Seizure disorders B Must differentiate seizure from a Migraine b Psychogenic seizure seizure like activity that is more related to a psych diagnosis Syncope c d Other movement dx e TIA C EEG electroencephalogram a Provides 3 types of info i Confirmation of abnormal electrical activity ii Type of seizure disorder iii Location of seizure focus b Should obtain 48hr post seizure because abnormal activity may dissipate c 5 pts with epilepsy have normal EEGs If suspicion high 2nd EEG i ii So it is very helpful when it is able to show abnormal activity D Smart watch a Wrist watch device b Monitor detect alert Phone calls text messages with location Patient history A Most impt info obtained a Patient witnesses describe event before during and after seizure b PMH c Medication history d FH Diagnostic studies A PE a Head trauma b Ear sinus infections c Hyperventilation in children can result in loss of consciousness d Alcohol drug abuse e Cancer brain tumor B Brain neuroimaging a CT scan excludes mass lesion hemorrhage stroke b MRI preferred probably do an EEG first i More specific that CT Why we treat seizures A Prevent death B Quality of life in epilepsy inventory 10 QOLIE 10 a 10 item questionnaire that measures i Overall QOL ii Emotional well being iii Role limitations due to a Seizures cause brain ischemia and potential brain damage the longer the seizure lasts or the more seizures you have b Seizures beget seizures Epileptogenesis i The ssoner you start therapy and make someone seizure free the less likely they are to have more c Improve QOL Control of seizures will give patient back control over at least a part of their lives 1 Emotional problems 2 Social support isolation 3 Energy fatigue 4 Worry about seizure 5 Medication efforts 6 Pain 7 Health discouragement 8 Work driving social function 9 Attention concentration 10 Physical function 11 Memory 12 Health perceptions C State driver s license laws MA a 6 month seizure free period detailed MD report i May be less time with MDs recommendation b Agreement upon periodic medical updates at time of licensing i May be required to submit periodic medical reports c MDs not required to report any new diagnoses of epilepsy in the state but in other they are Treatment of seizures A Principles a Remove known causes b Educate patient i Risk of falls fall proofing the house c Mainstay of treatment DRUG THERAPY d Start with 1st line agent as monotherapy i Add others as needed ii Always try to wean once pt controlled iii You always want to try treating with the fewest meds possible iv Number one cause of status epileptics is NON ADHERENCE B Non pharm therapies i 20 of epilepsy pts medically intractable ii Surgery good option for some iii Ketogenic diet good for kids wth certain types iv Vagus nerve stimulation pace maker for vagus nerve v Seizure dogs b Neurosurgery i Used only in medication refractory pts 1 Failed 2 3 optimal trials of antiepileptics AEs ii Highest efficacy in pts with COMPLEX PARTIAL seizures of the TEMPORAL LOBE 1 4x better success rates than drugs alone to make pts seizure free in refractory cases iii May result in seizure free outcomes in 80 90 1 Way more effective than drugs iv Mortality rate of temporal lobe resection 1 1 May have visual field defects v They are resecting the area where the seizure is they are cutting or burning it out c Ketogenic diet i First used in 1921 when few anti seizure meds were available ii Premise starvation stops seizures primarily in kids iii Diet initiated with starvation until ketones present in urine iv Diet very high fate low protein carbs 1 Typically 4 1 fat protiens carbs 2 No sugar v MOA unknown vi Indicated for use primarily in young children with drug refractory cases Lennox Gastaut mix of seizure disorder and mental retardation vii Efficacy 30 50 show 50 decrease in seizures viii Strengths no sedative cognitive effects of drugs ix Weakness compliance A LOT of teaching 1 Potential growth retardation 2 Long term hyperlipidemia d Vagus nerve stimulation i Implanted generator similar to pacemaker Intermittently stimulated the left vagus nerve causes the nerve to fire at a regular pace 1 2 Ex stimulates for 30 sec every 5 minutes ii MOA changes the CSF concentration of NTs through increases blood flow iii Efficacy 23 50 pts experience 50 decrease in seizures iv Adverse effects hoarseness cough throat pain tingling at electrode site v Seems most promising in children and pts with symptomatic generalized epilepsy vi 100 compliance maintained may allow for dosage decrease of d c of drugs e Seizure dogs i Some dogs may be able to predict seizures by 15 45 mins before ii Many trained to 1 Bark or alert families when child having seizure 2 3 Activate alarm symptoms Lie next to person during seizure to prevent harm iii Develops over time with owner 1 Usually in patients having 1 seizure month f g Linear PK Little or no allergic or idiosyncratic reactions rare but really serious h Availability of IV formulatio Antiepileptic drugs A Wish list B Options a Effective b QD BID dosing c d Minimal sides e Few or no DIs Low cost a Carbamazepine b Phenytoin c Valproic acid d Oxcarbazepine e Ethosucimide f Lamotrigine g Gabapentin Topiramate Tiagabine h Leviteracetam i j k Zonisamide l Felbamate m Phenobarbital n Primidone C FDA alert 1 08 a Reports of suicidality from placebo controlled trials of 11 AEDs b Pts receiving AEDs 2x risk of suicide behavior ideation i Seen as early as 1wk after starting AED up to 24wks ii No specific subgroup to which the increased risk could be attributed to it s across the board c ALL PTS currently taking or starting on any AED should be closely monitored for changes in behavior that could indicate emergence or worsening of suicidal thought or behavior or depression D General AED monitoring parameters Therapuetic QOL QOLIE 10 Seizure frequency Serum drug concentrations if needed Toxic Suicidal ideation depression Specific SEs CBC Rash for SJS Seizure frequecy Serum drug concentrations if needed E General AED counseling a Explain use of drug dose regimen b STRESS ADHERENCE c Avoid alcohol minimize stress d Never abruptly stop AEDs risk of status epilepticus e Monitoring periodic blood levels only if routinely obtained f Side effects conc dependent vs idiosyncratic vs chronic i When to call D what to watch out for ii Suicidal ideation depression iii Advise not to drive operate complex machinery or engage in other hazardous activities until know how drug affects them g Dosing