CDM 4 Exam 2 Review Seizure Types I Definitions brain II Epidemiology A Seizure rhythmic and repetitive coordinated discharge of many neurons in a localized area of the B Epilepsy condition of having chronic seizures you can have seizures and NOT have epilepsy C Convulsion involuntary paroxysmal muscle contractions seen during certain seizures A 9 of population have a seizure in lifetime 2 4 have recurrent seizure B 2 million Americans with epilepsy C 75 of epileptics have 1st seizure 20 D Chronic disabling disease 30 of patients cannot be controlled WITH drugs high incidence of ADE III Potential seizure causes A Head Trauma B CNS infections C Toxins solvents lead D Sleep deprivation E Metabolic 1 Fever 1 in infants 2 Thyroid disorders 3 Anoxia ischemia stroke 4 Renal failure 5 Hyponatremia 6 Hypoglycemia 7 Hypocalcemia 8 Hypomagnesemia F Drug induced seizures IV Seizure types 1 Antibiotics imipenem PCNs CEPHs Quinolones inhibit GABA 2 Antidepressants especially buproprion 3 Antipsychotics 4 Lithium 5 Meperidine 6 Drugs of Abuse Amphetamine cocaine methylphenidate 7 Withdrawal of Alcohol Benzos Barbs 8 Theophylline 9 Estrogen A Partial limited to a specific portion of the brain asymmetric can secondarily generalize 1 Simple partial patient is CONSCIOUS convulsion may be in one limb only may have sensory symptoms fould odor visual auras 2 Complex partial IMPAIRED CONSCIOUSNESS 40 of ALL seizure patients bizarre behavior symptoms related to site of brain activity often mistaken for psychosis B Generalized symmetric across entire brain LOSS OF CONSCIOUSNESS 1 Tonic clonic grand mal fall body rigid muscle jerks shallow or no breathing with loss of bladder bowel control post ictal state of confusion and fatigue 2 Absence petit mal Blank stare rapid blinking more common in children hard to diagnose NO post ictal state C Prodromal symptoms before a seizure are often characterized by the area of the brain in which the seizure focus exists Seizure Pathophysiology I Neuron Ion Channel Review A Normal resting membrane potential is negative B When cell becomes more depolarization which runs down neuron to synapse where action potential is propagated to the next neuron C Neurotransmitters involved 1 Excitatory facilitate propagation Ach NE Histamine H1 Glutamate 2 Inhibitory reduce propagation GABA DA 3 Also Na and Ca2 channels involved 1 II Pathophys of epileptogenesis D AMPA a glutamate receptor others are NMDA and Kainate 1 Located on post synaptic neuron concentrated in brain 2 Mediate synaptic signaling target for antagonistic drug action PerAMPAnel PER A Insult Seizures Cellular alterations altered receptors altered ion channels neuronal loss B Cellular alterations cause excitability sprouting others reorganized brain circuitry excitability SEIZURES repeat 1 Ion channels located in neuronal membranes change in type number properties 2 Receptors biochemical changes 3 Extracellular ion concentrations imbalanced excitatory inhibitory glut GABA 4 NT uptake and metabolism 5 Changes in inhibitory systems 6 Sprouting additional projections on neurons allowing for easier atypical firing A Na channels cause rapid depolarization of neurons and release excess amounts of glutamate III Pathophysiology of a seizure causing abnormal neuronal firing Seizure Treatment I Patient history A Most important info obtained 1 Patient witnesses describe events before during and after seizure 2 Past medical history of patient 3 Medication history 4 Family History B Must differentiate seizure from 1 Migraine 2 Syncope fainting 3 TIA mini stroke 4 Psyogenic seizure related to psych diagnosis 5 Other movement disorder i e Parkinsons C Diagnostic studies 1 Physical exam Head trauma ear sinus infection hyperventilation in children alcohol drug abuse cancer brain tumors can cause seizures 2 Brain neuroimaging CT scan excludes mass lesion hemorrhage stroke MRI preferred more specific than CT D EEG electroencephalogram 1 Provides 3 types of info a Confirmation of abnormal electrical activity b Type of seizure disorder c Location of seizure focus 2 Should obtain 48 hours post seizure 48 hrs abnormal activity dissipates a If suspicion is high 2nd EEG should be done II Detecting seizures before they occur A Smart Watch a wrist watch device that monitors detects and alerts for seizure activity to mobile phones phone calls or text messages with location 1 Patient weirs smart watch that is hooked up to their phone if a seizure occurs an alert is sent to parents and or caregivers the data is then stored for physician use III Why do we treat seizures A Prevent death seizures cause brain ischemia and potential brain damage the longer the seizure lasts or the more seizures you have a seizure can the seizure threshold causing the patient to have even more seizures 2 B Seizures beget seizures the sooner you start therapy and make someone seizure free the less likely they are to have more C Improve QOL control of seizures will give patients back control over at least part of their lives D QOL in epilepsy inventory 10 QOLIE 10 1 10 multi item questionnaire that measures a Overall WOL b Emotional well being c Role limitations due to Emotional problems social support isolation work driving social function energy fatigue worry about seizure medication effects pain health discouragement attention concentration physical function memory health perceptions E State driver s license laws 1 MA 6 month seizure free period detailed doctor s report may be less time with 2 Agreement upon periodic medical updates at time of licensing may be required to submit doctor s recommendation periodic medical reports 3 Doctors NOT REQUIRED to report any new diagnoses of epilepsy IV Treatment of seizures A Principles 1 Remove known causes 2 Educate patient risk for falls risk for fall proofing the house etc 3 Mainstay of treatment DRUG THERAPY 4 Start with a 1st line agent as monotherapy add other agents as needed always try to wean once patient controlled DO NOT abruptly stop seizure meds taper off V Non pharmacologic treatments A 20 of epilepsy patients medically intractable still not well controlled with drugs 1 Surgery ketogenic diet select patient population vagus nerve stimulation seizure dogs B Neurosurgery C Ketogenic diet 1 Used only in medication refractory patients less effective vs drug tx a Failed 2 3 optimal trials of AEDs 2 Highest efficacy in patients with complex partial seizures of the temporal lobe a 4X better success rates than drugs