1 / 50

seizures

seizures. Joseph Breuner, MD 6/24/03. Goals . How to work up first seizure in an adult how to order an eeg which drugs for which seizures status. How to work up first seizure in an adult. Objectives 1. Was it a seizure? What kind? 2. Does the patient have epilepsy.

oren-brock
Download Presentation

seizures

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. seizures Joseph Breuner, MD 6/24/03

  2. Goals • How to work up first seizure in an adult • how to order an eeg • which drugs for which seizures • status

  3. How to work up first seizure in an adult • Objectives • 1. Was it a seizure? What kind? • 2. Does the patient have epilepsy

  4. How to work up first seizure in an adult • Is it a seizure? • A seizure is a sudden change in behavior that is the consequence of brain dysfunction. • Learn the following 3 typical and most common seizures

  5. Auras =simple partial seizures • Affect enough of the brain to cause symptoms • does not impair consciousness--simple • does not affect the whole brain--partial

  6. Auras =simple partial seizures • Can precede complex partial seizure • can evolve to secondarily generalized seizure • implies epilepsy as opposed to physiologic nonepileptic seizures--more on this later

  7. Auras =simple partial seizures • Long list(50) of typical symptoms, • symptom depends on which part of the cortex is disrupted • most common: jerking of an extremity, epigastric discomfort, fear, or an unpleasant smell • I like: foot stomping, spacing out, psychic experience, deja and jamais vu

  8. Complex partial seizure • Most common type in epileptic adults • appear to be awake • consciousness is impaired

  9. Complex partial seizures • stare into space/engage in automatisms, such as grimacing, gesturing, chewing, lip smacking • last 3 minutes or less • post-ictal: somnolence, confusion, headache for up to several hours

  10. Generalized tonic-clonic seizure • No aura • tonic phase x 10-20 seconds: • sudden LOC, loss of posture, arms flex, eyes deviate upward • extension of back, neck, arms, legs • involuntary crying out • ends with tremors which merge c clonic phase

  11. Generalized tonic-clonic seizure • Clonic phase x 90 seconds: • brief, violent, generalized flexor contractions alternating with progressively longer muscle relaxation • cyanosis • cheek or tongue biting, salivation • loss of bowel, bladder control

  12. Generalized tonic-clonic seizure • Post ictal phase x minutes to hours • headache • mild confusion • sore muscles • may sleep and feel refreshed

  13. How to work up first seizure in an adult • Is it a seizure? • 4 conditions can mimic a seizure and are worth knowing about: • REM behavior disorder • Transient ischemic attack • Transient global amnesia • Migraine

  14. How to work up first seizure in an adult • A good time to point out that • history rules!!! • Physical exam, lab and even EEG are way less important than history

  15. How to work up first seizure in an adult • REM behavior disorder — REM behavior disorder is a parasomnia that consists of sudden arousals from REM sleep immediately followed by complicated, often aggressive, behaviors for which the patient is amnestic. Diagnosis is clarified by overnight sleep testing

  16. How to work up first seizure in an adult • Transient ischemic attack(TIAs) may last seconds to minutes. • characterized by "negative" symptoms and signs (such as weakness or visual loss) • postictal state may include lateralizing "negative" symptoms such as weakness;

  17. How to work up first seizure in an adult • Transient global amnesiais a condition of vascular etiology, • occurs after the age of 50. • deficit of short-term memory that begins abruptly and persists for minutes to hours, without other cognitive or motor impairment. Episodes are usually not recurrent.

  18. How to work up first seizure in an adult • Migraine — Migraine auras such as visual illusions and basilar migraine symptoms, including altered consciousness, can mimic complex partial seizures • the headache that follows complex partial and generalized tonic-clonic seizures is migrainous in quality and duration.

  19. How to work up first seizure in an adult • Is it a seizure? • If it’s not REM behavior disorder • Transient ischemic attack • Transient global amnesia, or • Migraine • it’s probably a seizure

  20. Is it epilepsy? • Question 2: is it epilepsy? • Differentiate physiological and psychogenic seizures from epileptic seizures

  21. Is it epilepsy? • Why do I care about this? • Epilepsy treated with anticonvulsants • Physiologic/psychogenic seizures you treat the disorder • This evaluation will determine the likelihood that a patient will have additional seizures and assist in the decision whether to begin anticonvulsant therapy

  22. Is it epilepsy? • Is it epilepsy? • In epileptic seizures the EEG is abnormal

  23. Is it epilepsy? • Physiologic seizures are caused by • hyper- and hypothyroidism • Hypoglycemia • Nonketotic hyperglycemia -focal motor seizures

