Seizures.cme

SEIZURES
CME
9/6/15
Consensus Guidelines on the Management
of Epilepsy 2010
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definition
[ Harrison’s Principle 18th ed,pg 6440]
• Seizure
A seizure (from the Latin sacire, "to take
possession of") is a paroxysmal event due to
abnormal excessive or synchronous neuronal
activity in the brain
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• Epilepsy -describes a condition in which a
person has recurrent unprovoked seizures due
to a chronic, underlying process
• This definition implies that a person with a
single seizure, or recurrent seizures due to
correctable or avoidable circumstances, does
not necessarily have epilepsy
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• Epilepsy syndrome – complex of signs and
symptoms that define a unique epilepsy
condition
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Classification of epilepsies and epilepsies syndrome are
based on electroclinical criteria
Described by ‘’International Classification Of Epilepsies
and Epileptic syndrome’’
Mainly divided into 3:
i) Idiopathic : genetically determined and no structural
cause
i) Symptomatic : known cause
ii) Cryptogenic: unknown cause
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1) Focal : subdivided to
a) Idiopathic
b) Symptomatic
c) Unknown ( whether symptomatic or idiopathic)
2) Generalized
a) Idiopathic
b) Cryptogenic or symptomatic
c) Symptomatic
3) Undetermined whether focal or generalized
4) Special syndromes
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examples
• 70 year old who presents with focal seizures
after left middle cerebral artery stroke is said
to have localization-related epilepsy
• A patient who is developmentally challenged
with generalized seizures but normal cerebral
imaging
• 6-year-old, otherwise normal child who
presents with absence seizures
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Causes
1) Focal Seizures
a) Idiopathic
b) Focal structural lesions
c) Dysembryogenic- sturge weber syndrome
d) Cerebrovascular disease: ICH, cerebral infarction, A-V
malformation, cavernous haemangioma
e) Tumors ( primary and secondary)
f) Trauma: neurosurgery, head injury
g) Infective causes: cerebral abscess, tuberculoma,subdural
empyema
h) Inflammatory causes: sarcoidosis, vasculitis
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2)Generalized Seizure
i) Genetic ( IEM, Storage diseases, Tuberous sclerosis)
ii) Cerebral Birth injury
iii) Hydrocephalus
iv) Cerebral anoxia
v) Drugs
vi) Alcohols ( withdrawal)
vii) Toxins: organophospates, heavy metal ( lead, tin)
viii) Metabolic diseases/derangements
ix) Infective: post-inf encephalopathy, meningitis
x) Inflammatory: MS, SLE
xi) Diffuse degenerative diseases : Alzheimer
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Differential diagnosis
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Approach to epilepsy
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history
HOPI
• When did you experience the first seizure in
your life?
-early neonatal period are usually secondary to
perinatal insults, metabolic disorders, and
congenital malformation.
-70 year old who presents with new onset
seizures is likely to have structural pathology such
as a stroke or brain tumor.
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• Do you experience some kind of a warning or
unusual feeling at the onset, or immediately
preceding the seizure?
-aura actually represents a simple partial
seizure,and thus indicates that the seizure is focal
in origin
-temporal lobe epilepsy may report a déjà vu
and/or a rising epigastric sensation
-paresthesias may be reported in parietal lobe
epilepsy
-visual distortions or transient blindness
experienced in occipital lobe epilepsy
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• What happens during the seizure?
-Seizures originating from the frontal eye fields may
cause head and eye deviation to the contralateral side.
-Temporal lobe seizures manisfested with automatism
which most pronounced in the ipsilateral extremity,
along with dystonic posturing
of the contralateral arm.
-Occipital lobe seizures can present with excessive
blinking at the onset, negative visual symptoms or
visual distortions
-Tongue biting and urinary incontinence more often
seen with generalized seizures, complex partial seizures
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• What happens immediately following the
seizure?(post ictal)
-generalized tonic-clonic seizure goes into a period
of postictal sleep.
-Periods of disorientation and lack of awareness of
the surroundings may follow some complex partial
seizures.
-Hemiparesis or hemiplegia following a seizure
(Todd’s paralysis) is suggestive of a focal onset
-Aphasia with otherwise normal awareness is
suggestive of involvement of the language areas in
the dominant hemisphere.
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• Is there a diurnal variation?
