Northeast Regional Epilepsy Group Christos Lambrakis M.D.

1. Northeast Regional Epilepsy Group Christos Lambrakis M.D.

2. September 20th, 2014 How is Epilepsy Diagnosed Recognizing Types of Seizures and Imitators of Epilepsy

4. Brain *Weight: 3 lbs *Made of 75% water * 2% of body weight * 20% of energy requirements *Contains 100 billion neurons *Each neuron has 1000 to 10,000 synapses *100,000 miles of blood vessels *Likes: Oxygen, Glucose, Cute cat videos

9. What is a Seizure? • A seizure is caused by abnormal electrical activity between cells of the brain (neurons) • A seizure can temporarily disturb many of the brains normal functions. • This abnormal electrical activity results in the clinical manifestations of the seizure.

10. What is a Seizure? • The clinical manifestations of the seizure are determined by the region of the brain where the abnormal electrical activity is located. • Clinical manifestations of a seizure are varied depending on the region of the brain involved. Examples include changes in movement, sensation, behavior or awareness.

11. EEG (Normal)

12. EEG (Seizure)

13. What is Epilepsy? • Epilepsy is the term applied to the state of recurrent seizures. • Epilepsy is a condition of the brain, of various causes, which predisposes the patient to recurrent epileptic seizures. • Epilepsy is a tremendously variable condition in terms of its cause, seizure types and response to treatment.

14. How is Epilepsy Diagnosed?

15. Epilepsy Diagnosis • Clinical description of the seizure events provides very important information. • What was seen? (Confusion, Loss of consciousness, Body movements, Head turning, Eye deviation, Right side/Left side or both) • What was felt by the patient? (At the start of the seizure (Aura) or as seizure evolves) • **Helps us to localize the seizure (where in the brain did it originate from).

16. Epilepsy Diagnosis • Precipitating factors: • Lack of sleep, fever, current illness, medications, flashing lights, hyperventilation. • Predisposing factors: • Past medical history (head trauma, stroke), Family history • **Helps us to better understand why the seizures occurred (Etiology).

17. Epilepsy Diagnosis • Physical Examination • Vitals (Fever) • General (Head size, dysmorphic features, skin lesions, stiff neck). • Neurologic Examination (Confusion, memory loss, speech difficulty, motor weakness, sensory loss)

18. Epilepsy Diagnosis • Acute Symptomatic Seizures • Chronic Symptomatic Seizures • Idiopathic Seizures

19. Epilepsy Diagnosis-Etiology • Acute Symptomatic Seizures (Seizures caused by a suspected acute reason). • Trauma (Head injury) • Metabolic (Electrolyte imbalance, Uremia) • Toxic (Ingestion, Medication) • Infectious (Meningitis, Encephalitis, Sepsis) • Vascular (Stroke, Hemorrhage)

20. Epilepsy Diagnosis-Etiology • Chronic Symptomatic Seizures (Seizures caused by preexisting conditions which favor the development of seizures). • Remote injury (Past head injury, Birth trauma) • Developmental (Cortical dysplasia) • Degenerative Disorders (Alzheimer’s) • Metabolic (Amino and organic acid disorders)

21. Epilepsy Diagnosis-Etiology • Idiopathic Seizures (Etiology is unclear) • The cause of the seizures cannot be determined from our current knowledge or conventional testing. • Approximately 50% of patients will fall under this category.

22. Epilepsy DiagnosisDiagnostic Studies • Blood work (Electrolytes such as Sodium, Potassium, Calcium; Glucose, Kidney and Liver function) • Electro-diagnostic (EEG) • Imaging (CT, MRI, SPECT, PET and MEG)

23. Electroencephalogram (EEG)

24. ElectroencephalogramEEG • Represents a record of the small shifting brain electrical potentials from the surface of the brain recorded over the scalp. • As seizures are caused by a disturbance of electrical activity, the EEG is uniquely suited to further our understanding of a patients seizures.

25. Goals of Video-EEG Monitoring Is it really an epileptic seizure? (Epilepsy vs. non-epileptic events) What type of seizure is it? (Characterize epilepsy type) Where does the seizure originate from? Is it focal? (i.e. does it come from one specific region?)

26. Electrodes

32. Video-EEG Monitoring • Long term inpatient monitoring allows for recording of seizure events. • Clinical and electroencephalographic features can be reviewed aiding in seizure characterization and localization. • Baseline EEG may be helpful in determining risk of future seizures.

33. Inpatient Video-EEG

34. Outpatient Ambulatory Video-EEG

35. Brain MRI • Provides a structural assessment of the brain. • We look for developmental abnormalities, strokes, tumors or scar tissue that could be focus for electrical irritation that could cause a seizure.

36. Brain MRI

37. Recognizing Types of Seizures

38. Seizure Classification • Two major categories: • Generalized • Partial

39. Generalized Seizures

40. EEG (Seizure)

41. Seizure Classification • Generalized Seizures Tonic/Clonic Absence Myoclonic Atonic Tonic

42. Generalized SeizuresTonic/Clonic • Electrically the entire brain is affected all at once. • Patients loses consciousness at the onset of the seizure. • Stiffening (tonic) and rhythmic jerking movements (clonic) follow. • Cyanosis, tongue biting and loss of bladder control are common.

43. Generalized SeizuresAbsence • Results in a brief period of staring (5-10 sec). • Patient is usually unaware of his surroundings. • Sometimes accompanied by eye blinking or chewing movements. • Prompt recovery. • Commonly seen in childhood and may be mistaken for day-dreaming.

44. Generalized SeizuresOther Less Frequent • Myoclonic seizure: Brief jerk like contractions which can be localized or generalized. • Atonic seizure: Drop attacks

45. Partial SeizuresComplex

47. Partial Seizures • Seizures originate from a specific (focal) region of the brain. Depending on what area of the brain is stimulated a variety of clinical presentations can occur. • Seizures are often stereotypic to the patient. • Examples include changes in awareness, sensation, rhythmic jerking or stiffening of a specific limb, visual hallucinations.

48. Partial Seizures • Can progress to a Generalized Tonic/Clonic seizure ‘Secondary Generalization’. • Often associated with aura. • Often associated with automatisms (coordinated involuntary, non-purposeful movements). Examples would include lip smacking, picking, rubbing etc.

49. Partial Seizures • Two Types: Simple and Complex • Simple Partial: No impairment of consciousness. • Complex Partial: Impairment of consciousness.

50. Partial SeizuresMotor