Seizures and Epilepsy Lecture

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Seizures and Epilepsy
Hazel Paragua, MD, MBA, FPNA

by: Paulo Mara
August 2, 2010

I wondered what happened when you offered yourself to someone, and they opened you, only to discover you were not the gift they expected and they had to smile and nod and say thank you all the same. –My Sister’s Keeper Epileptics in History Julius Caesar Alexander the Great Charles V St. Joan of Arc Alfred Nobel Socrates Lord Byron G.F. Handel Peter Tchaikovsky Flaubert Napoleon Bonaparte Peter the Great James Madison St. Paul Vincent van Gogh Pythagoras Fyodor Dostoyevsky Moliere Jonathan Swift

Infants, children and adolescents  Febrile seizures  Idiopathic  CNS Infection  Head Injury  Toxic / Metabolic  Vascular  Tumor  Degenerative Adults        Cerebrovascular disease Tumors Head Injury CNS Infection Toxic /Metabolic Degenerative Idiopathic

Seizure  transient and reversible alteration of behavior caused by a paroxysmal, abnormal and excessive neuronal discharge  attack of cerebral origin  sudden and transitory abnormal phenomena motor, sensory, autonomic, or psychic  transient dysfunction of part or all of the brain Black & White = Aura with Migrane Colours & Circles = Aura of Seizure Epilepsy  A paroxysmal brain disorder of various etiologies characterized by recurrent seizures due to excessive electrical discharge of cerebral neurons associated with a variety of clinical and laboratory manifestations  Two or more seizures not directly provoked by intracranial infection, drug withdrawal, acute metabolic changes or fever Etiology of Epilepsy Seizure is a symptom of disease rather than a disease itself The investigation of epilepsy depends on the knowledge of possible etiologies Probable etiology depends on: o age of the patient at onset o type of seizures Etiology : Neonates      

International Classification of Epileptic Seizures Partial (focal, local) seizures I. Simple partial seizures  With motor signs  With somatosensory or special sensory symptoms  With autonomic symptoms or signs  With psychic symptoms II. Complex partial seizures  Simple partial onset followed by impairment of consciousness  With impairment of consciousness at onset  Partial seizures evolving to secondarily generalized seizures  Simple partial seizures evolving to generalized seizures  Complex partial seizures evolving to generalized seizures  Simple partial seizures evolving to complex partial seizures evolving to generalized seizures III. Generalized seizures (convulsive or nonconvulsive)          Absence seizures Typical absences Atypical absences Myoclonic seizures Clonic seizures Tonic seizures Tonic-clonic seizures Atonic seizures (astatic seizures) Unclassified epileptic seizures

Metabolic disorders Hypoxic Ischemic Encephalopathy CNS Infection Intracranial hemorrhage Cerebral dysgenesis Idiopathic (genetic)

*Commission on Classification and Terminology of the Int’l League Against Epilepsy, 1981

Seizures and Epilepsy
Hazel Paragua, MD, MBA, FPNA

by: Paulo Mara
August 2, 2010

 GENERALIZED SEIZURE Seizure with clinical and/or EEG evidence Both hemispheres involved Bilateral motor manifestations Consciousness impaired Ictus lasts 1-2 minutes Post - ictal state may last 10-15 minutes or even hours to days Generalized Tonic – Clonic Seizure Bilateral Motor Fencing Impairment of consciousness High pitched cry (tonic) TONIC PHASE:  Crying out as tonic contraction of trunk forces expiration.  Interrupted by short periods of relaxation followed by tonic o contractions. CLONIC PHASE :  More frequent periods of relaxation  Increase in heart rate and BP  May occur in rapid succession leading to status epilepticus  Incontinence: relaxation of sphincters after end of seizure Absence Seizure  Most common in childhood  Impairment of consciousness (looked awake, not aware)  Automatisms: eyelid blinking, staring (blank stares)  (3 seconds wave) Few seconds to a minute and may occur many times a day in rapid succession  Poor school performance  Test: EEG  Treatable 2 to 3 years Myoclonic Seizures  Quick muscle jerks, bilateral or unilateral  Consciousness usually intact  Usually seen in specific epilepsy syndromes (ex. JME in teenagers)  Myoclonic activity may also be associated with other neurologic disorders  Mental retardation Atonic Seizures  “DROP ATTACKS”  Commonly in Lennox-Gastaut Syndrome  Sudden loss in postural muscle tone  Last a few seconds and can occur without alteration of consciousness  Usually patients are 1-2 years old  

Often difficult to distinguish from tonic seizures Streotypical repeated (same situation) Headtrauma

