Seizures and Epilepsy by: Paulo Mara

Hazel Paragua, MD, MBA, FPNA August 2, 2010

I wondered what happened when you offered Infants, children and adolescents
yourself to someone, and they opened you, only to  Febrile seizures
discover you were not the gift they expected and  Idiopathic
they had to smile and nod and say thank you all the  CNS Infection
same. –My Sister’s Keeper  Head Injury
 Toxic / Metabolic
Epileptics in History  Vascular
 Tumor
Julius Caesar Napoleon Bonaparte  Degenerative
Alexander the Great Peter the Great
Charles V James Madison Adults
St. Joan of Arc St. Paul  Cerebrovascular disease
Alfred Nobel Vincent van Gogh  Tumors
Socrates Pythagoras  Head Injury
Lord Byron Fyodor Dostoyevsky  CNS Infection
G.F. Handel Moliere  Toxic /Metabolic
Peter Tchaikovsky Jonathan Swift  Degenerative
Flaubert  Idiopathic

Seizure International Classification of Epileptic Seizures

 transient and reversible alteration of
behavior caused by a paroxysmal, abnormal Partial (focal, local) seizures
and excessive neuronal discharge
 attack of cerebral origin I. Simple partial seizures
 sudden and transitory abnormal
phenomena motor, sensory, autonomic, or  With motor signs
psychic  With somatosensory or special sensory
 transient dysfunction of part or all of the symptoms
brain  With autonomic symptoms or signs
 With psychic symptoms
Black & White = Aura with Migrane
Colours & Circles = Aura of Seizure II. Complex partial seizures

Epilepsy  Simple partial onset followed by

 A paroxysmal brain disorder of various
etiologies characterized by recurrent
seizures due to excessive electrical
discharge of cerebral neurons associated
with a variety of clinical and laboratory
manifestations
 Two or more seizures not directly provoked
by intracranial infection, drug withdrawal,
acute metabolic changes or fever
Etiology of Epilepsy
Seizure is a symptom of disease rather than
a disease itself
The investigation of epilepsy depends on the
knowledge of possible etiologies
Probable etiology depends on:
o age of the patient at onset
o type of seizures
Etiology :
Neonates
 Metabolic disorders
 Hypoxic Ischemic Encephalopathy
 CNS Infection
 Intracranial hemorrhage
 Cerebral dysgenesis
 Idiopathic (genetic)
impairment of consciousness
 With impairment of consciousness at
onset
 Partial seizures evolving to secondarily
generalized seizures
 Simple partial seizures evolving to
generalized seizures
 Complex partial seizures evolving to
generalized seizures
 Simple partial seizures evolving to
complex partial seizures evolving to
generalized seizures
III. Generalized seizures (convulsive or
nonconvulsive)
 Absence seizures
 Typical absences
 Atypical absences
 Myoclonic seizures
 Clonic seizures
 Tonic seizures
 Tonic-clonic seizures
 Atonic seizures (astatic seizures)
 Unclassified epileptic seizures
*Commission on Classification and Terminology of
the Int’l League Against Epilepsy, 1981
 Seizures and Epilepsy by: Paulo Mara
Hazel Paragua, MD, MBA, FPNA August 2, 2010

 Often difficult to distinguish from tonic

GENERALIZED SEIZURE
Seizure with clinical and/or EEG
evidence
Both hemispheres involved
Bilateral motor manifestations
Consciousness impaired
Ictus lasts 1-2 minutes
Post - ictal state may last 10-15
minutes or even hours to days
Generalized Tonic – Clonic Seizure
Bilateral Motor
Fencing
Impairment of consciousness
High pitched cry (tonic)
TONIC PHASE:
 Crying out as tonic contraction of trunk
forces expiration.
 Interrupted by short periods of relaxation
followed by tonic
o contractions.
seizures
 Streotypical repeated (same situation)
 Headtrauma
PARTIAL SEIZURE
 Seizure with clinical and/or EEG evidence
 Focal onset
 Abnormal discharge arising from a part of
one cerebral hemisphere
 Origin of Seizure: Hippocampus
 Lesion in the Right Frontal Lobe, Left Side
Paralysis
 One extremities to the whole body
Simple Partial Seizure
 “AURA” = breeze
 Originates from a motor or somatosensory
area
 May progress into a secondarily generalized
tonic-clonic seizure
Parietal Lobe Lesion – Somatosensory
Occipital Lobe Lesion – Visual
Temporal Lobe (Auditory Area) – Auditory
Inferior Frontal Lobe (Olfactory Cotex) – Olfactory

