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

 Often difficult to distinguish from tonic


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

CLONIC PHASE : Simple Motor Seizure


 Arise from the contralateral motor
 More frequent periods of relaxation cortex
 Increase in heart rate and BP  Versive or postural movements
 May occur in rapid succession leading to  May have Jacksonian march
status epilepticus  Usually progresses to a GTC seizure
 Incontinence: relaxation of sphincters after
end of 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 by: Paulo Mara
Hazel Paragua, MD, MBA, FPNA August 2, 2010

 Prolonged absence seizure Cryptogenic


 Medial part of the temporal lobe  West Syndrom
 Lennox – Gastaut Syndrome
EPILEPTIC SYNDROMES  Epilepsy with myoclonic – astatic seizures
 Epilepsy with myoclonic absences
 Syndrome : Disorder characterized by a
cluster of symptoms that commonly occur Localization – related (focal, local, partial)
together Idiopathic (primary)
 Benign childhood epilepsy with
 Epileptic syndromes : centrotemporal spikes
 Childhood epilepsy with occipital paroxysms
o clinical pathogenesis (i.e. whether  Primary reading epilepsy
they begin in one part of the brain
or in a bilaterally synchronous Symptomatic (secondary)
fashion  Temporal lobe epilepsies
 Frontal lobe epilepsies
o etiology
 Parietal lobe epilepsies
CRITERIA FOR SYNDROME CLASSIFICATION  Occipital lobe epilepsies
 seizure type  Chronic progressive epilepsies of childhood
 age at onset syndromes
 precipitating factors
 natural history Cryptogenic, defined by:
 cause  Seizure type
 anatomic localization of seizure onset  Clinical features
 ictal and interictal EEG abnormalities  Etiology
 Anatomical localization
Epilepsy Syndromes
Undetermined epilepsies
 IDIOPATHIC With both generalized and focal seizures
o Normal CNS function  Neonatal seizures
o No accepted pathologic correlate  Severe myoclonic epilepsy in infancy
of the syndrome  Epilepsy with continuous spike-waves during
o Interparoxysmal (background) EEG slow wave sleep
is normal  Acquired epileptic aphasia (Landau-Kleffner
o There maybe close family members syndrome)
with a similar condition
o AED treatment is usually effective Other undetermined epilepsies
 SYMPTOMATIC  Without unequivocal generalized or focal
 CRYPTOGENIC features

International Classification of Epilepsies, Special syndromes


Epileptic Syndromes, and Related Seizure
Disorders * Situation-related seizures (Gelegenheitsanfälle)

Generalized  Febrile convulsions


Idiopathic (primary)  Isolated seizures or isolated status
 Benign neonatal familial convulsions epilepticus
 Benign neonatal convulsions  Seizures occurring only when there is an
 Benign myoclonic epilepsy in infancy acute or toxic event due to actors such as
 Childhood absence epilepsy (pyknolepsy) alcohol, drugs, eclampsia, hyperglycemia
 Juvenile absence epilepsy
 Juvenile myoclonic epilepsy (impulsive petit *Commission on Classification and Terminology of
mal) the International League Against Epilepsy 1989
 Epilepsies with grand mal seizures (GTCS) on
awakening Childhood Absence Epilepsy
 Other generalized idiopathic epilepsies
 Epilepsies with seizures precipitated by  “pyknolepsy”
specific modes of activation  age of onset : 5 - 15 yrs.
 peak: 6-7 yrs.
Symptomatic (secondary)  absence seizures/daily; several times a
 Non-specific etiology day
 Early myoclonic encephalopathies  Typical EEG : 3 per second spike and
 Epilepsies in other disease states wave complex
 activated by hyperventilation
Seizures and Epilepsy by: Paulo Mara
Hazel Paragua, MD, MBA, FPNA August 2, 2010

