(NEURO) 006 SEIZURES-and-EPILEPSY
(NEURO) 006 SEIZURES-and-EPILEPSY
(NEURO) 006 SEIZURES-and-EPILEPSY
OUTLINE DEFINITIONS
I. INTRODUCTION A. SEIZURE
A. Seizures
• An occasional excessive and disordered discharge of
B. Epilepsy nerve tissue (so seizure comes only from neuron or brain
C. Seizure vs Epilepsy cells)
D. Classification of Epileptic Seizure • Manifestation of transient hypersynchronous abnormal
II. SEIZURE DISORDERS neuronal behavior
A. Focal Seizures • Transient occurrence of signs and/or symptoms resulting
B. Generalized Seizures from abnormal excessive or synchronous neuronal activity
C. Epilepsy Syndromes (in Pediatrics) in the brain
III. REFERENCES • Paroxysmal disorder (It causes altered neurological
IV. TEST YOURSELF function secondary to abnormal cortical electrical
discharges of your brain or neuron)
I. INTRODUCTION • Altered neurological function
• Abnormal cortical electrical discharge
Learning Objectives • Beginning and an end Involuntary. (You cannot make
seizure of your own)
• Define what we mean by Seizures and Epilepsy • Seizures are grouped in several ways according to their
• Know the pathophysiology of seizures presumed etiology it can be Idiopathic (primary),
• Understand the different types of seizures symptomatic (secondary), site of origin, their clinical form
• Understand the different Epilepsy syndromes (generalized or focal), frequency, closely spaced
• Understand the causes of seizures sequence of status epilepticus) or by special
• Know what laboratory examinations should be requested electrophysiologic correlates.
in patient with seizure
• Know the emergency and long-term management of
seizures
• Know the management of Status Epilepticus
• Other issues
HISTORY TAKING
In getting a history of a patient who presents with seizure or Depending on the seizure type you can localize, especially if its
convulsion the following should asked if this is a real seizure or focal you can localize what area of the brain is affected. If its
not. generalized. Homunculus- Little brain mapping both for sensory
and motor cortex.
Questions:
• What was the patient doing just prior to the event? (Sitting, PATHOPHYSIOLOGY
running, eating)
• What happened during the event? (How does the patient
look like? was there upward rolling of the eyeball? was
there extension and flexion of extremities? was there
drooling of the saliva or is the patient just having blank
stare or is the patient have episodes of jerks)
• What was the patient’s condition just after the event? (Is
the patient febrile? was the patient tired? was the patient
sleep deprived?)
• Is it a seizure?
• If so, what kind?
• What caused it?
• What should be done?
This is important in choosing the right anti-seizure drug. Seizure • Epilepsy is a disease of the brain defined by any of the
generation is brought about now in the cellular level and in the following conditions:
synaptic level. i At least two unprovoked (or reflex) seizures occurring
>24 h apart (Ex. A month prior to consult the patient
At the cellular level, the interplay of cations plays a big role in has episodes of generalized seizure while sleeping,
seizure generation. Cations, they are positive the anions are the no consult was done, bo medications taken, and few
the negative. Positive ions are sodium, potassium and calcium. hrs to consult while the patient is sleeping again, the
On the other hand, if there’s influx of sodium in the cell, there is patient does episode of generalized seizure. Now,
also increase influx of water which causes neuronal swelling that unprovoked, you can diagnosed the patient as
causing increase tissue excitability producing seizure. having epilepsy, because diagnosis of epilepsy is
clinical and based on the symptom of the patient.)