CLONIC PHASE : Simple Motor Seizure

 More frequent periods of relaxation
 Increase in heart rate and BP
 May occur in rapid succession leading to
status epilepticus
 Incontinence: relaxation of sphincters after
end of seizure
 Arise from the contralateral motor
cortex
 Versive or postural movements
 May have Jacksonian march
 Usually progresses to a GTC seizure
Simple Partial Seizure

Absence Seizure Symptomatology

 Most common in childhood
Somatosensory - feeling of breeze
 Impairment of consciousness (looked
Visual - light flashes, visual
awake, not aware)
hallucinations
 Automatisms: eyelid blinking, staring (blank
Auditory - buzzing
stares)
Olfactory - burning rubber
 (3 seconds wave) Few seconds to a minute
Vertiginous - dizziness
and may occur many times a day in rapid
Autonomic - epigastric, “rising”,
succession
sweating, flushing,
 Poor school performance
piloerection,
 Test: EEG
pupillodilatation
 Treatable 2 to 3 years
Gustatory - hallucinations
Psychic - fear, anger, dreamy
Myoclonic Seizures
states, déjà vu, jamais vu,
 Quick muscle jerks, bilateral or unilateral
visual distortions
 Consciousness usually intact
 Usually seen in specific epilepsy syndromes
Complex Partial Seizure
(ex. JME in teenagers)
 With impaired consciousness at the onset
 Myoclonic activity may also be associated
 Most last 1-3 minutes, at times longer
with other neurologic disorders
 Complicated behaviors
 Mental retardation
 Automatisms – no lateralizing value
 Aura
Atonic Seizures
 Post-ictal confusion; amnesia for event
 “DROP ATTACKS”
 May secondarily generalize
 Commonly in Lennox-Gastaut Syndrome
 “Psychomotor”, “temporal lobe” seizures
 Sudden loss in postural muscle tone
 Alteration of consciousness as a result of
 Last a few seconds and can occur without
dysfunction in the mesial temporal lobes,
alteration of consciousness
orbitofrontal lobes or in more widespread
 Usually patients are 1-2 years old
areas of the brain
 Seizures and Epilepsy
Hazel Paragua, MD, MBA, FPNA
 Prolonged absence seizure
 Medial part of the temporal lobe
EPILEPTIC SYNDROMES
 Syndrome : Disorder characterized by a
cluster of symptoms that commonly occur
together
 Epileptic syndromes :
o clinical pathogenesis (i.e. whether
they begin in one part of the brain
or in a bilaterally synchronous
fashion
o etiology
CRITERIA FOR SYNDROME CLASSIFICATION
 seizure type
 age at onset
 precipitating factors
 natural history
 cause
 anatomic localization of seizure onset
 ictal and interictal EEG abnormalities
Epilepsy Syndromes
 IDIOPATHIC
o Normal CNS function
o No accepted pathologic correlate
of the syndrome
o Interparoxysmal (background) EEG
is normal
o There maybe close family members
with a similar condition
o AED treatment is usually effective
 SYMPTOMATIC
 CRYPTOGENIC
International Classification of Epilepsies,
Epileptic Syndromes, and Related Seizure
Disorders *
Generalized
Idiopathic (primary)
 Benign neonatal familial convulsions
 Benign neonatal convulsions
 Benign myoclonic epilepsy in infancy
 Childhood absence epilepsy (pyknolepsy)
 Juvenile absence epilepsy
 Juvenile myoclonic epilepsy (impulsive petit
mal)
 Epilepsies with grand mal seizures (GTCS) on
awakening
 Other generalized idiopathic epilepsies
 Epilepsies with seizures precipitated by
specific modes of activation
Symptomatic (secondary)
 Non-specific etiology
 Early myoclonic encephalopathies
 Epilepsies in other disease states
by: Paulo Mara
August 2, 2010
Cryptogenic
 West Syndrom
 Lennox – Gastaut Syndrome
 Epilepsy with myoclonic – astatic seizures
 Epilepsy with myoclonic absences
Localization – related (focal, local, partial)
Idiopathic (primary)
 Benign childhood epilepsy with
centrotemporal spikes
 Childhood epilepsy with occipital paroxysms
 Primary reading epilepsy
Symptomatic (secondary)
 Temporal lobe epilepsies
 Frontal lobe epilepsies
 Parietal lobe epilepsies
