Epilepsy and Seizures

1
Epilepsy and Seizures

• Clinical Correlation

2
Epilepsy and Seizures

• Definition of seizures and epilepsy
• Epidemiology
• Classification of seizures
• Examples
• Focal motor seizures
• Complex partial seizures
• Temporal lobe epilepsy and frontal lobe epilepsy
• Generalized seizures

3
What are Seizures?

• Clinical Definition of Seizures
• Paroxysmal episodes of brain dysfunction
  manifested by stereotyped alteration in behavior
• Clinical manifestations of a seizure based on
  anatomy of the brain that is seizing
• Symptoms sensory, motor, autonomic with or
  without loss of consciousness
• Epilepsy is recurrent and unprovoked seizures

4
What are Seizures?

• Cellular Definition
• Excessive or oversynchronized discharges of
  cortical neurons
• Primarily grey matter!!!!!!
• Ineffective recruitment of inhibitory neurons
  together with excessive neuronal excitation
• GABA receptor mediates inhibition responsible for
  normal termination of a seizure.
• NMDA (Glutamate) receptor activation required for
  propagation of seizure activity

Seizure
NMDA Rcptr Activation
Reduced GABAa Rcptr function
5
Epidemiology

• Approximately 1 population (3 million epilepsy
  cases in US).
• Second most common neurological disease
• Comparable prevalence in men vs. women

Begley CE et al. Epilepsia 200041342-351 MMWR
Weekly. November 11, 1994/43(44)810-811,817-818 S
ander JW. Cur Opin neurol 200316165-170
6
Epilepsy Incidence Rates by Age
Incidence per 100,000
Age (years)
Data from Rochester, MN (1975-84) Hauser WA et
al. Epilepsia. 199132429-445.
7
Seizure Terms

• Ictalseizure
• Post Ictalafter the seizure
• Aurasensation seconds before seizure occurs
• Automatismsnonsensical movements that pts do
  during a seizure.
• Convulsionsshake
• Tonicposturing
• Clonicrepetitive, forceful rhythmic movements

• Complexlose consciousness
• Simpledont lose consciousness
• Partialinvolving part of the brain
• Generalizedinvolving whole brain
• Grand mal and petite malstreet terms for
  convulsive and non-convulsive seizure
  respectively

8
Classification of Seizure TypesFocal Vs
Generalized

• Partial Seizures
• Simple Partial Seizures
• Motor
• Somatosensory
• Autonomic
• Psychological
• Complex Partial Seizures
• Simple partial with impaired consciousness
• Partial Seizures with generalization

• Generalized Seizures
• Absence seizures
• Tonic seizures
• Clonic seizures
• Tonic-Clonic seizures
• Atonic seizures
• Myoclonic seizures

9
Classification of Seizures

• Partial Seizures (focal onset)
• Simple Partial Seizure (without impaired
  consciousness)
• Motor Symptoms (aka focal motor seizure)
• Involves motor strip.
• Patients will have abnml movements of an
  extremity.
• Jacksonian March-spread or march of seizure
  over whole motor
• Todds paralysis-post ictal weakness of extremity
  that was seizing
• Somatosensory symptoms
• Involves sensory strip, temporal lobe (hearing
  and smell), occip (visual)
• Autonomic symptoms
• Involves temporal lobe (tachycardia, pallor,
  flushing, sweating)
• Psychological symptoms
• Involve frontal or temporal lobe (limbic system).
  Pts appear agitated

10
Partial SeizuresHomunculus
Neurology and Neurosurgery Illustrated. Lindsay,
Kenneth, Bone Ian, 3rd edition. Churchill
Livingstone, 1999.London
11
Classification of Seizures

• Partial Seizures
• Complex Partial Seizures (loss of consciousness)
• Simple partial onset followed by impaired
  consciousness
• Many times will progress to a generalized seizure
• Frequently seen in adult onset epilepsy
• Temporal lobe epilepsy usually involves complex
  partial seizures

12
Classification of Seizures

• Generalized Seizures (diffuse onset)
• Always with loss of consciousness
• Can be with convulsive or nonconvulsive movements
• Types
• Absence seizures
• Clonic seizures
• Tonic seizures
• Tonic Clonic seizures
• Myoclonic seizures (rapid jerks)
• Atonic seizures (drop attacks)

