This document discusses seizure disorders. It defines a seizure as excessive electrical activity in the brain that can cause abnormal movements, behaviors, sensations, or loss of awareness, depending on the involved brain regions. Seizures can be provoked by insults like metabolic disturbances or substance withdrawal, or unprovoked. The pathophysiology involves an imbalance between excitatory and inhibitory forces in neuronal networks. Evaluation involves a detailed history, exam, EEG, imaging, and labs to diagnose epilepsy or another condition. Management focuses on controlling seizures with antiepileptic drugs while minimizing side effects and maintaining quality of life.

1. Seizure
Dr. Amna M. Hameed
Family Medicine
Seizure
Dr. Amna M. Hameed
Family Medicine

2. Introduction
• Seizure → is an excessive rise of electrical activity in the brain that can lead to a variety of
symptoms, depending on which parts of the cerebral cortex are involved; Abnormal
movements, unusual behaviors, sensations, and sometimes loss of awareness.
• Unprovoked seizures are → occurring in the absence of
precipitating factors.
• Provoked seizure → occurring at the time of insult, for example
, electrolyte imbalance.

3. Pathophysiology
• A seizure results when an abrupt imbalance occurs between the excitatory
and inhibitory forces within the network of cortical neurons.
• so the increase in cellular excitability is the main mechanism, but the
synchronization appears to considerably differ between the focal-onset
seizures and the generalized-onset seizures.

4. Pathophysiology
Provoked seizure = seizure that occurs at the time of a systemic insult or brain insult
• Metabolic disturbance within 24 hours (hypo/hypernatremia, hypocalcemia, hypomagnesemia,
uremia, hypothyroid, hypo/hyperglycemia)
• Substance withdrawal (alcohol, benzodiazepines)
• Drug intoxication, poisoning and overdose
• Brain damage (stoke within 1 week, trauma,
meningitis/encephalitis/abscess

5. Pathophysiology
Seizure of unknown etiology; high risk of future epilepsy
Epilepsy = any of the following
• >2 unprovoked seizures
occurring > 24 hours apart.
• 1 unprovoked seizure + a
probability of further seizures
>60% within 10 years
• Diagnosis of an epilepsy
Syndrome

6. Nearly 80%
of people with epilepsy
live in low- and middle-income
countries

7. Etiology
There are six major etiologies:
• Genetic: genetic defects as down syndrome.
• Structural: could be congenital structural etiologies (e.g., tuberous sclerosis) or
acquired structural etiologies (e.g., stroke, traumatic.)
• Metabolic: as mitochondrial defects that may be associated with Epilepsy.
• Immune: inflammatory central nervous system (CNS) disorders as Rasmussen
encephalitis.
• Infections: chronic CNS infections as human immunodeficiency virus (HIV),
Malaria, Tuberculosis.
• Unknown: the underlying cause is idiopathic.

8. Seizure categories

9. Seizure categories

10. Etiology

11. Clinical Features
Temporary confusion
Uncontrollable jerking movements of the arms
and legs
Loss of consciousness or awareness
Cognitive or emotional symptoms,
such as fear & anxiety
Automatisms like hand rubbing, lip gestures,
repeating certain words, and walking in circles

12. Comorbidities And Complications
• Psychosocial issues; loss of independence, underemployment, decreased leisure time,
decreased physical activity, ↑ substance use, depression, anxiety, and suicidality are more
common in patients with Epilepsy.
• Cognitive impairment.
• Sleep disorders as Obstructive sleep apnea (OSA).
• Medical comorbidities; hypertension (HTN), coronary artery diseases (CAD), stroke, obesity.
• Sudden unexpected death in Epilepsy (SUDEP), status epilepticus, and unintentional
injuries.

13. DDx Of Seizure Disorders (seizures mimic)
Psychogenic non epileptic seizure
Fluctuating, asymmetrical motor activity, eye closure, side-to-side body movements, always in front of
a witness; fully or partially alert; without tongue-biting.
Ix/confirm by >>>>> video EEG
Syncope
Prodrome of lightheadedness →Transient LOC → sweating, palpitations, pallor, myoclonic jerks/tonic
posturing, especially if the patient is kept upright; no or minimal post-event confusion.
Ix/confirm by >>>>> ECG/ECG ambulatory, orthostatic BP measurement.
TIA
Rapid loss of neurologic function due to interrupted blood flow; symptoms depend on affected vascular but
are typically "negative" (e.g., Weakness, numbness, aphasia, visual loss); intensity is usually maximal at
onset; consciousness; preserved.
Ix/confirm by >>>>> MRI/MRA, CTA