 Occipital lobe epilepsies
 Chronic progressive epilepsies of childhood
syndromes
Cryptogenic, defined by:
 Seizure type
 Clinical features
 Etiology
 Anatomical localization
Undetermined epilepsies
With both generalized and focal seizures
 Neonatal seizures
 Severe myoclonic epilepsy in infancy
 Epilepsy with continuous spike-waves during
slow wave sleep
 Acquired epileptic aphasia (Landau-Kleffner
syndrome)
Other undetermined epilepsies
 Without unequivocal generalized or focal
features
Special syndromes
Situation-related seizures (Gelegenheitsanfälle)
 Febrile convulsions
 Isolated seizures or isolated status
epilepticus
 Seizures occurring only when there is an
acute or toxic event due to actors such as
alcohol, drugs, eclampsia, hyperglycemia
*Commission on Classification and Terminology of
the International League Against Epilepsy 1989
Childhood Absence Epilepsy
 “pyknolepsy”
 age of onset : 5 - 15 yrs.
 peak: 6-7 yrs.
 absence seizures/daily; several times a
day
 Typical EEG : 3 per second spike and
wave complex
 activated by hyperventilation
 Seizures and Epilepsy
Hazel Paragua, MD, MBA, FPNA
Juvenile Myoclonic Epilepsy
 “Impulsive Petit Mal of Janz”
 Appears around puberty
 Seizures - bilateral, single or repetitive
arrhythmic, irregular myoclonic jerks
predominantly in the arms
 No disturbance of consciousness
 Often associated with GTCS
 Infrequent absences
 Seizures often occur after awakening
 Precipitated by sleep deprivation
 Interictal and ictal EEG : 4 – 6 Hz
generalized spike / polyspike / slow waves
 Frequent photosensitivity
 Response to appropriate drugs is good
Benign Febrile Seizures
 Onset between 3 months and 5 y/o
 Associated with fever without evidence of
intracranial infection or defined cause
 More in males
 Recurrence : 1/3 will have at least 1
recurrence
o ¾ of recurrences take place within
a year of the first seizure and 90%
within two years
st
 The younger the child at the 1 attack; the
most likelihood of further febrile seizures
 Risk for epilepsy is small.
 It is increased when:
o seizure lasts more than 15 minutes
o more than 1 seizure in 24 hours
o focal features
o abnormal neurologic development/
neuro exam
 In the absence of specific clinical indications,
there is no
o further need for diagnostic tests
 Mainstay of treatment is fever control
Epileptic vs Nonepileptic Events
 Most patients with seizures have
normal neurological exams,
neuroimaging and even EEG
 Some patients may have events that
are difficult to classify
 Most important tool for diagnosis:
GOOD HISTORY!
Differential Diagnosis of Episodic Events in Adults
 Paroxysmal vertigo
 Syncope/Convulsive syncope
 Arrythmia
 Paroxysmal abdominal pain
 Pheochromocytoma
 Sleep Disorders
 Paroxysmal nocturnal dystonia
 Episodic dyscontrol
 Transient global amnesia
 Psychogenic seizures
 Somnambulism
 Sleep apnea
by: Paulo Mara
August 2, 2010
 Sleep myoclonus
 Drug adverse effects
 Tics
 Myoclonus
 Dyskinesia
 Chorea
 TIA (transient ischemic attack)
 Complicated/Acephalgic migraine
 Panic disorder
Pseudoseizures
 Brief, very unusual behaviors:
 copious motor activity, cursing, pelvic-
thrusting
 10% of all CPS don’t produce EEG change,
most especially frontal lobe seizures
 May have partly-preserved consciousness
although individual frequently amnesic for
event afterward
Basic Laboratory Tests
 CBC
 Random Blood Sugar
 Electrolytes, BUN, Creatinine
 ECG
Neurodiagnostic Procedures
Electroencephalography (EEG)
 Epilepsy is essentially a clinical diagnosis
 The most important single diagnostic
procedure in patients with epilepsy
 10% of epileptics will have a normal EEG
despite multiple recordings
 A normal EEG does not exclude epilepsy
 Not all abnormal EEGs mean epilepsy
Interictal EEG in Epilepsy
 confirms clinical diagnosis of epilepsy
 classification of seizure types
 definition of epileptic syndromes