13
Generalized Seizures

• Consciousness
• 2 Systems Involved
• Both Cerebral Hemispheres
• Reticular Activating System
• various neurotransmitters

14
Classification of Seizures

• Unclassified Seizures.
• Pseudoseizures-Are clinical manifestations
  anatomically impossible?
• Can be conversion or malingering
• Many pts have history of abuse
• Commonly seen when observers around
• Episodes involve disorganized movements that
  are not clearly tonic-clonic
• Pelvic thrusting
• Violent behavior directed towards certain people
• VideoEEG can be helpful in diagnosing

15
Etiology for Seizures

• Pediatric Etiology
• Genetic
• Congenital malformations
• Infection
• Tumor
• MetabolicDisorders
• Idiopathic

• Adult Etiology
• Tumor
• Trauma
• Vascular
• Infection
• Occult cortical dysplasias
• Idiopathic

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Seizure Phenotypesthink of anatomy!!
17
Cortex
Central Sulcus
Frontal Eye Field
Visual Assoc. Cortex
Brocass Speech Area
Primary Visual Cortex
Wernickes Speech
Primary Auditory Cortex
Sylvian Fissure
18
Frontal Lobe

• Frontal Eye Field (Brodmans 8)
• Lesion deviation of eyes to ipsilateral side
• Sz overstimulation-gteyes to contralateral side
• Prefrontal Cortex (Brodmans 9-12,46,47)
• Lesion deficits in concentration, judgment and
  behavior
• Sz agitation, odd behavior
• Brocas Speech Area (Brodmans 44,45)
• Lesion/Sz expressive nonfluent aphasias
• Primary Motor Cortex (Brodmans 4)
• Lesion contralateral spastic paresis
• Sz contralateral posturing/convulsions

19
Temporal Lobe

• Hippocampal Cortex
• Bilateral lesions inability to process short
  term to long term memory
• Sz chronic seizures lead to deficits in short
  term memory
• Wernickes Speech area (Brodmans 22)
• Lesion/Sz loss of receptive speech, fluent
  aphasia
• Anterior Temporal Lobe
• Bilateral lesions Kluver-Bucy syndrome of
  visual agnosia, oral tendencies, hyperphagia,
  hypersexuality, docility
• Sz pts freeze and might have oral automatisms
• Primary Auditory (Brodmans 41, 42)
• Bilateral lesion cortical deafness
• Sz auditory hallucinations
• Olfactory Bulb (Brodmans 34)
• Lesion ipsilateral anosmia
• Sz olfactory and gustatory hallucinations

20
Limbic System

• Means border in Latin
• Border between cortex and hypothalamus
• Involved with emotional behavior
• Fear/anger/sexual behavior
• Short term memory
• Includes
• Hippocampus
• Fornix
• Mammilary bodies
• Ant. Nucleus thalamus
• Cingulate cortex
• Seizures involving the hippocampus can have
  clinical symptoms of poor short term memory and
  abnormal mood

21
Parietal and Occipital Lobe

• Primary Sensory Cortex (Brodmans 3,1,2)
• Lesion contralateral hemihypestheisa and
  astereognosis
• Sz contralateral sensory symptoms ie tingling,
  heat
• Occipital lobe (Brodmans 17)
• Lesion contralateral hemianopsia with macular
  sparing
• Sz flashing or colored lights in contralateral
  visual field

22
Clinical Cases
23
Case 1

• 38 year old male with episodes of right arm
  tingling with occasional stiffening of right
  hand/wrist with no loss of consciousness.
  Episodes last lt30sec can occur multiple times a
  week.
• PMH
• Resected oligodendroglioma involving left
  parietal cortex 10 years ago.
• Social History
• Works as a driver of a snow plow, married no
  children
• Exam
• Within normal limits, non-focal
• EEG
• Frequent abnormal discharges and slowing over the
  left parietal area

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Case 1
25
Case 1

• Seizure type
• Simple partial seizure with onset over the left
  sensory-motor strip
• Patient does not lose consciousnesssimple
• Focal onset over left sensory-motor stripright
  hand symptoms

