Epilepsy and Seizure Disorders

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Epilepsy and
Seizure disorders

Juan G. Ochoa, MD
Associate Professor of Neurology
University of South Alabama

1

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

5

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.

• Symptomatic: The seizure is the manifestation of a
an underlying brain structural abnormality or known
chemical or metabolic disturbance

• Cryptogenic: Unknown origin, normal neurologic
exam and brain MRI

6

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)

Focal seizure on EEG
Are they aware during these seizures? Yes

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

• Usual duration 30-120 sec.
• Postictal confusion,
somnolence, with or without
transient focal deficit
10

Question you ask yourself
when you see seizure….
1. Seizure or not?

Yes

no

2. Can Identify focal onset?Yes

no

3. Evidence of CNS dysfunction?

4. Precipitant factors? View potential factors
5. If MRI and neurologic exam is normal What is
the seizure type? syndrome type? Answer
6. Start AED?
11

Primarily Generalized
Seizures
• Atonic: Sudden loss consciousness and loss of muscle

tone, frequently resulting in falls and head injury. Rare in
adults, mainly seen in mentally retarded patients. Video

• Tonic/Tonic-clonic: Generalized convulsion without

warning or focal symptoms. Tonic seizures result as rapid
firing within the motor cortex preventing muscle relaxation
between each epileptic discharge resulting in a tonic
posturing of the body, whereas clonic seizures result from
slower seizure discharge rate allowing the muscle to
recover between each contraction and presenting as a
phasic rhythmic movement.
12

Primarily Generalized
Seizures
• Absence: “Day dreaming” brief

episodes of staring, eyelid flutter
may be present, usually few
seconds but could be longer, mainly
during childhood. Typically without a
post ictal confusion and no memory
of the event. Easily unrecognized
by family and doctors.

– EEG

Myoclonic
Seizure

Myoclonic: Brief body jerks
occurring randomly and arrhythmic
involving part of the body or the
whole body. No loss of
consciousness. May be associated
with absence or generalized
tonic/clonic seizures

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

• Childhood and adolescence
– Idiopathic/genetic syndrome
– CNS infection
16

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

Seizures in Lennox-Gastaut Syndrome:
valproate, lamotrigine, felbamate**
* the risk of valproate-induced hepatic failure must be carefully weighed in
young children
** associated with aplastic anemia and hepatic failure
24

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

Dose Initiation and
Monitoring
• Discuss likely and unlikely but
important adverse effects
• Discuss likelihood of success
• Discuss recording/reporting seizures,
adverse effects, potential precipitants
29

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






Control achieved easily on one drug at low dose
No previous unsuccessful attempts at withdrawal
Normal neurologic status and EEG?
Primarily generalized seizures except JME
“Benign” syndrome

• Consider relative risks/benefits (e.g., driving,
pregnancy)

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

Vagal Nerve Stimulator
• Intermittent programmed electrical stimulation of left vagus
nerve
• Option of patient-triggered stimulation (auras)
• Adverse effects local, related to stimulus (hoarseness,
throat discomfort, dyspnea)
• Mechanism unknown
• Clinical trials show 26% effective and ___% seizure free
• FDA says useful for partial onset seizure — found to
improve by _____%
34

Patient Selection for
Surgery: Criteria
• Epilepsy syndrome not responsive to
medical management
– Unacceptable seizure control despite
maximum tolerated doses of 2-3
appropriate drugs as monotherapy

• Epilepsy syndrome amenable to
surgical treatment
35

Evaluation for Surgery
• History and Exam: consistency, localization of seizure
onset and progression
• MRI: 1.5 mm coronal cuts with sequences sensitive to
gray-white differentiation and to gliosis
• Other neuroimaging options: PET, ictal SPEC
• EEG: ictal and interictal, special electrodes
• Neuropsychological battery and WADA test
• Psychosocial evaluation
• Intracarotid amobarbital test
36

