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    Seizures Seizures Presentation Transcript

    • What Spell is This? Marcos J. Valdez, M.D. Pediatric Neurology
    • What Spell is This?
      • At the conclusion of the activity, the participant should be able to:
        • Be familiar with the classification of seizures
        • Distinguish seizure from epilepsy
        • Identify some of the clinical manifestations
        • Distinguish between seizure and other disorders that can present similarly
        • Learn different causes of seizures
    • What Spell is This?
      • At the conclusion of the activity, the participant should be able to:
        • Be familiar with the different treatment modalities
        • Learn First Aid for Seizures
    • What Spell is This?
      • An overview of the following aspects of diagnosis and treatment will be discussed:
        • Incidence and Prevalence
        • Patient evaluation
        • Risk of Recurrence Following a First Seizure
        • Factors Influencing Remission Rates
        • Treatment
        • Withdrawal of Antiepileptic Drugs
    • Incidence and Prevalence
      • Epileptic seizure: paroxysmal event of the central nervous system characterized by abnormal cerebral neuronal discharges with or without a loss of consciousness
      • Epilepsy: condition characterized by a tendency for recurrent epileptic seizures (two or more) unprovoked by any known proximate insult
    • Incidence and Prevalence
      • The risk of any individual having an epileptic seizure in their lifetime is approximately 10%
      • The prevalence of epilepsy requiring protracted medical treatment is only < 1%
    • Patient Evaluation
      • Evaluation should include a complete history, thorough general medical and neurological examination, and pertinent laboratory examinations.
    • Patient Evaluation
      • HISTORY: A precise and extensive history is the most crucial step in the evaluation
      • A good description of the event and symptoms and signs surrounding the event must be obtained
    • Patient Evaluation
      • Pertinent information includes:
        • Precipitating factors
        • Determination of the Presence of an Aura and its Description
        • Description of the event
        • Post Event Signs and Symptoms
        • Effect of Consciousness
        • Duration of Event
        • History of Previous Events
    • Patient Evaluation
      • It is important to determine common risk factors:
        • Abnormalities of pregnancy, birth, and development
        • Febrile seizures
        • Meningitis or encephalitis
        • Head trauma with loss of consciousness
        • Drug and alcohol abuse
        • Predisposing medical/neurological conditions
    • Patient Evaluation
      • It is important to determine common risk factors:
        • Family history
        • Prescribed medications
        • Birthmarks or skin lesions
        • Exposure to toxins
        • Metabolic or nutritional disturbances
        • Vascular disturbances
    • Physical and neurological examination
      • A thorough general physical and neurological examination are required at the time of presentation
      • The clinician must search for evidence of an underlying systemic or neurological disorder
    • Laboratory Examination
      • The following investigations should be performed:
        • Serum studies: electrolytes, calcium, magnesium, phosphorus, complete blood count, toxic substance screen, alcohol level
        • Electroencephalogram
        • MRI of the brain
        • Lumbar puncture (if suspect central nervous system infection, inflammation, or bleeding
    • Differential Seizure Diagnosis
      • Seizure Classification
        • Partial seizures
          • Simple partial
          • Complex partial
          • Secondary generalized
        • Generalized seizures
          • Absence
          • Myoclonic
          • Tonic
          • Clonic
          • Tonic-clonic
        • Unclassified seizures
          • Infantile spasms
          • Febrile seizures
        • Non-epileptic seizures
    • Differential Seizure Diagnosis
      • Partial seizures: are characterized by a focal disruption of cerebral electrical activity
      • They produce epileptiform discharges in a localized area of a cerebral hemisphere
      • Conscious contact is maintained in simple partial seizures and is lost in complex partial seizures
    • Differential Seizure Diagnosis
      • Generalized seizures: involve simultaneous disruption of electrical activity of both cerebral hemispheres
      • May present in various combinations in a given patient
      • Represent the majority of the genetically determined seizure disorders
    • Differential Seizure Diagnosis
      • Non-epileptic seizures
        • Non-epileptic seizures represent 25-33% of the patients referred for closed circuit TV/EEG monitoring
    • Differential Seizure Diagnosis
      • Conditions resembling seizures and epilepsy
        • Syncopes
        • Cardiac Arrhythmias
        • Pseudoseizures
        • Paroxysmal torticollis
        • Movement disorders
        • Gastroesophageal reflux
        • Migraines
        • Breath-holding spells
        • Sleep disorders (sonambulism, night terrors)
        • Attention deficit-hyperactivity disorder (ADHD)
    • Predictors of Recurrence and Remission
