66
45
Improved
23
35
22
35
61
20
12
20
31
100
100
100
100
100
Not improved
Total
38
Status Epilepticus
Definition
More than 30 minutes of continuous seizure
activity
or
Two or more sequential seizures spanning this
period without full recovery between seizures
39
Status Epilepticus
A medical emergency
Adverse consequences can include hypoxia,
hypotension, acidosis and hyperthermia
Know the recommended sequential protocol for
treatment with benzodiazepines, phenytoin,
barbiturates, and valproic acid.
Goal: stop seizures as soon as possible
40
Status Epilepticus
Treatment
Time post
onset Treatment
Onset
draw
41
Status Epilepticus
Treatment (cont.)
Time post
onset Treatment
10 min. Can repeat lorazepam or diazepam if
ongoing
seizures
and patient
minute
Neonatal Seizures
Incidence: 3-25%
Association with increased morbidity and
mortality
May be symptomatic of treatable, dangerous
condition (hypoglycemia, meningitis)
Diagnosis: observation with vs. without EEG
43
Recognition of Neonatal
Seizures
Observation of abnormal, repetitive attacks of
movements, postures or behaviors
Classification
subtle
tonic
clonic
myoclonic
autonomic
Evaluation for cause(s) of seizures
Confirmation/support by EEG
44
Examples of Acquired
Conditions That May
Provoke
Neonatal Seizures
Hypoxia-ischemia
Physical trauma
Toxic-metabolic
Inborn errors of metabolism
Systemic or CNS infections
Intracranial hemorrhage
45
Acute Treatment of
Neonatal Seizures
Phenobarbital
loading dose: 20 mg/kg
Phenytoin
loading dose: 20 mg/kg @ 1 mg/kg per minute
Diazepam
first dose about 0.25 mg/kg
Lorazepam
first dose about 0.05 to 0.1 mg/kg
46
Selected Pediatric
Epilepsy Syndromes
Epileptic Encephalopathies
West Syndrome infantile onset, hypsarrhythmic EEG,
tonic/myoclonic seizures; idiopathic vs. symptomatic
Lennox-Gastaut Syndrome childhood onset, slow
spike-wave EEG, tonic, atypical absence, atonic and
other seizure types
Myoclonic epilepsies of infancy and early childhood
heterogenous
47
Selected Pediatric
Epilepsy Syndromes
Febrile convulsions
6 mo.-5 yrs.,
(cont.)
Selected Pediatric
Epilepsy Syndromes
Benign epilepsy
with centrotemporal
(cont.)
spikes nocturnal oropharyngeal
simple partial, rare secondarily
generalized seizures
Selected Pediatric
Epilepsy Syndromes
Idiopathic generalized
(cont.)epilepsies
Childhood absence epilepsy
absence, often with tonic-clonic seizures
Juvenile myoclonic epilepsy
myoclonic, tonic-clonic, at times absence
50
AEDs in Pediatrics
Extrapolation of efficacy data from adult studies
Importance of adverse effects relative to efficacy
Susceptibility to specific adverse effects
(valproate hepatotoxicity, lamotrigine rash)
Age-related pharmacokinetic factors
Neonate: low protein binding, low metabolic rate,
possible decreased absorption if given with
milk/formula
Children: faster metabolism
51
Differential Diagnosis of
Paroxysmal Behavioral
Seizure
Event
Syncope
Migraine
Cerebral ischemia
Movement disorder
Sleep disorder
Metabolic disturbance
Psychiatric disturbance
Breath-holding spells
52
Psychogenic
Nonepileptic Seizures
10-45% of refractory epilepsy
(referral centers)
Females>males
Psychiatric mechanism
dissociation, conversion
Association with physical,
sexual abuse
53
Psychogenic
Nonepileptic Seizures
Represent genuine
psychiatric disease
(cont.)