26
Case 2

• 36 year old male with monthly episodes of
  burning smell and epigastric rising and loss
  of consciousness. Peers noticed staring spells
  with loss of speech and eyes looking to the
  right. Patient had one episode 2 years ago of
  convulsions.
• PMH
• None
• Social Hx
• Works as a paramedic, married with 2 children
• Exam
• Within normal limits and non-focal
• EEG
• Rare left temporal abnormal discharges

27
Case 2
28
Case 2

• Seizure Type
• Complex partial epilepsy with focal onset over
  the left temporal lobe
• Patient has aura prior to onset of seizure
• Aura involves gastric uprisingseen with temporal
  onset
• Loss of consciousnesscomplex partial
• Loss of speech, aphasialeft hemisphere dominant
  for speech
• Eyes look to rightspread of seizure to left
  frontal eye field

29
Case 3

• 21 year old female with episodes at night of
  awakening with bitten tongue. Spouse notices
  stiffening of arms and legs during sleep. During
  the daytime, patient is noticed by family to
  appear agitated with alteration of consciousness.
  
• Outside physicians have been concerned for
  pseudoseizrues
• PMH
• History of febrile seizures when she was an
  infant
• Social History
• Housewife, has a 3 year old son
• Exam
• Within normal limits, non-focal
• EEG
• Outpatient 20 minute eeg read as within normal
  limits
• -gt To best characterize these events we
  recommended VideoEEG
• gt20 seizures recorded in first 24 hrs
• Episodes of alteration of consciousness were
  seizures.

30
Case 3
31
Case 3

• Seizure Type
• Complex partial seizures with onset over the
  right frontal lobe
• Alteration of consciousnesscomplex partial
• Agitated behavior frontal/temporal onset

32
Case 4

• 23 year old female with history of daily episodes
  of blurry vision and right sided tingling
  lasting few seconds. No loss of consciousness
• PMH
• None
• Social Hx
• College student
• Exam
• Post-ictal patient has a right field cut with
  right armgtleg weakness. Symptoms resolve 5
  minutes after the seizure.
• Brain MRI-normal
• EEG
• Frequent left parietal and occipital abnormal
  discharges and brief seizures.

33
Case 4
34
Case 4

• Seizure Type
• Simple partial seizure with onset over the left
  parietal/occipital region
• No loss of consiousnesssimple partial seizure
• Visual symptomsoccipital lobe
• Right armgtleg tinglingleft parietal region
• Post-ictal symptomssuggestive of a Todds
  paralysis

35
Case 5

• 22 year old female with history of convulsive
  seizures that occur around 1 every 3 months.
  Seizures occur at night and with no warning.
• PMH
• None
• Social Hx
• College student
• Exam
• Within normal limits, non-focal
• EEG
• Generalized spike and wave abnormal discharges

36
Case 5
37
Case 5

• Seizure Type
• Primary generalized epilepsy with tonic-clonic
  seizures
• Loss of consciousness, no aurageneralized onset
• EEG with generalized dischargesgeneralized
  epilepsy

38
Seizure Management
39
Seizure Treatment

• Acute Management
• 90 of seizures stop without treatment in under 5
  minutes!!!
• Can give ativan or valium for seizures gt5min
• Monitor ABCDs, avoid injury and aspiration
• Long Term Management
• Anti-epileptic medications
• Surgery-Best for temporal lobe epilepsy
• VNS (vagal nerve stimulator)

40
Anti Epileptic Medication

• Older Agents
• Phenobarbital (Mysoline)
• Dilantin
• Depakote
• Tegretol
• Ethosuximide

• Newer Agents
• Lamictal
• Keppra
• Topamax

41
Other Treatment Options

• Ketogenic diet in children
• Surgery
• Removal of epileptic focus
• Mostly for patients with temporal lobe seizures
• Possibility of a 70 chance of cure!!
• VNS (Vagal nerve stimulator)
• Current given to vagus nerve with theory of
  decreasing seizures over time

