Seizure and Epilepsy
INTRODUCTION
•Epilepsy implies a periodic recurrence of seizures with or without
convulsions.
•A seizure results from an excessive discharge of cortical neurons and is
characterized by changes in electrical activity as measured by the
Electroencephalogram (EEG).
• A convulsion implies violent, involuntary contraction(s) of the
voluntary muscles.
Ddipiro. Epilepsy chapter 52 Section 9, Neurologic Disorders.
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EPIDEMIOLOGY
Approximately 50 million people worldwide have epilepsy, making it one
of the most common neurological diseases.
Available at: http://www.who.int/mediacentre/factsheets/fs999/en/. Accessed on November 7, 2016.
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CLASSIFICATION OF SEIZURES
Partial: Seizure activity
starts in one area of the brain.
Complex: Altered awareness
and behavior, e.g., confusion,
repetitive movements.
Simple: Patient remains
alert, e.g., jerking of a limb,
nausea, strange taste or smell
May become generalized (spreading from one area to
the whole brain).
Available at: https://www.epilepsy.org.au/sites/default/files/Seizure%20Smart%20-%20Classification%20of%20Seizures.pdf. Accessed on November 7, 2016.
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CLASSIFICATION OF SEIZURES
Generalized: Seizure involves whole
brain – consciousness is lost at the onset.
Tonic Clonic
Convulsion with loss of
consciousness, stiffening
of body, then jerking of
limbs.
Absence
Staring or trance-like
state.
Tonic or Atonic
Abrupt fall, either with
stiffening (tonic) or loss of
muscle tone (atonic or astatic
attacks)
Myoclonic
Sudden muscle
jerks
Available at: https://www.epilepsy.org.au/sites/default/files/Seizure%20Smart%20-%20Classification%20of%20Seizures.pdf. Accessed on November 7, 2016.
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CLASSIFICATION OF SEIZURES
Partial Seizures
Seizures are often very subtle or unusual, and may go unnoticed or be
confused with other events. They occur in one small area of the brain
and can sometimes spread to other regions
Simple Partial Seizures
There is no loss of awareness or consciousness and they usually last less
than a minute and include: Sensory – numbness, tingling or burning
sensation in a region of the body
Available at: https://www.epilepsy.org.au/sites/default/files/Seizure%20Smart%20-%20Classification%20of%20Seizures.pdf. Accessed on November 7, 2016.
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CLASSIFICATION OF SEIZURES
Partial Seizures
Simple Partial Seizures
Motor – Jerking of a limb, twitching of the face
Autonomic – Blushing, pallor, racing heart rate, nausea
Complex Partial Seizures
Many complex partial seizures begin with a vacant stare, loss of
expression or a vague, confused appearance. Consciousness or awareness
is altered, and the person may or may not respond.
Available at: https://www.epilepsy.org.au/sites/default/files/Seizure%20Smart%20-%20Classification%20of%20Seizures.pdf. Accessed on November 7, 2016.
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CLASSIFICATION OF SEIZURES
Generalized Seizures
Generalized seizures can also occur following a simple or complex
partial seizure. When this happens, they are termed a secondarily
generalized tonic clonic seizure.
Generalized Tonic Clonic Seizures
These are the most recognized seizures. They begin with a sudden
loss of consciousness and often the person will cry out. If standing,
the person will fall, their body stiffens (tonic) followed by jerking of
the muscles (clonic).
Available at: https://www.epilepsy.org.au/sites/default/files/Seizure%20Smart%20-%20Classification%20of%20Seizures.pdf. Accessed on November 7, 2016.
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GENERALIZED SEIZURES
Absence Seizures
•These seizures usually start in childhood (but can occur in adults), and are
sometimes mistaken for daydreaming and inattentiveness
•They start suddenly and are characterized by,
–
–
–
–
Staring
Loss of expression
Unresponsiveness
Stopping any activity they are doing
Myoclonic Seizures
• These seizures are very brief but intense muscle jerks usually involving the upper
body
• Many people mistake them for clumsiness as they often occur after awakening
resulting in dropping or spilling things
Available at: https://www.epilepsy.org.au/sites/default/files/Seizure%20Smart%20-%20Classification%20of%20Seizures.pdf. Accessed on November 7, 2016.
