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Flashcards in Reisert: Seizures Deck (82)
1

Paroxysmal event due to abnormal CNS discharge with resultant manifestations depending on area involved

seizure

2

5-10% of population in lifetime

More prevalent in early childhood and later in adulthood

 

Seizure

3

Patient with reccurent seizures

0.3-0.5% of population

Epilepsy

4

Two types of seizures?

Partial and Generalized 

5

Deranged area of cerebral cortex often due to a structural anomaly

Consciousness is preserved

Simple partial seizure 

6

Third type of partial seizure?

Partial seizure secondarily generalized 

7

partial seizure where consciousness is impaired

complex partial seizure 

8

Diffuse region of brain firing simultaneously 

Often a widespread problem:

Cellular disorder (mental retardation)

Biochemical disruption (low sodium)

Structural issue (brain tumor)

Generalized seizure 

9

Motor, sensory, autonomic psychic but without loss of consciousness. Often clonic with repetitive flexion/extension 

Example: hand tremor on opposite side of abnormal brain activity 

 

______ partial seizure

Simple 

10

EEG shows abnormal impulses in focial area of brain

Simple partial seizure 

11

Jacksonian March

Todd's paralysis

Epilepsia partialis continua

Variations of simple partial seizures 

12

Motor activity begins distally, like fingers, and spreads to whole extremity

EEG: spike waves 

Which variation of simple partial seizure?

Jacksonian March

13

Local paresis lasting minutes to hours 

What variation of simple partial seizure?

Todd's paralysis

14

Continues hours to days

What variation of simple partial seizure?

Epilepsia partialis continua 

15

Changes in somatic sensations (paresthesias)

Change in vision (flashing lights, hallucinations)

Changes in equilibrium (falling, vertigo)

Autonomic changes (flushing, sweating)

Odd feelings (déjà vu)

Sx of what type of seizures?

Simple partial seizures 

16

  • Focal activity progresses to loss of contact with environment (ictal stage)
    • Stare and amnesia
  • Often begins with aura stereotypical for patient --> feel funny
  • Followed by ictal stage
    • involuntary behaviors 
    • chewing, picking
  • Post inctal confusion
  • Lasts seconds to hours

Signs/Sx of _______ partial seizures?

Complex

17

EEG between spells (inter ictal) usually normal or brief discarhge of spikes

Complex partial seizures 

18

electrical discharge spread and both hemispheres become involved

Results in tonic-clonic seizure

Common when partial seizures in frontal lobe --> look like generalized seizures

Partial seizures with secondary generalization 

19

Arise in both cerebral hemispheres simultaneously

Look like focal seizure that secondarily generalized though not associated with specific focal onset event

generalized seizures

20

Absence seizures and tonic-clinic seizures 

These are included in ______ seizures?

generalized 

21

Brief loss of consciousness without postural control that lasts a few seconds

No post ictal confusion

Other subtle findings include: eye blinking, chewing, clonic movements of hands

Absence seizures (petit mal)

22

Onset: typically childhood - 4-8 y/o or early adolescence

15-20% of childhood seizures

May occur all day long --> daydreaming appearance 

Absence seizures

23

EEG shows symmetrical discharge 

Spike and wave

Start stop with inter-ictal normal EEG

Worsens with hyperventilation manuever

Absence seizures

24

_________ seizures may be associated with T-C seizures

Absence 

25

What % of cases of absence seizures remiss in childhood?

60-70%

26

Similar to absence but symptoms last longer and have more motor features

May have brain abnormality such a mental retardation/developmental delay

Harder to tx than absence seizures

Atypical absence seizures 

27

Which seizures are considered grand mal?

Generalized tonic-clonic seizures 

28

10% of patients with epilepsy

Most common type when seizures are due to metabolic derangement

Generalized tonic-clonic seizures 

29

Episodes often of sudden onset

May have prodrome but less so than aura in focal seizures that secondarily generalize 

 

Generalized tonic-clonic seizures 

30

Tonic phase: increased muscle tone

Often moan or cry

Change in respiration: secretions pool, cyanosis, jaw clenches, bite tongue

Sympathetic sx: increased BP & HR, pupil dilation 

Characteristics of what type of seizure?

