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Seizures and Epilepsy

Questions:
 What was the patient doing just prior to the event?
 What happened during the event?
 What was the patient’s conditions just after the event?
 Is it a seizure? If so, what kind?
 What caused it?
 What should be done?

Definitions:

Seizure
- An occasional excessive & disordered discharge of nerve tissue.
- Manifestation of transient hypersynchronous abnormal neuron behavior.
- Transient occurrence of signs and/or symptoms resulting from abnormal excessive or synchronous
neuronal activity in the brain.
- Has a beginning and an end
- Involuntary
- Paroxysmal disorder
- Alter neurological function

Homunculus
- Focal seizures depend on what part of the brain is the electrical discharge.

*No seizure from the cerebellar area.

Pathophysiology

Epilepsy
- Diagnosis based on clinical
- No fever, infection, metabolic imbalance
- Disorder characterized by the occurrence of at least 2 unprovoked seizure
- Disorder of the brain characterized by an enduring predisposition to generate seizure and by. . . . .
Seizure Disorder
- A general term that is usually used to include any of several disorders including epilepsy, febrile
seizures, and possibly single seizure & seizure. . . .
Epileptic Syndrome
- Cluster or signs and symptoms
- Common in pediatric patients
- WS, LKS, LGS, JME

Classification of Seizure

Partial Seizure
- From a specific or single focus

Focal Seizure
- Limited at one hemisphere
- May be discretely localized.
- Can transfer from one side to another
Simple Partial
- Consciousness is not impaired
- With motor symptoms
- Focal motor without. . .
- Focal with march
- Postural
- Phonation (vocalization or arrest of speech)

Partial Seizure with Secondary Generalization


- Single area  generalized

Complex Partial Seizure


- Unaware or unresponsive
- Appears to be in a dream-like state
- Feel confused for several minutes
- No recollection of the event
- Impairment of consciousness
- Limbic lobe
- Affective and perceptual disturbance
- Muscle may jerk

Tonic-Clonic Seizure
 Clonic
 Tonic
 Atonic seizure (Astatic)
 Absence – difficult to notice
 Myoclonus – muscle jerking

Differential Diagnosis – seizure like episodes

Adult and Adolescents


 Syncope – has a triggering event
o Neurovasogenic
o Cardiac causes
 Psychogenic Attack
o Psychogenic non-epileptic seizure
o Depersonalization/Derealization
o Panic Attack
o Hyperventilation Attack
 Sleep Disorders
o Parasomnias
o Narcolepsy with Cataplexy
 Movement Disorder
o Paroxysmal Dyskinesia
o Myoclonus
o Hyperekplexia
 TIF
 Migraine
 TGA
 Metabolic
3 most common causes of Transient Loss of Consciousness
 Seizure
 Syncope
 Psychogenic non-epileptic seizure

Feature Seizure Syncope PNEs


Manifestation <10 yo Common Occasional Unusual
Motor Activity Typical seizure patterns Loss of postural tone Motor activity with
pauses
Purposeful Movements Very rare Rare Occasional
Skin Cyanosis common Pallor, sweating No cyanosis despite long
seizures
Closed eyes Rare Rare Very common
Resistance to eye Very rare Very rare Common
opening
Incontinence Rare Not rare Rare
Seizure duration >2 Uncommon Very common Common
min
Tongue biting Not infrequent Occasional Occasional
Seizure at night Common Rare Not rare
Change of seizure Rare Rare Occasional
semiology
Recurrent Seizure Rare Never Common
Seizure Provocation Rare Common Not rare
Vascular Factors Rare Not rare Common
Sexual & Physical Rare Rare Common
Abuse
History of Suicide Rare Rare Common
Attempt
Multiple unexplained Rare Rare Common
symptoms
History of learning Common Rare Common
disability

Etiology
 Determining the event
 History
o Associated symptoms
o Intercurrent illness
o Past Medical History
o Exposures (drugs, toxins, pets)
 Physical Examination
Most Common Cause of Epileptic Seizures According to Age of Onset

1st Week
 Perinatal asphyxia
 Perinatal trauma (often with intracranial bleeding)
 Very early CNS infection
 Cerebral malformation
 Hypocalcemia
 Hypoglycemia

2nd Week
 Early CNS infection
 Hypocalcemia
 Kernicterus – unconjugated blirubin
 Cerebral malformation

4th Month – 2 Years


 Febrile convulsions
 CNS infection
 Residual epilepsy due to early CNS discharge (cerebral palsy)
 Cerebrovascular problem
 Inborn errors of metabolism
 Neurocutaneous disorders

3 -13 Years Old


 Benign Rolandic Epilepsy – occurs at night; outgrow
 Trauma
 Neurocutaneous Disorders
 CNS infections
 CNS poisoning (Lead)
 IEMs
 Residual Epilepsy

11-20 Years Old


 Primary Generalized Epilepsy
 Trauma
 Residual Epilepsy
 CNS Infection
 AV Malformation – Vascular

21-40 Years
 Trauma
 Brain tumors
 Chronic Alcoholism
 AV Malformation

41-60 Years
 Brain Tumor
 Chronic Alcoholism
 Trauma
 Cerebrovascular Disease

>60 Years
 Cerebral arteriosclerosis
 Primary Brain Tumor
 Metastatic Brain Tumor
What to request?
 Blood
o Electrolytes
o Glucose
 Urine
o Toxicology
o AA and Organic Acid measurement
 EEG
o Useful for evaluating intercerebral abnormalities
o Occasionally useful for determining nature of clinical symptoms
o Helpful in predicting recurrence of seizures
o A normal EEG does not exclude a diagnosis of seizures
o Indications:
 To determine the type of epilepsy
 To prognosticate risk of seizure recurrence
 For the diagnosis of paroxysmal events which could be epileptic or non-epileptic
 For evaluation of patient with unexplained mental status
 To prognosticate patients in coma
 Confirmation of brain death
 Presurgical evaluation

Neuroimaging
 MRI with Gadolinium contrast – imaging procedure of choice
 CT Scan – trauma, emergencies
 PET Scanning

Treatment
 Establish the disease and rule out underlying cerebral pathology
 Classify seizure type
 Select AED of 1st choice for seizure type
 Increase dose slowly until end-point is reached:
 Complete seizure control
 Toxic side effects appear
 3-5 years seizure-free – stop the treatment
 Factors to consider:
o Control of seizure
o Tolerability
o Pharmacokinetic properties
o Patient characteristics
o Cost