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Seizures and Epilepsy Lecture Notes
May 28, 2024
Seizures and Epilepsy
Introduction
Seizure Definition:
Abnormal excessive synchronous electrical activity in the central nervous system leading to outward manifestations.
Causes of Seizures
Mnemonic: VITAMIN D and E
Vascular Causes:
Acute ischemic stroke
Intracerebral hemorrhage
Subarachnoid hemorrhage
Hypertensive encephalopathy / PRES (Posterior Reversible Encephalopathy Syndrome)
Severe anoxic brain injuries
Infectious Causes:
Meningitis
Encephalitis
Brain abscess
Traumatic Causes:
Epidural hematoma
Subdural hematoma
Autoimmune Causes:
Systemic lupus erythematosus (SLE)
Paraneoplastic syndromes
Metabolic Causes:
Thiamine (Vitamin B1) deficiency
Hypoglycemia (and less common hyperglycemia)
Hyponatremia (more common) / Hypernatremia
Hypocalcemia
Hypomagnesemia
Hypophosphatemia
Uremia
Liver failure (Ammonia buildup)
Hyperthyroidism
Idiopathic Causes:
Defined as epilepsy (≥ 2 unprovoked seizures >24 hours apart or 1 unprovoked seizure with a 60% recurrence rate)
Non-compliance or sub-therapeutic dose of anti-epileptic drugs
Epilepsy syndromes (West syndrome, Lennox-Gastaut syndrome, Juvenile myoclonic epilepsy)
Neoplasia:
Glioblastoma multiforme
Meningioma
Metastatic brain tumors
Drug Causes:
Mnemonic: OTIS CAMPBELL
Opioids, Tricyclic antidepressants, Anticholinergics, Isoniazid, Salicylates, Cocaine, Cefepime, Amphetamines, Metronidazole, Penicillins, Benzodiazepine withdrawal, Bupropion, Ethanol withdrawal, Lithium
Eclampsia:
Pregnant women
High blood pressure
Seizures
Other Causes
Fevers (esp. children with Roseola)
Genetic disorders
Pathophysiology
Increased stimulatory glutamate pathway
(NMDA, AMPA receptors → more cations → depolarization → action potentials)
Decreased inhibitory GABA pathway
(GABA-A receptors → chloride ions → hyperpolarization → decreased action potentials)
Focal seizures vs. generalized seizures
Focal: One hemisphere
Generalized: Bilateral hemispheres
Clinical Features
Phases of Seizure
Trigger:
Stress, sleep deprivation, bright lights/sounds, vitamin D and E causes
Aura:
Deja vu, impending fear, nausea, automatisms (e.g., rapid blinking, chewing, lip smacking)
Ictal Event:
Visible seizure activity (focal or generalized)
Post-ictal Phase:
Confusion, lethargy, amnesia, Todd's paralysis
Types of Seizures
Focal Seizures
Motor: Tonic, clonic, myoclonic, Jacksonian march (distal to proximal spread)
Sensory: Pain, paresthesias, visual/auditory/olfactory/gustatory hallucinations
Autonomic: Tachycardia, hypertension, urinary incontinence, salivation, sweating
Psychological: Emotional changes, hypersexual behavior, deja vu, depersonalization, derealization
Generalized Seizures
Motor:
Tonic-clonic (Grand mal), Atonic, Clonic, Tonic, Myoclonic
Features: Respiratory cry, up gaze, pooling of oral secretions, tongue biting, incontinence, tachycardia, hypertension
Non-motor:
Absence (Petit mal)
Features: Staring, daydreaming, rapid blinking, lip smacking, no post-ictal state
Diagnostic Indicator: EEG shows 3 Hz spike and wave pattern
Diagnosis
History of Seizures
: Assess AED (Anti-Epileptic Drug) levels
If low: Increase dose
If normal: Adjust or switch AED
First-time Seizure:
Vascular:
CT, MRI, Lumbar puncture
Infectious:
CT, MRI, Lumbar puncture, Blood cultures, CBC
Trauma:
CT scan for hematomas
Autoimmune:
Autoimmune panel, CT chest/abdomen/pelvis
Metabolic:
Check B1, glucose, BMP + Mg/Phos, TSH with reflex, ammonia, liver function
Idiopathic:
Evaluate AED compliance
Neoplasia:
CT, MRI with contrast
Drugs:
Review med list, toxicology screen
Eclampsia:
Urine/serum beta HCG
Others:
Temperature, genetic testing
Additional Labs:
CK, Lactate, Prolactin, Troponin, EKG
EEG:
Essential to check for abnormal electrical activity
Treatment
Initial Management:
ABCs (Airway, Breathing, Circulation), reverse easy causes, benzodiazepines
Status Epilepticus:
Seizure > 5 mins or multiple seizures without recovery
ABCs, reverse easy causes, benzodiazepines (Lorazepam IV, Midazolam IM)
Proceed with AED loading (Levetiracetam, Phenytoin, Fosphenytoin, Valproate)
Continue with IV anti-epileptics (Propofol, Midazolam, Ketamine, Pentobarbital)
Add maintenance doses of AED
Consider ketogenic diet and further workup if seizures persist
Note:
Continual assessment and management based on patient status and underlying cause
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