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Seizure
Aka: Seizure, Convulsion, Epilepsy
- See Also
- Single Seizure Evaluation
- Status Epilepticus
- Febrile Seizure
- Newborn Seizure
- Infantile Spasms
- Pediatric Spells
- Epilepsy in Pregnancy
- Epilepsy in Women
- Epilepsy in the Elderly
- Psychogenic Nonepileptic Seizure
- Definitions
- Seizure
- Excessive synchronous, abnormal cortical Neuron electrical activity
- Epilepsy
- Two or more unprovoked, afebrile Seizures
- Epidemiology
- Lifetime risk: 3.9%
- U.S. Prevalence: 1% (since Seizure disorder does not persist in many, e.g. children)
- Gender: Males slightly more than females
- Age: Most common in Infants and older adults
- Causes
- See Seizure Causes
- Types
- Secondary Seizures (provoked) due to underlying lesion
- See Seizure Causes
- Primary Generalized Seizures
- Generalized Tonic Clonic Seizure (Grand Mal Seizure, generalized motor Seizure)
- Absence Seizure (Petit Mal Seizure, generalized, non-motor Seizure)
- Primary Focal Seizures (Partial Seizures, single hemisphere)
- Awareness
- Focal Seizure Without Impairment of Awareness (Simple Partial Seizure)
- Focal Seizure with impaired awareness (Complex Partial Seizure)
- Subtypes
- Motor Seizures (focal motor activity)
- Sensory Seizures
- Autonomic Seizures (e.g. sweating)
- Common Focal Seizure syndromes
- Rolandic Epilepsy
- Other types
- Epileptic spasms (e.g. Infantile Spasms)
- Signs
- Jerking movements
- Muscle stiffness or rigidity
- Eye Rolling
- Drooling
- Altered Level of Consciousness
- Altered breathing pattern
- Incontinence
- Vital Sign abnormalities
- Differential Diagnosis
- See Seizure Differential Diagnosis
- Labs
- See First Seizure Evaluation
- See Status Epilepticus
- Drug level monitoring indications
- Establish therapeutic concentrations when adequate Seizure control reached
- Clinical toxicity suspected
- Noncompliance suspected
- Expected variability in pharmacokinetics
- Extremes of age
- Change of drug formulation
- Pregnancy
- References
- Tomson (2007) Cochrane Database Syst Rev (1):CD002216 [PubMed]
- Imaging: Structural study
- See Seizure Indications for Neuroimaging
- Evaluation
- See Seizure Evaluation (includes Single Seizure Evaluation)
- Management: General
- See Status Epilepticus
- Seizure Prophylaxis
- See Seizure Prophylaxis for indications
- See specific Seizure types for optimal management
- Generalized Seizure (includes Generalized Tonic Clonic Seizure, Myoclonic Seizure)
- Absence Seizure
- Focal Seizure (includes simple and Complex Partial Seizure)
- Other adjuncts
- Ketogenic diet (high fat, low carbohydrate, low protein)
- Associated with gastrointestinal side effects (Vomiting, Abdominal Pain, altered stool consistency)
- Risk of high Uric Acid, renal stones, decreased Calcium, Magnesium, QT Prolongation, Cardiomyopathy
- Poor level of evidence for support
- Martin (2016) Cochrane Database Syst Rev (2): CD001903 [PubMed]
- Vagus Nerve Stimulation
- Indicated for over age 12 years with medically refractory Epilepsy who are not surgical candidates
- Battery-powered stimulator/Pacemaker with leads at Vagus Nerve
- Morris (2013) Neurology 81(16): 1453-59 [PubMed]
- Responsive neurostimulation
- Similar to Vagus Nerve stimulator, but leads are inserted into the actual Seizure focus
- In response to sensing abnormal electrical activity, neurostimulator delivers electrical stimulation
- Risk of implant site infection, Headache, dysesthesia
- Bergey (2015) Neurology 84(8): 810-7 [PubMed]
- Management: Special topics
- Epilepsy in Pregnancy
- See Epilepsy in Pregnancy
- Contraception is key
- Estrogen-based Contraception is less effective in those on antiepileptic drugs
- Plan pregnancy on non-Teratogenic agents
- Major birth defects occur in 4-7% of those born to mothers on Seizure Prophylaxis monotherapy
- Driving
- Most U.S. states require no driving for 3-12 months since last Seizure
- Exact duration of non-driving varies by state
- http://www.epilepsy.com/driving-laws
- Physical Activity
- Physical Activity is recommended in Epilepsy (may decrease Seizure frequency)
- Most sports are not contraindicated in well controlled patients (e.g. biking, Contact Sports, swimming)
- Avoid high risk sports (e.g. hang gliding, Scuba Diving, free climbing)
- Screen for comorbid neuropsychiatric disorders
- Cognitive Impairment and Mood Disorders are common in Seizure disorder (which may affect compliance)
- Management: Surgery for Medically refractory Epilepsy
- Seizures continue despite antiepileptic drug prophylaxis in 30% of patients
- Surgical resection of Seizure focus results in Seizure resolution in 76% of cases
- Predictors of Seizure-free after surgery
- Seizures without loss of consciousness
- Complete or extensive Seizure focus resection
- Prolonged Febrile Seizures
- Predictors of continued Seizures after surgery
- Non-structural Epilepsy
- Normal MRI
- Generalized Tonic-Clonic Seizures
- Infantile Spasms
- Tonic Seizures
- Invasive EEG monitoring to identify Seizure focus
- Complications
- Neurologic deficits (5%)
- Verbal memory deficits occur with Temporal Lobe resection (44% with left-sided resection)
- Medical complications (e.g. CSF leak, Hydrocephalus, Aseptic Meningitis)
- Operative mortality (<0.5%)
- References
- Jobst (2015) JAMA 313(3): 285-93 [PubMed]
- Complications
- Todd's Paralysis
- Sudden Unexplained Death in Epilepsy (SUDEP)
- Idiopathic Epilepsy related death (no other cause identified)
- More common in nocturnal Seizures
- Effective Seizure Prophylaxis lowers risk
- Typically in young adults (rare in children)
- Incidence: 9 per 1000 with Epilepsy (up to 1 in 150 for poorly controlled Seizures)
- Surges (2012) Curr Opin Neurol 25(2): 201-7 [PubMed]
- References
- Nocera, Valente, Amanullah (2018) Crit Dec Emerg Med 32(11): 3-9
- Wilfong (2017) Epilepsy in Children, UpToDate, accessed 7/17/2017
- Liu (2017) Am Fam Physician 96(2): 87-96 [PubMed]