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

8

Improved

23

35

22

35

61

9

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

Ensure adequate ventilation/O2

2-3 min. IV line with NS, rapid assessment, blood

draw

4-5 min. Lorazepam 4 mg (0.1 mg/kg) or diazepam 10 mg (0.2
mg/kg) over 2 minutes via
second IV line or rectal diazepam
7-8 min. Thiamine 100 mg, 50% glucose 25 mg IV Phenytoin or
fosphenytoin 20 mg/kg IV at  50 mg/per minute phenytoin
or150 mg/kg per minute fosphenytoin ( 0.75 mg/kg/min)
Pyridoxine 100-200 mg IV in children
under 18 mo.

41

Status Epilepticus
Treatment (cont.)
Time post
onset Treatment
10 min. Can repeat lorazepam or diazepam if
ongoing

seizures

30-60 min. EEG monitoring unless status ended
waking up

and patient

40 min. Phenobarbital 20 mg/kg at  5 mg per
(0.75 mg/kg per minute)

minute

70 min. Pentobarbital 3-5 mg/kg load, 1 mg/kg per hour
infusion, increase to burst-suppression
(or midazolam
0.15-0.20 mg/kg load, 0.05-0.30
mg/kg per hour infusion)
42

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.)

simple vs. complex based on duration,
focality, repetition; prognostic
implications of complex febrile seizures
and of abnormal neurologic status
• Benign partial epilepsy syndromes of
childhood
48



Selected Pediatric
Epilepsy Syndromes
Benign epilepsy
with centrotemporal
(cont.)
spikes — nocturnal oropharyngeal
simple partial, rare secondarily
generalized seizures

• Benign childhood epilepsy with occipital
paroxysms — visual phenomena, at
times with secondary generalization
49



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.)

• Once recognized, approximately 50%
respond well to specific psychiatric treatment
• Epileptic and nonepileptic seizures may coexist
• Video-EEG monitoring often helps clarify the
diagnosis
54

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

• Fetal anomalies (up to 10% of pregnancies) are
multifactorial
– Drug effects
– Consequences of the mother’s underlying diseases
– Consequence of maternal seizures during
pregnancy
• All antiepileptic drugs carry teratogenic risks
• Polytherapy increases risk
56

Pregnancy and Epilepsy
(cont.)
• Effects on pregnancy on epilepsy
– Risk of increased seizures (low if compliance
maintained, doses adjusted upward to maintain
free levels)
– Risk of seizures during delivery (impaired
absorption, sleep deprivation, exhaustion)

• Effects of epilepsy on pregnancy
– Genetic factors in some cases
– Risks of convulsive seizures
– Risks of AEDs
57

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

Driving and Epilepsy
• Regulation varies state by state regarding:
– Reporting requirements
– Required seizure-free period
– Favorable/unfavorable modifiers

• 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

• DO NOT put rigid object in mouth or restrain
60



Case 1: 5 yo female
with episodes of “
A 5 yoBlanking
female is brought to
your office
Out


because of episodic “ blanking out” which
began 1 month ago. The patient has
episodes in which she abruptly stops all
activity for about 10 seconds, followed by a
rapid return to full consciousness. The
patient’s eyes are open during the episodes
and she remains motionless with occasional “
fumbling” hand movements.
61

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

• Seizure Assessment Algorithm
71

• Nurse Reference ppt slides

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)

Remote Symptomatic Seizures: High risk of developing
epilepsy
• Birth injury, congenital malformation, migration disorders, Tuberous
Sclerosis, Sturge-Weber, congenital toxoplasmosis
• Old Head injury , old stroke

Back

75

References for Nurses,
Cont ’d
Networking
American Association of Neuroscience Nurses (AANN), 4700 W. Lake Avenue,
Glenview, IL 60025-1485, (847) 375-4733, http://www.aann.org. The professional
organization for nurses specializing in the neurosciences.

