SEIZURES & EPILEPSY Associated with TBI

1. SEIZURES & EPILEPSYAssociated with TBI Tracey A. Milligan, MD Director of Epilepsy, Faulkner Hospital Associate Neurologist, BWH Assistant Professor Harvard Medical School

2. No disclosures

3. What do you want to know?

4. Outline • Definitions and epidemiology • Manifestations of seizures • Diagnosis • Treatment • Co-morbidities and quality of life • Special situations

5. Epilepsy Case

6. Team Approach • Epileptologist (neurologist with sub-specialty training in epilepsy) • Neuropsychologist • Neurosurgeon • Nurse • Psychiatrist • Social worker

7. Definitions • What is a seizure? • A seizure is the result of a sudden disruption oforderly communication among nerve cells in the brain • Some lay terms that have been used to describe a seizure are a “fit,” “attack,” or “spell” • “Post-traumatic seizure” • What is epilepsy? • Epilepsy is not a single disease • Epilepsy is a group of related disorders characterized by recurrent spontaneous seizures • Two or more nonprovoked seizures • “Post-traumatic epilepsy”

8. What Is Epilepsy? • Epilepsy is one of the most common disorders of the nervous system • More than 3 million Americans of all ages areliving with epilepsy • Each year, approximately 200,000 Americans are diagnosed with epilepsy • Epilepsy can develop at any time of life and has many different causes • Epilepsy is the same as “seizure disorder”

9. 200 150 100 50 0 0 20 40 60 80 Epidemiology Age Specific Incidence of Epilepsy Incidence per 100,000 person-years Age Hauser WA, et al. Epilepsia. 1993;34:453-468.

10. What Causes Epilepsy? • Idiopathic—Unknown cause (may be genetic) • Symptomatic—epilepsy for which an underlying cause has been identified • Usually an injury or structural abnormality in the brain • Cryptogenic (probably symptomatic)—epilepsy for which an underlying cause has not been identified but is suspected

11. Trauma as a Cause of Epilepsy • Risk of epilepsy is related to the severity of the trauma • Greatest risk is in the first 2 years after TBI • Most common cause of epilepsy in teens and young adults

12. Epilepsy Facts • Epilepsy and its treatment produce a health-related quality of life similar to that associated with arthritis, heart problems, diabetes, and cancer • More than 1 of every 3 persons with epilepsy have depression • Overall mortality 2-3 times that of general population • Risk of sudden unexpected death is 24 – 40 times that in the general population and the cause of death in 2-18% of patients http://www.epilepsyfoundation.org/about/factsfigures.cfm.

13. Seizure Categories • There are two types of seizures: Partial seizures Seizures that originate in one specific area on one side (hemisphere) of the brain Generalized seizures Seizures that originate inseveral areas on both sides (hemispheres) of the brain

14. Partial Seizures • Simple partial seizures • Affect one specific part of the brain only, and do not cause a change in consciousness • Complex partial seizures • Affect a larger area of the brain and result in alteration or loss of consciousness • Secondarily generalized seizures • Begin as a partial seizure in one area of the brain and spread to affect the whole brain

15. Simple Partial Seizures • Manifestation is dependent on area of brain • Temporal lobe seizures most common • Deja-vu • Anxiety • Out of body experience

16. Complex Partial Seizures • Alteration in consciousness • Staring • Automatisms (Quasi-purposeful motor or verbal behaviors) • Verbal automatisms: simple vocalizations, stereotyped • Motor: oral (lip smacking, chewing, swallowing) and manual (picking, fumbling, patting) • Erroneously called “absence” or “petit mal” seizures by some

17. Absence Seizure • Most common in children • Involves a brief disruption of consciousness • Previously referred to as a “petit mal” seizure Between Seizures: • Normal appearance During Seizure: • Vacant stare • Eyes roll upward• Lack of response

18. Generalized Tonic-Clonic Seizure • Occurs in all age groups • Involves complete loss of consciousness • Previously referred to as a “grand mal” seizure

19. Possible sequence of partial seizure

20. Diagnosis

21. Differential Diagnosis of Paroxysmal Behavioral Event • Seizure • Syncope (convulsive) • Migraine • Cerebral ischemia (TIA) • Movement disorder • Sleep disorder • Metabolic disturbance • Psychiatric disturbance

22. Diagnosis • History • Physical examination • Lab tests • EEG • MRI

23. EEG • Assess for epileptiform discharges • Help diagnose presence, type, and location of epilepsy • Negative EEG does not rule out epilepsy • Sleep deprived EEG more sensitive • EEG after spell or seizure is more sensitive (51% vs. 30%) • Extended monitoring: video EEG or ambulatory EEG can be helpful