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GENERALIZED SEIZURES
Tonic Seizures
• These cause a sudden, brief stiffening of the muscles of the whole
body, causing the person to become rigid and fall rapidly if they are
standing
• Recovery is swift, but injuries can be sustained, tonic seizures can
also occur in sleep
Atonic seizures
•Atonic seizures are sudden, brief loss of muscle tone of the body
•The person will go limp and collapse, usually head first, so facial and
head injuries are common
• There is no noticeable loss of consciousness, and recovery is swift
unless the person is injured
Available at: https://www.epilepsy.org.au/sites/default/files/Seizure%20Smart%20-%20Classification%20of%20Seizures.pdf. Accessed on November 7, 2016.
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ETIOLOGY
Stroke
Congenital
abnormalities
Meningitis
Etiology
Encephalitis,
neurocysticerc
osis
Brain
tumor
Genetic
syndromes
Available at: http://www.who.int/mediacentre/factsheets/fs999/en/. Accessed on November 7, 2016.
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MECHANISM IN SEIZURE
Seizures result from excessive excitation or from disordered inhibition
of a population of neurons. Initially, a small number of neurons fire
abnormally.
Then normal membrane conductances and inhibitory synaptic currents
break down, excitability spreads locally (focal seizure) or more widely
(generalized seizure).
Ddipiro. Epilepsy chapter 52 Section 9, Neurologic Disorders.
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MECHANISM IN SEIZURE
Mechanisms that may contribute to synchronous hyperexcitability include,
• Alterations of ion channels in neuronal membranes
• Biochemical modifications of receptors
• Modulation of second messaging systems and gene expression
• Changes in extracellular ion concentrations
• Alterations in neurotransmitter uptake and metabolism in glial cells
• Modification in the ratio and function of inhibitory circuits
• Local neurotransmitter imbalances (e.g., glutamate, γ-aminobutyric acid [GABA],
acetylcholine, norepinephrine, and serotonin)
Ddipiro. Epilepsy chapter 52 Section 9, Neurologic Disorders.
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MECHANISM IN SEIZURE
•Large numbers of Generalized Tonic-clonic (GTC) seizures (more than
100) and multiple episodes of status epilepticus may be associated with
neuronal damage
•In particular, continued exposure to glutamate may contribute to
neuronal damage
Ddipiro, Epilepsy chapter 52 Section 9, Neurologic Disorders.
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DIAGNOSIS
•The patient and family should be asked to characterize the seizure for
frequency, duration, precipitating factors, time of occurrence, presence
of an aura, ictal activity, and post-ictal state
• Physical, neurologic, and laboratory examination (SMA-20, complete
blood cell count, urinalysis, and special blood chemistries) may identify
an etiology. A lumbar puncture may be indicated if there is fever.
Ddipiro. Epilepsy chapter 52 Section 9, Neurologic Disorders.
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OTHER DIAGNOSTIC TESTS
Electroencephalogram (EEG)
This is the most common test used to diagnose epilepsy. In this test,
doctors attach electrodes to your scalp with a paste-like substance. The
electrodes record the electrical activity of your brain.
Available at: http://www.mayoclinic.org/diseases-conditions/epilepsy/diagnosis-treatment/diagnosis/dxc-20117234. Accessed on November 7, 2016.
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OTHER DIAGNOSTIC TESTS
Computerized Tomography (CT) Scan
A CT scan uses x-rays to obtain cross-sectional images of your brain. CT
scans can reveal abnormalities in your brain that might be causing your
seizures, such as tumors, bleeding and cysts.
Available at: http://www.mayoclinic.org/diseases-conditions/epilepsy/diagnosis-treatment/diagnosis/dxc-20117234. Accessed on November 7, 2016.
