Diagnoses, symptoms, history, treatments of Epilepsy.

1. You’ve Got Nerve: Clinical
Pearls of Epilepsy
Akilah Mikel, MSN, FNP-BC
Pediatric Specialists of Virginia
Neurology Nurse Practitioner

2. No Disclosures

3. Objectives
• Describe seizures and epilepsy according to
standard classification
• Discuss common types of seizures
• Explain the diagnostic evaluation of seizures
• Gain some familiarity with anti-seizure
treatment
• Discuss safety and management of seizures

4. • Seizures have been documented since the
earliest civilizations
• An account of a boy with epileptic-like seizures is
recorded in 3 of the 4 gospels of the bible using
phrases like “possessed by a spirit”, “a spirit
seizes him (Matthew 17:14–18; Mark 9:14–29; Luke 9:38–42)
• The word epilepsy comes from the Greek verb
epilambanein (over seize), derived from the notion
that gods take hold or “seize” a person

5. Neuron

6. Definitions
• Seizure – a disturbance in the electrical
activity of the brain
• Epilepsy – two or more unprovoked
seizures separated by more than 24
hours
• Proposed ILAE (International League
Against Epilepsy) definition – one
seizure and risk for additional seizures
>60%

7. Epilepsy Epidemiology
• 2.2 million people in the United States
and more than 65 million people
worldwide
• 150,000 new cases of epilepsy are
diagnosed in the United States annually
• 1 in 26 people in the United States will
develop epilepsy at some point in their
lifetime

8. New Onset Seizure Evaluation
• Electrolytes?
• Lumbar puncture?
• EKG?
• Neuroimaging?
• EEG?
• Other?

9. Seizure Differential Diagnosis
• Syncope
• Pseudo-seizures
• Breath-holding
• Sandifer syndrome-related to reflux
• Migraine
• Movement Disorder
• TIA
• Sleep myoclonus

10. History
• Pre-monitory
• Ictal
• Post-ictal
• Other spells
• Tongue biting
• Incontinence

12. Neuroimaging
• Almost always indicated for seizure
evaluation
• MRI (Magnetic Resonance imaging)
preferred 3 Tesla (T) epilepsy protocol
• Look for signs of tumors, stroke,
infection, structural abnormalities in the
brain such as hydrocephalus and
vascular malformations that would
indicate a cause for seizures

13. MRI

14. Neuroimaging
• Immediate noncontrast CT is possibly
useful for emergency patients
presenting with seizure to guide
appropriate acute management
especially where there is an abnormal
neurologic examination, predisposing
history, or focal seizure onset.

15. EEG
Electroencephalogram
• A non-invasive procedure that detects
abnormalities in the brain waves, or in the
electrical activity of the brain.
• It records the brains electrical activity as a
series of traces. Each trace corresponds to a
different region of the brain
• Activation procedures: Photic stimulation
(flashing lights) and hyperventilation
(breathing fast for 3 min)

16. EEG
Electrodes consisting of small metal discs
with thin wires are pasted onto the scalp.

17. EEG
• Useful for evaluating new onset seizure:
• Prognosis
• Focal vs. generalized
• Epilepsy syndrome
• 25-60% chance of catching abnormal
discharges on routine EEG
• A negative EEG does not exclude the
possibility of seizures
• Prolonged video EEG when indicated

18. Epilepsy classification

19. Seizure classification

20. Generalized Seizures-affect the
entire brain
• Tonic Clonic (rigid/jerking)
• Absence (starring spell)
• Other motor including:
• Myoclonic (muscle jerks)
• Atonic (drop seizure)
• Epileptic Spasms

21. Focal seizure-affect part of the brain
• Aware:
Alert, involuntary movement, odd taste/smell,
fear/happiness, sweating/goose bumps
• Impaired awareness:
Aura, unconscious, lip smacking, meaningless
movements, picking at clothing, wandering
around, repeating words

22. Examples of Seizures
Generalized seizure:
Focal Seizure:

23. Febrile Seizures
• 2-5% of children (Hauser 1975, Nelson
1978, Offringa 1991) between 6
months and 6 years of age
• Simple vs complex
• Complex:
• Duration > 15 minutes
• Focal features
• ≥ 2 in 24 hours

24. Febrile Seizures: management
• Anti-pyretics do not decrease risk for
febrile seizures with subsequent illness
• However, they (acetaminophen) may
decrease risk for febrile seizures within
the same illness (9% vs 24%) (Murata
et al., 2018)

