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 Risk of recurrence after a first unprovoked seizure Abnormal MRI or EEG after single seizure indicates a high risk of future recurrent seizures Benefit seen with antiepileptic drugs (decreases risk to 20-25%) Normal MRI/EEG May not need antiepileptics Considerations in the treatment of a first unprovoked 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 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 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 seizures Diagnosis: Treatment Lifelong AED Levetiracetam 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 co-morbid 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