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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.

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seizures

seizures

Joseph Breuner, MD

6/24/03

goals
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
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 adult4
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
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 seizures6
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 seizures7
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
Complex partial seizure
  • Most common type in epileptic adults
  • appear to be awake
  • consciousness is impaired
complex partial seizures
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
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 seizure11
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 seizure12
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 adult13
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 adult14
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 adult15
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 adult16
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 adult17
How to work up first seizure in an adult
  • Transient global amnesiais 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 adult18
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 adult19
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
Is it epilepsy?
  • Question 2: is it epilepsy?
  • Differentiate physiological and psychogenic seizures from epileptic seizures
is it epilepsy21
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 epilepsy22
Is it epilepsy?
  • Is it epilepsy?
  • In epileptic seizures the EEG is abnormal
is it epilepsy23
Is it epilepsy?
  • Physiologic seizures are caused by
  • hyper- and hypothyroidism
  • Hypoglycemia
  • Nonketotic hyperglycemia -focal motor seizures
is it epilepsy24
Is it epilepsy?
  • Physiologic seizures caused by:
  • Precipitous falls in serum sodium-high mortality
  • Hypocalcemia--neonates
  • Renal failure and uremia
is it epilepsy25
Is it epilepsy?
  • Physiologic seizures:
  • Acute intermittent porphyria--also includes abdominal pain and behavior changes
  • Cerebral anoxia--including brief syncope, though these patiens won’t be post ictal
  • alcohol withdrawal:3-72 hrs post last drink
is it epilepsy26
Is it epilepsy?
  • Medication history: tricyclic antidepressants can lower seizure threshold
is it epilepsy27
Is it epilepsy?
  • PMH--head injury
  • stroke
  • alzheimer’s disease
  • history intracranial infection
  • alcohol/drug abuse
is it epilepsy28
Is it epilepsy?
  • Family history
  • if positive, highly suggestive of epilepsy
  • especially for absence seizures and myoclonic seizures
is it epilepsy29
Is it epilepsy?
  • Physical exam/neuro exam
  • rarely helpful except in setting of acute infection or hemorrhage
  • look for lateralizing abnormalities
is it epilepsy30
Is it epilepsy?
  • Lab eval: epilepsy vs physiologic
  • glucose
  • calcium
  • magnesium
  • BUN/cr
  • tox screen
  • TSH
is it epilepsy31
Is it epilepsy?
  • Lumbar puncture--only useful if infection or malignant metastasis to the meninges
is it epilepsy32
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
How to order an eeg
  • Looking for seizure focus
  • substantiates epilepsy if positive
  • can indicate generalized vs partial seizure disorder
how to order an eeg34
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 eeg35
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 eeg36
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
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 seizures38
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 seizures39
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 seizures40
Which drugs for which seizures
  • Absent risk factors, it makes sense to wait for second seizure prior to initiating treatment
which drugs for which seizures41
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 seizures42
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 seizures43
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 seizures44
Which drugs for which seizures?
  • Phenytoin better than phenobarb solely due to side effects--treatment efficacy the same
which drugs for which seizures45
Which drugs for which seizures?
  • Carbamazepine equivalent to phenytoin
which drugs for which seizures46
Which drugs for which seizures?
  • Phenytoin equivalent to valproate
which drugs for which seizures47
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
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
references
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
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