In patient with generalized epilepsy, drugs that acts on sodium ii One unprovoked (or reflex) seizure and a probability
channel (carbamazepine and phenytoin). In calcium channels of further seizures similar to the general recurrence
specifically the t-type calcium channel, if there’s influx of calcium risk (at least 60%) after two unprovoked seizures,
(calcium going inside the cell) it causes cell hyperexcitability and occurring over the next 10 years (Ex. patient has 1
deep gray matters are involve in thalamic and cortical neurons unprovoked seizure but the patient has disability, no
(there’s a firing in thalamic and cortical neurons producing history of hypoxia, cns infection, traumatic brain injury
seizure). The t-type calcium channel, this is the pathophysiology even though there’s one episode, the general
of patients with absence epilepsy. It’s a generalized absence recurrence risk for those patient is at least 60% on
epilepsy, drug of choice is ethoxamide which acts to specific t- having the second seizure, then you can treat the
type calcium channel. In K channel, if you have decreased patient and label them as having epilepsy)
intracellular potassium it causes influx of calcium causing cell iii Diagnosis of an epilepsy syndrome (Ex. Juvenile
hyperexcitability producing the firing of thalamic and cortical myoclonic epilepsy, absence epilepsy west syndrome
neurons roducing seizure. etc.)
• Epilepsy is considered to be resolved for individuals who
At the synaptic level, this is the connection of one neuron to had an age-dependent epilepsy syndrome but are now
another, there’s an interplay of neurotransmitter (there’s a lot of past the applicable age or those who have remained
neurotransmitter but what we want specifically acts on gaba) the seizure-free for the last 10 years, with no seizure
one that acts on gaba which is inhibitory and glutamate which is medicines for the last 5 years. (the chance of recurrence is
excitatory. If there’s decrease inhibitory there will be increase like the normal population of around 1-4% having epilepsy)
excitatory. There’s hyperexcitable state producing seizure. This
• View issue TOC, Volume 55, Issue 4, April 2014, Pages
is the mechanism of action of benzodiazepine (diazepam and
475-482.
midazolam) acts on in the gaba neurotransmitter. In glutamate
• This is the specific definition of epilepsy, it’s the clinical/
which is excitatory, an increase excitatory concentration,
practical definition which was published by international
increase glutamate, there’s increase concentration of
league against epilepsy official report in 2014.
hyperexcitable neurotransmitter producing hyperexcitable state
producing seizure. • Epilepsy is a disease of the brain defined by any of the
following conditions:
B. EPILEPSY iv At least two unprovoked (or reflex) seizures occurring
• Seizure is a symptom; epilepsy is a disease. (don’t >24 h apart (Ex. A month prior to consult the patient
diagnose patient with seizure because seizure is a has episodes of generalized seizure while sleeping,
manifestation of epilepsy). By contrast, epilepsies no consult was done, bo medications taken, and few
manifesting as seizures that begin locally and may evolve hrs to consult while the patient is sleeping again, the
into generalized tonic-clonic seizures patient does episode of generalized seizure. Now,
that unprovoked, you can diagnosed the patient as
• Disorder characterized by the occurrence of at least 2
having epilepsy, because diagnosis of epilepsy is
unprovoked seizures (means the patient is apparently well,
clinical and based on the symptom of the patient.)
no fever, no metabolic imbalance, no CNS infection. So, if
the patient has 2 unprovoked seizure you can diagnosed a v One unprovoked (or reflex) seizure and a probability
patient having epilepsy) of further seizures similar to the general recurrence
• Is a disorder of the brain characterized by an enduring risk (at least 60%) after two unprovoked seizures,
occurring over the next 10 years (Ex. patient has 1
predisposition to generate seizures and by the
neurobiologic, cognitive, psychological, and social unprovoked seizure but the patient has disability, no
consequences of this condition? history of hypoxia, cns infection, traumatic brain injury
even though there’s one episode, the general
• Epileptic seizures are almost by definition associated with
recurrence risk for those patient is at least 60% on
some abnormality in the EEG provided that it is being
having the second seizure, then you can treat the
recorded at the time of the seizure.
patient and label them as having epilepsy)
Epilepsy by Fisher et al. vi Diagnosis of an epilepsy syndrome (Ex. Juvenile
myoclonic epilepsy, absence epilepsy west syndrome
• This is the specific definition of epilepsy, it’s the clinical/
etc.)
practical definition which was published by international
league against epilepsy official report in 2014.
