Seizure and Epilepsy

[blank_start]Seizure[blank_end] is a transient occurrence of signs and symptoms due to abnormal excessive or synchronous neuronal activity in the brain

[blank_start]Epilepsy[blank_end] is a neurological disease marked by the sudden and recurrent episodes of seizures

A person is considered to have epilepsy if they meet any of the following conditions:

More than 30 minutes of: - continuous seizure activity - two or more sequential seizures without full recovery of consciousness between seizures.

Some seizures occur as single events - Withdrawal of [blank_start]CNS[blank_end] depressants - During acute [blank_start]neurologic[blank_end] illnesses - Systemic [blank_start]toxic[blank_end] conditions - Cocaine use - Overdosing on [blank_start]digoxin[blank_end] - [blank_start]Electrolyte[blank_end] disturbances - Hypoglycemia

Causes of seizures [blank_start]Vascular[blank_end]: stroke, post-stroke, AV malformations [blank_start]Infections[blank_end]: meningitis, Lyme disease, brain abscess, HIV related [blank_start]Trauma[blank_end]: Brain injury [blank_start]Autoimmune[blank_end]: SLE [blank_start]Metabolic[blank_end]: hypoglycemia, electrolyte disturbances (Na⁺, Ca⁺⁺, Mg⁺⁺) [blank_start]Idiopathic[blank_end]: versus cryptogenic [blank_start]Neoplasm[blank_end]: primary brain tumor or metastatic [blank_start]Syndromes[blank_end]: Down’s Syndrome [blank_start]Stimulants[blank_end]: IV drug use, cocaine, ephedrine, herbal remedies

[blank_start]Seizures[blank_end] are also called the electrical storms in the brain

[blank_start]GABA[blank_end] is the main inhibitory neurotransmitter [blank_start]Glutamate[blank_end] is the major excitatory neurotransmitter

Every individual has a seizure [blank_start]threshold[blank_end], which is the level of excitability at which neurons will discharge abnormally

Patients with epilepsy have a [blank_start]lower[blank_end] seizure threshold

[blank_start]Prodrome[blank_end] is feelings, sensations, or changes of behavior hours or days before a seizure - warning that a seizure is coming - not considered part of the seizure

[blank_start]Aura[blank_end] or warning is the first symptom of a seizure - Changes in smells, sounds, tastes, vision, “strange” feelings, racing thoughts, fear/panic, headache, nausea, numbness or tingling in part of the body - Considered part of the seizure

[blank_start]Ictal[blank_end] phase is the middle of a seizure - Correlates with the electrical activity in the brain - Where the symptoms are observed

[blank_start]Post-ictal[blank_end] phase is the end of a seizure - Recovery period after the seizure (immediate or can take minutes to hours)

Every person with seizures will not have every stage or symptom

[blank_start]Partial[blank_end] seizures start in one area or side of the brain

[blank_start]Generalized[blank_end] seizures start on both sides of the brain at the same time and usually loss of consciousness is observed

A partial seizure in which consciousness is not impaired is referred to as a [blank_start]simple[blank_end] partial seizure

A partial seizure in which consciousness is impaired is referred to as a [blank_start]complex[blank_end] partial seizure

A partial onset evolving to generalized tonic-clonic is referred to as a [blank_start]secondarily generalized[blank_end] seizures

Name the type of the seizure: Generally occurs in young children Sudden onset, interruption of ongoing activity Blank stare Possibly a brief upward rotation of the eyes

Name the type of seizure: Brief shock-like muscular contractions of the face, trunk, and extremities

Name the type of seizure: Rhythmic, repetitive, jerking muscle movement

Name the type of seizure: Flexion, extension, and adduction of extremities Extension of back and neck Contraction of thoracic and abdominal muscles (may become apneic) Upward eye movement and mouth partially open May cry out as air is forced from the lungs

Which of the following statements about Atonic seizures are true?

There are NO diagnostic laboratory tests for epilepsy

[blank_start]Prolactin[blank_end] levels can be transiently elevated after GTC or CP seizures, however this observation can not be used as a diagnostic marker for epilepsy.

[blank_start]Electroencephalogram (EEG)[blank_end] is very useful in the diagnosis of various seizure disorders (only to confirm a diagnosis)

Which of the following is NOT useful in the diagnosis of seizure disorders?

Focal seizures: previously called [blank_start]partial seizures[blank_end], these start in an area or network of cells on one side of the brain Generalized seizures: previously called [blank_start]primary generalized[blank_end], these affect both sides of the brain at onset Unknown onset: is the onset of the seizure is not known Focal to bilateral seizure: previously called [blank_start]secondary generalized seizure[blank_end], it starts in one side of the brain and spreads to both sides

Focal aware: replaces the term [blank_start]simple partial[blank_end]; if awareness remains intact even if person is unable to talk or respond during a seizure Focal impaired awareness: replaces the term [blank_start]complex partial[blank_end] seizure; if awareness is impaired or affected at any time during a seizure even if a person has a vague idea of what happened Awareness unknown: for example if person lives alone or has seizures only at night Generalized seizures: these are all presumed to affect a person’s awareness or consciousness in some way

Which of the following statements are true in regards to febrile seizures?

