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SEIZURES

Definition:Transient /abnormal event resulting from paroxysmal discharge of cerebral neurons

Epilepsy:Recurrent unprovoked seizures.

Epidemiology:common condition,prevalence of active epilepsy is 1%.

Classification of seizures

Partial seizures Generalised Seizures


• Simple partial - consciousness is not Absence
impaired -brief episodes of impaired consciousness
• Complex partial - consciousness is with no aura or postictal confusion(≤10s)
impaired -classic ictal EEG consists of 3.0-Hz
generalized spike-and–slow wave
• Partial seizures evolving to 20 gen complexes
seizures
-present in childhood.
- Usually precede by aura Myoclonic
-brief, arrhythmic, jerking, motor
movements that last less than a second.
Partial seizures reflect the area of cortex affected This seizures often cluster within a few
by the neuronal discharge minutes
Tonic
• Temporal lobe: a rising sensation in the -sudden-onset tonic extension or flexion of
epigastrium, déjà vu, olfactory (smell) or the head, trunk, and/or extremities for
gustatory (taste) sensations which are several seconds
stereotyped Clonic
• Occipital lobe: visual symptoms often of -rhythmic, motor, jerking movements with
coloured lights or without impairment of consciousness.
• Frontal lobe: bizarre motor activity e.g. Tonic-clonic (grand mal)
posturing or bicycling movements -motor behaviors, including generalized
tonic extension of the extremities lasting for
few seconds followed by clonic rhythmic
movements and prolonged postictal
confusion
-10 gen.tonic-clonic seizures has no
warning.
Atonic
-flaccid/brief loss of postural tone

Pseudoseizures/ Psychogenic nonepileptic seizures (PNES)

Def: paroxysmal episodes that resemble and often misdiagnosed as epileptic seizures
Psychological :ie, emotional, stress-related) in origin.
Organic Syncope, migraine, and transient ischemic attacks (TIAs)

CAUSES of epilepsy (2/3 of cases-no cause found)

Structural Metabolic Infection


• Trauma • Alcohol/bdz withdrawal • Encephalitis
• SOL • Glucose (+/-) • Syphilis
• Stroke • Hypoxia • Cysticercosis-parasite
• Tuberous sclerosis • Uraemia infection of CNS
• SLE/PAN • HIV
• Sarcoid • Na+(+/-)
• Vascular malformations • Ca2+(-)
• Liver disease
• Drugs
(phenothiazines,TCA,coc
aine.

Seizures or Snycope?(gen.cerebral hypoperfusion)

Features Seizures Syncope


Occurs when sitting or lying Common Rare
Occurs during sleep Common Never
Prodrome May occur with focal neurological Typical-
symptoms,automatism or dizziness,sweating,blurred vision,
hallucinations yawning, disturbance of hearing
Focal neurological features on May occur eg due to SOL Never
onset
Tonic-clonic movement Characteristics within 30 s of May occur after 30s of syncope
onset due 2dary anoxia
Facial colours Flush/cyanosis on onset Pallor at onset and after syncope
Tongue biting Common Rare
Urinary Incontinence Common Uncommon
Injury May occur Uncommon
Postc-ictal confusion Common Common

Diagnosis and Ix

1. History (patient -details about auras, preservation of consciousness, and postictal states)and
witness account(the best are those who has witnessed several time)

List of Qs that might help clarity the type of seizures

Patient account

• Was any warning noted before the spell? If so, what kind of warning occurred? –taste,smell.de
javu.butterflies in stomach
• What did the patient do during the spell? Side tongue biting?Anything that bring it’s on?
(eg.flickering tv light/alcohol)
• Was the patient able to relate to the environment during the spell and/or does the patient have
recollection of the spell?
• How did the patient feel after the spell? How long did it take for the patient to get back to baseline
condition? Long recovery very suggestive.
• NB:On set of the spell (this help to diff partial & generalize)
• How long did the spell last?
• How frequent do the spells occur?
• Are any precipitants associated with the spells?
• Has the patient shown any response to therapy for the spells?

Witness Account

-Confirm by asking description of seizures, frothing from mouth,whether pts was


unconscious/incontinent,how long the ep lasted,how long pts unconscious after attack,any weakness after
attack (Todd’s paralysis)
2. EEG

• Don’t do it if dx is simple syncope

• EEG cannot rule out epilepsy (often false +ve)

• Help classification and prognosis

• Ix at the time of seizures is the best to diff from pseudoseizures.