Syncope
Characteristic warning, usually gradual (except
with cardiac arrhythmia)
Typical precipitants (except with cardiac
arrhythmia)
Minimal to no postictal confusion/somnolence
Convulsive syncope tonic>clonic
manifestations, usually < 30 sec; usually from
disinhibited brainstem structures (only rarely
from cortical hypersynchronous activity)
55
Pregnancy and
Most pregnancies Epilepsy
in epileptic mothers produce normal
children
Pregnancy and
Epilepsy Guidelines
Risk of fetal malformation is increased twofold
to threefold
Prenatal diagnosis should be discussed
Seizures may be deleterious to the fetus
Adequate folate should be ensured
(at least 1 mg/day)
Monotherapy should be used if possible,
with the lowest effective dose
58
Insurance issues
Employment issues
59
First Aid
Tonic-Clonic Seizure
Turn person on side with head inclined
toward ground to keep airway clear, protect
from nearby hazards
Transfer to hospital needed for:
Multiple seizures or status epilepticus
Person is pregnant, injured, diabetic
New onset seizures
Case 1: 5 yo female
with episodes of
A 5 yoBlanking
female is brought to
your office
Out
Case Study 1
EEG for
Case
Study 1
62
Case Study 3
CT Scan for
Case Study 3
63
Case Study 3
EEG
for
Case
Study
3
64
Case Study 4
MRI for
Case Study 4
65
Case Study 4
MRI (from top) for
Case Study 4
66
Case Study 4
EEG for
Case Study 5
67
Case Study 5
MRI reveals an
atrophic L.
Hippocampus
68
Case Study 5
MRI showing
language areas for
Case Study 5
69
Case Study 5
MRI showing
temporal lobe
resected (arrow) for
Case Study 5
70
Appendix
72
Absolutely!!!!!!
The term simple means that there is no
impairment of consciousness. The patient is fully
aware of the symptoms and has complete
recollection of the event. Simple partial seizures
cause impairment of a small part of the brain
preserving major association areas
back
73
Oooopppss!!
The term simple means that there is no
impairment of consciousness. The patient is
fully aware of the symptoms and has
complete recollection of the event. Simple
partial seizures cause impairment of a small
part of the brain preserving major association
areas
Back
74
Symptomatic Seizures
Etiologies
Acute Symptomatic Seizures:May not develop epilepsy
Toxic, Metabolic and Electrolyte Imbalance
Low (less often, high) blood glucose, low sodium, low calcium, low
magnesium
Stimulation/Other Pro-convulsant Intoxication (IV drug use,
cocaine, ephedrine, other herbal remedies, medication reduction,
withdrawal.
Structural Brain abnormalities:
Head trauma, stroke, brain tumor, CNS infection ( toxo and malaria,
meningitis, cisticercosis)
Back
75
American Epilepsy Society, 342 North Main Street, West Hartford, CT 06117-2507, (860)
586-7505, www.aesnet.org. A membership society of professionals interested in epilepsy.
Within the society are special interest groups including a nurses group. Contact the Society
for more information.
Association of Child Neurology Nurses (ACNN), 1000 West County Road East, Suite
290, St. Paul, MN, 55126, (651) 486-9447. A membership organization of nurses interested
in child neurology.
Epilepsy Foundation, eCommunities. Chat rooms for four different groups: Women and
Epilepsy; Parents Helping Parents; The Teen Chat Room; and Living Well with Seizures.
Located at www.epilepsyfoundation.org
76
http://www.aann.org
http://www.acnn.org
http://www.aesnet.org
http://www.epilepsyfoundation.org
or http://www.efa.org/education.firstaid.html
http://www.epinet.org.an/info/general.asp
http://www.nurseweek.com/ce/191-sb1.html
http://www.nursecen.com/nur.htm
http:www.webclinics.org
(log in as AED and use password NURSE)
77
78
79
Case 1: 5 yo female
with episodes of
Blanking Out
80
Case 1: 5 yo female
with episodes of
A 5 yoBlanking
female is brought to
your office
Out
Case 1: 5 yo female
with episodes of
After the
episode the patient
Blanking
Outresumes
82
Case 1: 5 yo female
with episodes of
Past medical,
physical Out
and
Blanking
Case 1: 5 yo female
with episodes of
General
physical and neurological
Blanking
Out
examination is normal.
Hyperventilation in your office replicates
the episodes.
84
Case 1: 5 yo female
with episodes of
EEG (demonstrated)
Blanking Out
3 hz spike and wave
(arrows)
85
Case 1: 5 yo female
with episodes of
What Blanking
is the diagnosis? Out
86
Case 2: Nervous
Disorder
87
Case 2: Nervous
Disorder
25 year-old right-handed marketing executive
for a major credit card company, began
noticing episodes of losing track of
conversations and having difficulty with
finding words.
These episodes lasted 2-3 minutes.
At times, the spells seemed to be brought on
by a particular memory from her past.
No one at her job noticed anything abnormal.
