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Seizures Part 2

Seizures Part 2. Incomplete (lacking first part ) SORRY… : (. Absence Seizures. Onset 5 y.o . 24% 5-15 y.o . 8.3% 15 y.o . 7%. Differential Diagnosis for Loss of Consciousness. Syncopial Attacks ( Vaso-vagal ) Hyperventilation Drop attacks Migraine Meniere’s disease

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Seizures Part 2

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  1. Seizures Part 2 Incomplete (lacking first part) SORRY… : (

  2. Absence Seizures • Onset • 5 y.o. 24% • 5-15 y.o. 8.3% • 15 y.o. 7%

  3. Differential Diagnosis for Loss of Consciousness • Syncopial Attacks • (Vaso-vagal) • Hyperventilation • Drop attacks • Migraine • Meniere’s disease • Cardiac disease • Hypoglycemia

  4. Differentiating Psychogenic “Seizures” From True Epileptic Seizures

  5. Differentiating Psychogenic “Seizures” From True Epileptic Seizures

  6. Most Common Causes of Epileptic Seizures According to Age of Onset • First week • Perinatal asphyxia • Perinatal trauma (often with intracranial bleeding) • Second week • Early CNS infection • Hypocalcemia • Kernicterus • Cerebral malformations

  7. Most Common Causes of Epileptic Seizures According to Age of Onset • Four months to 24 months • Febrile convulsions • CNS infection • Residual epilepsy due to early CNS damage (cerebral palsy) • Cerebrovascular problems, arteria • Inborn errors of metabolism

  8. Most Common Causes of Epileptic Seizures According to Age of Onset • 3 to 10 years • Benign Rolandic epilepsy • Primary generalized epilepsy • Residual epilepsy due to early CNS damage • Trauma • Inborn errors of Metabolism • Neurocutaneous disorders • CNS infection • CNS poisoning (e.g. lead)

  9. 11 to 20 years • Primary generalized epilepsy • Trauma • Residual due to early CNS damage • CNS infection • Arteriovenous malformation

  10. 21 to 40 years • Trauma • Brain tumor • Chronic alcoholism • 41 to 60 years • Cerebrovascular disease • Trauma • 60 above • Cerebral arteriosclerosis • Brain tumor, primary • Brain tumor, metastic

  11. Common precipitating factors in young patients • Fever • Stress • Fatigue • Sleep • Deprivation • Substance abuse • Menstrual cycle • Photic stimulation – flashing lights • Alcoholism

  12. Factors Lowering Seizure Threshold • Common • Sleep deprivation • Alcohol withdrawal • Dehydration • Drugs and drug interaction • System infection • Trauma • Malnutrition • Occasional • Barbiturate withdrawal • Hyperventilation • Flashing lights • Diet and missed meals • Specific “reflex” triggers

  13. Prognosis • Remission highest in patients with idiopathic grandmal or absence seizures • Remission lowest in patients with minor seizures other than absence and in those with complex partial seizures • The longer the follow-up, the lower the final remission rate

  14. Risk of recurrence • After 1st seizures = 27.82% recurrence • Recurrence greatest within 3 months • 30 % within 3 months • ¾ within 2 years • Higher recurrence if with structural disorders • With appropriate treatment complete seizure control is achieved 50-90% of cases

  15. Features associated with an increased risk of seizure recurrence in epilepsy • Certain seizure type (partial seizure, tonic, seizure, absence seizure • Structural of diffuse cerebral disorder • Primary generalized epilepsy • Lennox-gestaut syndrome • Additional neurologically/psychiatric handicap

  16. Risk of persistent seizures • Progressive neurologic damage • Worsening seizures • Adverse cognitive and psychological effects

  17. Principles of treatment seizures • Establish diagnosis and rule out underlying cerebral pathology • Classify seizure type using EEG and clinical criteria • Select AED (anti-epileptic drug) of first choice for seizure type

  18. Principles of treatment • Increase dose slowly till end point is reached • Complete seizure control • Optimum plasma drug level • Toxic side effects • If poor seizure control gradually withdraw first drug while replacing with second drug of choice • Monotherapy is preferable to polypharmacy

  19. Principles of treatment • If improvement with medication only partial, other drug may be necessary • Keep in mind drug-drug interactions • Adjust gradually (if possible using plasma levels as a guide) keeping in mind • Pharmacokinetics of each drug • Potential drug interactions

  20. Principles of treatment • Continue treatment to achieve minimum seizure free period of 3 to 5 years • If best medical therapy is unsuccessful, epilepsy surgery should be considered (lubectomy – remove focus of seizure)

  21. Phenobarbital – trade name: Luminal • Indication: tonic-clonic seizures, simple and complex, absence • Phenytoin – TN: dilatin • Tonicclonic status epilepticus, tonic clonic simple and complex partial seizures • Carbamazepine – TN: tegretol • Simple and partial seizures, tonic clonic seizures • Valproic acid – TN: Epival • Tonic clonic seizures complex partial seizures absence • Myoclonicclonazepam – TN: rivotril • Myoclonic seizures

  22. Anticonvulsant drug interactions • Valproate • Phenobarbitalethosuximide (raises) • Phenytoin (lowers levels of interactions) • May produce status with clonazepam and coma with barbiturates (unsual) • Primidinephenobarbital • Phenytoin (raise level) • Oral anticoagulatnsantidepressanes, contraceptives, quinidine, griseofulvin, corticostreoids • Carbamazepine • Raises level: Isoniazid • Lower levels: phenytoinwarfarindoxycycline haloperidol • Phenytoin • Lower: digoxin • Gabapentin (new, no side effe • cts)

  23. ValproatePrimidone Phenobarbital • Raises: Salicylates (aspirin)carbamazepine, dicumarol, ethosuximide • EthosuximideValproate, MAO inhibitors (raises) • Phenytoin (lowers level) • Carbamazepine • Erythromycin, cimetidine, calcium channel blocker, isoniazid, propoxyphene (raises) • Phenobarbital phenytoin (lowers)

  24. Antiepileptic • Phenobarbital • Phenytoin • Carbamazepine • Clonazepam • Valproate NA

  25. StatusEpilepticus • Single prolonged seizure lasting more than 30 minutes • Frequent seizures, no recovery of consciousness

  26. Convulsive status • Generalized tonic clonic seizures • Partial motor seizure • Non convulsive • Absence status • Complex partial • Partial

  27. Causes • Sudden withdrawal of epileptic medication • Infection of CNS (Meningitis) • Others (history of stroke, brain tumors)

  28. Protocol of medications 1. Diazepam or Lorazepam (benzodiazepines, substance being abused by young adults) 2. Phenytoin – 18-20 MG/KG/SLOW IV 3. Phenobarbital – 20-25 MG/KG/SLOW IV (expect respiratory depression) 4. Penthotal – sodium *all intravenously given, guided by EEG(burst suppression- no epileptoform charges, induce coma)

  29. Associations with intractable epilepsy • Structural brain disease • Focalvs diffuse • Static vs progressive • Ineffective treatment • Inappropriate AED choice or • Inadequate dose • Drug interactions • Non-compliance

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