OBJECTIVES

Define seizures and epilepsy

Discuss approach to the patient with
epilepsy
Discuss classifications of epilepsy
Brief review of epilepsy treatment
Discuss status epilepticus
 What is a seizure?

Abnormal synchronous firing of neurons

Presentation may vary depending on
area of brain affected and spread of
abnormal discharges
Consciousness may or may not be
spared
Tonic clonic, myotonic, absence
 20 year old female presents to the
emergency room after having had a
seizure while shopping at Walmart. She
has no history of seizures and felt well
all day long. Witnesses describe jerking
of all extremities. Her tongue is bitten
but she is currently awake and alert.
 History is crucial
Drinking/recreational drugs (did they try to
quit)
New medications (antidepressants can lower
threshold)
Family history
Recent or present illnesses? Fever?
History of prior similar events
 LABS
UDS
Electrolytes
Blood glucose
 Imaging

MRI is preferred (gets better look at

parenchyma)
CT may be done to rule out gross
pathology: bleeds, tumors, large stroke
(& can do MRI later)
CT may miss mesial temporal sclerosis,
cortical dysplasia, cavernoma, benign
temporal lobe tumors
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 EEG

Frequently normal. One routine EEG

may be normal in about 40% of people
with epilepsy.
Sensitivity may approach 90% with
repeat study. Sleep increases accuracy.
Repeat EEG or prolonged EEG
monitoring may be necessary
Is it epilepsy?
Should we start treatment?
 Definition of Epilepsy

A disease of the brain defined by any of

the following conditions:
At least two unprovoked seizure occurring
more than 24 hours apart
One unprovoked seizure and a probability of
further seizures similar to the general
recurrence risk (at least 60%) after two
unprovoked seizures occurring over the next
ten years
 5-10% lifetime risk of seizure
3% risk of epilepsy
After a single unprovoked seizure, risk
for another is 30-52%, with two
unprovoked seizures chance of another
seizure is 60-90%
Factors that increase risk
of recurrent seizure
History of previous seizure
Epileptiform abnormalities on EEG
Family history of epilepsy
Presence of a neurologic disorder:
Alzheimers, cerebral palsy,
developmental delay
Abnormal findings on MRI: tumors,
stroke, vascular malformations
 6 year old child presents to pediatric
clinic for spells of staring. Teachers
say this happens in school. Mom reports
she has noticed this on a daily basis.
The patient has been healthy, met all
milestones, is awake, alert, with normal
vital signs.
EEG is ordered
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 Is it epilepsy?
 Epilepsy is a family of
disorders with many subsets
 Generalized vs Focal
Epilepsy
Largely based on EEG findings
Generalized:bilateral synchronous
discharges
Focal: Originate within one hemisphere
 Generalized vs Focal
Epilepsy
Distinguishing between focal and
generalized epilepsy has important
implications for therapy and prognosis
Antiepileptic drugs may be more
appropriate for one type
Patients with focal epilepsy may be surgical
candidates
Children with some types of epilepsies
(generalized) may outgrow them
 17 year old female presents to PCP for
seizure. She has no history of seizures
but reports she has had little jerks in
the morning for the past year. On the
day she had her seizure she had been up
all night studying for a test but
otherwise felt well.
MRI is normal
 Epilepsy syndromes

Defined by age of onset, EEG patterns,

imaging features and co-morbidities
Childhood absence epilepsy
Childhood epilepsy with centrotemporal
spikes
Juvenile myoclonic epilepsy
Lennox Gastaut
Landau-Kleffner
 38 year old female with history of
seizures since childhood presents to
neurology clinic. She has been followed
by multiple neurologists and is on
multiple meds. Continues to have spells
described as funny feeling followed by
head turning, hand fumbling and lip
smacking
Initial EEG is normal
 Prolonged EEG monitoring
Helpful in defining spells as epileptic
vs non epileptic
Aids in seizure localization
 Can we find an etiology?
Our ability to make etiologically based
diagnoses is expanding as imaging, molecular
chemistry and genetics research expands (i.e.
Dravet syndrome and glucose transporter 1
deficiency, syndrome of epilepsy of infancy
with migrating focal seizures)
Allows a more targeted therapy (surgery,
quinidine)
 In most patients an etiology cannot be
defined.
 Treatment

AEDs are considered after more than

one seizure or if a high probability of
recurrent seizure exists
All AEDs have side effects
 Treatment

Try to tailor meds to type of epilepsy

(carbamazepine (tegretol) is better for
focal. Valproic acid (Depakote) better
for generalized)
Women of childbearing years deserve
special consideration
 60 year old female brought to the emergency
room for mental status changes. Family reports
she has been confused for a couple days now.
Today became less responsive.
In the ED has 3 tonic clonic seizures. Was given
Ativan and is now unresponsive.
Has no prior history of seizures
Is febrile, labs show leukocytosis
CT brain is unremarkable
 Status Epilepticus

Usually defined as a continuous seizure

or more than one seizure without
complete recovery in between, which
lasts for >30 minutes.
May occur in setting of epilepsy or
systemic illness
May be life threatening
 May be convulsive or nonconvulsive.
Convulsive may evolve into nonconvulsive
after treatment (EEG required)
May be generalized or focal
Abnormal loss of GABA and sustained
Glutamate lead to continuous neuronal
activity
This leads to autonomic instability and
neuronal injury
 May be seen in systemic illness, after
stroke, after drug withdrawal, trauma,
recreational drug use, hypoxia,
metabolic disturbances, meningitis,
encephalitis, tumors, post surgery
 Nonconvulsive Status

Accounts for approximately 50% of

status epilepticus, and 3%-37% of
patients presenting with altered mental
status
May present as confusion,
hallucinations, lethargy, subtle eye or
muscle movement
EEG required for definitive diagnosis
but treatment should be given when
clinical suspicion is high
 Treatment

Benzodiazepines, first line

ABCs
Phenytoin second line
Treat underlying cause, give glucose
and thiamine
 Refractory Status

Transfer to ICU for intubation, cardiac

monitoring
May try pentobarbital, midazolam, or
ketamine drips to elicit burst
suppression