14. DDx Of Seizure Disorders (seizures mimic)
Migraine Aura
Positive and/or negative neurologic symptoms (Aura); most often visual & sensory, evolving gradually
over ≥3-5 minutes (slower onset than TIA or focal seizure); slow spread of positive followed by negative
symptoms, usually followed by headache.
Ix/confirm by >>>> personal/family history of migraine
Panic attack
Palpitations, shortness of breath, chest pain, dizziness, sense of impending doom; hyperventilation
may result in perioral and distal limb paresthesia.
Ix/confirm by >>> clinically history of anxiety /depression/stressors.
Transient global amnesia
Prominent anterograde amnesia (inability to form new memories) & variable retrograde amnesia; the
patient is disoriented in time, asking repetitive questions; other cognitive and motor functions spared;
rare in adults <50 years.
Ix/confirm by >>>> Clinically

15. DDx Of Seizure Disorders (seizures mimic)
Narcolepsy with cataplexy
Narcolepsy is a rare sleep disorder associated with rapid eye movement (REM) sleep invading
normal wakefulness, tetrad (4 symptoms) =↑daytime sleep +cataplexy (strong emotion lead
to sudden loss of muscles tone & fall while awake) +sleep paralysis+ hypnagogic
hallucination).
Ix/confirm by >>> Polysomnography and a multiple sleep latency test.
Paroxysmal movement disorders
motor activity is classic in appearance, is sustained rather than episodic, like tics, chorea.
Ix/confirm by >>> Video EEG

16. Assessment
A detailed history from the patient and available eyewitnesses is important to the evaluation:
Description of event: Aura, onset, progression, and duration.Ictal Behavior; generalized /focal, +/- loss
of consciousness (LOC), bilateral/unilateral lateralization, tongue bit/urine incontinence.
Time in relation to sleep
Postictal: confusion and suppressed alertness/Todd paralysis/ aphasia, hemianopsia, or numbness,
duration (e.g., recover in 10-20 minutes after generalized seizure).
Aggravating factors→ as strong emotions, intense exercise, loud music, and flashing lights, fever, the
menstrual period, lack of sleep, and stress (majority of Epilepsy with no triggers) → (e.g., photic-
induced seizures→↑children).
History of previous seizure: young adults should be asked directly as sudden jerks in the arms or legs
shortly after awakening in the mornings, commonly seen in juvenile myoclonic epilepsy (JME) or other
generalized epilepsy syndromes.

17. Assessment
• Ask about focal seizures/auras that may go unrecognized until patients experience a first-time (secondarily)
generalized seizure:
− Olfactory or gustatory hallucinations → Temporal lobe epilepsy.
− Brief episodes of panic/anxiety → Temporal or frontal lobe epilepsy.
− Visual hallucinations → Occipital-onset seizures.
• Drug history → over-the-counter drugs (OTC), especially if underlying liver or renal damage, and Drug
abuse.
• Ask about risk factors for epileptic seizures → head injury, abnormal early neurologic development or
intellectual disability, stroke, Alzheimer's disease, history of intracranial infection, alcohol/drug abuse,
immunosuppression, history of cancer, rheumatologic disorders as Systemic lupus erythematosus (SLE) &
hematologic disorders; porphyria and Antiphospholipid syndrome (APS).
• Family history→ + ve history is a risk factor for Epilepsy. especially; absence seizures and myoclonic
seizures.
• In follow up→ Asses compliance, drugs side effects, controlling of seizures.

18. Drugs that Provoke seizures
Opioid
Amphetamine
Alcohol
Anti psychotics
Anti cancer
Oral hypoglycemic agents Decongestants

19. Physical exam
• Vital signs/General look/mental status (could be postictal; confusion)
• Neuro examination: e.g., weakness/hyperreflexia/+ve Babinski sign→ contralateral.
• Tongue bite/laceration →generalized tonic-clonic seizures (not specific).
• If active seizure in hospital/clinic: observe clearly/video recording.