Which drugs can be used as prophylaxis in the treatment of febrile seizures?

What medications can be given at the time of a febrile seizure?

Initiation of AEDs is recommended in the following cases: After one seizure in patients with [blank_start]risk factors[blank_end] After two seizures that occurred within a period of [blank_start]6-12[blank_end] months

Risk factors for seizures (at least one is need to initiate treatment) - [blank_start]CNS[blank_end] insult (stroke, head trauma, bleeding) - Family history of [blank_start]epilepsy[blank_end] - changes in [blank_start]EEG[blank_end] - some [blank_start]childhood[blank_end] illness (babies born small for their age, babies who have seizure in the first month of life, babies born with abnormal areas in the brain) - [blank_start]brain[blank_end] tumor - autism - use of [blank_start]illegal drugs[blank_end] such as cocaine

The probability of a 2nd seizure can be as high as [blank_start]80[blank_end]% after 5 years

If the probability of a 2nd seizure is less than 10% in the 1st year and 24% after 2 years, you are NOT considered to be at risk and treatment initiation should not begin.

A 50 year old male had a documented GTC seizure at 10am this morning. Patient has been recently diagnosed with a brain tumor. What is your recommendation regarding initiating AEDs for this patient?

Which of the following are triggers for seizures?

Diphenhydramine raises the seizure threshold

Which of the following factors must be considered when selecting the appropriate AED therapy for a patient?

An antiepileptic drug should not be considered ineffective unless patient develops an unacceptable ADR with continued seizure

Despite appropriate initial treatment, [blank_start]30-35[blank_end]% of patients are refractory to treatment

carbamazepine half-life is variable because of [blank_start]auto-induction[blank_end] which is usually complete 3 to 5 weeks after initiation of a fixed carbamazepine regimen

Which of the following agents can cause acute hepatic failure, acute pancreatitis, and alopecia?

Serum concentrations are useful when optimizing AED therapy, they should be assessed by: - Checking "[blank_start]steady state[blank_end]": different for each drug (average 1 to 3 weeks) - Checking at a [blank_start]consistent[blank_end] time: preferably first thing in the [blank_start]morning[blank_end] - Its best to check a [blank_start]trough[blank_end] level first thing in the morning, [blank_start]8[blank_end] hours after the last dose (lowest level)

Give the following information, calculate the corrected phenytoin concentration. (Total phenytoin is 8mcg/mL ; albumin 1mg/dL) Corrected phenytoin = measured phenytoin / [(0.29 x albumin) + 0.1)

What is the most common type of seizure experienced by adults?

[blank_start]Carbamazepine[blank_end] and phenytoin first line therapy in new-onset partial and generalized seizures

Of the agents listed below, which received FDA approval for use as monotherapy in patients with partial seizures?

[blank_start]Lamotrigine[blank_end] was determined to be a cost effective alternative to carbamazepine

Indicate the appropirate drug therapy treatment for absence seizures: 1st line: [blank_start]Ethosuximide (Zarontin)[blank_end] 2nd line: [blank_start]Valproate (Depakote)[blank_end] 3rd line: [blank_start]Lamotrigine (Lamictal)[blank_end]

Which of the following agents are infective in absence seizures and can precipitate and increase seizure frequency

What is the appropriate therapy to utilize in the treatment of mixed absence and partial or generalized:

[blank_start]Ethosuximide[blank_end] in combination with another AED is a n alternative therapy in the treatment of mixed absence and partial/generalized seizures.

[blank_start]Phenytoin (Dilantin)[blank_end] is the traditional treatment for tonic-clonic seizures. [blank_start]Carbamazepine (Tegretol)[blank_end] and Valproate (Depakote) are equally efficacious and have less side effects.

What drugs are alternative in the treatment of tonic-clonic seizures?

Seizure freedom for ≥ 2 years implies overall >[blank_start]60[blank_end]% chance of successful withdrawal in some epilepsy syndromes

Patients who are seizure free: [blank_start]2[blank_end] years: Absence [blank_start]4[blank_end] years: simple partial, complex partial, tonic-clonic seizures

Sudden discontinuation of AED therapy can precipitate withdrawal seizures and status epilepticus. Especially with benzodiazepines and barbiturates

When converting to monotherapy from polytherapy: Eliminate [blank_start]sedative[blank_end] drugs first Withdraw antiepileptic agents [blank_start]slowly[blank_end] over several months

AEDs and Pregnancy - AED teratogenicity is related to exposure in the [blank_start]first[blank_end] trimester of pregnancy - [blank_start]Seizures[blank_end] may be deleterious to the fetus - Risks from seizures are greater than risks from [blank_start]medications[blank_end] - All antiepileptic patient drugs carry [blank_start]teratogenic[blank_end] risks - Polytherapy of AED's [blank_start]increases[blank_end] risk - [blank_start]Breastfeeding[blank_end] is encouraged and can be done safely, advise the mother to take the AED immediately after breastfeeding