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OTHER DIAGNOSTIC TESTS
Magnetic Resonance Imaging (MRI)
An MRI uses powerful magnets and radio waves to create a detailed
view of your brain. Your doctor may be able to detect lesions or
abnormalities in your brain that could be causing your seizures.
Available at: http://www.mayoclinic.org/diseases-conditions/epilepsy/diagnosis-treatment/diagnosis/dxc-20117234. Accessed on November 7, 2016.
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OTHER DIAGNOSTIC TESTS
Functional MRI (fMRI)
A functional MRI measures the changes in blood flow that occur when
specific parts of your brain are working.
Positron Emission Tomography (PET)
PET scans use a small amount of low-dose radioactive material that is
injected into a vein to help visualize active areas of the brain and detect
abnormalities.
Available at: http://www.mayoclinic.org/diseases-conditions/epilepsy/diagnosis-treatment/diagnosis/dxc-20117234. Accessed on November 7, 2016.
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OTHER DIAGNOSTIC TESTS
Single-photon Emission Computerized Tomography (SPECT)
This type of test is used primarily if you have had an MRI and EEG that
did not pinpoint the location in your brain where the seizures are
originating.
A SPECT test uses a small amount of low-dose radioactive material that
is injected into a vein to create a detailed 3D map of the blood flow
activity in your brain during seizures.
Available at : http://www.mayoclinic.org/diseases-conditions/epilepsy/diagnosis-treatment/diagnosis/dxc-20117234. Accessed on November 7, 2016.
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OTHER DIAGNOSTIC TESTS
Neuropsychological Tests
In these tests, doctors assess your thinking, memory and speech skills.
The test results help doctors determine which areas of your brain are
affected.
Available at : http://www.mayoclinic.org/diseases-conditions/epilepsy/diagnosis-treatment/diagnosis/dxc-20117234. Accessed on November 7, 2016.
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TREATMENT
•Non-pharmacological Treatment
Vagus nerve stimulation
Ketogenic diet
Activity restriction
•Pharmacological Treatment
Available at: http://emedicine.medscape.com/article/1184608-treatment#d10. Accessed on November 7, 2016
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TREATMENT – NON-PHARMACOLOGICAL TREATMENT
Vagus Nerve Stimulation
•The vagus Nerve Stimulation (VNS) is only for the treatment of partial seizures
•Open-label VNS registry results have also shown that some patients with generalized
tonic-clonic seizures respond well.
•In many years of clinical use of VNS, many patients with primary generalized seizures
have had seizure reduction
•No other surgical option exists for pure generalized tonic-clonic seizures
•Patients must be carefully evaluated and may necessitate video-EEG because some
partial seizures with quick secondary bilateral synchrony may be labeled as primary
generalized tonic clonic
Available at: http://emedicine.medscape.com/article/1184608-treatment#d10. Accessed on November 7, 2016.
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TREATMENT – NON-PHARMACOLOGICAL TREATMENT
Ketogenic Diet
•The exact mechanism by which this diet works is not known. The diet typically
contains a fat-to-carbohydrate ratio of 4:1
•The ketogenic diet is used for intractable epilepsy, especially in childhood.
•It is less commonly prescribed for adults because the diet, being very
restrictive, is very difficult to maintain. In adults, a high-protein diet is being
studied
•Adverse effects are mainly gastrointestinal and include bloating, constipation,
renal stones, and bone and weight loss. Urinary ketones are checked daily and
need to be greater than 4+ (80-160 mg/dL).
•In general, related to diet, avoid excessive amounts of stimulants such as
energy drinks
Available at: http://emedicine.medscape.com/article/1184608-treatment#d10. Accessed on November 7, 2016.
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TREATMENT
Activity Restriction
•Driving is restricted if patients are still having seizures as per
particular state laws
•In addition, common-sense restrictions for patients with epilepsy
should be followed, such as,
– Not operating dangerous equipment
– Not swimming alone
– Not taking baths unsupervised, among others
Available at: http://emedicine.medscape.com/article/1184608-treatment#d10. Accessed on November 7, 2016.