 monitoring of response to AED
treatment
 evaluation of patients with single
seizures
 guide in the decision to discontinue
AED treatment
Indications for Neuroimaging
 partial seizures especially in adults
 conditions which suggest progressive
neurologic disease or structural lesion
that may be surgically correctible
 intractable seizures
Simple First Aid for persons with seizure
1. First, clear everything out of the way.
2. Don't hold the patient down or try to stop
the jerking.
3. Put something flat and soft under the
patient’s head.
4. Make sure there's nothing tight round his
 Seizures and Epilepsy
Hazel Paragua, MD, MBA, FPNA
neck that could interfere with breathing.
5. Check your watch so you'll know how long
the seizure lasts.
6. Turn the patient gently onto one side so he
or she doesn't choke.
7. Don't try to open his mouth.
8. Don't try to put anything in his mouth.
9. Don't try to give him or her anything to
drink during the seizure.
10. Comfort the patient as he starts to wake up
afterwards. Help her get cleaned up. if she
wet or soiled herself during the seizure.
Indications for AED treatment
Q. When should AED be started?
When the diagnosis of epilepsy is made
Epilepsy – recurrence of two or more spontaneous
cerebral seizures
AED treatment for single unprovoked seizure
 Focal seizure
 Signs of a focal lesion on neurologic exam
 Abnormal EEG
o focal slowing
o epileptiform activity
 Abnormal neuroimaging
General Principles for Initiation of Antiepileptic
Drug (AED) Treatment
 Aim for monotherapy
 AED choice dependent on seizure type or
epileptic syndrome
General Principles for Initiation of Antiepileptic
Drug (AED) Treatment
 Start low, go slow.
 Start at a low dose and gradually
increase until seizures are controlled or
toxic effects appear (be guided by
pharmacokinetics)
 If first drug fails, try a second drug with
similar efficacy and withdraw the
previous drug gradually (overlap
according to half-lives)
Antiepileptic Drug Treatment
Generalized Seizures
Partial Seizures
Choice of AED
 Efficacy
 Safety
 Side Effects
 Ease of use
 Cost
 Availability
Treatment Goals for Epilepsy
 Treatment of underlying cause
 Control of seizures
 Quality of life
by: Paulo Mara
August 2, 2010
Gradual Discontinuance of AED’s maybe considered
if the patient meets the following :
 Seizure - free 2 to 5 years on AED’s (mean 3-
5 years)
 Single type of partial seizure or single type
of primary generalized tonic-clonic seizures
 Normal neurologic examination / normal
I.Q.
 EEG normalized with treatment
Prognosis
 60 - 70% will respond to monotherapy
 10 - 15% will respond to at least 2 AEDs
 Half of responders (both groups above)
will be successfully withdrawn from
AEDs
 10 - 12% will be medically intractable
Factors associated with increased risk of relapse
 Long duration of epilepsy
 Difficulty in achieving control of seizure
 Duration of remission
 Seizure type / epilepsy syndrome
 Presence of additional handicaps
Status Epilepticus
 Seizures so frequent or so prolonged as
to create a fixed and lasting condition.
(Mortality : 20- 30%)
 A continuous, generalized tonic-clonic
seizure lasting more than 30 minutes or
absence of lucid intervals in between
seizures
 Most seizures last for 3 to 5 minutes
and occasionally up to 10 minutes. If
seizure persists more than 10 minutes,
therapeutic intervention must be
initiated
 EEG monitoring is a must.
PHASE I: Compensation Phase 30 mins of
continuous seizures
PHASE II: Decompensation Phase
The rate and extent of physiological change is
dependent on:
1. Etiology
2. Site of seizures
3. Severity of seizures
4. Rapidity of treatment
Treatment of Status Epilepticus
 establish airway
 determine blood pressure
 administer dextrose and thiamine
 terminate SE
 prevent recurrence of SE
 treat complications
 Seizures and Epilepsy by: Paulo Mara
Hazel Paragua, MD, MBA, FPNA August 2, 2010