T-C seizures 

31

Clonic activity: muscles relax and contract, usually lasts about a minute

Post-ictal state: unresponsive, flaccid, salvation or airway obstruction, bowel/bladder incontinence

May last min - hours before awakening

Post seziure: HA, fatigue, muscle aches 

Characteristics of what type of seizures?

T-C seizures 

32

Tonic phase: Increased low voltage fast activity with high amplitude polyspike discharges

Clonic phase: spike and wave activity develops

Post-ictal: slowing then recovery

EEG for what type of seizures?

T-C seizures 

33

_________ and ________ are variations of T-C seizures

Atonic and Myoclonic seizures 

34

1-2 sec lose motor tone

brief loss of consciousness

no post-ictal confusion

associated with other epileptic syndromes 

Atonic seizures 

35

When are you at risk of atonic seizures?

After head injury 

36

Brief contraction or jerk similar to when you fall asleeo and you twitch

Myoclonic seizures 

37

Myoclonic seizures are seen in _______ injury

brain 

38

Bilateral jerk with maintained consciousness

Worse with awakening, sleep deprivation 

Seen in adolescence 

Juvenile myoclonic epilepsy

39

benign

good response to meds

may spontaneously remit

Juvenile myoclonic epilespy 

40

Seen in children 

Usually impaired cognitive function

Associated with CNS disease: developmental delay, trauma, infection, neural injuries

EEG: slowing and spike waves 

Often difficult to control

Lennox Gastaut syndrome 

41

Difficult to control

partial epilepsy with characteristic features 

MRI shows hippocampal sclerosis 

Mesial temoral lobe epilepsy 

42

Shift in balance of excitation and inhibition in CNS 

Etiology of seizures 

43

Change in seizure threshold (fevers in children)

Genetic role

Traumatic brain injury

Other events including strokes, infection

Mechanisms of _________

seizures 

44

Stress

Sleep deprivation

Menses

Medications

precipitating factors of seizures 

45

  • A burst of electrical activity
  • Influx of extracellular calcium
    • Excitatory molecules such as NMDA (N-methyl-D-aspartate) may further calcium influx
  • Influx of sodium
    • Under influence of GABA (Gamma-aminobutyric acid) or potassium channels
  • Spike discharge
  • Inhibitory neurons overwhelmed by calcium and potassium
  • Propagation of action potentials
  • Channel problems may be source of genetic epilepsy

seizure 

46

Birth injury

Hypoxemia

Congenital abnormalities

Drugs (maternal)

Cause seizures in what age range?

Neonates

47

Febrile seizures

seen in which age range?

Early childhood

48

What % of children have febrile seizures?

3-5%

49

3mo-5 years

Most commonly 18-24 mo

 

Febrile seizures 

50

Otitis media 

Respiratory infection

Gastroenteritis 

Infections seen with which type of seizure?

Febrile seizures

51

Early on in febrile illness T-C activity

Can be simple (one event) or complex (repeated activity)

NOT epilepsy 

Recurrence about 1/3 of patients

Febrile seizures 

52

Age where epilepsy becomes apparent

Childhood

53

Think trauma

Worse the trauma, worse the seizures

Seizures in adolescence 

54

Cerebrovascular disease (50% new onset seizures)

Trauma

CNS tumor

Degernative disease

Medical (Hypo/hyperglycemia, renal failure, liver dx, drugs)

Seizures in adulthood 

55

______ is key (observe/bystander) when diagnosing a seizure disorder

History! 

56

ASAP to measure brain activity: awakeness/activity

Burst of action potentials

Baseline alpha wave (8-13 Hz) with eyes closed

Faster beta activity (>13 Hz) increase with activity /eye opening

Slower theta activity (4-7 Hz) and delta (<4 Hz)

EEG to diagnosis seizure disorder 

57

Awake/sleep 

Eyes open/closed or with photo stimulation

Hyperventilation

Sleep deprivation

_____ situations assessed for seizure disorder 

EEG 

58

Abnormal activity that starts/stops abruptly or abnormal acitivty during T-C seizure

 

EEG key findings with seizure disorder 

59

Inter-ictal may see spikes or sharp waves in ____% of cases (worse prognosis)

40%

60

  • EEG
  • Imaging
    • Most get
    • MRI best
  • Blood tests
    • Usually normal
    • May see elevated prolactin level in first 30 mins.