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

References for Nurses,
Cont ’d
Web Sites
American Association of Neuroscience Nurses

http://www.aann.org

American Child Neurology Nurses

http://www.acnn.org

American Epilepsy Society

http://www.aesnet.org

Epilepsy Foundation (National Office)

http://www.epilepsyfoundation.org
or http://www.efa.org/education.firstaid.html

First Aid for Epilepsy

http://www.epinet.org.an/info/general.asp

Nursing Care Implications

http://www.nurseweek.com/ce/191-sb1.html

Nursing CEUs for Neurological Nursing

http://www.nursecen.com/nur.htm

Nursing Case Studies

http:www.webclinics.org
(log in as AED and use password NURSE)

77

Medical Student Cases .ppt

78

Medical Student Cases

Medical Student Education
Subcommittee
American Epilepsy Society

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


because of episodic “ blanking out” which
began 1 month ago. The patient has
episodes in which she abruptly stops all
activity for about 10 seconds, followed by a
rapid return to full consciousness. The
patient’s eyes are open during the episodes
and she remains motionless with occasional “
fumbling” hand movements.
81



Case 1: 5 yo female
with episodes of “
After the
episode the patient
Blanking
Outresumes


whatever activity she was previously
engaged with an unawareness that
anything has occurred
• She has 30 episodes per day
• No convulsions

82



Case 1: 5 yo female
with episodes of “
Past medical,
physical Out
and ”
Blanking

developmental histories are
unremarkable.
• No history of previous or current
medications; No allergies
• Family history is pertinent for her father
having similar episodes as a child.
83



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 ”


• What would you do?
• Initiate medication? If so; Which?
• How would you counsel the family
regarding prognosis

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?

• How would you evaluate the patient in
the ER if you saw her after this
episode?
93

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

Case 3: 70 yo man with
his first seizure

102

Case 3: 70 yo man with
his first seizure
• 70 yo male presents to the ER with a history of a
single seizure.
• His wife was awakened at 5:30 am by her
husband making an odd gurgling noise with his
head deviated to the left and left arm tonically
stiffened.
• This was followed by generalized body jerking
• Patient was unresponsive
• Event lasted 2 minutes with 10 minutes until full
recovery
103

Case 3: 70 yo man with
his first seizure
• In the ER, initially the patient is weaker in the
left hand than the right side and is fully
responsive and his wife feels that he has
returned to baseline.
• PMH: Non-insulin dependent diabetes
• Family history: Negative for seizures
• Social history: No smoking or alcohol use
• Neuro examination: Normal
104

Case 3: 70 yo man with
his first seizure
• Current medications: Glyburide 5
mg/day
• Vital signs: BP 200/130, HR 75
( regular)
• RR 14, Temp 100.1

105

Case 3: 70 yo man with
his first seizure
• Sodium 141 meq/L
• Potassium 4.2
meq/L
• Chloride 99 meq/L
• Bicarbonate 27
meq/L
• BUN 8 mg/dL
• Cr 0.7 mg/dL
• Glucose 60 mg/dL

• Hematocrit 44%
• Hemoglobin 15.4
g/dL
• WBC 12,000/
• 80% Neutrophils
• Platelets 180,000

106

Case 3: 70 yo man with
his first seizure
• Urine analysis: 15 WBC/HPF, nitrite
positive
• ABG: pH 7.3, pCO2- 36, pO2- 86, O2
saturation 93%

107

Case 3: 70 yo man with
his first seizure
• CT scan: normal
• EEG: minimal bitemporal slowing

108

Case 3: 70 yo man with
his first seizure
• What work-up is needed after a single
seizure?
• What are the causes of seizures, including
what conditions lower the seizure threshold?
• Would you treat this patient or not? If you
choose to start a medication, which drug
would you choose and why?
• What are the predictors of seizure
recurrence?
109

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

of seizures presents to the Emergency Room
with repeated tonic-clonic seizures. The
patient presented to the ER following one
generalized tonic-clonic seizure.
• However, while you left to check the
computer for his lab results, the patient has
begun to seizure again.
111