PARTIAL SEIZURE  Seizure with clinical and/or EEG evidence  Focal onset  Abnormal discharge arising from a part of one cerebral hemisphere  Origin of Seizure: Hippocampus  Lesion in the Right Frontal Lobe, Left Side Paralysis  One extremities to the whole body Simple Partial Seizure  “AURA” = breeze  Originates from a motor or somatosensory area  May progress into a secondarily generalized tonic-clonic seizure Parietal Lobe Lesion – Somatosensory Occipital Lobe Lesion – Visual Temporal Lobe (Auditory Area) – Auditory Inferior Frontal Lobe (Olfactory Cotex) – Olfactory Simple Motor Seizure  Arise from the contralateral motor cortex  Versive or postural movements  May have Jacksonian march  Usually progresses to a GTC seizure Simple Partial Seizure Symptomatology Somatosensory Visual Auditory Olfactory Vertiginous Autonomic - feeling of breeze - light flashes, visual hallucinations - buzzing - burning rubber - dizziness - epigastric, “rising”, sweating, flushing, piloerection, pupillodilatation - hallucinations - fear, anger, dreamy states, déjà vu, jamais vu, visual distortions

Gustatory Psychic

Complex Partial Seizure  With impaired consciousness at the onset  Most last 1-3 minutes, at times longer  Complicated behaviors  Automatisms – no lateralizing value  Aura  Post-ictal confusion; amnesia for event  May secondarily generalize  “Psychomotor”, “temporal lobe” seizures  Alteration of consciousness as a result of dysfunction in the mesial temporal lobes, orbitofrontal lobes or in more widespread areas of the brain

Seizures and Epilepsy
Hazel Paragua, MD, MBA, FPNA

by: Paulo Mara
August 2, 2010

 

Prolonged absence seizure Medial part of the temporal lobe

EPILEPTIC SYNDROMES  Syndrome : Disorder characterized by a cluster of symptoms that commonly occur together Epileptic syndromes : o clinical pathogenesis (i.e. whether they begin in one part of the brain or in a bilaterally synchronous fashion etiology

Cryptogenic  West Syndrom  Lennox – Gastaut Syndrome  Epilepsy with myoclonic – astatic seizures  Epilepsy with myoclonic absences Localization – related (focal, local, partial) Idiopathic (primary)  Benign childhood epilepsy with centrotemporal spikes  Childhood epilepsy with occipital paroxysms  Primary reading epilepsy Symptomatic (secondary)  Temporal lobe epilepsies  Frontal lobe epilepsies  Parietal lobe epilepsies  Occipital lobe epilepsies  Chronic progressive epilepsies of childhood syndromes Cryptogenic, defined by:  Seizure type  Clinical features  Etiology  Anatomical localization Undetermined epilepsies With both generalized and focal seizures  Neonatal seizures  Severe myoclonic epilepsy in infancy  Epilepsy with continuous spike-waves during slow wave sleep  Acquired epileptic aphasia (Landau-Kleffner syndrome) Other undetermined epilepsies  Without unequivocal generalized or focal features Special syndromes Situation-related seizures (Gelegenheitsanfälle)  Febrile convulsions  Isolated seizures or isolated status epilepticus  Seizures occurring only when there is an acute or toxic event due to actors such as alcohol, drugs, eclampsia, hyperglycemia *Commission on Classification and Terminology of the International League Against Epilepsy 1989 Childhood Absence Epilepsy     “pyknolepsy” age of onset : 5 - 15 yrs. peak: 6-7 yrs. absence seizures/daily; several times a day  Typical EEG : 3 per second spike and wave complex  activated by hyperventilation



o

CRITERIA FOR SYNDROME CLASSIFICATION  seizure type  age at onset  precipitating factors  natural history  cause  anatomic localization of seizure onset  ictal and interictal EEG abnormalities Epilepsy Syndromes  IDIOPATHIC o Normal CNS function o No accepted pathologic correlate of the syndrome o Interparoxysmal (background) EEG is normal o There maybe close family members with a similar condition o AED treatment is usually effective SYMPTOMATIC CRYPTOGENIC International Classification of Epilepsies, Epileptic Syndromes, and Related Seizure Disorders * Generalized Idiopathic (primary)  Benign neonatal familial convulsions  Benign neonatal convulsions  Benign myoclonic epilepsy in infancy  Childhood absence epilepsy (pyknolepsy)  Juvenile absence epilepsy  Juvenile myoclonic epilepsy (impulsive petit mal)  Epilepsies with grand mal seizures (GTCS) on awakening  Other generalized idiopathic epilepsies  Epilepsies with seizures precipitated by specific modes of activation Symptomatic (secondary)  Non-specific etiology  Early myoclonic encephalopathies  Epilepsies in other disease states