-tonic-clonic and myoclonic seizures are
more common on awakening or in early morning
-Certain frontal lobe seizures have nocturnal
presentation
• Are there any known triggering factors?
• -sleep deprivation, flickering lights, menses,
alcohol consumption, medication non-
compliance, use of antihistamines, stress,
fever,or exercise
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• What is the seizure frequency?
• What has been the maximum seizure-free period
since the seizure onset?
• What is the frequency of visits to the emergency
department?
-response to treatment, degree of seizure control
-to determine if any specific antiepileptic drug was
more efficacious than the others.
-specific situation with each hospital visit,such as non-
compliance, changes in the medication,and
concurrent medical illnesses
-frequent hospital visits result from the poor comfort
level of the caregivers, proper education may help
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• Has the patient sustained injuries related to the
seizures?
-Patients who are injured either do not have auras
or do not have enough time after the aura to take
preventive measures.
-prompt recommendations for wearing a helmet
and modifying the home environment to minimize
injuries.
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PMH
1.Was the patient the product of a normal full-term
pregnancy, labor, and delivery?
2. Was there any asphyxia or respiratory distress at birth?
3. Were the developmental milestones age-appropriate?
4. Any history of febrile seizures?
5. Any history of central nervous system infections such
as meningitis, encephalitis?In endemic regions, obtain
history of known cysticercosis(JE).
6. Any history of head injuries, especially associated with
depressed skull fracture, intracerebral hemorrhage, loss
of consciousness and prolonged amnesia?
7. History of brain tumor?
8. History of cerebrovascular accident?Consensus Guidelines on the Management
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Social hx
• What is your level of education?
• Are you employed? What is your job
description?
-can provide guidance regarding welfare plans and
other kinds of community support.
-office job, as a cashier, or other sedentary tasks
may not be at risk
-construction worker, heavy equipment mechanic,
or someone responsible for supervising others in
high-risk areas, detailed education with some job
modification is critical
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• Do you drive?
-uncontrolled seizures who have altered awareness
should not be driving
-risk to their personal safety, and endanger other civilians
• Are you sexually active? Do you use contraception?Are
you planning pregnancy in the near future?
-teratogenicity of antiepileptic drugs, the lower efficacy of
oral contraceptives with enzyme-inducing medication
(phenytoin, carbamazepine, and phenobarbital), and the
need for using more than one form of contraception
-daily supplement of folic acid to reduce the risk of neural
tube defects in the newborn
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• Do you drink alcohol?
-risk factor for a first generalized tonic-clonic seizure
-adversely interact with the metabolism of the
antiepileptic drugs, or may directly result in seizure
exacerbation, especially after continued or binge
drinking
Family hx
-determine specific epilepsy syndromes or other
genetically mediated neurological disorders
Allergic hx and medication
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Review of systems
*potential side effects of antiepileptic drugs
-Excessive drowsiness:early use of
phenobarbital,gabapentin,and primidone
[carbamazepine, phenytoin,and levetiracetam]
-GIT:more common with carbamazepine
-Weight gain,hair loss,postural tremors:valproic acid
-weight loss and paresthesias: topiramate
-Blurry vision,diplopia, and incoordination:phenytoin,
carbamazepine, and lamotrigine
-Gingival hyperplasia and hirsutism :phenytoin
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Physical/neurological examination
• Look for stigmata of neurocutaneous syndrome
such as café au lait spots and iris hamartoms with
neurofibramatosis, Ash leaf spots, shahgreen
patches, subungual fibromas, and adenoma
sebaceum  [?]
or port-wine stain (capillary hemangioma) [?]
• Look for asymmetries in the size of limbs or one half
of the body (hemiatrophy), which may suggest
perinatal cerebral insult.
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• Gingival hyperplasia can be seen with phenytoin.
• Dupytrens contractures can be seen with chronic
use of barbiturates.
• Dystonic posturing of one arm on stressed gait,
such as walking on the sides of the feet may
suggest a remote insult to the corticospinal
tracts.
• Multiple bruises or injuries may result from falls
secondary to seizures.