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PHARMACOLOGICAL TREATMENT
The epilepsies, the diagnosis and management of the epilepsies in adults
and children in primary and secondary care
Seizure
type
First-line AEDs
Adjunctive
AEDs
Generalized
tonic–clonic
Carbamazepine
Clobazam
Lamotrigine
Lamotrigine
Oxcarbazepine
Levetiracetam
Sodium valproate
Sodium
Other AEDs
that may be
considered on
referral to
tertiary care
(If there are absence or
myoclonic seizures, or if
JME suspected):
Carbamazepine
Gabapentin
Oxcarbazepine Phenytoin,
Pregabalin Tiagabine,
Vigabatrin
valproate
Topiramate
Tonic or
atonic
Sodium valproate
Lamotrigine
Do not offer AEDs
(may worsen seizures)
Rufinamide
Topiramate
Carbamazepine
Gabapentin
Oxcarbazepine
Pregabalin, Tiagabine
Vigabatrin
Available at: http://www.youngepilepsy.org.uk/dmdocuments/Full-NICE-epilepsy-guidance-2012.pdf. Accessed on November 9,2016.
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PHARMACOLOGICAL TREATMENT
Seizure type
First-line
AEDs
Adjunctive
AEDs
Other AEDs that
may be
considered on
referral to
tertiary care
Do not offer AEDs
(may worsen
seizures)
Absence
Ethosuximide
Lamotrigine
Sodium
valproate
Ethosuximide
Lamotrigine
Sodium valproate
Clobazam
Clonazepam
Levetiracetam
Topiramate
Zonisamide
Carbamazepine
Gabapentin
Oxcarbazepine
Phenytoin Pregabalin
Tiagabine Vigabatrin
Myoclonic
Levetiracetam
Sodium
valproate
Topiramate
Levetiracetam
Sodium valproate
Topiramate
Clobazam
Clonazepam
Piracetam
Zonisamide
Carbamazepine
Gabapentin
Oxcarbazepine
Phenytoin Pregabalin
Tiagabine Vigabatrin
Prolonged or
repeated seizures and
convulsive status
epilepticus in the
community
Buccal
midazolam
Rectal
diazepam
Intravenous
lorazepam
Available at: http://www.youngepilepsy.org.uk/dmdocuments/Full-NICE-epilepsy-guidance-2012.pdf. Accessed on November 9,2016.
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PHARMACOLOGICAL TREATMENT
Seizure
type
First-line AEDs
Adjunctive AEDs
Other AEDs that may be
considered on referral
to tertiary care
Focal
Carbamazepine Lamotrigine
Carbamazepine Clobazam
Eslicarbazepine acetate
Levetiracetam Oxcarbazepine
Gabapentin Lamotrigine
Lacosamide Phenobarbital
Sodium valproate
Levetiracetam
Phenytoin Pregabalin
Oxcarbazepine Sodium
Tiagabine Vigabatrin
valproate Topiramate
Zonisamide
Convulsive
status
epilepticus
in hospital
Intravenous lorazepam
Intravenous
Intravenous diazepam
phenobarbital Phenytoin
Refractory
convulsive
status
epilepticus
Intravenous midazolam
Buccal midazolam
Propofol (not in children)
Thiopental sodium
Available at: http://www.youngepilepsy.org.uk/dmdocuments/Full-NICE-epilepsy-guidance-2012.pdf. Accessed on November 9,2016.
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Do not offer
AEDs (may
worsen
seizures)
PROGNOSIS
•Patients whose epilepsy is well controlled have a normal life-span.
Their long-term survival rates are lower than average if medications or
surgery fail to stop the seizures.
•There is a very low risk for sudden death in patients with epilepsy.
Although the causes of such events are not fully known, heart
arrhythmias may be a factor in many cases.
Available at: http://www.nytimes.com/health/guides/disease/epilepsy/prognosis.html. Accessed on November 7 , 2016.