 

Seizures and Epilepsy
Hazel Paragua, MD, MBA, FPNA

by: Paulo Mara
August 2, 2010

Juvenile Myoclonic Epilepsy  “Impulsive Petit Mal of Janz”  Appears around puberty  Seizures - bilateral, single or repetitive arrhythmic, irregular myoclonic jerks predominantly in the arms  No disturbance of consciousness  Often associated with GTCS  Infrequent absences  Seizures often occur after awakening  Precipitated by sleep deprivation  Interictal and ictal EEG : 4 – 6 Hz generalized spike / polyspike / slow waves  Frequent photosensitivity  Response to appropriate drugs is good Benign Febrile Seizures  Onset between 3 months and 5 y/o  Associated with fever without evidence of intracranial infection or defined cause  More in males  Recurrence : 1/3 will have at least 1 recurrence o ¾ of recurrences take place within a year of the first seizure and 90% within two years st  The younger the child at the 1 attack; the most likelihood of further febrile seizures  Risk for epilepsy is small.  It is increased when: o seizure lasts more than 15 minutes o more than 1 seizure in 24 hours o focal features o abnormal neurologic development/ neuro exam  In the absence of specific clinical indications, there is no o further need for diagnostic tests  Mainstay of treatment is fever control Epileptic vs Nonepileptic Events  Most patients with seizures have normal neurological exams, neuroimaging and even EEG  Some patients may have events that are difficult to classify  Most important tool for diagnosis: GOOD HISTORY! Differential Diagnosis of Episodic Events in Adults             Paroxysmal vertigo Syncope/Convulsive syncope Arrythmia Paroxysmal abdominal pain Pheochromocytoma Sleep Disorders Paroxysmal nocturnal dystonia Episodic dyscontrol Transient global amnesia Psychogenic seizures Somnambulism Sleep apnea

        

Sleep myoclonus Drug adverse effects Tics Myoclonus Dyskinesia Chorea TIA (transient ischemic attack) Complicated/Acephalgic migraine Panic disorder

Pseudoseizures  Brief, very unusual behaviors:  copious motor activity, cursing, pelvicthrusting  10% of all CPS don’t produce EEG change, most especially frontal lobe seizures  May have partly-preserved consciousness although individual frequently amnesic for event afterward Basic Laboratory Tests  CBC  Random Blood Sugar  Electrolytes, BUN, Creatinine  ECG Neurodiagnostic Procedures Electroencephalography (EEG)  Epilepsy is essentially a clinical diagnosis  The most important single diagnostic procedure in patients with epilepsy  10% of epileptics will have a normal EEG despite multiple recordings  A normal EEG does not exclude epilepsy  Not all abnormal EEGs mean epilepsy Interictal EEG in Epilepsy     confirms clinical diagnosis of epilepsy classification of seizure types definition of epileptic syndromes monitoring of response to AED treatment  evaluation of patients with single seizures  guide in the decision to discontinue AED treatment Indications for Neuroimaging  partial seizures especially in adults  conditions which suggest progressive neurologic disease or structural lesion that may be surgically correctible  intractable seizures Simple First Aid for persons with seizure 1. 2. 3. 4. First, clear everything out of the way. Don't hold the patient down or try to stop the jerking. Put something flat and soft under the patient’s head. Make sure there's nothing tight round his

Seizures and Epilepsy
Hazel Paragua, MD, MBA, FPNA

by: Paulo Mara
August 2, 2010

neck that could interfere with breathing. Check your watch so you'll know how long the seizure lasts. 6. Turn the patient gently onto one side so he or she doesn't choke. 7. Don't try to open his mouth. 8. Don't try to put anything in his mouth. 9. Don't try to give him or her anything to drink during the seizure. 10. Comfort the patient as he starts to wake up afterwards. Help her get cleaned up. if she wet or soiled herself during the seizure. 5. Indications for AED treatment Q. When should AED be started? When the diagnosis of epilepsy is made Epilepsy – recurrence of two or more spontaneous cerebral seizures AED treatment for single unprovoked seizure  Focal seizure  Signs of a focal lesion on neurologic exam  Abnormal EEG o focal slowing o epileptiform activity  Abnormal neuroimaging General Principles for Initiation of Antiepileptic Drug (AED) Treatment  Aim for monotherapy  AED choice dependent on seizure type or epileptic syndrome General Principles for Initiation of Antiepileptic Drug (AED) Treatment  Start low, go slow.  Start at a low dose and gradually increase until seizures are controlled or toxic effects appear (be guided by pharmacokinetics)  If first drug fails, try a second drug with similar efficacy and withdraw the previous drug gradually (overlap according to half-lives) Antiepileptic Drug Treatment Generalized Seizures Partial Seizures Choice of AED  Efficacy  Safety  Side Effects  Ease of use  Cost  Availability Treatment Goals for Epilepsy  Treatment of underlying cause  Control of seizures  Quality of life