Immediate Measures of EEG monitoring.

 secure airway
 give oxygen Indications for Intravenous Antiepileptic Drugs
 assess cardiac and respiratory function  Patients who are unable to swallow
 secure intravenous (IV) access in large  Rapid initiation of therapy with a new
veins agent
 Rapid correction of low AED level
Protocol for Management of Status Epilepticus  Seizure emergencies
 Acute, repetitive seizures
Time: 0 minutes  Prolonged seizures
 Status epilepticus
Initiate general systemic support of the airway and
BP; Factors Influencing IV AED Choice
 Indication
Begin nasal O2; monitor EKG and respiration; check  Seizure type
T°;  Prior AED therapy
 Need for rapid treatment
Obtain history; perform neurological examination.  Ease of dosing/administration
 Complicating medical conditions
Send sample serum for evaluation of e¯, BUN, RBS,  Potential adverse effects
CBC, drug screen, and anticonvulsant levels; check  Need for long term AED therapy
ABG’s.
Ideal IV AED Characteristics
Start IVF with isotonic saline at a low infusion rate.  Ease of administration
 Rapid onset of action
Inject D50-50 and 100 mg thiamine.  Intermediate to long duration
 Broad spectrum
Time: 0 minutes  Minimal morbidity
 Useful as maintenance AED
Start EEG recording as soon as possible.  IV solution compatibility

Administer diazepam 0.3 mg/kg IV; immediately IV AED Options

followed by Phenytoin 20 mg/kg IV with an  Benzodiazepines
additional 10 mg/kg IV if seizures continue  Diazepam
OR  Lorazepam
Administer lorazepam 0.1-1.5 mg/kg IV; if seizures  Phenytoin
persist administer fosphenytoin 18 mg/kg IV with an  Fosphenytoin
additional 7 mg/kg if seizures continue  Phenobarbital
 Valproate sodium
Time: 20 - 30 minutes (if seizures persist)  Levetiracetam

Intubate, insert bladder catheter, start EEG When to Call the Ambulance or Rush to the
recording, check T°. Emergency Room

Administer phenobarbital, loading dose of 20 mg/kg When a seizure doesn't show any signs of stopping
IV after five minutes.

Time: 40 - 60 minutes (if seizures persist)
Begin pentobarbital infusion 5 mg/kg IV initial dose
then push until seizures have stopped using EEG
monitoring; continue pentobarbital infusion at 1
mg/kg/hr; slow infusion rate every 4-6 hours to
determine if seizures have stopped, with EEG
guidance; monitor BP and respiration carefully.
Support blood pressure with pressors if needed.
When the seizure happened in water and there's any
chance that the patient inhaled or swallowed a lot
of water.
When a patient doesn't recover consciousness or
isn't breathing properly afterwards
When a patient vomits during the seizure and then
doesn't come round or isn't breathing properly
afterwards

Time: 40 - 60 minutes (if seizures persist) When another seizure starts soon after the first one.