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investigations
Objectives:
• Clarify the diagnosis of epilepsy and non epileptic
attack
• Determine nature of seizure types and epilepsy
syndrome
• Identify and localization of seizure(partial seizure)
• Identify the aetiology of epilepsy
• Identify concomittant problem,-neurological and
general
• Monitor the progression of condition and
consequences of epilepsy and treatments
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Blood biochemistry
• Random blood sugar
• Renal profile
• Liver profile
• Serum calcium and magnesium
- Hyponatremia, hypoglycemia,hypomagnesaemia,
uremia and hepatic encephalopathy
• Serum and urine toxicology should be done
when substance abuse or drug overdose is
suspected
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• A lumbar puncture is indicated if there is any
suspicion of meningitis or encephalitis,
• and it is mandatory in all patients infected
with HIV, even in the absence of symptoms or
signs suggesting infection.
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Cardiac assessment
• chest radiograph, ECG and echocardiogram are
mandatory in all elderly patient and those
suspected having cardiac disease
• Cardiac arrhythmias and obstruction to cardiac
output may cause generalised seizure
• Heart block relative contraindication to use
carbamazepine
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Electroencephalography
• except for adult patient with clear metabolic or
structural abnormality on brain imaging
• Types : A)routine interictal scalp EEG
B) Video EEG monitoring
C) Invasive EEG recording/ sphenoidal electrodes
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Normal eeg
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Idiopathic generalised epilepsy
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West syndrome
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Benign childhood epilepsy with
centrotemporal spikes
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Neuroimaging
Structural neuroimaging -MRI or CT brain
-mandatory in following:
• Partial seizure based on history and/or EEG
• Fixed or progressive neurological or psychological
deficit
• Onset of generalised seizure <1yr old & >20 yr old
• Loss of seizure control or status epilepticus,without
clear explanation
• Acutely after significant head trauma
Functional neuroimaging
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Follow up
• repeat EEG and neuroimaging if there is
progression of underlying disease
• Repeat biochemical and haemato profile-side
effect of AED
• If on enzyme inducing AED, repeat FBC,LFT &
serum calcium every 1-2 years
• If on valproate,FBC annually or before surgical
procedure
• Monitor serum AED concentration
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management
Prophylactic treatment
• in head injuries or large haemorrhagic strokes
Single seizures
• high risk of recurrence given option to start
treatment
• Recommendations:
1. Unprovoked GTCS a)a/w previous absence or/&
myoclonic seizure
b)risk of recurrence
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2. Simple and complex partial seizure depends on
frequency and severity
3. Seizure d/t alcohol withdrawal,metabolic or drug
related,sleep deprivation NOT be treated with AED
4.Develop seizure within a week of head injury-AED
withdrawal must be considered
5.NOT be treated if uncertain of diagnosis
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Newly diagnosed epilepsy
Factors influencing decision to treat
i) Firm dx of epilepsy- NO TRIAL of treatment to clarify
diagnosis.
ii) Seizure must be sufficiently troublesome-
-if minimal impact/less frequency *benefit of AED< side
effect of AED
iii) Epilepsy Syndrome : Some Benign epilepsy syndrome
have good prognosis without treatment
iv) Compliance : if doubtful, reconsider ( For AEDs to be
effective, it have to be taken regularly &reliably)
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v) Reflex seizures & Acute symptomatic seizures:
Seizures only precipitated under specific
circumstances ( alcohol, photosensitivity), CAN BE
TREATED by avoiding these precipitants.
vi) Patients’ wishes : Final decision left to the
patient. Our role is to explain the relative
advantages and disadvantages of therapy.
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Once Diagnosis is Clear Formulate
Treatment Plan
How?
i)Identify precipitating factors and counsel patients and
their caregivers about their avoidance
ii)COUNSEL patients & caregivers about:
- The reason to start therapy
- Expectations
- Limitations
- Likely duration of therapy
- Need for GOOD compliance
- potential risks of therapy
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iii) Syndromically classify each patients epilepsy
- To choose best medication
- Avoid aggravation/worsening of certain
syndromes/seizure
iv) Start patient on first line single drug therapy
first and adjust dose accordingly.
Monotherapy has better tolerability, compliance
and fewer side effects, simpler regime
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Anti epileptic drug
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Initiation and maintenance of AEDs
i) Start with Single 1st line drug : guided by types of
seizure/syndrome, hosp. policies, cost, and patients
factors)
ii) Begin with low dose increase gradually over 2-3 wks
( don’t forget to counsel)
iii) Review patient within a month to assess:
-compliance
- Side effects
-seizure control
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iv) Continue review every 6-8 weeks . If seizure
not control AND NO side effects, increase dose
appropriately.