PREPARED BY: CMED 2B Page 2 of 16
(006) SEIZURES & EPILEPSY
DR. J. VIADO | 03/16/2022
• Complex partial
• Simple partial
• Partial
• Psychic
• Dyscognitive
• Secondarily generalized tonic-clonic
FOCAL ONSET subserving the left upper extremity. after the seizure, the
patient looks very tired. This is an example of focal onset
aware of tonic clonic.
Motor
• Tonic – clonic
• Clonic – action (shaking)
• Tonic – rigid (arms straighten forward)
• Myoclonic – nagugulat/surprised
• Myoclonic tonic clonic
• Myoclonic atonic
• Atonic
• Epileptic spasms
Non-motor
• Typical
• Atypical
• Myoclonic
• Eyelid myoclonic – just like eye blinking – type of
generalized onset seizure
Figure 11. EEG – Focal Onset with Impaired Awareness
There’s a specific area or focality of epileptiform discharges over A. GO: TONIC-CLONIC SEIZURES
the bilateral form to central area (epileptiform discharges only in I. Tonic phase (Protracted extension)
some part of brain) • Breathing is suspended and after some seconds the
skin and lips may become cyanotic. The pupils are
dilated and unreactive to light.
GENERALIZED ONSET (GO) • This is the tonic phase of the seizure and lasts for 10
to 20 s
GENERALIZED ONSET
• Begin – Begin throughout both hemispheres, more or less
simultaneously
• Do not have – Do not have localized onset
• Reflect – Reflect generalized disturbance of cortical
function
III. Post-ictal phase • You can see that the patient is confused and then suddenly
• All movements have ended and the patient is she's okay and the EEG went back to normal again. so that
motionless and limp in a deep coma. The pupils now is your typical absence epilepsy.
begin to contract to light. Breathing may be quiet or • "It's just blank stares just like student looking at the class or
stertorous. This state persists for several minute. you guys looking at my or listening to my video without
actually understanding it, so sometimes, most of the
students like they have absence epilepsy or generalized
absence epilepsy"
• Electrical discharges associated with absence seizures
have a more stereotyped pattern of 3-per-second spike-
and-wave complexes that characteristically appear abruptly
in all leads of the EEG simultaneously and disappear
almost as suddenly at the end of the seizure.
B. GO: MYOCLONIC
There is a sudden jerking of the muscles specifically the right
hand that's why the patient actually was not able to hold the
spoon properly.
Characterized by a brusque, brief, muscular contraction, some
myoclonic jerks may be so small as to involve only one muscle
or part of a muscle; others are so large as to displace a limb on
one or both sides of the body or the entire trunk musculature
Table 1. Selected Epilepsy Syndromes by Age of Onset Figure 18. Spike example
West Syndrome Common Etiologies • Seizure types – tonic (mostly nocturnal), atonic,
• Tuberous Sclerosis (10-30%) myoclonic, atypical absence, generalized tonic clonic,
• Tuberous sclerosis is the most common it's actually a focal
neurocutaneous syndrome they have lesions in the skin • Associated EEG patterns – generalized 1-2 hz (happens
and lesions also in the brain. within one second) slow spike and wave, generalized
• Perinatal (15-25%) slowing, paroxysmal fast activity (recruiting rhythm) during
o Fetal infections sleep
o HIE (Hypoxic-ischemic encephalopathy) /perinatal • If you have a patient that presents with seizure definitely
brain injury request for an EEG to actually check if there's a specific
o Hypoglycemia syndrome for your patient
• Brain malformations • Common etiologies – variety of etiologies, proceeded by
• Metabolic abnormalities infantile spasms in 9-40% of cases
• Pyridoxine deficiency • Some, not all, Ohtahara syn developes West syn, then
• Chromosomal Abnormalities progress to LG Syndrome.