Begin midazolam at 0.2 mg/kg then at a dose of 0.75
to 10 g/kg/min titrated to EEG monitoring.,
OR
Begin propofol at 1-2 mg/kg loading followed by 2-
10 mg/kg/hr. Adjust maintenance dose on the basis
When an unexpected seizure happens in a person
who does not have epilepsy.
When the patient is pregnant, diabetic or is injured.
 Seizures and Epilepsy
Hazel Paragua, MD, MBA, FPNA
Frequent Reactions to the Diagnosis of Epilpesy
 Denial
 Anger
 Despair
 Fear
 Shame
 Uncertainty
 Hopelessness
-paulo mara
As doctors, as friends, as human beings, we all try
to do the best we can. But the world is full of
unexpected twists and turns. And just when you’ve
gotten the lay of the land, the ground underneath
you shifts. And knocks you off your feet. If you're
lucky, you'll end up with nothing more than a flesh
wound, something a bandaid will cover. But, some
wounds are deeper than they first appear, and
require more than just a quick fix. With some
wounds, you have to rip of the bandaid, let them
breathe and give them time to heal.
BREAK TIME sa pag rereview pang patanggal
stress..
10 Conyo-mandments
by Gerry Avelino and Arik Abu
1. Thou shall make gamit "make+pandiwa".
ex. "Let's make pasok na to our class!"
"Wait lang! I'm making kain pa!"
"Come on na, we can't make hintay anymore! It's
in Andrew pa, you know?"
2. Thou shall make kalat "noh", "diba" and "eh" in
your pangungusap.
ex. "I don't like to make lakad in the baha nga, no?
Eh diba it's like, so eew, diba?"
"What ba: stop nga being maarte noh?"
"Eh as if you want naman also, diba?"
3. When making describe a whatever, always say
"It's SO pang-uri!"
ex. "It's so malaki, you know, and so mainit!"
"I know right? So sarap nga, eh!"
"You're making me inggit naman.. I'll make bili
nga my own burger."
4. When you are lalaki, make parang punctuation
"dude", 'tsong" or "pare"
ex. "Dude, ENGANAL is so hirap, pare."
"I know, tsong, I got bagsak nga in quiz one, eh"
5. Thou shall know you know? I know right!
ex. "My bag is so bigat today, you know"
"I know, right! We have to make dala pa kasi the
jumbo Physics book eh!"
6. Make gawa the plural of pangngalans like in
English or Spanish.
ex. "I have so many tigyawats, oh!"
by: Paulo Mara
August 2, 2010
7. Like, when you can make kaya, always use like.
Like, I know right?
ex. "Like, it's so init naman!"
"Yah! The aircon, it's, like sira!"
8. Make yourself feel so galing by translating the
last word of your sentence, you know, your
pangungusap?
ex. "Kakainis naman in the LRT! How plenty tao, you
know, people?"
"It's so tight nga there, eh, you know, masikip?"
9. Make gamit of plenty abbreviations, you know,
daglat?"
ex. "Like, OMG! It's like traffic sa LRT"
"I know right? It's so kaka!"
"Kaka?"
"Kakaasar!"
10. Make gamit the pinakamaarte voice and
pronunciation you have para full effect!
ex. "I'm, like, making aral at the Arrhneo!"
"Me naman, I'm from Lazzahl!"
Ways of dealing with the burdens of life:
1. Accept that some days you're the pigeon, and
some days you're the statue.
2. Always keep your words soft and sweet, just in
case you have to eat them.
Always read stuff that will make you look good if
you die in the middle of it.
Drive carefully. It's not only cars that can be
recalled by their Maker.
If you can't be kind, at least have the decency to
be vague.
3. If you lend someone $20 and never see that
4. person again, it was probably worth it.
5. It may be that your sole purpose in life is simply
to serve as a warning to others.
6. Never buy a car you can't push.
7. Never put both feet in your mouth at the same
time, because then you won't have a leg to
stand on.
8. Nobody cares if you can't dance well. Just get up
and dance.
… (excertpts from “I am an MD-to be”) its already
5am and i dont feel like sleeping yet... my class is at
7am but what the heck.. im getting used to this
routine of killing myself softly (i can take a nap
during lectures any way! haha)... it feels like every
day is the same pressure- and stress-filled day... i
know a lot of people can relate to this circulating
"med anxiety" or watever u call it... its only been 4
weeks and i can see that a lot of people are on the
verge of giving up on this career/vocation we
enrolled in to... i cant deny the fact that I am on the
verge of giving up too... but i would never do so...
this is the life I've chosen to pursue... and there's no
turning back... this is the life we wanted, this is the
life I wanted so I would carry on no matter what.