AEDs and Pregnancy Before pregnancy: - Attempt AED monotherapy with [blank_start]lowest[blank_end] effective dose - [blank_start]Folate[blank_end] supplementation (at least 1mg/day orally) During pregnancy: - Avoid use of: Barbiturates, [blank_start]phenytoin[blank_end], carbamazepine, - Limit dose of [blank_start]Valproate (Depakote)[blank_end] during the 1st trimester (1,400 mg/day) - [blank_start]Lamotrigine (Lamictal)[blank_end] is considered safe - Continue [blank_start]folate[blank_end] supplementation (1mg/day) - Consider [blank_start]Vitamin K[blank_end] (10mg/day) starting at 36 weeks (baby should receive 1 mg IM at birth)

[blank_start]Brief[blank_end] seizures are defined as lasting less than 5 minutes [blank_start]Prolonged[blank_end] seizure are defined as lasting between 5 and 30 minutes

Status epilepticus (SE) is defined as more than [blank_start]30[blank_end] minutes of either (1) A [blank_start]continuous[blank_end] seizure activity (2) Two or more sequential seizures without full recovery of [blank_start]consciousness[blank_end] in between seizures

The 30-minute definition is based on the duration of convulsive status epilepticus that may lead to permanent neuronal injury. What are some of the adverse consequences?

Types of Status Epilepticus status epilepticus consisting of repeated generalized tonic-clonic (GTC) seizures with persistent neurological depression of neurologic function between seizures

Types of Status Epilepticus status epilepticus where seizures produce a continuous “ epileptic twilight” state

Types of Status Epilepticus manifested as focal motor signs, focal sensory symptoms, or focal impairment of function (e.g. aphasia) not associated with loss of consciousness

Causes of Status Epilepticus [blank_start]Type I[blank_end]; no structural lesion: infection, CNS infection, metabolic, low AED levels, alcohol, idiopathic [blank_start]Type II[blank_end]; structural lesion (poor prognosis): anoxia/hypoxia, CNS tumors, CVA, drug overdose, hemorrhage, trauma

Clinical Presentation of Generalized Convulsive SE Symptoms: Impaired [blank_start]consciousness[blank_end] [blank_start]Disorientation[blank_end] once is controlled Pain associated with injuries Early signs: Generalized [blank_start]convulsions[blank_end] Acute injuries/CNS insults that cause extensor or flexor posturing [blank_start]Hypothermia[blank_end]/fever suggestive of inter-current illnesses Incontinence Normal blood pressure/hypotension and respiratory [blank_start]compromise[blank_end] Late signs: Clinical seizures/may not be apparent [blank_start]Pulmonary[blank_end] edema with respiratory failure Cardiac failure, hypotension or hypertension Disseminated intravascular coagulation, multisystem [blank_start]organ[blank_end] failure Rhabdomyolysis

Which of the following is the proposed interventions for the treatment of Status epilepticus during the stabilization phase (0-5 minutes) ?

Which of the following is the proposed interventions for the treatment of Status epilepticus during the initial therapy phase (5-20 minutes) ?

Which of the following is the proposed interventions for the treatment of Status epilepticus during the second therapy phase (20-40 minutes) ?

Which of the following is the proposed interventions for the treatment of Status epilepticus during the third therapy phase (40-60 minutes) ?

Of the two major ingredients in marijuana, which one causes the psychoactive effect of getting "high"

Medical Marijuana and Epilepsy Currently open-labeled studies in the U.S. of [blank_start]Epidiolex[blank_end] produced by GW Pharmaceuticals, a drug derived from CBD (99% oil-based extract)

Which of the following are non-pharmacologic treatment of seizures and epilepsy?

Ketogenic Diet Traditionally started gradually in the hospital after a [blank_start]24 – 48[blank_end] hour fast Ratio (fat: carbs and proteins) - [blank_start]4:1[blank_end] more strict - [blank_start]3:1[blank_end] for infants, adolescents - Vitamins and minerals are supplemented Side effects: due to large amount of fat consumption -Constipation -Weight [blank_start]gain[blank_end] -[blank_start]Acidosis[blank_end] when ill - [blank_start]Vitamin[blank_end] deficiency (if unsupplemented) - [blank_start]Renal[blank_end] stones - Impaired weight and height - Dyslipidemia - Gastrointestinal upset Requires strict control and patient compliance

Which of the following statements are true in regards to Vagal Nerve stimulation?

National Institute of Health Consensus Conference: 3 requirements for surgery: (1) Absolute diagnosis of [blank_start]epilepsy[blank_end] (2) [blank_start]Failure[blank_end] on adequate trial of drug therapy (3) Definition of the electro clinical syndrome