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Epilepsy week prereading. Talley & O’Connor p400-402. Causes of unconsciousness = C.O.M.A. CO 2 narcosis (uncommon) Overdose Metabolic/endocrine Apoplexy (Stroke or other CNS insult) General inspection DRABC Posture (neck extension, decerebrate , decorticate) Involuntary movements.

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talley o connor p400 402
Talley & O’Connor p400-402
  • Causes of unconsciousness = C.O.M.A.
    • CO2narcosis (uncommon)
    • Overdose
    • Metabolic/endocrine
    • Apoplexy (Stroke or other CNS insult)
  • General inspection
    • DRABC
    • Posture (neck extension, decerebrate, decorticate)
    • Involuntary movements
talley o connor p400 4021
Talley & O’Connor p400-402
  • Level of consciousness
    • GCS
    • Coma, stupor, drowsy, alert
    • AVPU:Alert, Voice response, Pain response, Unresponsive
  • Neck
    • Trauma, stiffness, Kernig’s sign
  • Head
    • Inspect, palpate, Battle’s sign
talley o connor p400 4022
Talley & O’Connor p400-402
  • Face
    • General
      • Asymmetry, jaundice, myxoedema
    • Eyes
      • Pupils, fundus, haemorrhage, position, movement
    • Ears and nostrils
      • Blood and CSF
    • Mouth and tongue
      • Trauma, corrosion, gum hyperplasia, breath odor
talley o connor p400 4023
Talley & O’Connor p400-402
  • Limbs
    • Trauma, needle marks, tone, reflexes, pain response
  • Trunk
    • Trauma, heart, lungs, abdomen
  • Other
    • Urine
    • Blood sugar
    • Body temp
    • Stomach contents (if indicated)
harrison s chap 363
Harrison’s chap 363

Partial seizure – discrete CNS focus

  • Simple – fully conscious
    • Motor, sensory, autonomic, or psychic symptoms
    • May progress (egJacksonian march)
    • May proceed to complex partial seizure
    • May proceed to general seizure
  • Complex – impaired consciousness
    • Preceded by aura (simple partial seizure)
    • Automatisms – unconscious behaviour
    • Postictal confusion, anterograde amnesia
harrison s chap 3631
Harrison’s chap 363

Generalized seizure – affects both hemispheres

  • Absence seizure (petit mal)
    • Brief lapse of awareness
    • Subtle motor signs (eg blinking)
    • No post-ictal confusion
  • Tonic-clonic seizure (grand mal)
    • 10-20s general muscle contraction (tonic)
    • Periods of relaxation (clonic)
    • Post ictal flaccidity and unresponsiveness, then impaired consciousness, confusion, headache, fatigue
  • Atonic seizure
    • Brief loss of postural control and impaired consciousness
    • No post-ictal confusion
  • Myoclonic seizure
    • Sudden, brief muscle contraction
    • Focal or generalized
    • Eg jerk while falling asleep
harrison s chap 3632
Harrison’s chap 363

Epilepsy syndromes (disorders featuring epilepsy)

  • Juvenile myoclonic epilepsy
    • Responds well to anticonvulsants
  • Lennox-Gastaut syndrome
    • Underlying CNS disease, poor prognosis
  • Mesial temporal lobe epilepsy syndrome
    • Refractory to anticonvulsants
    • Responds well to surgery
  • Other examples with known genetic basis
harrison s chap 3633
Harrison’s chap 363

Causes of seizures

  • Neonates
    • Perinatal hypoxia, infection, drug withdrawal, trauma, metabolic, genetic, developmental
  • Children
    • Febrile, trauma, developmental, infection, genetic, idiopathic
  • Adolescents
    • Trauma, drugs, brain tumour, infection, genetic, idiopathic
  • Young adults
    • Trauma, drugs, brain tumour, alcohol withdrawal, idiopathic
  • Older adults
    • Trauma, CVA, brain tumour, alcohol withdrawal, metabolic disorder, degenerative CNS, idiopathic
harrison s chap 3634
Harrison’s chap 363