• Trisomy 21 • Treatment – felbamate, clobazam, rufinamide, topiramate,
• ARX zonisamide, ketogenic diet, valproate, levetiracetam, VNS,
• TSC1 corpus callosotomy, focal cortical resection (if there is a
• TSC2 focus)
• SCN2A • Prognosis – moderate to severe intellectual impairment,
• ETC. usually correlates with etiology and seizure control
II. REFERENCES
Viado, J. (2022, March 16). Seizures and Epilepsy
Anschel, David J.Neurology Pretest Self-assessment and Review. 6th Edition, McGraw-Hill
Robert M. Kliegman. Nelson Textbook of Pediatrics 20th Ed. 2016, Elsevier, Inc.
2. A 19-year-old right-handed man who carries the diagnosis of epilepsy is seen in the urgent care clinic. He had been healthy until
about age 12, when he began to have episodes of eye fluttering lasting several seconds. Sometimes he would lose track of his
thoughts in the middle of a sentence. There was one fall off of a bicycle that may have been related to one of these events. He has
been treated with valproic acid. At one point he was off all medications, but the seizures returned. He is now at the end of his first
semester of college and came in today because he had a witnessed generalized tonic-clonic seizure this morning. He had had only
about 2 hours of sleep the night before because he was studying for a final exam. Which of the following is the most appropriate
thing to tell this patient?
a) “I know that you faked this seizure to avoid taking a test.”
b) “Lack of sleep may have contributed to triggering this seizure.”
c) “You can expect to have tonic-clonic seizures on a regular basis from now on.”
d) “Your seizures are getting worse and there is nothing we can do about it.”
e) “You should take the next semester off to recover and get extensive testing.”
3. A 56-year-old man with epilepsy is brought into the emergency room. He has been having continuous generalized tonic-clonic
seizures for the past 30 min. He is treated with 2 mg of intravenous lorazepam. Most physicians recommend using a high dose of
intravenous benzodiazepine as part of the management of status epilepticus because it has which of the following qualities?
a) Ability to suppress seizure activity for more than 24 h after one injection
b) Lack of respiratory depressant action
c) Rapid onset of action after intravenous administration
d) Lack of hypotensive effects
e) Lack of dependence on hepatic function for its metabolism and clearance
4. A 34-year-old woman is having her medications tapered in the epilepsy monitoring unit. She has a convulsive seizure that does not
stop after 5 min, even after she receives a lorazepam injection. A second intravenous drug is given. Infusing which of the following
antiepileptic drugs at more than 50 mg/min in an adult may evoke a cardiac arrhythmia?
a) Carbamazepine
b) Diazepam
c) Phenobarbital
d) Clonazepam
e) Phenytoin
5. A 44-year-old man presents with left arm shaking. Two days ago, the patient noticed left arm paresthesias along the lateral aspect
of his left arm and left fourth and fifth fingers while he was reading. He thinks he may have been leaning on his left arm at the time;
the symptoms resolved after 30 seconds. This morning, he noted the same feelings, lasting a few seconds, but then his fourth and
fifth fingers started shaking rhythmically, and the shaking then spread to all of his fingers, his hand, and then his arm up to his elbow.
This episode lasted a total of 30 seconds. He denies any strange smells or tastes, visual changes, or weakness. Afterward, his
fingers felt locked in position for a few seconds. Then he felt as if he did not have control of his hand and had difficulty donning his
socks. He and his wife decided to drive to emergency room, and in the car he had trouble putting his seat belt latch into its socket.
Examination and routine labs are normal. Which of the following is the most appropriate next action?