      • Following a single unprovoked seizure, the risk of recurrence varies from 16% to 61%
      • The second seizure usually occurs within the following year
      • Prognostic factors that increase the risk of recurrence include: remote symptomatic etiology, initial partial seizure, and an abnormal EEG
    • Predictors of Recurrence and Remission
      • The probability of remission varies from 41-75% across studies
      • Favorable prognosticators for remission are younger age of onset and generalized seizure disorder, especially tonic-clonic seizures
    • Treatment
      • Medications
      • Surgery
      • Ketogenic diet
      • Vagus nerve stimulator
    • Treatment
      • Medications
        • Phenobarbital
        • Phenytoin
        • Carbamazepine
        • Valproic acid
        • Ethosuximide
        • Lamotrigine
        • Topiramate
        • Lorazepam
        • Diazepam
    • Treatment
      • Treatment with antiepileptic drugs (AED’s) can result in life threatening idiosyncratic reactions, teratogenicity, cognitive impairment, systemic toxicity, and adverse behavioral effects
      • The physician should discuss all the associated risks with the patient and the family prior to treatment
    • Treatment
      • If the risk of further seizures outweighs the risks of treatment, then AED’s therapy is needed
      • The primary intent of AED therapy is to provide cessation of seizures without associated adverse effects
      • Clinical indications for laboratory examinations include: clinical evidence of toxicity, suspected non-compliance, drug interactions, and changes in seizure frequency
    • Treatment
      • The physician should initiate therapy with a single AED
      • The medications should be increase until seizure control is obtained or the patient is experiencing clinical toxicity
      • Any patient who has failed and adequate trial of AED’s should be referred to an epilepsy center to receive a comprehensive evaluation
    • Treatment
      • Withdrawal of Antiepileptic Medication
        • 50-75% of patients will become seizure free without or with minimal side effects to their AED’s
        • After the patient has been seizure free for 2 years, AED’s withdrawal is contemplated
        • An EEG is recommended prior to withdrawal
        • Seizure relapse usually occurs within the first year following AED withdrawal
    • Treatment
      • Vagus Nerve Stimulator (VNS)
        • Mild electrical pulses applied to the left vagus nerve in the neck send signals to the brain
        • Automatic intermittent stimulation
        • Magnet use allows the patient/caregiver
          • On-demand stimulation
        • Simple in office programming
        • Assured compliance
    • Treatment
      • Vagus nerve stimulator (VNS)
        • 6 to 11 year battery life
      • Historical Overview of VNS Therapy in Humans
        • 1988 First human implant
        • 1994 European community approval
        • 1997 US (FDA) commercial approval
        • 2004 >30,000 patients treated worldwide
    • Treatment
      • Vagus Nerve Stimulator (VNS)
      • Adverse events (occurring in > 5% of patients)
        • Hoarseness 37%
        • Throat pain 11%
        • Coughing 6%
        • Dyspnea 6%
        • Tingling 6%
        • Muscle pain 6%
    • Treatment
      • Ketogenic Diet
        • Rigid, carefully controlled, medically supervised diet, requiring hospital admission for initiation
        • Appears to be equally effective for all seizure types
        • Most effective in children; not commonly used in adults
    • Treatment
      • Ketogenic Diet
        • Diet consists of high ratio of fat to protein and carbohydrate
      • Efficacy
        • 54% of patients experience >50% seizure reduction at 3 months
        • 10% have seizure freedom at 1 year
    • Treatment
      • Ketogenic Diet
      • Side effects may include:
        • Hyperlipidemia
        • Constipation/diarrhea
        • Vitamin deficiencies
        • Kidney stones (6.2%) typically uric acid
        • Weight loss
        • Growth retardation
    • Status Epilepticus
      • Partial or generalized seizures usually have a duration of 1-2 minutes
      • Status epilepticus is defined as: more than 30 minutes of continuous seizure activity or two or more sequential seizures without full recovery of consciousness between seizures
      • Status epilepticus is a Medical Emergency
    • Seizure precautions
      • No tub baths
      • No unsupervised swimming by a trained personnel in case of an emergency
      • No other activities that may put the person’s life in danger
      • No driving at least for 6 months (policy by DPS) from the last event
    • First Aid for Seizures
      • Keep the patient safe by moving away hard, sharp, or hot objects
      • Put something soft but flat under the patient’s head
      • Turn the patient’s head on a side for optimal airway patency
      • DON’T put anything in the patient’s mouth
      • DON’T introduce your fingers in the patient’s mouth
    • First Aid for Seizures
      • DON’T try to hold the patient’s tongue (it can’t be swallowed)
      • Activate EMS if this is the first seizure activity
      • DON’T restrain movement
      • DON’T try to give liquids or medications during or just after the seizure
      • Reassure when consciousness returns
    • Questions?