Mechanisms of seizures

  • Initiation and propagation
    • high-frequency action potentials bursts
    • Hypersynchronization
    • Interstitial and synaptic funkiness with electrolytes and neurotransmitters
    • Funkiness spreads to surrounding areas
  • Epileptogenesis
    • Normal neural network becomes hyperexcitable
    • Injury? Development?
  • Genetic
    • Ion channelopathies
harrison s chap 3635
Harrison’s chap 363

Antiepileptic drugs block initiation or propogation

  • Inhibit Na+-dependent action potentials:
    • phenytoin, carbamazepine, lamotrigine, topiramate, zonisamide
  • Inhibit voltage-gated Ca2+channels:
    • Phenytoin
  • Decrease glutamate release:
    • Lamotrigine
  • Potentiate GABA receptor function:
    • benzodiazepines and barbiturates
  • Increase GABA availability:
    • Valproicacid, gabapentin, tiagabine
  • Modulate release of synaptic vesicles:
    • Levetiracetam
  • (Probably) Inhibit T-type Ca2+ channels in thalamic neurons:
    • Ethosuximideand valproicacid
harrison s chap 3636
Harrison’s chap 363

Approach to seizure management

harrison s chap 3637
Harrison’s chap 363

Approach to seizure management

harrison s chap 3638
Harrison’s chap 363

DDx of seizures

  • Syncope
    • Vasovagal, arrythmia, hypotension, cardiac failure
  • Psychological
    • Panic attack, psychogenic seizure, hyperventilation
  • Metabolic
    • Hypoglycemia, hypoxia, alcoholic blackout, DTs, psychoactive drugs
  • Migraine
  • TIA
  • Sleep disorders
    • Narcolepsy, cataplexy, benign sleep myoclonus
  • Movement disorders
    • Tic, nonepilepticmyoclonus, paroxysmal choreoathetosis
  • Special considerations in children
    • Breath-holding, apnea, night terrors, migraine, benign paroxysmal vertigo
harrison s chap 3639
Harrison’s chap 363

Treatment of seizures and epilepsy

  • Treat underlying condition
  • Avoid precipitating factors
  • Antiepileptic drugs
    • Big table of doses and adverse effects
  • Some patients can eventually cease drug therapy
harrison s chap 36310
Harrison’s chap 363

Treatment of seizures and epilepsy

  • Surgery
    • focal neocortical resection
    • anteromedialtemporal lobe resection
    • Amygdalohippocampectomy
    • Lesionectomy
    • multiple subpialtransection
    • Multilobar resection
    • Hemispherectomy
    • Corpus callosotomy
harrison s chap 36311
Harrison’s chap 363

Status epilepticus

  • Continuous seizures
  • Repetitive seizures with impaired consciousness between
  • GCSE = generalized convulsive status epilepticus
  • GCSE > 5min is an emergency:
    • cardiorespiratory dysfunction, hyperthermia, metabolic derangement, irreversible CNS injury
  • EEG may be required to show seizure activity after 30-45 minutes
harrison s chap 36312
Harrison’s chap 363

GCSE management

  • ABC and hyperthermia
  • IV access, lab tests for metabolic abnormalities
  • Anticonvulsants
    • Begin with Lorazepam
    • Valproate?
    • Phenytoin or Fosphenytoin
    • Admit to ICU if seizures continue
    • General anesthesia (propofol, midazolam, pentobarbital)
harrison s chap 36313
Harrison’s chap 363

Ongoing epilepsy management

  • Interictalbehavior
    • Depression, memory deterioration, postictal psychosis or anxiety
  • Psychosocial issues
    • Cultural stigma, fears of death and mental retardation
  • Employment, driving, other activities
    • Legislation varies
  • Mortality
    • Underlying disease, Accidents, GCSE, SUDEP – Sudden unexpected death in epileptic patients
harrison s chap 36314
Harrison’s chap 363

Special issues for women with epilepsy

  • Catamenial epilepsy
    • Association of seizures with menstruation
  • Pregnancy
    • Seizure frequency may increase or decrease
    • Teratogenic effect of antiepileptic drugs
  • Contraceptive pill
    • Interactions with medication
  • Breastfeeding
    • Drugs are expressed in breast milk, but no evidence of long term harm to infants