-60%-70% patients achieve good seizure control
with this step
v)If AED fails :
-Review diagnosis and seizure pattern
- Review compliance
- Ensure maximum tolerable dosage have been
used
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vi) IF AED continue to be ineffective
despite maximum tolerable dose..
-introduce an alternative AED slowly WITHOUT tapering the
first
- If good response for the second AED consider
withdrawing the 1st AED gradually
- If Second AED ineffective/produce side effects withdraw
it slowly AND SIMULTANEOUSLY replace it with second add-
on AED from the remaining choices.
- *this process can be repeated with other possible add-on
AEDs
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vii) If seizures are not completely controlled with 2 AEDs
some patient benefit from an additional third AED
viii) If Still persist + period of 2-3 years elapsed(chronic
active epilepsy) 
REVIEW diagnosis and aetiology
-reclassify the epilepsy ; possibility of
-NEAD
-POOR COMPLIANCE
-progressive structural lesion ( especially when patient have
partial seizure) surgery maybe considered
-intractable epilepsy : counsel patient and accept their
disability and continue with life
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Decision to withdraw AED
• Can be consider if seizure free for at least 2 years
• exception in certain epilepsy syndrome which
has high relapse rate : eg JME
a) Patient in whom recurrence of seizure less likely
:
- Seizure free for atleast 3-5 or more years
- Those with benign Rolandic and Familial neonatal
Convulsions
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b) Patients with high risk of relapse-
-patient with seizure needing >1 AED
-past h/o status epilepticus
-experience one ore more seizure after treatment has
start
-short duration of seizure freedom
-treatment exceed >10 years
-known aetiology of seizure
-partial onset seizure
-tonic clonic /myoclonic seizure
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Decision of whether to withdraw AEDs should
take into account :
i) Patients need to work and drive a motor
vehicle
ii) Patients fear of seizure and attitude to
prolonged AED therapy
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Social issues and epilepsy :
Driving and epilepsy
• Epileptic seizure can result in road traffic
accident by causing sudden incapacity at the
wheel.
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Decision to drive or not to drive , is a choice best made after
discussions between physician and patients
Some condition that may allow for safe driving include :
i) Well controlled epilepsy and patient is on treatment
ii) Seizure freedom for at least 1 year, on or off treatment
iii) Preceding aura – however aura may not occur with
every seizure , OR driver may have no enough space to
pull over despite and aura signaling an impending
seizure
iv) Purely nocturnal seizure
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Education and epilepsy
• Kementerian Pendidikan Malaysia confirmed ,
person with epilepsy can pursue with higher
education
• Advised to inform the authorities of their
condition , so that modification of
surroundings and courses can be done
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Employement
Major contributing factors :
i) Epilepsy
ii) AEDs side effects ( poor concentration, drowsiness,
reduce cognitive function)
- Encourage to disclose their diagnosis at the workplace
- Absolute rule in employment of patient with epilepsy is not
available
-BUT similar rules in driving can be applied
look for suitable job : according to seizure control, types of
seizure, medication Side effects, intellectual functions
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OTHERs
-stigma and discrimination : associated with
poor psychosocial outcome. Family plays major
role in protecting patients
-Sports : Sport provoked seizure are uncommon.
since sports beneficial to physical health and
also build self confidence, patients choice to
participate or not depending on type of seizures
and with appropriate safety precautions.
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Sexual life in epilepsy
Sexual dysfunction can be a significant but
hidden issues.
An open discussion of this issue with patient
followed by appropriate management can
improve patients lifestyle
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Malaysia Society of epilepsy
• Interaction among people with epilepsy will
enable the sharing experience and emotion.
• Advocating patient initiated support
• www.epilepsy.org.my
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Special medical conditions
-eg : hepatic dysfunction , renal dysfunction,
hypoalbuminemia and acidosis.
Reduces plasma albumin level and binding
affinity increase fractions of free drug
Monitor of free drugs levels in these patient are
necessary to avoid toxicity and improve efficacy
in of AEDs.
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Renally excreted drugs
• Eg : gabapentin, vigabatrin , topiramate,
levetiracetam and phenytoin
• These accumulates in renal failure and
dosages need to be adjusted ( TDM)
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Hepatic dysfunction
Phenobarbitone, phenytoin , and
carbamazepine induce liver enzyme
Use drugs with low protein binding and limited
liver metabolism : eg : gabapentin, topiramate,
vigabatrin.