3. Establised the cause

• Do U&E,LFT,blood glucose,calcium, phosphate,FBC,blood gas

• Serum n urine alcohol and toxin screens


• Blood test for medications level

4. Brain imaging if appropriate

• CT-if ok, don’t assume no SOL.

• If epilepsy worsen, do MRI.

5. ECG for everyone

• TRO cardiac causes.

6. Admission if indicated for observation and investigatons.Counselling for first ever seizures.

DDx

CNS Cardiac Metabolic


-Syncope (simple faints) -Cardiac syncope (arrhythmias, -Metabolic dysfunction e.g.
-Psychogenic non-epileptic attacks conduction defects) hypoglycaemia ,hypoxia
-Migraine -Transient ischaemic attacks
- Parasomnias (disorders of sleep-
abnormal movement)
- Movement disorders

Treatment
Drug indicated after firm dx.
Start with 1st line , dose increase until seizures controlled /tolerance achieved.
Aim at using only one drug-switch to 2nd most appropriate drug.
Use 2 drugs only if the 1st has been titrated to highest dose.

Partial Gen

carbamazepine(1st line) –rashes, , Sodium valproate (1st line)& for


diplopia, nausea,dizziness,fluid absence seizures
retention,blood dyscrasia,gynaecomastia
sodium valproate –ataxia,sedation, lamotrigine
tremor, weight loss,hair thinning/loss,
ankle sweeling,liver failure, ethosuximide-abscence seizures.SE
hyperammonemia(causing includes rashes,blood dyscrasia, night
encephalopathy) terror.

lamotrigine –
rash,drowsiness,photosensitivities,diplop
ia,
vomiting,tremor,agitation
oxcarbazepine

Adjunct
Lamotrigine-rash,fever Levetiracetam
Levetriacetam-keppra Lamotrigine
Topiramate Topiramate
Tiagabin Clonazepam
Oxcarbazepine
Gabapentin ?-drowsiness,confusion
(Vigabatrin) –drowsiness, confusion

Surgical treatment

• Cures epilepsy in 50% of pts with poorly controlled epilepsy

• /clearly focus of abnormal electrical activity.

Pregnancy

• Preconception counseling-teratogenicity.

• Enzyme induce AED(carbamazepine,phenytoin, phenobarbitol, primidone)

-≥50 microgram oestrogen might be needed,reduce pills free days from 7 to


4 days/depo provera.

• High folic supplement (5mg/day)during pregnancy/preconception.

Withdrawal of AED

• normal CNS examination


• normal IQ
• normal EEG
• seizure free >2 years
• no juvenile myoclonic epilepsy.

Driving and seizures


• Seizures when awake/asleep-restrain driving for a year from attack.
• Attack while sleeping > 3 years ago and no attack while awake-can be
considered for driving again.

Status Epilepticus(MEDICAL EMERGENCY)


• Defn: single seizure lasting > 20mins? 30mins?
OR
• 2 or more discrete seizures where there is incomplete recovery inbetween.
NB: In practice any continuous seizure > 5 mins is at risk of becoming status
epilepticus so treat as.

Management of Status Epilepticus

• Airway-open and maintain airway, lay in recovery position, remove false


teeth/denture,oral/nasal airway, intubate if necessary.NB:C-spine injury.
• Breathing-100% O2 +suction
• Circulation-BP n HR.Secure venous access (2 large bore cannula, antecubital
fossa)and take blood
• U&E, LFT, FBC, glucose,calcium
• Toxicology screen
• Give IV Glucose,50ml 50% if hypoglycemia possible.
• If seizure è follow status epilepticus guideline
è Lorazepam 4mg IV. Wait 10mins.
è Not stopped. Repeat lorazepam 4mg IV. Wait 10mins
è Not stopped. Phenytoin 15mg/kg IVI over 20mins and call ITU.Bolus
dose of 30mg/kg if seizures persist.Maintenance dose 100 mg IV at 6-8
hourly.
è Thiamine IV if any suspicion of alcohol induced.
• Refractory status-Anasthetics with thiopental or propofol (GA with assisted
ventilation)

• ED AMNCH Alcohol withdrawal score (AWS)


è Librium PO according to score. Hourly re-assessment.
è Thiamine IV or PO for all patients
• If head injury è CT brain. Have low threshold.
• Consider other investigation-MRI,LP,blood culture-depends on clinical
pictures.
Phenytoin SE=seizures, peripheral neuropathy,gingival hyperplasia, folate
deficiency