is a transient occurrence of signs and symptoms due to abnormal excessive or synchronous neuronal activity in the brain
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:
At least two unprovoked (or reflex) seizures occurring greater than 24 hours apart
One unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years
Diagnosis of an epilepsy syndrome
Have an single unprovoked seizure event
More than 30 minutes of: - continuous seizure activity - two or more sequential seizures without full recovery of consciousness between seizures.
Seizure
Epilepsy
Status Epilepticus
Some seizures occur as single events - Withdrawal of depressants - During acute illnesses - Systemic conditions - Cocaine use - Overdosing on - disturbances - Hypoglycemia
Causes of seizures
: stroke, post-stroke, AV malformations : meningitis, Lyme disease, brain abscess, HIV related : Brain injury : SLE : hypoglycemia, electrolyte disturbances (Na⁺, Ca⁺⁺, Mg⁺⁺) : versus cryptogenic : primary brain tumor or metastatic : Down’s Syndrome : IV drug use, cocaine, ephedrine, herbal remedies
are also called the electrical storms in the brain
is the main inhibitory neurotransmitter
is the major excitatory neurotransmitter
Every individual has a seizure , which is the level of excitability at which neurons will discharge abnormally
Patients with epilepsy have a seizure threshold
Prodrome Aura Ictal phase post-ictal phase( Prodrome, Aura, Ictal phase, post-ictal phase ) 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
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
phase is the middle of a seizure - Correlates with the electrical activity in the brain - Where the symptoms are observed
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
seizures start in one area or side of the brain
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 partial seizure
A partial seizure in which consciousness is impaired is referred to as a partial seizure
A partial onset evolving to generalized tonic-clonic is referred to as a 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
Absence
Myoclonic
Clonic
Tonic
Name the type of seizure:
Brief shock-like muscular contractions of the face, trunk, and extremities
Rhythmic, repetitive, jerking muscle movement
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?
Sudden loss of muscle tone
common in children
may present with head drop, dropping of a limb, and slumping to the ground
Patients often wear protective headgear to prevent trauma
There are NO diagnostic laboratory tests for epilepsy
levels can be transiently elevated after GTC or CP seizures, however this observation can not be used as a diagnostic marker for epilepsy.
Electroencephalogram (EEG) Magnetic Resonance Imaging (MRI) Computed Tomography (CT)( Electroencephalogram (EEG), Magnetic Resonance Imaging (MRI), Computed Tomography (CT) ) 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?
Electroencephalogram (EEG)
Magnetic Resonance Imaging (MRI)
Computed Tomography (CT)
Focal seizures: previously called , these start in an area or network of cells on one side of the brain
Generalized seizures: previously called , 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 , it starts in one side of the brain and spreads to both sides
Focal aware: replaces the term ; if awareness remains intact even if person is unable to talk or respond during a seizure
Focal impaired awareness: replaces the term 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?
Children aged 3 months to 6 years may have tonic-clonic seizures when they have a high fever
More likely to occur if there is a family history of febrile seizures
Most children do not require daily treatment with medications
The outlook is excellent; the majority of children will not have seizures without a fever after the age of 5
Medications can be considered for children who have repeated episodes of multiple febrile seizures
Which drugs can be used as prophylaxis in the treatment of febrile seizures?
Phenobarbital
Valproate
Lamotrigine
Lorazepam
What medications can be given at the time of a febrile seizure?
Diazepam gel or liquid (can be given rectally)
clonazepam (placed on the tongue)
diazepam tablet (crushed and put between the cheek and gum)
lorazepam tablet (crushed and put between the cheek and gum)
can be treated with AED's
Initiation of AEDs is recommended in the following cases: After one seizure in patients with After two seizures that occurred within a period of months
Risk factors for seizures (at least one is need to initiate treatment)
- insult (stroke, head trauma, bleeding) - Family history of - changes in - some 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) - tumor - autism - use of such as cocaine
The probability of a 2nd seizure can be as high as % 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?
Treatment with anticonvulsants should be initiated
Treatment with anticonvulsants should be deferred at this point
Which of the following are triggers for seizures?
Missed medicine
Lack of sleep
Stress
Alcohol
Drug abuse (amphetamine, stimulant, marijuana, heroin, nicotine, caffeine)
Menstruation (hormonal change, can adjust medication dose in women with regular cycles or prescribe lorazepam (Ativan) for several days around the menstrual cycle
Others (OTC agents such as diphenhydramine, some herbal medicines)
Diphenhydramine raises the seizure threshold
Which of the following factors must be considered when selecting the appropriate AED therapy for a patient?
Seizure type
Age
Gender (pregnancy)
Pharmacokinetic profile
Interactions/other medical conditions
Efficacy
Expected adverse effects
Ability to comply with a prescribed regimen
Cost
An antiepileptic drug should not be considered ineffective unless patient develops an unacceptable ADR with continued seizure
Despite appropriate initial treatment, 30-35 20-30 40-50( 30-35, 20-30, 40-50 )% of patients are refractory to treatment
carbamazepine half-life is variable because of 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?