Don’t forget TDM
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STATUS EPILEPTICUS
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definition
Status epilepticus
• A condition characterized by epileptic seizures
that are sufficiently prolonged
• or repeated at sufficiently brief intervals so as
to produce an unvarying and enduring
epileptic condition (WHO)
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Refractory status epilepticus
• seizures persisting despite initial treatment with
adequate doses af AEDs(usually benzodiazepine
and one other drug)
• Or SE refractory after 30-60 min of treatment.
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Non convulsive status epilepticus (NCSE)
• no (or only subtle) motor
manisfestations
• Typical presentation:alteration of
awareness ranging from confusion to
coma
• Bizarre behaviours-agitation,
inapproprate laughter,staring,oral
automatism

0-5min
• General measures
6-10min
• Benzodiazepine:
• IV lorazepam, IV Diazepam, Midazolam
10-20min
• IV Phenytoin / Fosphenytoin
• Allergy: IV Valproate, levetiracetam
20-60min
• Anaesthetics : IV Midazolam, IV valpraoate , IV phenobarbitone ,
IV propofol ( most of the time need intubation)
>60min
• IV Pentobarbital
alternate : IV thiopentone
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management
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First line of therapy {6-10 mins}
• Benzodiazepines
-IV lorazepam 2-4 mg [max: 10 mg]
every 5-10 min OR
-IV diazepam 0.2mg/kg(5-10 mg) or rectal
Rate: 5mg/min
repeat after 5 min
[max :3mg /kg/day]
Until seizure stop / significant respiratory depression OR
-Midazolam 10 mg
Intranasal ,buccal or IMConsensus Guidelines on the Management
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Second line therapy {10 – 20 mins}
• IV Phenytoin *continuous ECG & BP monitoring
initial loading dose :
-IV 15-20 mg/kg
-diluted in 100 ml NS (via large bore *glucose free saline)
-rate: <50 mg/min OR 25mg/min in elderly/cardiac dx
Additional dose if seizure continue
-5-10 mg/kg [max: 30mg/kg ]
• IV fosphenytoin
-phenytoin pro drug
*in those allergic to phenytoin/hypotension,use IV
valproate or levetiracetam
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If seizure still persists, one of the following
IV Midazolam IV Valproate IV Phenobarbitone IV propofol
load: 0.2 mg/kg
-repeat: 0.2-
0.4mg/kg boluses
every 5 min until
seizure stops
15-40 mg/kg over
10-15 min
-if still seizing,add
20mg/kg over 5-10
min
15-20mg/kg at 500-
100mg/min
Load 1-2mg/kg
Repeat 1-2mg/kg
BOLUSES every 3-5
mins until seizure
stops
MAX : 10mg/kg
STILL Persist
add or switch to
propofol or
pentobarbital
STILL PERSIST switch
to IV midazolam or
propofol
STILL PERSIST
Add or switch to IV
midazolam, propofol,
pentobarbital
STILL PERSIST
Add or switch to
midazolam or
pentobarbital
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>60 min
• IV pentobarbitol
-load:5mg/kg [max: 50mg/min]
-repeat:5mg/kg boluses until seizure stops
-alternative: iv thiopentine
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during management of refractory SE
 ventilatory and hemodynamic support needed
If hypotension, infusion should be slowed down
/stopped , and appropriate fluid and vasopressor
given
EEG monitoring essential : to assess response to
treatment
BEFORE WEANING DOWN anaesthetic agents, high
therapeutic range of other AEDs should achieved
and maintained
Anaesthetic agent can be weaned down if seizure
free for >24-48 H.
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0-5min
• General measures
6-10min
• Benzodiazepine:
• IV lorazepam, IV Diazepam, Midazolam
10-20min
• IV Phenytoin / Fosphenytoin
• Allergy: IV Valproate, levetiracetam
20-60min
• Anaesthetics : IV Midazolam, IV valpraoate , IV phenobarbitone ,
IV propofol ( most of the time need intubation)
>60min
• IV Pentobarbital
alternate : IV thiopentone
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references
Consensus Guidelines on the Management of
Epilepsy 2010
International League Against Epilepsy
Sarawak Handbook of Medical Emergencies
Wisconsin Medical Journal
Textbook : Harrisons, Davidson
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