Lecture (1) of a series discussing the clinical approach to epilepsy and related disorders.

1. EPILEPSY (I)
Yasser Alzainy
Neurology Resident
Al-Azhar University Hospitals
AL-AZHAR UNIVERSITY
Faculty of Medicine
Neurology Department

2. DEFINITIONS
 Epileptic seizure: Sudden transient si/sx 2/2 abnormal, excess, or
synchronous neuronal activity.
 Electrographic seizure: An EEG pattern like that seen during an epileptic
seizure (+/- si/sx).
 Provoked / Symptomatic seizure: +attributable cause (e.g., systemic illness,
direct neuro insult).
 Unprovoked seizure: Occurs w/o acute illness, 2/2 persistent brain
abnormality/dz.

3.  Aura: First part of seizure, often the only part remembered by pt; a focal
seizure that sometimes progresses to focal dyscognitive or secondarily
generalized seizure.
 Postictal period: The period from end of seizure until return to baseline.
 Psychogenic nonepileptic seizure (PNES): Si/sx resemble seizures but w/o
EEG correlate.
 Epilepsy: ≥2 unprovoked seizures ≥24 h apart, or a tendency toward
recurrent unprovoked seizures.
 Epilepsy syndrome: Specific form of epilepsy; implies specific cause, si/sx,
prognosis.
 Status epilepticus (SE): Continuous seizure lasting >5 min or >1 seizure w/o
full return to baseline.

4. CLINICAL APPROACH

5. DIFFERENTIAL DIAGNOSIS OF SEIZURES
 Seizures can be confused with other d/o that cause transient neurological manifestations; they
include:
 Syncope
 Transient ischemic attack
 Transient global amnesia
 Migraine
 Sleep related: hypnagogic jerks, sleep-related movement disorders, narcolepsy-cataplexy.
 Paroxysmal movement disorders: Paroxysmal dyskinesia, episodic ataxia, tics, hyperekplexia.
 Psychiatric: PNES, panic attack, dissociative state, hallucinations (psych d/o), factitious d/o.

6. APPROACH TO A PATIENT WITH TRANSIENT LOC

11. FURTHER W/U
 If HPI suggests syncope (and initial w/u neg):
 Echo: r/o structural heart disease
 Exercise stress test: esp. w/exertional syncope
 Tilt table (provokes vasovagal syncope): (+) in 50% w/recurrent unexplained syncope
 Holter or loop monitor.
 Referral to cardiology.
 If HPI suggestive of seizure:
 Imaging (CT/MRI brain)
 EEG
 Seizure w/u

12. SEIZURE VS. PNES

13. PNES
 Def: Spells resembling epileptic seizures but w/o EEG correlate.
 Psych origin; usually somatoform (conversion > somatization> > factitious, malingering).
 ˜30% PNES pts also have epileptic seizures.
 HPI suggestive of PNES:
 Multiple normal EEGs
 No response to AEDs
 Strange triggers (stress, pain, specific movement, sounds, lights)
 Occur only around others
 Inappropriate lack of concern
 H/o depression, anxiety

14. SEMIOLOGY
PNES
 Preserved awareness
 Eye flutter
 Stuttering coarse
 Forced eye closure
 Pelvic thrusting
 Arched back
 Crying
Seizure
 Eyes open / widen
 Eyes fixed
 Clenched mouth
 Hand automatism
 Ictal scream
 Grasping
 Postictal nose wiping / snoring / aphasia

15. CASES

16. CASES

17. CASES

18. CASES

19. CASES

20. EVALUATION OF PATIENTS WITH SEIZURE

21. HISTORY
 HPI: Provoked vs. unprovoked; preceding illness/fever, trauma; Aura, ictal/postictal si/sx
 PMH/ROS: Epilepsy risk factors: FHx sz, early hx (prenatal, birth, perinatal), febrile sz, delay
in developmental milestones, birthmarks/congenital anomalies, prior szs, stroke, head trauma,
CNS infxns.
 Seizure hx: Semiology (best directly from witness), diurnal variation, relation to menses, injuries
during sz, prior AEDs & why discontinued.
 Triggers: AED noncompliance, sleep deprivation, EtOH use, stress, flashing lights, fever, menses.
 Prior studies: EEG, CT, MRI, PET, SPECT.

22. EXAMINATION AND W/U
 Examination
 Gen: Skin exam for neurocutaneous d/os (e.g., café au lait, ash leaf macules), body asymmetry, head
circumference.
 Neuro: Focal abnormalities (suggestive of underlying cause).
 Tests: Standard w/u:
 Labs: CBC, chem7, LFTs, toxicology screening, AED levels, UA, CXR.
 Imaging: CT if urgent (if concern for acute stroke, ICH, large mass). MRI ± gado preferable (structural
abnls: tumor, stroke, infxn, AVM), w/coronal T2 (assess hippocampus).
 EEG
 Consider further w/u: LP if suspected meningitis/encephalitis, SAH, all HIV+ pts.

23. EXAMINATION AND W/U
 Examination
 Gen: Skin exam for neurocutaneous d/os (e.g., café au lait, ash leaf macules), body asymmetry, head
circumference.
 Neuro: Focal abnormalities (suggestive of underlying cause).
 Tests: Standard w/u:
 Labs: CBC, chem7, LFTs, toxicology screening, AED levels, UA, CXR.
 Imaging: CT if urgent (if concern for acute stroke, ICH, large mass). MRI ± gado preferable (structural
abnls: tumor, stroke, infxn, AVM), w/coronal T2 (assess hippocampus).
 EEG
 Consider further w/u: LP if suspected meningitis/encephalitis, SAH, all HIV+ pts.

24. EXAMINATION AND W/U
 Examination
 Gen: Skin exam for neurocutaneous d/os (e.g., café au lait, ash leaf macules), body asymmetry, head
circumference.
 Neuro: Focal abnormalities (suggestive of underlying cause).
 Tests: Standard w/u:
 Labs: CBC, chem7, LFTs, toxicology screening, AED levels, UA, CXR.
 Imaging: CT if urgent (if concern for acute stroke, ICH, large mass). MRI ± gado preferable (structural
abnls: tumor, stroke, infxn, AVM), w/coronal T2 (assess hippocampus).
 EEG
 Consider further w/u: LP if suspected meningitis/encephalitis, SAH, all HIV+ pts.

25. MANAGEMENT
 When to Start AEDs:
 Start AEDs
 Single definite seizure with abnormal exam, imaging, EEG
 ≥2 seizures
 Defer treatment
 Single definite seizure with normal neuro exam, normal imaging, & normal EEG

26. Thank you