Gradual Discontinuance of AED’s maybe considered if the patient meets the following :     Seizure - free 2 to 5 years on AED’s (mean 35 years) Single type of partial seizure or single type of primary generalized tonic-clonic seizures Normal neurologic examination / normal I.Q. EEG normalized with treatment

Prognosis  60 - 70% will respond to monotherapy  10 - 15% will respond to at least 2 AEDs  Half of responders (both groups above) will be successfully withdrawn from AEDs  10 - 12% will be medically intractable Factors associated with increased risk of relapse      Long duration of epilepsy Difficulty in achieving control of seizure Duration of remission Seizure type / epilepsy syndrome Presence of additional handicaps

Status Epilepticus  Seizures so frequent or so prolonged as to create a fixed and lasting condition. (Mortality : 20- 30%)  A continuous, generalized tonic-clonic seizure lasting more than 30 minutes or absence of lucid intervals in between seizures  Most seizures last for 3 to 5 minutes and occasionally up to 10 minutes. If seizure persists more than 10 minutes, therapeutic intervention must be initiated  EEG monitoring is a must. PHASE I: Compensation Phase 30 mins of continuous seizures PHASE II: Decompensation Phase The rate and extent of physiological change is dependent on: 1. Etiology 2. Site of seizures 3. Severity of seizures 4. Rapidity of treatment Treatment of Status Epilepticus       establish airway determine blood pressure administer dextrose and thiamine terminate SE prevent recurrence of SE treat complications

Seizures and Epilepsy
Hazel Paragua, MD, MBA, FPNA

by: Paulo Mara
August 2, 2010

Immediate Measures  secure airway  give oxygen  assess cardiac and respiratory function  secure intravenous (IV) access in large veins Protocol for Management of Status Epilepticus Time: 0 minutes Initiate general systemic support of the airway and BP; Begin nasal O2; monitor EKG and respiration; check T°; Obtain history; perform neurological examination. Send sample serum for evaluation of e¯, BUN, RBS, CBC, drug screen, and anticonvulsant levels; check ABG’s. Start IVF with isotonic saline at a low infusion rate. Inject D50-50 and 100 mg thiamine. Time: 0 minutes Start EEG recording as soon as possible. Administer diazepam 0.3 mg/kg IV; immediately followed by Phenytoin 20 mg/kg IV with an additional 10 mg/kg IV if seizures continue OR Administer lorazepam 0.1-1.5 mg/kg IV; if seizures persist administer fosphenytoin 18 mg/kg IV with an additional 7 mg/kg if seizures continue Time: 20 - 30 minutes (if seizures persist) Intubate, insert bladder catheter, start EEG recording, check T°. Administer phenobarbital, loading dose of 20 mg/kg IV Time: 40 - 60 minutes (if seizures persist) Begin pentobarbital infusion 5 mg/kg IV initial dose then push until seizures have stopped using EEG monitoring; continue pentobarbital infusion at 1 mg/kg/hr; slow infusion rate every 4-6 hours to determine if seizures have stopped, with EEG guidance; monitor BP and respiration carefully. Support blood pressure with pressors if needed. Time: 40 - 60 minutes (if seizures persist) Begin midazolam at 0.2 mg/kg then at a dose of 0.75 to 10 g/kg/min titrated to EEG monitoring., OR Begin propofol at 1-2 mg/kg loading followed by 210 mg/kg/hr. Adjust maintenance dose on the basis

of EEG monitoring. Indications for Intravenous Antiepileptic Drugs  Patients who are unable to swallow  Rapid initiation of therapy with a new agent  Rapid correction of low AED level  Seizure emergencies  Acute, repetitive seizures  Prolonged seizures  Status epilepticus Factors Influencing IV AED Choice  Indication  Seizure type  Prior AED therapy  Need for rapid treatment  Ease of dosing/administration  Complicating medical conditions  Potential adverse effects  Need for long term AED therapy Ideal IV AED Characteristics  Ease of administration  Rapid onset of action  Intermediate to long duration  Broad spectrum  Minimal morbidity  Useful as maintenance AED  IV solution compatibility IV AED Options  Benzodiazepines  Diazepam  Lorazepam  Phenytoin  Fosphenytoin  Phenobarbital  Valproate sodium  Levetiracetam When to Call the Ambulance or Rush to the Emergency Room When a seizure doesn't show any signs of stopping after five minutes. When the seizure happened in water and there's any chance that the patient inhaled or swallowed a lot of water. When a patient doesn't recover consciousness or isn't breathing properly afterwards When a patient vomits during the seizure and then doesn't come round or isn't breathing properly afterwards When another seizure starts soon after the first one. When an unexpected seizure happens in a person who does not have epilepsy. When the patient is pregnant, diabetic or is injured.