20. Investigations
• (CBC) , Urinalysis , (RFT), (LFT) ,Toxicology screen , Electrolyte.
• Pregnancy test: to rule out eclampsia.
• (CK): elevated serum CK can provide evidence that a generalized tonic- clonic seizure has
occurred.
• MRI (preferred)/CT.
• Lumbar Puncture (selected patients) (after excluding space-occupying lesion phosphate. by
image)
• ECG ;(for the patient with LOC) to rule out arrhythmia, prolong QT...etc.
• EEG; (if Normal doesn't rule out Epilepsy); sensitivity about 20-50 %, higher depend on many
factors as the number, duration of EEG & timing in relation to seizure).
• Serum prolactin: if a sample can be drawn 10-20 minutes after seizure termination; it's high (it ↓
doesn't rule out epileptic seizure).
• Antiepileptic drugs (AEDs) blood level: for uncontrolled patients, in follow-ups, in pregnancy.

21. Diagnosis of Epilepsy
Any of the following:
• ≥2 unprovoked seizures were occurring >24 hours apart.
• 1 unprovoked seizure+ a probability of further seizures ≥60% within ten years.
• Diagnosis of an epilepsy syndrome; over 20 epilepsy syndromes, each has a distinctive combination of
clinical features, signs, and symptoms, and EEG patterns; many begin in childhood. (e.g., infantile
spasm, febrile seizure).

22. Management
• Controlling seizures. • Avoiding treatment side effects. • Maintaining or restoring quality of
life
If diagnosed with Epilepsy (all 1st seizures should be seen by a neurologist):
1. Provide patient education/counseling.
2. Start AED the decision should be individualized, mainly after the second unprovoked
seizure) or 1st unprovoked with following risk factors;
− Epileptiform abnormalities on interictal EEG.
− Remote symptomatic cause, as identified by clinical hx or neuroimaging (e.g.,
brain tumor, brain malformation, prior central nervous system infection)
− Abnormal neurologic examination; focal findings & intellectual disability.
− A first seizure occurs during sleep

23. Management
• Controlling seizures. • Avoiding treatment side effects. • Maintaining or restoring quality of
life
If diagnosed with Epilepsy (all 1st seizures should be seen by a neurologist):
1. Provide patient education/counseling.
2. Start AED the decision should be individualized, mainly after the second unprovoked
seizure) or 1st unprovoked with following risk factors;
− Epileptiform abnormalities on interictal EEG.
− Remote symptomatic cause, as identified by clinical hx or neuroimaging (e.g.,
brain tumor, brain malformation, prior central nervous system infection)
− Abnormal neurologic examination; focal findings & intellectual disability.
− A first seizure occurs during sleep

24. Management
Treatment Options of Epilpsy
1- Medical Treatment
2- Diet ( Ketogenic Diet )
3- Epilepsy Surgery
4- Laser Surgery
5- Vagus nerve stimulation (VNS )
6- Deep Brain Stimulation ( DBS )
7- Resposive NeuroStimulation (RNS)

25. Therapeutic Spectrum Of Antiseizure Drugs
Broad spectrum: Treat a broad range of seizure types
+ Valproate: first drug of choice for generalized seizures
+Lamotrigine: first drug of choice for focal, good choice during preconceptual planning, it is not good
choice for initiating during pregnancy
+Levetiracetam: good choice for initiating during pregnancy next slide Topiramate
Narrow spectrum: Primary for focal onset seizures ( Carbamazepine ,Gabapentin ,Oxcarbazepine
Phenobarbital ,Phenytoin ,Pregabalin)
Narrow spectrum: For absence seizures only (Ethosuximide)

27. Counselling For Epileptic Patients
Seizure precautions
To be aware of seizure triggers; sleep deprivation, alcohol, some drugs, illness, intense exercise,
strong emotions, loud music/flashlights.
Avoid any OTC, supplements/herbal, ask a doctor first (it may affect AED levels) Avoid unsupervised
danger activities; bathing, swimming, heights, operating heavy machinery. (take a shower instead of
the bath as bathtubs are the most common site of seizure-induced drowning).
Physical activity
Participate in regular physical activity, in addition to providing cardiovascular and psychological
benefits, may decrease seizure frequency.
Bicycling, contact sports, & swimming are safe → if seizures are well controlled & supervision is
available.
Avoid High-risk sports (result in severe injury/death); as hang-gliding, scuba diving & free climbing.

28. Counselling For Epileptic Patients
Vaccines Precautions
DTaP/Tdap vaccines Precautions; In uncontrolled Epilepsy, defer until neurologic status is clarified and
stabilized. (as ↑the risk of febrile seizure in 1st day)
MMR vaccine precaution inpatient with personal or Family history of seizure. (as ↑the risk of febrile
seizure within two weeks).
Work
Better to till his/her manager (provide medical report). Better to tell co-workers for safety aid.
Avoid shift work if it triggers a seizure.
Assure safety in the office.
Use light or a glare guard for computer screens (if the light is a trigger).