24. EEG

25. Imaging • After 1st seizure MRI is indicated • May help determine risk of seizure recurrence • May help determine where in the brain the seizure originated

26. Long Term Monitoring (LTM) • Done at an Epilepsy Monitoring Unit (EMU) • Diagnostic • Investigative • Therapeutic change • Presurgical • Team Approach

27. Psychogenic Nonepileptic Seizures • 10-45% of refractory epilepsy (referral centers); minority have both NES and ES • Females>males • Psychiatric mechanism — dissociation, conversion • Common association with physical, emotional, or sexual abuse • Often requires video-EEG monitoring  Once recognized, approximately 50% respond well to specific psychiatric treatment  Epileptic and nonepileptic seizures may co-exist

28. Treatment

29. Seizure Triggers? • In some people, seizures are triggered by specific events • Missing a dose of medication • Increased stress level • Excessive use of alcohol • Drugs such as cocaine • A small number of people may be sensitiveto flickering lights (atypical after TBI) • Poor sleep • Menstrual cycle • Many people with epilepsy cannot pinpoint specific triggers for their seizures • Avoid triggers if possible

30. Seizure Prevention and Improved Quality of Life • Get a good night’s sleep • Eat a healthy diet • Exercise regularly • Learn how to decrease effects of stress • Healthy support network (including employer) • Develop routine to take medications on schedule and as prescribed • Find the right physician

31. Treatment Options in Epilepsy • Antiepileptic drugs (AEDs) • Devices • Vagus nerve stimulation (VNS®) • Feedback devices in development • Epilepsy surgery • Alternative therapies

32. How Many Anti-Epileptic Drugs(AEDs) Are There? Drugs@FDA: FDA Approved Drug Products. Available at:http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm.

33. ANTI-EPILEPTIC DRUG (AED) CONSIDERATIONS • Spectrum of action (broad vs. narrow) • Parenteral administration/loading options • Pharmacokinetics and drug interactions • Concomitant disease • Birth control • Likely adverse effects • Efficacy • Cost

34. Possible Side Effects • Fatigue • Memory and concentration difficulties • Mood change (depression, anxiety) • Change in sleep • Dizziness • Nausea • Vision change (blurred, double) • Unsteady walking • (Weight change)

35. Other Treatments • 30% to 40% of people with epilepsy continue to have seizures despite treatment • Ketogenic diet • High-fat, low-carb diet • Mostly used in very young children with difficult-to-control generalized epilepsies • Vagal Nerve Stimulator (VNS) • Surgery

36. Surgical Treatment  Potentially curative • Resection of epileptogenic region (“focus”) avoiding significant new neurologic deficit  Palliative • Partial resection of epileptogenic region • Disconnection procedure to prevent seizure spread • Callosotomy • Multiple subpial transections

37. Surgery for TLE Wiebe, Blume, Girvin, Eliasziw. A Randomized Controlled Trials of Surgery for Temporal Lobe Epilepsy; NEJM, 2001

38. Seizure First Aid • Call for help • Look at the time • Observe • Create safe environment • Do not place anything in the mouth • If easily possible, turn person on their side • Most seizures last less than 2 minutes

39. Co-Morbidities

40. Depression • Greater risk of developing epilepsy • More common in people with epilepsy • Greater risk of suicide • Undertreated in many people with epilepsy

41. The “Different Faces” of Depression in Epilepsy • Interictal • Range from hours to days • Anhedonia, poor frustration tolerance • Ictal • Anhedonia • Guilt • Suicidal ideation • Post-ictal Kanner 2003

42. Other Co-Morbidities • Anxiety • Bipolar disease • Psychosis • Memory dysfunction

43. Quality of Life

44. Special Situations

45. Status Epilepticus (SE) • 30+ minutes of seizure activity • Can be life threatening • Can be first presentation of epilepsy • Treated as an emergency

46. Women With Epilepsy • Birth control and drug interactions • Preconception counseling • Folic acid • Bone health (important for men too)

47. Safety Issues • Water safety (e.g., swimming, boating, skiing) • Employment/safety-sensitive jobs (e.g., commercial truck driver, pilot, medical personnel, military service)* • Trauma/emergency care • Seizure-related injuries • Driving • SUDEP (sudden unexplained death in epilepsy) *http://www.epilepsyfoundation.org/living/wellness/employment/adasafety.cfm.

48. Dispelling Myths • Biggest problem faced by individuals with epilepsy is DISCRIMINATION

49. Epilepsy Foundation

50. Modern Case