Case 4: A 62 yo male
with Continuous
Initial assessment
after the first seizure
Seizures

revealed poorly reactive pupils, no
papilledema or retinal hemorrhages and
a supple neck.
• Oculocephalic reflex is intact.
• Respirations are rapid at 22/min and
regular, heart rate is 105 with a
temperature of 101.
112



Case 4: A 62 yo male
with Continuous
What should
the initial management be?
Seizures

• What initial investigations should be
performed in this setting?
• What is the appropriate management
with continued seizures if initial therapy
does not terminate the seizures?
113



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


• Cell count tube # 1 – 500 RBC/ 35
WBC- 100% Neutrophils

# 3 - 100 RBC/ 11 WBC
• Protein 65
• Glucose 60

115





Case 4: A 62 yo male
with Continuous
Urinalysis- Seizures
(+) ketones
0 WBC
0 bacteria

• Tox screen: negative for alcohol
positive for benzodiazepines
116



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?

• Would you ask for other studies?
• What are the CSF findings during
repeated convulsions?
120

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

Case 5: 51 year old
female with frequent
seizures

122

Case 5: 51 year old
female with frequent
• Seizure History:
Her birth was
seizures

unremarkable except that she was
born with syndactyly requiring surgical
correction.
• Early developmental milestones were
met at appropriate ages.
• She had her first convulsive episode at
age 1 in the setting of a febrile illness.
123

Case 5: 51 year old
female with frequent
• How would
you evaluate and
seizures

treat a patient with a febrile
seizure? What clinical features
are important in guiding your
evaluation?

124

Case 5: 51 year old
female with frequent
• She began to
develop a new type of
seizures

episode in the third grade.
• The attacks consisted of her seeing a
pink elephant that was sitting on various
objects and waving to her
• (Of note, the patient has subsequently
found a ceramic model of an elephant
that was the same as the elephant that
she saw during her seizures).
125

Case 5: 51 year old
female with frequent
• How are seizures
her symptoms

different from most patients
with schizophrenia?

126

Case 5: 51 year old
female with frequent
• She was not
diagnosed with
seizures

seizures until the age of 15.
• Initially, the seizures were
controlled with medicine.
• After a few years, however, the
attacks occurred despite treatment
with anticonvulsants.
127

Case 5: 51 year old
female with frequent
• When she seizures
was 20-years-old, the

seizures changed in character to
the current pattern.
• The seizures begin with an aura of
“a chilling sensation starting at the
lower back with ascension to the
upper back over the course of 1020 seconds”.
128

Case 5: 51 year old
female with frequent
• Observers then
note a behavioral arrest.
seizures
• She tends to clench her teeth and
breath heavily, such that her breathing
sounds “almost as if she were laughing”.
• She is unable to fully respond to people
for 5-10 minutes.
• Typically, she experiences 4-5 seizures
per month

129

Case 5: 51 year old
female with frequent
• She has had
several EEGs in the past;
seizures

the most recent available report is from
5/95, which revealed mild, diffuse
slowing of background elements with
no abnormalities noted during three
minutes of hyperventilation and photic
stimulation.
• She had an MRI in 1987 with no
reported abnormalities.
130

Case 5: 51 year old
female with frequent
• She has triedseizures
several different medications,
but is currently maintained on Tegretol and
Lamictal. Her Tegretol dose consists of a
total of 700 mg a day and Lamictal 125 mg
a day.
• She feels excessively tired on higher doses.
• She has been on Tegretol since
approximately 1968 and on Lamictal since
approximately 1996.
131

Case 5: 51 year old
female with frequent
• She states that
she has had some
seizures
success with the Lamictal.
• In the past, she has been tried on
phenobarbital, Mysoline, Zarontin,
Neurontin, Dilantin, and Depakote.
• All of these were stopped due to lack of
efficacy.
• In addition, she had marked weight gain
while taking Depakote.
132

