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Seizure Disorders

General

  • Classified as Partial or Generalized
    • Partial (Question is consciousness impaired?)
      • Complex Partial Seizure
      • Simple Partial Seizure
    • Generalized (Question are they convulsive?)
      • Tonic-Clonic or Myoclonic Seizures
      • Absence Seizures
    • Provoked: 2/2 alcohol, medication, medication withdrawal, mass
  • W/U:
    • MRI > CT as well
    • Electroencephalogram (EEG) for a patient with first time seizures
      • EEG used to risk stratify normal brain-imaging pts
      • Continues EEG for nonconvulsive seizures
  • 1st Seizure
  • 1st Seizure + Status Epilepticus or multiple: Recurrence 60%: Antiepileptics
    • Treat ≥1 provoked or ≥2 unprovoked seizures >24hrs apart with Antiepileptics
    • May try to wean after 2 years on antiepileptics and no seizures

Psychogenic Nonepileptic Seizures (PNES)

  • Conversion disorder, not true seizure
    • 20% also have epilepsy
  • Symptoms
    • Forceful eye closure, side to side body movements, rapid alerting and reorienting, memory recall of seizure
    • NOT associated with abnormal cortical activity, lack post-ictal confusion
    • Intact reflexes, pelvic thrusts
    • Side to side head movements
  • Diagnosis: Video electroencephalogram gold standard, Psychiatric Assessment
    • Lack of epileptiform activity (normal EEG)
    • Prolactin normal 15-30 minutes after seizure (elevated in epileptic seizure)

Generalized Tonic-Clonic Seizure (GTCS)

  • Abrupt loss of consciousness, stiffening of the muscles, rhythmic jerking of extremities, open eyes during ictus
  • Most fall asleep immediately after seizure and have postictal confusion on awakening
    • 1) Valproic Acid
      • Anticonvulsant which limits the rapid firing of neurons by inhibiting voltage gated sodium channels
  • Treatment
    • Preventative
      • Carbamazepine, Phenytoin
    • Abortive?
      • 1) IV Lorazepam (Benzo)
      • 2) Phenytoin/Fosphenytoin (less respiratory depression)
      • 3) Propofol + Midazolam
      • 4) Phenobarbital

Myoclonic Seizure

  • Myoclonic may have twitching of the arms and legs, but usually bilateral and <1s
  • May result in dropping objects
  • Awareness maintained

Generalized Absence Seizures

  • Short period of profound impairment with intact body tone
  • Last <15s typically, occur multiple times per day
  • No associated postictal focal weakness or confusion
  • ⅔ outgrow
  • Non-convulsive
  • Consciousness lost
  • Diagnosis: 3-Hz per-second spike and wave pattern on EEG
  • Treatment
    • Ethosuximide and valproic acid

Focal Aware Seizure (Simple Partial Seizure)

  • Consciousness is preserved by definition
  • Jacksonian Seizures: Involve motor strip
  • Treatment
    • Gabapentin
    • Phenytoin and Carbamazepine

Focal Seizure with Diminished Consciousness (Complex Partial Seizure)

  • Aka Focal Impaired Awareness Seizures, Focal Dyscognitive Seizure
  • Consciousness Impairment with postictal confusion
  • Features
    • Sudden onset of staring or arrest speech (seizure-related aphasia) or behavior lasting 30-90s
    • Pt unaware and unresponsive
    • Postictal confusion or somnolence
    • May see twitching or stiffness during, transient weakness afterwards
    • Weekly to monthly
  • Treatment
    • Levetiracetam or Lamotrigine if reproductive age
    • Phenytoin
    • Carbamazepine
      • Inhibits activation of voltage gated sodium channels

Generalized Epilepsy

  • Definition: 2 seizures more than 24 hours apart w/o provoking factors
  • RF: Stroke, dementia
  • Treatment
    • Partial Seizures: Phenytoin and Carbamazepine
    • Tonic-clonic Seizures: Phenytoin and Carbamazepine
    • Absence Seizures: Ethosuximide and Valproic Acid
    • Old w/2 clearly documented unprovoked seizures:
      • Lamotrigine, Gabapentin, or Levetiracetam
      • Lamotrigine rash: Gabapentin

Juvenile Myoclonic Epilepsy (JME)

  • MC form of idiopathic generalized epilepsy
  • Onset typically in teens/twenties
  • Associated with triggers: sleep deprivation, alcohol use, stress
  • Features
    • “dropping items” especially in the morning
    • Generalized tonic-clonic seizures, 30% have absence seziures
  • Diagnosis:
    • Myoclonic Seizures
  • Treatment
    • Lifelong AED
    • Levetiracetam
      • Safe in pregnancy
    • Valproic Acid
      • Associated with weight gain, PCOS, teratogenic
    • Lamotrigine
      • May worsen myoclonic seizures in some patients, not preferred
      • Safe in pregnancy
    • Topiramate
      • Teratogenic, good for comorbid migraines

Nonconvulsive Status Epilepticus

  • Suspect in critically ill pts who have AMS w/o clear cause
  • Symptoms
    • Coming off propofol and not waking up w/twitching
  • Diagnosis: Continuous EEG for 24 hours

Convulsive Status Epilepticus (CSE)

  • GTCS for > 5 minutes or two GTCS within 5 minutes of each other without regaining consciousness or return to mental baseline
  • Treatment
    • A) Intubation ± Thiamine + IV glucose
    • B) Meds
      • 1) Lorazepam 0.1mg/kg IV up to max of 8mg
  • Diazepam rectally or IV 10mg q5min prn to max of 30mg
  • IM Midazolam 10mg if no IV - 2) IV Fosphenytoin > Phenytoin (Less likely to cause hypotension or bradycardia) alternatives are IV Valproic Acid or Levetiracetam
  • Levetiracetam 60mg/kg (up to 4500mg) IV over 10 minutes, >75kg = 4500mg. - 3) Phenobarbital (SE: respiratory depression) - 4) Propofol w/intubation

Todd’s Paralysis

  • Transient unilateral weakness following a tonic-clonic seizure that usually spontaneously resolves