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Seizure - Anik Amin
- 1. Seizure & Epilepsy ANIK AMIN, MD/MBA SLIDES COURTESY OF: JUSTIN STAHL, MD VIRGINIA MASON MEDICAL CENTER NEUROSCIENCE INSTITUTE
- 3. Learning Objectives Develop a framework for seizure and epilepsy classification An approach to the patient who had a new seizure Was it really a seizure or something else? Diagnostics Treatment options for seizures Epilepsy Status Epilepticus
- 4. Definitions Seizure Sudden, involuntary, usually time-limited alteration in behavior, including motor activity, autonomic function, consciousness, or sensation. Caused by abnormal/hypersynchronous electrical discharges of neuronal circuits Epilepsy – a predisposition to having unprovoked seizures 2 or more unprovoked seizures 1 unprovoked + >50% chance of having a 2nd unprovoked (e.g. abnl MRI/EEG) Provoked seizure – tricky concept! Alcohol withdrawal seizure = provoked Seizure from bupropion = provoked Seizure from glioma = UNprovoked Seizure from 3-day old brain hemorrhage = provoked (Acute symptomatic) Seizure from 3-month old brain hemorrhage = UNprovoked (Remote symptomatic)
- 8. Epidemiology Seizure: Lifetime incidence of single seizure: 10% Epilepsy: 0.5-1% of population Most new-onset adult epilepsy is focal
- 10. Temporal lobe epilepsy Most common focal epilepsy Rising epigastric sensation, fear, odd smell, déjà vu Speech or auditory changes Motor: Simple automatisms: chewing, lip smacking, swallowing, simple picking, fumbling Dystonic posturing of contralateral side Frontal lobe epilepsy (~20% of partial onset epilepsy) Nocturnal Brief Bizarre behavior Often no post-ictal confusion
- 11. Occiptal lobe epilepsy Elemental visual hallucination when involving the striate cortex Well formed hallucinations when involving the temporal-occipital cortices Parietal lobe epilepsy Paresthesias, ~Jacksonian march Other odd sensory changes In general, seizures cause ‘positive” sx (shaking, paresthesias) while TIA cause negative sx (weakness, numbness). But this is by no means always the case!
- 12. Selected Primary Generalized Epilepsy Syndromes Childhood absence Remission in adolescence common GTCS rare Drug of choice: ethosuximide Juvenile myoclonic epilepsy myoclonic, absence, GTCS Remission unlikely VPA, LTG, ZNG, TPM, LEV
- 13. Evaluation of a possible seizure Is this event a seizure or another paroxysmal event? If it is a seizure Any underlying causes? Risk for further seizures? Epilepsy? Is it still going on when I come to the room??
- 14. DDx for Paroxysmal events Adults Syncope (can be convulsive!) Migraine TIA Movement disorder (dystonia, tremor) Narcolepsy/other Sleep Disorders Panic Attacks Conversion d/o or PNES or Dissociative episodes. Formerly known as “Pseudoseizures” Malingering Infants/Children Breath Holding Shuddering/Chills Reflux Startle Other normal but potentially alarming behaviors
- 15. Is it psychogenic? Induced by stress or emotional upset Lack of physical injury / self-protecting behavior Tendency to occur when witnesses are around Biting the tip of the tongue as opposed to the side History of sexual or physical abuse (approx 25-35%) Memory of an event with 4-limb involvement. Very long duration (hours of shaking while at home without hemodynamic or respiratory compromise) Non-stereotyped, a wide variety of event types not fitting into a seizure syndrome or neuroanatomical correlate Fluctuating symptoms (on-off-on), crescendo Eyes closed Ineffectiveness of multiple antiepileptic drugs (AEDs)
- 16. Chung, S. S. et al. Neurology 2006;66:1730-1731 Ictal eye closure is a reliable indicator for psychogenic nonepileptic seizures
- 17. Workup for new seizure Studies EEG MRI (preferred over CT in the outpatient setting) EKG / cardiac monitoring if syncope on the ddx Laboratories Glucose, CMP, tox screen, CBC After the first seizure there is roughly a 50% risk of further seizures by 5 years without treatment. Use diagnostics to further risk stratify! Multiple seizures w/in 24 hours = 1 seizure
- 19. Chance of seizure freedom on AED About 50% on one AED Another 10-20% on 2 AED’s Another 5% on 3 AED’s Unlikely after adding more Adding AED’s diminishing marginal returns on efficacy, increasing marginal returns on side effects!
- 20. Refractory Epilepsy (i.e. refractory to 2 seizure meds) Refer to a Comprehensive Epilepsy Center Evaluation for surgery or advanced neurostimulation Vagal nerve stimulators or Ketogenic/modified Atkins diet may also be options for patients that are not surgical candidates
- 21. Status Epilepticus Neurologic emergency 5 minutes of continuous epileptic generalized convulsions or multiple such events without significant recovery w/in 30 minutes Prolonged convulsive status epilepticus causes CNS and systemic damage Key tips for an initial responder (e.g. IM resident on night float): Remember ABC’s Verify quickly that you think it could be a seizure Benzodiazepines
- 23. Game: Name that anti-seizure medication
- 24. PHENYTOIN I have tricky zero-order / nonlinear pharmacokinetics. Therefore, I can easily get into the toxic range with big dose increases. I can be associated with cerebellar dysfunction with long- term use Lately, Hepatologists seem to hate me even more. Probably because of things I might do to the new HepC meds.
- 25. CARBAMAZEPINE Like my buddy phenytoin, I will induce anything that walks. I even auto-induce myself! I am first line for trigeminal neuralgia
- 26. LEVETIRACETAM Inpatient neurologists love me a lot. I can be given quickly IV and don’t have all those medical side effects. But I am notorious in the outpatient setting for destabilizing mood, irritability etc. Avoid using me for patients with significant psychiatric history.
- 27. LAMOTRIGINE Objectively speaking, I am probably Dr. Amin’s favorite (i.e. most prescribed) anti-seizure medication for epilepsy patients in the outpatient clinic. But you have to be patient with me at first. Or I might very, very rarely blow up your skin. Both oral birth control pills and pregnancy can decrease my serum levels.
- 28. DEPAKOTE I like to think I am the most powerful oral anti-seizure med of them all: Broad spectrum for epilepsy, anti- headache, mood-stabilizing too! But I have plenty of side effects, and am the only seizure med Category X for pregnancy
- 29. MIDAZOLAM My cousin lorazepam may be the first-line benzo of choice for status epilepticus in the hospital, but I am able to be given in the field by EMT’s in IM form, and now even by family in intranasal form. I also am commonly used for refractory status epilepticus in infusion form.
- 30. TOPIRAMATE You might use me more often for migraine prophylaxis Recent studies have made me Category D for pregnancy
- 31. LACOSAMIDE Inpatient neurologists are loving me more and more: Minimal side effects, IV use, and unlike levetiracetam I am not associated with mood instability! It’s all good until the patient goes to his/her pharmacy and sees the bill
- 32. CBD I am all the rage Both anecdotal reports and randomized control trials have shown I can be of benefit in pediatric patients with refractory generalized epilepsy syndromes (e.g. Dravet, Lennox-Gastaut) I am not sure if I really help adult patients with epilepsy, but people are often willing to try me as a supplement to my main seizure medication thanks to my wellness rep on the streets. But I can cause some GI side effects and even interact with Depakote and Clobazam.
- 33. Thank You!