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

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

Auras =simple partial seizures

Affect enough of the brain to cause
symptoms
does not impair consciousness--simple
does not affect the whole brain--partial

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

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

Complex partial seizure

Most common type in epileptic adults
appear to be awake
consciousness is impaired

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

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

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

Generalized tonic-clonic seizure

Post ictal phase x minutes to hours

headache
mild confusion
sore muscles
may sleep and feel refreshed

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

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

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

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;

How to work up first seizure in

an adult
Transient global amnesia is 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.

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.

How to work up first seizure in

an adult

Is it a seizure?
If its not REM behavior disorder
Transient ischemic attack
Transient global amnesia, or
Migraine
its probably a seizure

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

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

Is it epilepsy?
Is it epilepsy?
In epileptic seizures the EEG is abnormal

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

Is it epilepsy?
Physiologic seizures caused by:
Precipitous falls in serum sodiumhigh mortality
Hypocalcemia--neonates

Renal failure and uremia

Is it epilepsy?
Physiologic seizures:
Acute intermittent porphyria--also includes
abdominal pain and behavior changes
Cerebral anoxia--including brief
syncope, though these patiens
wont be post ictal
alcohol withdrawal:3-72 hrs post
last drink

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

Is it epilepsy?

PMH--head injury
stroke
alzheimers disease
history intracranial infection
alcohol/drug abuse

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

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

Is it epilepsy?

Lab eval: epilepsy vs physiologic

glucose
calcium
magnesium
BUN/cr
tox screen
TSH

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

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

How to order an eeg

Looking for seizure focus
substantiates epilepsy if positive
can indicate generalized vs partial seizure
disorder

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

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

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%)

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

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)

Which drugs for which seizures

A record of cognitive impairment
A partial seizure as the first
seizure
An abnormal EEG (particularly
epileptiform abnormalities)

Which drugs for which seizures

Absent risk factors, it makes sense to wait
for second seizure prior to initiating
treatment

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

Which drugs for which seizures?

Carbamazepine better than phenobarb only
in longer time to treatment withdrawal due
to side effects--treatment efficacy the same

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

Which drugs for which seizures?

Phenytoin better than phenobarb solely due
to side effects--treatment efficacy the same

Which drugs for which seizures?

Carbamazepine equivalent to phenytoin

Which drugs for which seizures?

Phenytoin equivalent to valproate

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

status
Dont give meds unless youre 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

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

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