88
Case 2: Nervous
Disorder
Ms. Paul had no significant past medical
history, and took no medicines except for the
birth control pill.
She was in psychotherapy for feelings of
depression and anxiety, but was not taking
medications for mood or anxiety disorder
Her therapist notes that she has been under
significant stress from the breakup with her
boyfriend.
89
Case 2: Nervous
Disorder
What is your differential diagnosis at
this point?
90
Case 2: Nervous
Disorder
A careful medical history revealed that
she had one febrile seizure at age
three; no family members had epilepsy.
The psychiatrist prescribed a
benzodiazepine sleeping pill to be used
as needed, and scheduled her for an
electroencephalogram (EEG).
91
Case 2: Nervous
Disorder
Prior to the EEG, the patient had an episode
while on a cross country business trip in
which she awoke on the floor near the
bathroom of her hotel room.
She had a severe headache and noted some
blood in her mouth, along with a very sore
tongue. She called the hotel physician and
was taken to the local emergency room.
92
Case 2: Nervous
Disorder
What is your differential diagnosis now?
How would you classify the events both the
memory disturbance and the nocturnal
convulsions?
Case 2: Nervous
Disorder
In the emergency room, she was seen by the
doctors, examined and told she likely had a
seizure during her sleep.
A computerized tomographic scan of the
head was normal, showing no evidence of
bleeding or abnormal masses in the brain.
Her laboratory tests including a complete
blood count, blood chemistries including
glucose and toxicology screen were normal.
94
Case 2: Nervous
Disorder
She was given fosphenytoin 1000 mg
intravenously and observed. She was
then sent from the emergency room
with a prescription for phenytoin 300 mg
per day.
What would the continued evaluation
and treatment consist of?
95
Case 2: Nervous
Disorder
When Ms. Paul returned home, she
called the psychiatrist and related what
had happened.
She was advised to continue the daily
maintainence phenytoin dose and was
given the name of a neurologist.
She had no further episodes.
96
Case 2: Nervous
Disorder
The neurologist took a complete neurologic and medical
history. It was revealed that Ms. Paul had an
uncomplicated febrile seizure as a toddler, but no other
seizures.
There was no family history of epilepsy in her immediate
family members.
Medical history is otherwise benign and she has no
medication allergies. She had regular menstrual periods
since age 13 and has never been pregnant, although she
stated she wants to have children in the future.
General and neurologic examination was normal.
97
Case 2: Nervous
Disorder
Ms. Paul underwent an EEG that showed right
anterior temporal spike and wave discharges
interictally.
An MRI of the brain was normal. Due to her
persistent complaints of feeling sedated, the
neurologist was considering changing her
medication to another antiseizure medication.
With the patient included in the discussion, it was
decided to change phenytoin to oxcarbazepine, at a
dose starting at 150 mg twice a day and increasing
to 300 mg twice a day.
98
Case 2: Nervous
Disorder
Side effects were explained to the
patient. She was also started on folic
acid 1 mg per day and was advised to
take a multivitamin daily.
99
Case 2: Nervous
Disorder
What are the most reasonable choices of
antiseizure treatment for this patient?
Was an appropriate choice made?
What considerations must be made since
she is a woman of child-bearing potential?
100
Case 2: Nervous
Disorder
Are there considerations regarding the oral
contraceptive pill?
What is the reason for the extra folic acid
and multivitamin?
What advice should be given regarding
lifestyle (sleep habits, alcohol intake) and
driving?
101
102
105
Hematocrit 44%
Hemoglobin 15.4
g/dL
WBC 12,000/
80% Neutrophils
Platelets 180,000
106
107
108
Case 4: A 62 yo male
with Continuous
Seizures
110
Case 4: A 62 yo male
with Continuous
A 62-year-oldSeizures
male without a previous history
Case 4: A 62 yo male
with Continuous
Initial assessment
after the first seizure
Seizures
Case 4: A 62 yo male
with Continuous
What should
the initial management be?
Seizures
Case 4: A 62 yo male
with Continuous
Creatinine- 1.0
You opt to obtain
Seizures
laboratory studies.
The following results
are obtained:
CBC
WBC- 13.1
HGB 11
Plt 200,000
Mg 1.0
Na- 132
K- 4.5
Ca- 9.0
Glucose- 90
114
Case 4: A 62 yo male
with Continuous
CSF color- Seizures
clear
115
Case 4: A 62 yo male
with Continuous
Urinalysis- Seizures
(+) ketones
0 WBC
0 bacteria
Case 4: A 62 yo male
with Continuous
You obtain Seizures
an MRI of the brain with the
following images:
117
Case 4: A 62 yo male
with Continuous
Seizures
118
Case 4: A 62 yo male
with Continuous
Seizures
119
Case 4: A 62 yo male
with Continuous
Which of the
above studies helps to
Seizures
explain the current seizures?