25. Febrile Seizures: Prognosis
• Overall, 1/3 have recurrence of FS
• ~10% have ≥3 FS
• 1% without risk factors will develop epilepsy
by age 7
• Compared to 10% with 2/3 risk factors –
complex, preexisting neurological
abnormality, family history of afebrile seizures
Nelson & Ellenberg (1978)

26. Infantile Spasms
• Clinical – usually trunk flexion and
extremity extension in clusters
• 50-60% continue to have seizures (mostly
LGS)
• 71-81% MR
• West syndrome = spasms, psychomotor
deterioration, and hypsarhythmia
• Tx Corticotropin (ACTH) or high dose
steroids, alternatively Vigabatrin

27. Hypsarhythmia

28. Infantile Spasms

29. Absence seizures
• Starring spells
• <30-40 seconds
• No post-ictal
• Multiple per day
• 3 Hz spike-wave
• Can be triggered by hyperventilation

30. Absence seizures

31. Benign Epilepsy with Centrotemporal Spikes
(BECTS)
• Onset 3-14 years old; most outgrow by 16 years
• Most common focal childhood epilepsy
• Seizures from rolandic cortex
• 80% have < 6 seizures
• Classically, unilateral face, tongue, and/or hand/arm
clonic jerking/ parasthesia in early morning or while
asleep – may be on either side; often retained
awareness but expressive aphasia in ictal/ post-ictal
phase
• Seizures may generalize
• Central-temporal spikes, activated by drowsiness/ sleep

32. Juvenile Myoclonic Epilepsy
• Most common generalized epilepsy in
adolescents
• Myoclonic, absence, and GTC seizures
usually after morning awakening, provoked
by sleep deprivation, alcohol
• Myoclonic jerks necessary for diagnosis,
predominate in upper limbs
• 4-5 Hz generalized polyspike and slow wave
discharges; photosensitive
• Most easily treated; 16% pharmacoresistant

33. Pseudo-seizure
• Also known as: psychogenic non-
epileptic seizures (PNES), conversion
disorder, functional neurologic disorder
• A non-epileptic seizure: no abnormal
electrical activity in the brain correlating
with the event
• Tx: Cognitive behavioral therapy,
psychiatric evaluation, PT/OT

34. Pseudo-seizure
• Risks in children: history of abuse,
depression, anxiety, school phobia, mood
disorders, separation anxiety, ADHD, panic
disorder, PTSD, cognitive impairment,
learning disability, epilepsy
• Video EEG is the gold standard for diagnosis
• Common reason for admission to EMU; about
20-30% with refractory “seizures” have been
misdiagnosed and most are PNES

35. Status Epilepticus
• Single seizure ≥ 30 minutes
• Multiple seizures without regaining consciousness
• Impending status epilepticus (Chen JWY and
Wasterlain CG, 2006) or early status epilepticus
(Shorvon S, 2001) = 5 minutes
• Status epilepticus:
• Convulsive
• Non-convulsive
• Incidence 20 episodes per 100,000 per patient-year
• 1/3-1/2 present with SE as their first seizure

36. Status Epilepticus Etiology
• Missed medications (history of epilepsy)
• Febrile status epilepticus
• Meningitis/ encephalitis
• Electrolyte disturbance, hypoglycemia
• Traumatic brain injury
• Toxin/ overdose
• Stroke, Tumor, other lesion
• Eclampsia

37. SUDEP
• Sudden Unexpected Death in Epilepsy
• Each year about 1 in 1000 adults and
about 1 in 4,500 childeren with epilepsy
dies from SUDEP
• No known cause of SUDEP
• Risk increases with poorly controlled
epilepsy (particularly GTC seizures)
• Best prevention is to control seizures

38. Management
• ABCs
• High flow O2 via non-rebreather mask
• Do not put anything in the mouth
• Do not restrain the patient, but ensure they are in a
safe place
• May need to help keep the airway open
• Turn patient on his/her side when possible to prevent
aspiration
• Check blood sugar, electrolytes (more important if no
history of epilepsy)

39. New Onset Seizure: To Treat or
Not to Treat?
• Effect on long-term prognosis
• Generally do not treat first
unprovoked seizure
• Recurrence risk- 50% within 2
years after 1st unprovoked

40. Risk of Recurrence after
Unprovoked Seizure

41. Common Anti-Epileptic Drugs
• Medications:
• Broad-spectrum – levetiracetam,
lamotrigine, valproic acid,
phenobarbital, etc
• Focal – oxcarbazepine, carbamazepine,
phenytoin, etc
• Absence – ethosuximide