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SUMMARY
•Seizure is a paroxysmal event due to abnormal excessive or synchronous
neuronal activity sudden electrical activity in the brain
•It can include an abnormal level of sodium or glucose in the blood, brain
infection
•Anticonvulsant medication is the mainstay of treatment for seizures,
although the choice of anticonvulsant drug varies with different seizure
types and epileptic syndromes
•When medicines are not working well, surgery or implanted devices such
as vagus nerve stimulators may help
•Ketogenic Dietcan help some children with epilepsy
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CASE STUDY 1
Presentation
A 14-year-old female child was admitted in the hospital with the
complaints of 2 episodes of generalized tonic-clonic seizures 4 days
before, 1 episode of vomiting containing food particles and occasional
headache for past 2 months.
Present History
Loss of appetite, loss of weight, evening rise of temperature, cough with
expectoration and breathlessness.
Available at: http://globalresearchonline.net/journalcontents/v39-2/29.pdf. Accessed on November 10th, 2016.
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CASE STUDY 1
Past History
A known case of pulmonary tuberculosis and completed her 2 months of ATT
Category I
Regimen - isoniazid 50 mg, rifampicin 100 mg, pyrazinamide 300 mg and
ethambutol 800 mg in a thrice weekly schedule
Examination
She was conscious, oriented, afebrile with pulse rate of 78 bpm, BP 110/70
mmHg and respiratory rate of 18 bpm.
Available at: http://globalresearchonline.net/journalcontents/v39-2/29.pdf. Accessed on November 10th, 2016.
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CASE STUDY 1
Current Medications
•ATT withheld for first 2 days and started injection lorazepam 4 mg
•It was suggested that isoniazid can induce seizure as its minor
complication and this is to be informed to the physician
•On the third day, lorazepam discontinued and ATT restarted along with tablet
Benadon (pyridoxine) 40 mg twice a day
•Patient improved after taking this regimen
Lorazepam 4 mg administered intravenously.
She felt better on her follow-up.
Available at: http://globalresearchonline.net/journalcontents/v39-2/29.pdf. Accessed on November 10th, 2016.
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CASE STUDY 2
A 37-year-old man with a previously well-controlled seizure disorder was
brought to the emergency room of the hospital, generalized tonic-clonic
seizures that persisted for 2 hours.
Past History
Chronic alcohol abuse and was taking no medications.
Present History
At admission, the patient was unresponsive with frequent generalized tonicclonic seizures. The pupils, fundus, and extraocular movements were normal.
Cranial-nerve functions were intact. There were no focal motor findings.
Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0004-282X2000000500020. Accessed on November 10th , 2016.
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CASE STUDY 2
The patient was intubated and mechanically ventilated.
During the procedure, he vomited and aspirated a large amount of gastric
content.
Medication
He was treated with IV diazepam 10 mg, glucose, thiamine and IV phenytoin
1200 mg at 50 mg/min, with resolution of seizure activity.
Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0004-282X2000000500020. Accessed on November 10th , 2016.
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CASE STUDY 2
Clinical Examination
•
Hemoglobin - 12 g/dlL
•
White-cell count of 8,300 per mm3
•
Serum sodium was 130 mEq/L
•
Potassium was 4 mEq/L, and BUN, creatinine and glucose were normal
•
Chest x-ray studies displayed bilateral patchy alveolar infiltrates greatest at
the right apex
•
A head CT scan was normal, and an EEG showed a diffuse slowing pattern
and no seizure activity
Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0004-282X2000000500020. Accessed on November 10th , 2016.
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CASE STUDY 2
•During the next 48 hours, the patient had severe polyuria (14 and 10 liters in
the second and third day of hospitalization, respectively, despite high doses of
DDAVP), and continued to require mechanical ventilatory support
•On the fourth day, repeated arterial blood gas analysis markedly improved and
the urinary output was less than 2 liters
•Mental status normalized and DDAVP was discontinued
•The patient was removed from the ventilator and extubated in the sixth day
•He was discharged 10 days after the admission without neurologic sequelae
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