Juvenile Myoclonic Epilepsy  Sleep myoclonus


 Drug adverse effects
 “Impulsive Petit Mal of Janz”  Tics
 Appears around puberty  Myoclonus
 Seizures - bilateral, single or repetitive  Dyskinesia
arrhythmic, irregular myoclonic jerks  Chorea
predominantly in the arms  TIA (transient ischemic attack)
 No disturbance of consciousness  Complicated/Acephalgic migraine
 Often associated with GTCS  Panic disorder
 Infrequent absences
 Seizures often occur after awakening Pseudoseizures
 Precipitated by sleep deprivation  Brief, very unusual behaviors:
 Interictal and ictal EEG : 4 – 6 Hz  copious motor activity, cursing, pelvic-
generalized spike / polyspike / slow waves thrusting
 Frequent photosensitivity  10% of all CPS don’t produce EEG change,
 Response to appropriate drugs is good most especially frontal lobe seizures
Benign Febrile Seizures  May have partly-preserved consciousness
although individual frequently amnesic for
 Onset between 3 months and 5 y/o event afterward
 Associated with fever without evidence of
intracranial infection or defined cause Basic Laboratory Tests
 More in males  CBC
 Recurrence : 1/3 will have at least 1  Random Blood Sugar
recurrence  Electrolytes, BUN, Creatinine
o ¾ of recurrences take place within  ECG
a year of the first seizure and 90%
within two years Neurodiagnostic Procedures
st
 The younger the child at the 1 attack; the
most likelihood of further febrile seizures Electroencephalography (EEG)
 Risk for epilepsy is small.  Epilepsy is essentially a clinical diagnosis
 It is increased when:  The most important single diagnostic
o seizure lasts more than 15 minutes procedure in patients with epilepsy
o more than 1 seizure in 24 hours  10% of epileptics will have a normal EEG
o focal features despite multiple recordings
o abnormal neurologic development/  A normal EEG does not exclude epilepsy
neuro exam  Not all abnormal EEGs mean epilepsy
 In the absence of specific clinical indications,
there is no Interictal EEG in Epilepsy
o further need for diagnostic tests
 Mainstay of treatment is fever control  confirms clinical diagnosis of epilepsy
 classification of seizure types
Epileptic vs Nonepileptic Events  definition of epileptic syndromes
 monitoring of response to AED
 Most patients with seizures have treatment
normal neurological exams,  evaluation of patients with single
neuroimaging and even EEG seizures
 Some patients may have events that  guide in the decision to discontinue
are difficult to classify AED treatment
 Most important tool for diagnosis:
GOOD HISTORY! Indications for Neuroimaging

Differential Diagnosis of Episodic Events in Adults  partial seizures especially in adults


 conditions which suggest progressive
 Paroxysmal vertigo neurologic disease or structural lesion
 Syncope/Convulsive syncope that may be surgically correctible
 Arrythmia  intractable seizures
 Paroxysmal abdominal pain
 Pheochromocytoma
 Sleep Disorders Simple First Aid for persons with seizure
 Paroxysmal nocturnal dystonia
 Episodic dyscontrol 1. First, clear everything out of the way.
 Transient global amnesia 2. Don't hold the patient down or try to stop
 Psychogenic seizures the jerking.
 Somnambulism 3. Put something flat and soft under the
 Sleep apnea patient’s head.
4. Make sure there's nothing tight round his
Seizures and Epilepsy by: Paulo Mara
Hazel Paragua, MD, MBA, FPNA August 2, 2010

neck that could interfere with breathing. Gradual Discontinuance of AED’s maybe considered
5. Check your watch so you'll know how long if the patient meets the following :
the seizure lasts.
6. Turn the patient gently onto one side so he  Seizure - free 2 to 5 years on AED’s (mean 3-
or she doesn't choke. 5 years)
7. Don't try to open his mouth.  Single type of partial seizure or single type
8. Don't try to put anything in his mouth. of primary generalized tonic-clonic seizures
9. Don't try to give him or her anything to  Normal neurologic examination / normal
drink during the seizure. I.Q.
10. Comfort the patient as he starts to wake up  EEG normalized with treatment
afterwards. Help her get cleaned up. if she
wet or soiled herself during the seizure. Prognosis
 60 - 70% will respond to monotherapy
Indications for AED treatment  10 - 15% will respond to at least 2 AEDs
Q. When should AED be started?  Half of responders (both groups above)
will be successfully withdrawn from
When the diagnosis of epilepsy is made AEDs
Epilepsy – recurrence of two or more spontaneous  10 - 12% will be medically intractable
cerebral seizures
Factors associated with increased risk of relapse
AED treatment for single unprovoked seizure
 Focal seizure  Long duration of epilepsy
 Signs of a focal lesion on neurologic exam  Difficulty in achieving control of seizure
 Abnormal EEG  Duration of remission
o focal slowing  Seizure type / epilepsy syndrome
o epileptiform activity  Presence of additional handicaps
 Abnormal neuroimaging
Status Epilepticus
General Principles for Initiation of Antiepileptic
Drug (AED) Treatment  Seizures so frequent or so prolonged as
to create a fixed and lasting condition.
 Aim for monotherapy (Mortality : 20- 30%)
 AED choice dependent on seizure type or  A continuous, generalized tonic-clonic
epileptic syndrome seizure lasting more than 30 minutes or
absence of lucid intervals in between
General Principles for Initiation of Antiepileptic seizures
Drug (AED) Treatment  Most seizures last for 3 to 5 minutes
and occasionally up to 10 minutes. If
 Start low, go slow. seizure persists more than 10 minutes,
 Start at a low dose and gradually therapeutic intervention must be
increase until seizures are controlled or initiated
toxic effects appear (be guided by  EEG monitoring is a must.
pharmacokinetics)
 If first drug fails, try a second drug with PHASE I: Compensation Phase 30 mins of
similar efficacy and withdraw the continuous seizures
previous drug gradually (overlap PHASE II: Decompensation Phase
according to half-lives)
The rate and extent of physiological change is
Antiepileptic Drug Treatment dependent on:

Generalized Seizures 1. Etiology


Partial Seizures 2. Site of seizures
3. Severity of seizures
Choice of AED 4. Rapidity of treatment
 Efficacy
 Safety Treatment of Status Epilepticus
 Side Effects
 Ease of use  establish airway
 Cost  determine blood pressure
 Availability  administer dextrose and thiamine
 terminate SE
Treatment Goals for Epilepsy  prevent recurrence of SE
 Treatment of underlying cause  treat complications
 Control of seizures
 Quality of life
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) When the seizure happened in water and there's any
chance that the patient inhaled or swallowed a lot
Begin pentobarbital infusion 5 mg/kg IV initial dose of water.
then push until seizures have stopped using EEG
monitoring; continue pentobarbital infusion at 1 When a patient doesn't recover consciousness or
mg/kg/hr; slow infusion rate every 4-6 hours to isn't breathing properly afterwards
determine if seizures have stopped, with EEG
guidance; monitor BP and respiration carefully. When a patient vomits during the seizure and then
doesn't come round or isn't breathing properly
Support blood pressure with pressors if needed. 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 When an unexpected seizure happens in a person
to 10 g/kg/min titrated to EEG monitoring., who does not have epilepsy.
OR
Begin propofol at 1-2 mg/kg loading followed by 2- When the patient is pregnant, diabetic or is injured.
10 mg/kg/hr. Adjust maintenance dose on the basis
Seizures and Epilepsy by: Paulo Mara
Hazel Paragua, MD, MBA, FPNA August 2, 2010

Frequent Reactions to the Diagnosis of Epilpesy 7. Like, when you can make kaya, always use like.
 Denial Like, I know right?
 Anger ex. "Like, it's so init naman!"
 Despair "Yah! The aircon, it's, like sira!"
 Fear
 Shame 8. Make yourself feel so galing by translating the
 Uncertainty last word of your sentence, you know, your
 Hopelessness pangungusap?

-paulo mara 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,


As doctors, as friends, as human beings, we all try
daglat?"
to do the best we can. But the world is full of
ex. "Like, OMG! It's like traffic sa LRT"
unexpected twists and turns. And just when you’ve
"I know right? It's so kaka!"
gotten the lay of the land, the ground underneath
"Kaka?"
you shifts. And knocks you off your feet. If you're
"Kakaasar!"
lucky, you'll end up with nothing more than a flesh
wound, something a bandaid will cover. But, some
10. Make gamit the pinakamaarte voice and
wounds are deeper than they first appear, and
pronunciation you have para full effect!
require more than just a quick fix. With some
ex. "I'm, like, making aral at the Arrhneo!"
wounds, you have to rip of the bandaid, let them
"Me naman, I'm from Lazzahl!"
breathe and give them time to heal.

BREAK TIME sa pag rereview pang patanggal Ways of dealing with the burdens of life:
stress..
1. Accept that some days you're the pigeon, and
10 Conyo-mandments some days you're the statue.
by Gerry Avelino and Arik Abu 2. Always keep your words soft and sweet, just in
case you have to eat them.
1. Thou shall make gamit "make+pandiwa". Always read stuff that will make you look good if
ex. "Let's make pasok na to our class!" you die in the middle of it.
"Wait lang! I'm making kain pa!" Drive carefully. It's not only cars that can be
"Come on na, we can't make hintay anymore! It's recalled by their Maker.
in Andrew pa, you know?" If you can't be kind, at least have the decency to
be vague.
2. Thou shall make kalat "noh", "diba" and "eh" in 3. If you lend someone $20 and never see that
your pangungusap. 4. person again, it was probably worth it.
ex. "I don't like to make lakad in the baha nga, no? 5. It may be that your sole purpose in life is simply
Eh diba it's like, so eew, diba?" to serve as a warning to others.
"What ba: stop nga being maarte noh?" 6. Never buy a car you can't push.
"Eh as if you want naman also, diba?" 7. Never put both feet in your mouth at the same
time, because then you won't have a leg to
3. When making describe a whatever, always say stand on.
"It's SO pang-uri!" 8. Nobody cares if you can't dance well. Just get up
ex. "It's so malaki, you know, and so mainit!" and dance.
"I know right? So sarap nga, eh!"
"You're making me inggit naman.. I'll make bili … (excertpts from “I am an MD-to be”) its already
nga my own burger." 5am and i dont feel like sleeping yet... my class is at
7am but what the heck.. im getting used to this
4. When you are lalaki, make parang punctuation routine of killing myself softly (i can take a nap
"dude", 'tsong" or "pare" during lectures any way! haha)... it feels like every
ex. "Dude, ENGANAL is so hirap, pare." day is the same pressure- and stress-filled day... i
"I know, tsong, I got bagsak nga in quiz one, eh" know a lot of people can relate to this circulating
"med anxiety" or watever u call it... its only been 4
5. Thou shall know you know? I know right! weeks and i can see that a lot of people are on the
ex. "My bag is so bigat today, you know" verge of giving up on this career/vocation we
"I know, right! We have to make dala pa kasi the enrolled in to... i cant deny the fact that I am on the
jumbo Physics book eh!" verge of giving up too... but i would never do so...
this is the life I've chosen to pursue... and there's no
6. Make gawa the plural of pangngalans like in turning back... this is the life we wanted, this is the
English or Spanish. life I wanted so I would carry on no matter what.
ex. "I have so many tigyawats, oh!"