Case 5: 51 year old
female with frequent
• When areseizures
seizures “medically
refractory”?
• When should you consider an
inpatient video/EEG
evaluation?
• What might you learn from
such an evaluation

133

Case 5: 51 year old
female with frequent
• Past Medical
History: 1) Migraine
seizures

headaches (with the last one
occurring in 1996)
• 2) status-post hysterectomy with
removal of one ovary in 1976-1978
• 3) history of syndactyly at birth with
surgical corrections; 4) partial
thyroidectomy in 1968 during
pregnancy.
134

Case 5: 51 year old
female with frequent
• Social History:
She currently lives with
seizures

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

Case 5: 51 year old
female with frequent
• She tells seizures
you that she still has
her driver’s license.
• What are your legal and
ethical obligations as a
physician?

136

Case 5: 51 year old
female with frequent
• Family History: She has a cousin with a history
seizures
of ”grand mal” seizures who died at age 12.
• Habits: She does not use of alcohol, tobacco,
or illicit drugs.
• Medications: Tegretol 200/200/100/200 mg a
day, Lamictal 50/50/25 mg a day, Premarin
1.25 mg PO qd, Synthroid 100 mcg PO qd, and
Imitrex PRN.
137

Case 5: 51 year old
female with frequent
• Neurologicseizures
Examination: Normal

138



Case 5: 51 year old
female with frequent
• She hated
having seizures in
seizures

public and she “felt like a prisoner
in my own home”.
• Upon hearing of seizure surgery,
she requested a referral for
evaluation.
139



Case 5: 51 year old
female with frequent
The patientseizures
underwent video-EEG
monitoring.

140

Case 5: 51 year old
female with frequent
• During 5 days
of video EEG, she
seizures

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

Case 5: 51 year old
female with frequent
• EEG onsets seizures
consisted of a
rapid build up of
rhythmic theta
frequency activity
over the left
temporal region
(Arrows)

142



Case 5: 51 year old
female with frequent
MRI revealedseizures
an
atrophic left
hippocampus
(arrows)

143

Case 5: 51 year old
female with frequent
• Pre-surgical
Evaluation:
seizures





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

Case 5: 51 year old
female with frequent
Surgery
seizures
• Surgery under local
anesthesia
• Language map
determined by
electrical stimulation
• Language areas
(green arrow) and
epileptogenic tissue
(white arrow) labeled
 

145

Case 5: 51 year old
female with frequent
Surgery
seizures
• Anterior temporal
lobe resected
(arrow)
• Amygdala and
hippocampus also
resected

146

Case 5: 51 year old
female with frequent
Follow-up
seizures
• Immediately following surgery she had mild

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, “I’m now having a life I never knew
was possible”
147

Case 5: 51 year old
female with frequent
Pre-surgical Evaluation:
Conclusions
seizures
• She has complex partial seizures refractory to

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

EEG: Absence Seizure

3 Hz spike
and wave
( 3 discharges
per second,
generalized)
1 sec.
149

back

EEG: Partial Seizure
*Note
focal
seizure
activity
on EEG

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 don’t
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 don’t 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

Focal seizure with secondary
generalization
– Head deviation and tonic posturing of the
left arm correlates with a seizure focus
localizing in the right hemisphere involving
the motor cortex. For further localization
MRI brain, ictal SPECT , or intracranial
monitoring may be needed
– The patient has a secondary generalization

157

Seizure Precipitants
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 or inadequate treatment, non compliance
• Sedative withdrawal
Sleep deprivation
Hormonal variations
Stress ( very common precipitant)
Infection
158

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

Cryptogenic partial seizure
with secondary generalization
• Seizure Type: partial with secondary
generalization, there are focal
symptoms at the onset and later
become a generalized tonic seizure.
• Syndrome: Cryptogenic, not known
clear etiology, normal exam and MRI
160

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