Case 4: A 62 yo male
with Continuous
Seizures
1. Define Status Epilepticus.
2. Describe the systemic manifestations of status
epilepticus.
3. What causes status epilepticus?
4. What is the role of EEG in status epilepticus
management?
121
122
124
126
129
133
her mother.
She works as a sales clerk.
She completed twelve years of school
and finished one semester of college.
She has not driven a car after being
reported to the DMV by her doctor in
1977.
135
136
138
140
had 3 CPS
All began with her aura followed by
lip smacking and a post-ictal
aphasia
During the attack her right hand
was held in a fist
141
142
143
Neuropsychological Testing
Wada (Intracarotid amytal) test
Language on Left side only
No memory difference with left
and right injections
Performance and Verbal IQ normal
144
145
146
dysnomia
At three months post-op, cognitive testing
confirmed no change from pre-op
She has had no seizures for two years. She
declines a trial off of anticonvulsants for fear of
recurrent seizures. She drives to her
appointment in a new car.
She writes, Im now having a life I never knew
was possible
147
anticonvulsant treatment
Clinical and EEG features are compatible with
seizure origin from the left, language-dominant
temporal lobe
MRI suggests mesial temporal sclerosis is the
underlying pathology
She has an excellent chance for a seizure-free
outcome with a left anterior temporal lobe
resection
148
3 Hz spike
and wave
( 3 discharges
per second,
generalized)
1 sec.
149
back
back
150
Correct!!
This is a localization related seizure. Orobucal automatisms are typically seen when
the amigdala in the temporal lobe is involved.
This is a typical complex partial
seizure.Always suspect an underlying lesion.
Although CT scan may be normal, MRI is
recommended.
151
Incorrect
This is a localization related seizure. Oro-bucal
automatisms are typically seen when the amigdala in
the temporal lobe is involved. Absence seizures are
generalized and may look alike but typically dont
have the automatic behavior, last only few seconds
and occurs mainly in children. This is a typical
complex partial seizure. Always suspect an
underlying lesion. Although CT scan may be normal,
MRI is recommended.
152
Incorrect
This is a localization related seizure. Oro-bucal
automatisms are typically seen when the amigdala in
the temporal lobe is involved. The seizure remain
focal and there is no generalized tonic or clonic
activity that suggest generalization. This is a typical
complex partial seizure.Always suspect an underlying
lesion. Although CT scan may be normal, MRI is
recommended.
153
It is a seizure!!!
Other disorder may mimic epileptic seizures. Sleep
disorders are unlikely because this seizure occurred
during awake state, movement disorder dont alter
consciousness, presence of post-ictal confusion and
rhythmic movements evolving from focal areas to whole
body strongly suggest an epileptic seizure. Some
patients with conversion disorders may mimic seizures
pretty well but usually those pseudoseizures are very long,
asynchronous, involves pelvic thrusting, are triggered by
emotional distress and are typically in the presence of a
witness.
154
Ictal SPECT
Injection of
radioactive tracer
(Tc99) during a
seizure. The Tc99 is
taken up by the
neurons proportional
to brain perfusion. A
seizure focus is a
highly perfused
area.
Note arrows showing hot area in the left
temporal lobe during the seizure.
155
Intracranial Monitoring
Invasive monitoring is
performed when there are
some questions about
localization of the seizures
focus. Intracranial
electrodes are inserted
and then a video EEG
recording is performed
until the typical seizure is
captured. This procedure
allows a very accurate
localization of the focus.
156
157
Seizure Precipitants
Metabolic and Electrolyte Imbalance
Low (less often, high) blood glucose, low sodium, low calcium, low
magnesium
Evaluation of a Seizure
Etiology
Physical exam: Neurocutaneous signs,
dysmorphic features, mental retardation, focal
atrophy, focal neurologic findings.
Blood tests: CBC, electrolytes, glucose, Ca, Mg,
hepatic and renal function, toxicology screening
Lumbar puncture only if meningitis or
encephalitis suspected and potential for brain
herniation is ruled out
Electroencephalogram
CT or MR brain scan
159