a) Discharge the patient to follow up in clinic in 2 weeks
b) Obtain a brain MRI
c) Obtain an electroencephalogram
d) Obtain an orthopedic consult
e) Order electromyography and nerve conduction studies
6. A 31-year-old right-handed woman has a history of alcohol abuse requiring detox. Currently, she says she is drinking about nine
beers 3 days per week. She drank five glasses of wine and three beers 5 days ago. Last night, she had 10 beers. This morning, she
awoke feeling well. She was speaking with her fiancé, went to the bathroom, and got back into bed. She had no headache, fever,
chills, nausea, vomiting, or pain. Suddenly her body became stiff with arms flexed for a few seconds, followed by rhythmic jerking of
both arms. Her legs were shaking, but less so. Her eyes were open, and she was foaming at the mouth. After 1 min, this stopped,
and she initially did not recognize her fiancé or his sister. She slowly returned to a normal level of consciousness over a 10-minute
period. She remembers events just prior to the episode, and she remembers being in the car on the way to the hospital. Her only
medication is a multivitamin. She denies illicit drugs. Her examination is entirely normal. Routine labs and a brain MRI are normal.
Which of the following is the most likely underlying cause of her condition?
a) Autoimmune
b) Genetic
c) Infectious
d) Neoplastic
e) Toxic/metabolic
7. A 4-year-old boy has the onset of episodes of loss of body tone, with associated falls, as well as generalized tonic-clonic seizures.
His cognitive function has been deteriorating. EEG shows 1.5- to 2-Hz spike-and-wave discharges. Which of the following is the most
likely diagnosis?
a) Landau-Kleffner syndrome
b) Lennox-Gastaut syndrome
c) Juvenile myoclonic epilepsy
d) Mitochondrial encephalomyopathy
e) Febrile seizures
8. A 27-year-old man begins to experience infrequent episodes of nausea, warmth rising through his body, and an unusual odor like
rotting fish. His girlfriend notices that afterward he may develop twitching of the left side of his face and an inability to speak for
several minutes. Afterward the man appears dazed and cannot remember what has occurred. He has otherwise been well. Magnetic
resonance imaging (MRI) of his brain is most likely to show a lesion in which of the following areas?
a) Left occipital lobe
b) Right frontal lobe
c) Cribriform plate
d) Uncus
e) Left parietal lobe
9. An 18-year-old girl riding on the back of her boyfriend’s motorcycle without a helmet is brought in with a left frontal skull fracture and
cortical contusion. GCS is 10. She is admitted to the intensive care unit. She has had no seizures. Which of the following is true
regarding anticonvulsant therapy in this case?
a) It is contraindicated due to risk of rash
b) It is best achieved using phenobarbital
c) It is likely to cause increased cerebral edema
d) It is indicated to reduce the incidence of late posttraumatic epilepsy
e) It is indicated to reduce the incidence of early posttraumatic seizures
10. A patient with intractable complex partial seizures due to cortical dysplasia undergoes left temporal lobectomy. He is most likely to
develop which of the following problems after surgery?
a) Right superior quadrantanopsia
b) Right inferior quadrantanopsia
c) Right homonymous hemianopsia
PREPARED BY: CMED 2B Page 15 of 16
(006) SEIZURES & EPILEPSY
DR. J. VIADO | 03/16/2022
1. The answer is c. This is a common presentation for primary generalized epilepsy of childhood. An electroencephalogram showing
the classic 3-Hz spike-and-wave pattern would confirm this diagnosis. Brain MRI and CT are useful for evaluating brain anatomy.
Anatomic problems can cause seizures, but these tests will not provide any information about brain electrical activity. Lumbar
puncture is useful for measuring cerebrospinal fluid pressure and looking for central nervous system inflammation or infection. Central
nervous system inflammation or infection may cause seizures. Nerve conduction study is useful to evaluate peripheral nerve injuries
such as nerve entrapment.
2. The answer is b. Lack of sleep is a common seizure trigger. There is no reason to believe that the patient faked the seizure. It is
impossible to predict his future seizure course based on this one event; having one seizure does not necessarily mean that his
seizures are getting worse, and even if they are, many treatments are available. There is no reason for the patient to take a prolonged
leave of absence from school because of one seizure. This may even have detrimental psychological consequences
3. The answer is c. Until recently, the most popular benzodiazepine for use in status epilepticus was diazepam (Valium), which has a
rapid onset of action but is cleared relatively quickly. Because of this property, patients needed additional medications, such as
phenytoin, to protect them from recurrent seizure activity as early as 20 min after diazepam injection. A longer-acting benzodiazepine,
lorazepam (Ativan), has the advantage of acting rapidly like diazepam but being cleared more slowly from the brain.