42. New AEDs
• Cannabidiol (Epidiolex-Lennox
Gastaut, Dravet syndrome)
• Brivaracetam (Briviact-Focal)
• Steripentol (Diacomit-Dravet
syndrome)

43. Medication Management
• To avoid side effects, medications are
gradually titrated to a goal dose based on
weight. There is a risk for seizure during this
titration period.
• Ensure that medications are taken at the
same time twice daily (use alarm/pill box for
reminders)
• Labs are generally checked at trough levels
• Unless otherwise instructed contact your
neurology team with every seizure

44. Medication Management
• Vaccinations are generally recommended
including the flu shot (except for the nasal
spray)
• Please do not stop medications abruptly
without contacting your neurology team
• If seizure free for 2 years, your neurologist
may discuss weaning seizure medication if
patient has a normal EEG

45. Non-medication therapies
• Vagus Nerve Stimulator (VNS)-prevents
seizures by sending regular, mild pulses of
electrical energy to the brain via the vagus
nerve
• Deep Brain Stimulation (DBS)-electrodes
placed in target areas in the brain provide
brain stimulation to help stop the spread of
seizures
• Ketogenic Diet- 3-4 gms of fat for every 1 gm
carb and protein

46. Vagus Nerve Stimulator

47. Vagus Nerve Stimulator

48. Vagus Nerve Stimulator
• Magnet can be swiped once a minute 3-
5 times
• Needs to be turned off if getting MRI

49. Deep Brain Stimulation

50. SAFETY & RESPONSE
What to do during a seizure

51. When to call 911
• Seizure lasts longer than 5 min
• > 3 seizures in 1 hour
• Patient does not resume normal
breathing once seizure stops
• Respiratory distress
• Serious injury during seizure
• Water was inhaled

52. Rescue Medications
Diastat/Diazepam
(rectal)
Ativan/Lorazepam
(buccal)
Klonopin/Clonazepam Tab or
ODT (buccal)
Versed/Midazolam
(nasal spray)

53. Seizure Triggers
• Illness, fever, diarrhea, vomiting
• Sleep deprivation
• Missed medications
• Stress – worry, anxiety, anger
• Flashing lights – if photosensitive
• Alcohol or drug abuse
• Menstrual cycle in women

54. Safety
• Never swim alone
• No bathing without supervision (showers are
fine)
• Sports-helmet with bike riding, wear
protective gear for each sport, use buddy
system, stay hydrated
• Make sure coaches and referees are aware
of the possibility of seizures
• In Virginia must be seizure free for 6 months
to drive

55. Activities to Avoid
• Hang gliding
• Sky diving
• Rock/mountain climbing
• Scuba diving

56. • The International League Against
Epilepsy (ILAE) has proposed to
expand the definition of remission to 10
years seizure-free with the last 5 years
off antiepileptic drugs (AEDs).
Seizure Remission

57. Caleb is a 3 month old male who presents to your clinic with his
parents. They state over the past couple of weeks Caleb has been
having “weird movements”. Upon further questioning they report
that the movements consist of flexion of his trunk and extension of
his extremities in clusters particularly upon early morning
wakening.
A: Reassure them that babies sometimes have strange
movements
B: Refer them immediately to neurology for workup
including an EEG and to consider ACTH or high dose
steroids
C: Start them on Keppra and give them Diastat for
emergencies
Case Study 1

58. Brady is a 7 yo male who was brought into your clinic for evaluation
of inattention. His parents state he will often stop and stare for
about 30 seconds as if he is day dreaming. It occurs multiple times
a day and his teacher is reporting he is not listening in class and
his grades are dropping.
A: put him on Adderall for ADHD
B: tell him they need to discipline him better
C: Refer him to neurology for an EEG and to consider
treatment with Ethosuximide
Case Study 2

59. Caroline is a 16 yo female with a hx of abuse and depression. She
presents to the office for concerns for seizures. Upon further
questioning the movements consist of a violent thrashing of her
body, the arm and leg movements are out of phase, her eyes are
closed, and she turns her head from side to side. She sometimes
falls but never has hurt herself.
A: Send her to neurology for a video EEG to distinguish
between epileptic seizures and non-epileptic events
B: Tell her parents she must be faking it
C: Start her on Keppra and give her Diastat for rescue
Case Study 3

60. Questions

61. Thank You!!