29. Counselling For Epileptic Patients
Supplements
If on AEDs:
Ca 1000-1200mg/day (from diet & supplement)
Vit D 400-800IU/day to maintain vitamin d level >30ng/ml.
Home Environment
Cushioned flooring or carpets.
Protective covers on sharp edges of furniture.
Avoid glass in furniture.
Use secured heaters/Stair gates at the top of the stairs/microwave oven. Better to have bathroom or
bedroom downstairs.
Locks that can be opened from the outside/ non-slip flooring (bathroom). Use anti-suffocation’ pillows

30. Counselling For Epileptic Patients
Follow-ups
Keep diary of seizures(calendar)& its triggers. Regular follow-up.
Adherence to drugs & discuss drug's side effects.
Psychosocial issues
Explore Psychosocial issues of;
Loss of independence / employment /self-esteem/ability to drive/ insurance. Mood problems
(depression/anxiety/suicide);↑ prevalent in epileptic patient (also from AEDs use).

31. Counselling For Epileptic Patients
How to deal with active seizures as caregiver/witness?
Ease the person to the floor.
Turn the person gently onto one side, and this will help the person breathe.
Clear the area around from anything hard /sharp to prevent injury.
Put something soft and flat, like a folded jacket, under the head.
Take off eyeglasses.
Loosen ties /anything around the neck that may make breathing hard.
Time the seizure. Call an ambulance if (seizure last >5 min, first seizure, another seizure after this one,
medical conditions (DM, CVD), pregnant, seizure in water, hurt during seizure, difficult breathing.

32. Counselling For Epileptic Patients
Contraception
Provide counseling.
The best is long-acting reversible contraceptive (LARC) intrauterine devices (IUDs) or IM depot
medroxyprogesterone (DMPA).
Certain anticonvulsants (Oxcarbazepine, Carbamazepine, Phenytoin, Phenobarbital, Primidone,
Topiramate) = enzyme-inducing AEDs; it ↓ the effectiveness of COCP/Patch/vaginal Ring & Progestin-
only pills. (if COCP is chosen; A minimum of 30 μg of Ethinyl estradiol (EE) should be used).
No interaction between Lamotrigine & Progestin-only contraception (it is affected by estrogen-
containing hormonal contraception).
Subdermal levonorgestrel implants became less effective (as it metabolizes by the liver).

33. Counselling For Epileptic Patients
During pregnancy
(with the consultation of a neurologist)
Preconception; is it Epilepsy? (re-evaluate Diagnosis & treatment), counsel about Necessity for AED &
choice of AED, does the patient require AEDs? on minimum dose to control seizures? (discuss
teratogenicity of AED), The incidence of major birth defects from AED monotherapy is 4-7%.
Avoid valproate in childbearing age women (unless needed).
Folic acid supplement ( from 1-3 months preconception continue through pregnancy); *4mg/d if she is
on valproate or carbamazepine/history of Neural tube defect in a previous pregnancy or in the parent,
*0.4-0.8 mg/d if taking other AEDs (some expert gives 1mg/d).
In pregnancy: Follow up blood levels of AEDs at regular intervals & US anomaly screening.

34. Counselling For Epileptic Patients
During lactation
Taking AEDs does not contraindicate it; the majority lack adverse effects on nursing infants.
Discontinue breastfeeding if the baby is Failure to thrive, sedated, or irritated.
When to stop ?
There is no evidence to guide the timing of medication withdrawal in seizure-free AEDs? adults, but
many experts wait for at least 2 to 3 years of seizure freedom.

35. Choosing AEDs to depend on many factors
• Comparative efficacy
• Pharmacokinetics
• Dosing frequency
• Drug interactions
• Aging
• Side effect profiles
• Cost & availability of medications
• Type of seizure
• Women of childbearing age
• Medical comorbid conditions

36. Prognosis
Depends On Controlling Epilepsy ..
Adults with an unprovoked first seizure should be informed
that their seizure recurrence risk is greatest early within the first two years (21 - 45 %)

37. Role of Family Physicians
• Asses first seizure
• Refer to neurology
• Treat acute seizure
• Aware of AED Side effects
• Provide counseling and preventive care