4. The answer is e. Rapid infusion of phenytoin may produce a cardiac arrhythmia or hypotension. Phenytoin should not be administered
at rates greater than 50 mg/min in adults or 1 mg/(kgmin) in children to reduce the chances of this reaction occurring. Thus, it usually
requires approximately 20 min to administer a 1000- to 1500-mg standard loading dose of phenytoin in an emergent setting such as
status epilepticus. Fosphenytoin, a water-soluble prodrug of phenytoin, has the advantage of causing fewer infusion site reactions.
It can be given at doses of up to 150 mg/min in an adult, with risks of cardiac dysrhythmia similar to those of phenytoin. Another
advantage of fosphenytoin is that it can be administered intramuscularly when intravenous access is problematic. Carbamazepine is
not administered intravenously at all. Rapid infusion of phenobarbital may produce hypotension or respiratory arrest, but is much
less likely to depress cardiac activity. Diazepam and clonazepam are safer than phenobarbital, but rapid infusion of excessively high
doses may depress blood pressure and other autonomic functions.
5. The answer is b. This history is typical of a simple partial seizure. A focal brain lesion must be ruled out. It would be wrong to
discharge the patient to follow up in clinic in 2 weeks without at least a CT scan and preferably an MRI. Although he probably had a
seizure, obtaining an electroencephalogram at this point will not be as helpful as an MRI. This is unlikely to be a peripheral nerve
problem, and therefore an orthopedic consult or electromyography and nerve conduction studies are not indicated.
6. The answer is e. This is a typical example of alcohol withdrawal seizure. The greatest risk for alcohol withdrawal seizures occurs
within the first day after drinking cessation, in contrast to delirium tremens, which usually occurs within 2 to 4 days of drinking
cessation. There is no evidence of an autoimmune process in this patient. Rasmussen encephalitis is an example of a seizure
disorder thought to be of autoimmune etiology. There are many examples of genetically transmitted epilepsies, which usually present
during childhood. Infections such as meningitis, brain abscess, or encephalitis can cause seizures. Signs of these include meningeal
signs, fever, and MRI findings. If this patient had a brain tumor, you might expect a history of headache due to increased intracranial
pressure. Additionally, the exam and MRI would likely be abnormal.
7. The answer is b. Lennox-Gastaut syndrome is characterized by mental dysfunction, multiple seizure types and 1- to 2-Hz generalized
spike-wave discharges on EEG. It is often difficult to control the seizures that develop in children with this syndrome. Many affected
children have a history of infantile spasms (West syndrome). Infants and children with infantile spasms exhibit paroxysmal flexions
of the body, waist, or neck and usually have a profoundly disorganized EEG pattern called hypsarrhythmia.
8. The answer is d. Many patients with complex partial seizures have a preseizure phenomenon (the aura) that alerts them to an
impending seizure. This patient’s aura includes an olfactory hallucination, which is usually associated with lesions of the mesial
temporal lobe, particularly the uncus or parahippocampal gyrus. Diseases that can affect that region include tumors, trauma, and
mesial temporal sclerosis.
9. The answer is e. There is evidence that prophylactic phenytoin reduces the incidence of seizures after head injury. Because early
posttraumatic seizures may lead to increased morbidity and prolonged hospital stays, it is reasonable in some situations to treat
patients prophylactically. There is no evidence that prophylactic treatment reduces the long-term risk of developing posttraumatic
epilepsy
10. The answer is a. The most common complication of temporal lobectomy is a visual field defect due to interruption of fibers from the
optic tracts passing over the temporal horn of the lateral ventricles. Superior quadrantanopsia is more common than hemianopsia.
Some deficits may improve if the injury does not completely damage the nerves. Language deficits, particularly dysnomia, occur less
frequently. Hemiparesis is uncommon.