Phenytoin (Dilantin)
Carbamazepine (Tegretol)
Valproic Acid (Depakote)
Gabapentin (Neurontin)
Serum concentrations are useful when optimizing AED therapy, they should be assessed by:
- Checking "": different for each drug (average 1 to 3 weeks) - Checking at a time: preferably first thing in the - Its best to check a level first thing in the morning, 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)
10
20
30
40
What is the most common type of seizure experienced by adults?
partial seizures
generalized seizures
absence seizures
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?
Lamotrigine (Lamictal)
Topiramate (Topamax)
Oxcarbazepine (Trileptal)
Levetiracetam (Keppra)
Lamotrigine Gabapentin Topiramate( Lamotrigine, Gabapentin, Topiramate ) was determined to be a cost effective alternative to carbamazepine
Indicate the appropirate drug therapy treatment for absence seizures:
1st line: Ethosuximide (Zarontin) Valproate (Depakote) Lamotrigine (Lamictal)( Ethosuximide (Zarontin), Valproate (Depakote), Lamotrigine (Lamictal) ) 2nd line: Valproate (Depakote) Ethosuximide (Zarontin) Lamotrigine (Lamictal)( Valproate (Depakote), Ethosuximide (Zarontin), Lamotrigine (Lamictal) ) 3rd line: Lamotrigine (Lamictal) Ethosuximide (Zarontin) Valproate (Depakote)( Lamotrigine (Lamictal), Ethosuximide (Zarontin), Valproate (Depakote) )
Which of the following agents are infective in absence seizures and can precipitate and increase seizure frequency
Tiagabine (Gabitril)
Valproate (Depakote)
What is the appropriate therapy to utilize in the treatment of mixed absence and partial or generalized:
Felbamate (Felbatol)
in combination with another AED is a n alternative therapy in the treatment of mixed absence and partial/generalized seizures.
is the traditional treatment for tonic-clonic seizures. 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 >% chance of successful withdrawal in some epilepsy syndromes
Patients who are seizure free:
years: Absence 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 drugs first Withdraw antiepileptic agents over several months
AEDs and Pregnancy
- AED teratogenicity is related to exposure in the trimester of pregnancy - may be deleterious to the fetus - Risks from seizures are greater than risks from - All antiepileptic patient drugs carry risks - Polytherapy of AED's risk - is encouraged and can be done safely, advise the mother to take the AED immediately after breastfeeding
Before pregnancy: - Attempt AED monotherapy with effective dose - supplementation (at least 1mg/day orally)
During pregnancy: - Avoid use of: Barbiturates, , carbamazepine, - Limit dose of during the 1st trimester (1,400 mg/day) - is considered safe - Continue supplementation (1mg/day) - Consider (10mg/day) starting at 36 weeks (baby should receive 1 mg IM at birth)
seizures are defined as lasting less than 5 minutes seizure are defined as lasting between 5 and 30 minutes
Status epilepticus (SE) is defined as more than minutes of either (1) A seizure activity (2) Two or more sequential seizures without full recovery of 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?
hypoxia
acidosis
hyperthermia
hypothermia
Types of Status Epilepticus
status epilepticus consisting of repeated generalized tonic-clonic (GTC) seizures with persistent neurological depression of neurologic function between seizures
convulsive
non-convulsive
Repeated partial seizures
status epilepticus where seizures produce a continuous “ epileptic twilight” state
repeated partial seizures
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
; no structural lesion: infection, CNS infection, metabolic, low AED levels, alcohol, idiopathic
; structural lesion (poor prognosis): anoxia/hypoxia, CNS tumors, CVA, drug overdose, hemorrhage, trauma
Clinical Presentation of Generalized Convulsive SE
Symptoms: Impaired once is controlled Pain associated with injuries
Early signs: Generalized Acute injuries/CNS insults that cause extensor or flexor posturing /fever suggestive of inter-current illnesses Incontinence Normal blood pressure/hypotension and respiratory
Late signs: Clinical seizures/may not be apparent edema with respiratory failure Cardiac failure, hypotension or hypertension Disseminated intravascular coagulation, multisystem 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"
Tetrahydrocannabinol (or THC)
Cannabidiol (or CBD)
Medical Marijuana and Epilepsy
Currently open-labeled studies in the U.S. of 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?
Lifestyle modifications (adequate sleep, avoid alcohol & stimulants), avoid precipitants, use stress reduction techniques)
Ketogenic diet ( high in fats, low in proteins and carbs)
vagal nerve stimulation
surgery
Ketogenic Diet
Traditionally started gradually in the hospital after a hour fast
Ratio (fat: carbs and proteins) - more strict - for infants, adolescents - Vitamins and minerals are supplemented
Side effects: due to large amount of fat consumption -Constipation -Weight - when ill - deficiency (if unsupplemented) - 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?
Intermittent programmed electrical stimulation of left vagus nerve
FDA approved for partial onset seizures in patients >12 years old refractory to AEDs
Implanted Medical Device
Adverse effects local, related to stimulus (hoarseness, throat discomfort, dyspnea, cough, voice alteration)
May allow antiepileptic drug reduction (dose or number)
National Institute of Health Consensus Conference: 3 requirements for surgery: (1) Absolute diagnosis of (2) on adequate trial of drug therapy (3) Definition of the electro clinical syndrome
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