Work up for seizures 

61

Diff dx with seizures

Tired, sweaty, tunnel vision

May have 10 sec of convulsive activity

Syncope 

62

Diff diagnosis with seizures

Non-epileptiform behvaiors that resembles seizures 

Seen with stress/conversion reaction

Head turning, shaking, twitching, no LOC, pelvic thrust that waxes and wanes 

Psychogenic seizures 

63

  • Basic life support
    • Vital signs, CPR
  • Treat cause if identified
    • Infection, tumor, drugs
    • Cerebrospinal fluid tap?
    • Imaging (MRI preferred)
  • Meds if more than one episode or high risk
    • 31-71% risk of second seizure in one year
  • Assess for likelihood of recurrence
    • Are meds needed long term?
    • 2 year trial on meds?
  • Safety
    • Work
    • Driving

Seizure treatment 

64

______ meds are first line seizure meds

______ meds are second line 

Older

Newer 

65

If the patient is low risk

One seizure and then seizure free

Normal exam (no developmental delay, head injury, etc)

Normal EEG

DO SLOWLY 

When you can consider stopping seizure drugs 

66

Some say if more than 15-30 mins

Others if > 15 seconds

May range from T-C seizure to more subtle 

May need EEG to verify 

Contiuous seizure 

67

Cardiovascular implications

Hyperthermia

Metabolic derangements

CNS injury

These are conconsidered a _________ in status epilepticus

Medical emergency!

68

Metabolic problems

Drug toxicity

CNS infection or tumor 

Head injury

Refractory epilepsy 

Causes of ______

Status epilepticus 

69

  • Metabolic work up
  • Benzodiazepine (Lorazepam (Ativan®), diazepam (Valium®), midazolam (Versed®) [More water soluble than diazepam] others
  • Phenytoin (Dilantin®)
  • Phenobarbital
  • Anesthesia
    • Phenobarbital coma?

Treatment of status epilepticus 

70

Which type of seizure do you primarily use surgical treatment?

Refactory epilepsy 

71

Temporal lobectomy

Focal lesion removal 

Corpus callosotomy 

Surgical procedures for seizures 

72

Place bipolar electrode in left vagus nerve

Generator delivers a pulse

May take a while to work

MOA: may simply increase seizure threshold 

vagal nerve stimulator 

73

  • Developmental delay/mental retardation
  • Parenting
  • Stigma
  • 2-3x greater death rate
  • Work?  Driving?
  • Menstrual cycles may increase risk
  • Pregnancy
    • Seizures may worsen or improve in half of pts
    • May alter drug levels
    • Tx may cause birth defects
    • May affect contraception

Other issues seen with seizures 

74

What % of people with seizure like sx get CT?

100%!

75

Seizure tx

Blocks voltage dependent calcium channels, modulating excitatory neurotransmitter release 

Safe

Sedation and dizziness MC S/E 

Gagapentin 

76

Tx for seizures

Binds alpha2-delta subunit of calcium channels reducing neurotransmitter release producing anti-nociceptive and antiseizure effects 

Safe

Sedation and dizziness MC S/E 

Pregabalin 

77

Treatment for partial seizures, post herpetic neuralgia, neuropathic pain in diabetes and spinal cord, and fibromyalgia 

Pregabalin 

78

Carbamazepine

Phenytoin

Lamotrigine

Valproic acid 

Tx for ______ seizures?

Partial 

79

Valproic acid

Iamotrigine

Carbamazepine 

Phenytoin

Tx for ____ seizures?

Generalized 

80

Treatment for partial seizures, post herpectic neuralgia and neuropathic pain 

Gabapentin 

81

EEG, Video EEG

Neuroimaging

SPRCT or PET scans (functional)

Electrical mapping 

Requirements for surgical treatment of seizures 

82

What is it important to monitor with seizure medications?

Adverse drug reactions

Effectiveness

Levels 

LFT

Blood counts