42
Guideline for Management of the Adult Seizing
Patient1

• General Management
• Call for help
• Assess and secure the airway
• Do not place anything in the mouth except when to
  suction
• DO NOT try to force suction/airway through
  clenched teeth
• When the patient stops convulsing, place patient
  in lateral decubitus.
• Begin supplemental oxygen
• Assess safety of the patient
• Ensure lights in room are on
• Remove any object within reach of patient that
  could cause injury
• Loosen clothing
• Side rails should be up if patient is in bed
• Do not try to hold the patient down
• Obtain vital signs including pulse oximetry and
  stat accucheck
• Ask an associate to notify the primary service
• If concerned for overdose or withdrawal, contact
  toxicology service (pager 19708) and consider
  100 mg pyridoxine IV (alternative management may
  be necessary)
• If glucose is lt 70 mg/dl (or if accucheck
  unobtainable) administer amp D50.
• Note Ideally,100mg thiamine IVPB should be given
  prior to, or soon after, glucose
• Check CBC, BMP, Mg, Phos, urine tox. If patient
  on AEDs draw levels

43
Guideline for Management of the Adult Seizing
Patient1

• Initial Assessment
• Observation of the seizing patient is critical
  for diagnosis and management!
• Note time of the seizure and its length
• Assess
• Mental status/level of consciousness-can patient
  follow commands?
• Language function-can patient speak? Understand
  when spoken to? Is speech appropriate?
• Motor activity-does the patient have motor
  automatisms (picking, rhythmic movements), tonic
  (rigid), and/or clonic (jerking) movements? What
  part of body is involved in the movements? (face,
  arm, leg?) Are movements unilateral or bilateral?
  Is there head deviation, eye deviation? And to
  which side?

44
Guideline for Management of the Adult Seizing
Patient1

• At 3-5 minutes- Prolonged Seizure
• Note Most seizures cease without any medical
  intervention within 1-3 minutes
• General Management
• Consult neurology (pager 91516)
• Continue to monitor vital signs and assess airway
  (Q5 minutes).
• Continue to ensure patient safety
• Consider activating the rapid response team (if
  pt. is admitted)
• At 10 minutes - if seizures persist, patient is
  in Status Epilepticus (S.E.)
• Arrange transfer to the ICU
• Refer to LUMC Guidelines for the Acute Management
  of Status Epilepticus and Seizure Clustering in
  Adults and Children

45
Guideline for Management of the Adult Seizing
Patient1

• Medical Treatment (directed by primary service or
  neurology)
• First line agent
• Lorazepam (Ativan) 1-2mg IV one time.
• Can be repeated up to a dose of 0.1mg/kg IV at
  2mg/min.
• If IV access unavailable, consider IM
  administration.
• Monitor respiratory status
• Re-assess patient every 2 minutes for continued
  seizure activity. If seizures persist, consider a
  second line agent.
• Second line agents (select one of the following)
  
• Phenytoin (Dilantin) 20mg/kg IV at 50mg/min
• An additional 5-10mg/kg can be given
• Fosphenytoin (Cerebyx) 18-20mg/kg PE at
  150mg/minute
• An additional 5-10mg/kg PE can be given
• Neurology approval required for the use of
  Fosphenytoin
• If IV access is unavailable, consider IM
  administration.
• Newer agents are occasionally used at this stage
  
• Valproate (Depakote)
• Levetiracetam (Keppra)

46
Status Epilepticus
47
Status Epilepticus

• A Neurological EMERGENCY!!!!
• Definition
• A seizure that lasts greater than 30 minutes!
• Greater than 2 seizures in a row and patient does
  not regain consciousness in between
• Etiology
• New onset seizures, infection, trauma, SAH,
  Stroke, Drugs (legal and illegal), toxin, mets.
  Non-compliance with seizure meds

48
Status Epilepticus

• Initial Treatment
• ABCD!!!!!
• Lorezepam 2mg IV q2min x4
• Or diazepam 5mg IV x2
• Phenytoin (Dilantin) 15-18mg/kg IV
• Infuse slow, no greater than 50mg/min
• Evaluate for etiology
• Draw CBC, LFTs, head CT, Mg, Ca, drug screen
• Consider LP

49
Status Epilepticus

• Second line treatment (if initial fails)
• Phenobarbital-20mg/kg IV
• Watch for respiratory depression
• Depakote-10-15mg/kg IV
• Third line treatment
• Warrants an ICU admission/Intubation
• Pentobarbital
• 5mg/kg IV load and then titrate to burst
  suppression
• Midazolam
• 0.2mg/kg IV load and then titrate to burst
  suppression

50
Status Epilepticus

• Titrate IV agents to burst suppression

Suppression
Burst