  24. Is it epilepsy? • Physiologic seizures caused by: • Precipitous falls in serum sodium-high mortality • Hypocalcemia--neonates • Renal failure and uremia

  25. Is it epilepsy? • Physiologic seizures: • Acute intermittent porphyria--also includes abdominal pain and behavior changes • Cerebral anoxia--including brief syncope, though these patiens won’t be post ictal • alcohol withdrawal:3-72 hrs post last drink

  26. Is it epilepsy? • Medication history: tricyclic antidepressants can lower seizure threshold

  27. Is it epilepsy? • PMH--head injury • stroke • alzheimer’s disease • history intracranial infection • alcohol/drug abuse

  28. Is it epilepsy? • Family history • if positive, highly suggestive of epilepsy • especially for absence seizures and myoclonic seizures

  29. Is it epilepsy? • Physical exam/neuro exam • rarely helpful except in setting of acute infection or hemorrhage • look for lateralizing abnormalities

  30. Is it epilepsy? • Lab eval: epilepsy vs physiologic • glucose • calcium • magnesium • BUN/cr • tox screen • TSH

  31. Is it epilepsy? • Lumbar puncture--only useful if infection or malignant metastasis to the meninges

  32. Is it epilepsy? • Neuroimaging • unless obvious physiologic seizure, should obtain MRI. • MRI better than CT for infarcts and tumors • the older the patient, the more likely you will find a structural cause

  33. How to order an eeg • Looking for seizure focus • substantiates epilepsy if positive • can indicate generalized vs partial seizure disorder

  34. How to order an eeg • Sleep deprivation • hyperventilation • intermittent photic stimulation • all increase the yield • usually okay to begin with awake eeg, sleep deprive if high index of suspicion

  35. How to order an eeg • Study of 157 adult pts with untreated first idiopathic seizure • obtained single awake eeg, if normal, also obtained eeg p sleep deprivation

  36. How to order an eeg • Risk of 2nd seizure in 2 years (CI) • epileptic discharges: 83% (69-97%) • nonepileptic abnormalities 43% (29-53) • normal: 12% (3-21%)

  37. Which drugs for which seizures? • In general, recurrence risk at one year after first seizure is 15-30% • three year recurrence risk is 30-78% • treatment roughly halves recurrence risk

  38. Which drugs for which seizures? • Risk factors for recurrence are • head injury • A lesion on MRI • Focal deficits on neuro exam A record of cognitive impairment A partial seizure as the first seizure An abnormal EEG (particularly epileptiform abnormalities)

  39. Which drugs for which seizures • A record of cognitive impairment • A partial seizure as the first seizure • An abnormal EEG (particularly epileptiform abnormalities)

  40. Which drugs for which seizures • Absent risk factors, it makes sense to wait for second seizure prior to initiating treatment

  41. Which drugs for which seizures? • Cochrane reviews looked at 4 outcomes: • time to withdrawal of treatment • 6 month remission rate • 12 month remission rate • time to first seizure p randomization

  42. Which drugs for which seizures? • Carbamazepine better than phenobarb only in longer time to treatment withdrawal due to side effects--treatment efficacy the same

  43. Which drugs for which seizures? • Carbamazepine equivalent to valproate for both partial and generalized seizures • trend for carbamazepine to improved 12 month remission for partial seizures

  44. Which drugs for which seizures? • Phenytoin better than phenobarb solely due to side effects--treatment efficacy the same

  45. Which drugs for which seizures? • Carbamazepine equivalent to phenytoin

  46. Which drugs for which seizures? • Phenytoin equivalent to valproate

  47. Which drugs for which seizures? • Summary of cochrane data: • carbamazepine • phenytoin • valproate are all equivalent in efficacy and tolerability • phenobarb also efficacious but more side effects

  48. status • Don’t give meds unless you’re in a setting where you can control airway • ativan 2mg or valium 5mg IVP q 2-4 minutes PRN • load fosphenytoin 20 mg/kg iv • to icu

  49. References • Up to date • evaluation of the first seizure, 12/02/01 • treatment of chronic epilepsy • van donselaar, CA, value of the eeg in adult patients, arch neurol 1992 • cochrane database • swedish admit orders for status epilepticus

  50. Take home points • Workup of first seizure--was it a seizure, what kind was it. Aura important • physiologic seizures vs. epilepsy • anticonvulsant therapy reduces recurrence risk by 1/2

More Related