Seizures and Epilepsy
Hazel Paragua, MD, MBA, FPNA

by: Paulo Mara
August 2, 2010

Frequent Reactions to the Diagnosis of Epilpesy  Denial  Anger  Despair  Fear  Shame  Uncertainty  Hopelessness

7. Like, when you can make kaya, always use like. Like, I know right? ex. "Like, it's so init naman!" "Yah! The aircon, it's, like sira!" 8. Make yourself feel so galing by translating the last word of your sentence, you know, your pangungusap? ex. "Kakainis naman in the LRT! How plenty tao, you know, people?" "It's so tight nga there, eh, you know, masikip?" 9. Make gamit of plenty abbreviations, you know, daglat?" ex. "Like, OMG! It's like traffic sa LRT" "I know right? It's so kaka!" "Kaka?" "Kakaasar!" 10. Make gamit the pinakamaarte voice and pronunciation you have para full effect! ex. "I'm, like, making aral at the Arrhneo!" "Me naman, I'm from Lazzahl!" Ways of dealing with the burdens of life: 1. Accept that some days you're the pigeon, and some days you're the statue. 2. Always keep your words soft and sweet, just in case you have to eat them. Always read stuff that will make you look good if you die in the middle of it. Drive carefully. It's not only cars that can be recalled by their Maker. If you can't be kind, at least have the decency to be vague. 3. If you lend someone $20 and never see that 4. person again, it was probably worth it. 5. It may be that your sole purpose in life is simply to serve as a warning to others. 6. Never buy a car you can't push. 7. Never put both feet in your mouth at the same time, because then you won't have a leg to stand on. 8. Nobody cares if you can't dance well. Just get up and dance. … (excertpts from “I am an MD-to be”) its already 5am and i dont feel like sleeping yet... my class is at 7am but what the heck.. im getting used to this routine of killing myself softly (i can take a nap during lectures any way! haha)... it feels like every day is the same pressure- and stress-filled day... i know a lot of people can relate to this circulating "med anxiety" or watever u call it... its only been 4 weeks and i can see that a lot of people are on the verge of giving up on this career/vocation we enrolled in to... i cant deny the fact that I am on the verge of giving up too... but i would never do so... this is the life I've chosen to pursue... and there's no turning back... this is the life we wanted, this is the life I wanted so I would carry on no matter what.

-paulo mara
As doctors, as friends, as human beings, we all try to do the best we can. But the world is full of unexpected twists and turns. And just when you’ve gotten the lay of the land, the ground underneath you shifts. And knocks you off your feet. If you're lucky, you'll end up with nothing more than a flesh wound, something a bandaid will cover. But, some wounds are deeper than they first appear, and require more than just a quick fix. With some wounds, you have to rip of the bandaid, let them breathe and give them time to heal. BREAK TIME sa pag rereview pang patanggal stress.. 10 Conyo-mandments by Gerry Avelino and Arik Abu 1. Thou shall make gamit "make+pandiwa". ex. "Let's make pasok na to our class!" "Wait lang! I'm making kain pa!" "Come on na, we can't make hintay anymore! It's in Andrew pa, you know?" 2. Thou shall make kalat "noh", "diba" and "eh" in your pangungusap. ex. "I don't like to make lakad in the baha nga, no? Eh diba it's like, so eew, diba?" "What ba: stop nga being maarte noh?" "Eh as if you want naman also, diba?" 3. When making describe a whatever, always say "It's SO pang-uri!" ex. "It's so malaki, you know, and so mainit!" "I know right? So sarap nga, eh!" "You're making me inggit naman.. I'll make bili nga my own burger." 4. When you are lalaki, make parang punctuation "dude", 'tsong" or "pare" ex. "Dude, ENGANAL is so hirap, pare." "I know, tsong, I got bagsak nga in quiz one, eh" 5. Thou shall know you know? I know right! ex. "My bag is so bigat today, you know" "I know, right! We have to make dala pa kasi the jumbo Physics book eh!" 6. Make gawa the plural of pangngalans like in English or Spanish. ex. "I have so many tigyawats, oh!"

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