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Seizures and Epilepsy

Haining Li
General Hospital of Ningxia
Medical University
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Definitions
Seizure: abnormal hypersynchronous
electrical discharge of neurons.

 Epilepsy: two or more recurrent

seizures unprovoked by systemic or
acute neurologic insults
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Epidemiology of Seizures and

Epilepsy
 Seizures
• Incidence: approximately 80/100,000 per
year
• Lifetime prevalence: 9%
(1/3 benign febrile convulsions)

 Epilepsy
• Incidence: approximately 45/100,000 per year
• Point prevalence: 0.5-1%
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Classification of seizures
• Partial seizures: begin in a focal area of
the brain.
• Primarily generalized seizures: arise
from both hemispheres simultaneously.
• Unclassified seizures
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Partial Seizures
 Simple partial seizures (with motor,
sensory, autonomic, or psychic signs)

 Complex partial seizures

 Partial seizures with secondary

generalized
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Simple Partial Seizure Subclassification

 With motor signs
 With somatosensory or special
sensory symptoms
 With autonomic symptoms or signs
 With psychic symptoms (disturbance
of higher cerebral function)
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Simple partial seizures

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Complex Partial Seizures

 Impaired consciousness
 Clinical manifestations vary with site of origin
and degree of spread
▫ Presence and nature of aura
▫ Automatisms ( lip-smacking, chewing
movements, or picking at clothing)
▫ Other motor activity
 Duration (typically 1 minute)
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Complex Partial Seizures

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Secondarily Generalized Seizures

 Begins focally, with or without focal neurological
symptoms

 Variable symmetry, intensity, and duration of

tonic (stiffening) and clonic (jerking) phases

 Typical duration up to 1-2 minutes

 Postictal confusion, somnolence, with or

without transient focal deficit
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Primarily Generalized Seizures

• Absence
• Tonic- Clonic
• Tonic
• Atonic
• Myoclonic
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Absence Seizure
• It is a generalized seizure.
• Commonly occurs in children.
• Manifestation is an characterized by sudden,
brief lapses of consciousness without loss of
postural control.
• EEG: classic three-per-second generalized spike-
and-slow-wave.
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Absence Seizure
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Generalized, Tonic-Clonic Seizures

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Generalized, Tonic-Clonic Seizures

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Unclassified Seizures
• Neonatal seizures
• Infantile spasms
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Etiology of Seizures
and Epilepsy
 Infancy and childhood
▫ Prenatal or birth injury
▫ Inborn error of metabolism
▫ Congenital malformation

 Childhood and adolescence

▫ Idiopathic/genetic syndrome
▫ CNS infection
▫ Trauma
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Etiology of Seizures
and Epilepsy (cont.)
 Adolescence and young adult
▫ Head trauma
▫ Drug intoxication and withdrawal*
 Older adult
▫ Stroke
▫ Brain tumor
▫ Acute metabolic disturbances*
▫ Neurodegenerative
*causes of acute symptomatic seizures, not epilepsy
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Clinical manifestations
• History (patients and witnesses)
• Physical examination
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Seizure Precipitants
 Metabolic and electrolyte imbalance
 Stimulant/other proconvulsant
intoxication
 Sedative or ethanol withdrawal
 Sleep deprivation
 Antiepileptic medication reduction or
inadequate AED treatment
 Hormonal variations
 Stress
 Fever or systemic infection
 Concussion and/or closed head injury
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Evaluation of a First Seizure

 History, physical exam
 Blood tests: CBC, electrolytes, glucose,
Calcium, Magnesium, phosphate, hepatic and
renal function
 Lumbar puncture only if meningitis or
encephalitis suspected and potential for brain
herniation is ruled out
 Blood or urine screen for drugs
 Electroencephalogram
 CT or MR brain scan
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EEG Abnormalities
 Background abnormalities: significant
asymmetries and/or degree of slowing
inappropriate for clinical state or age
 Interictal abnormalities associated with
seizures and epilepsy
▫ Spikes
▫ Sharp waves
▫ Spike-wave complexes
 May be focal, lateralized, generalized
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EEG: Simple Partial Seizure

Right temporal
seizures with
maximal phase
reversal in the
right sphenoidal
electrodes

Continued on C-
Slide9
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EEG: Simple Partial Seizure

Continuation of same
seizure
(C-slide-8)

Right temporal
seizures with maximal
phase reversal in the
right sphenoidal
electrodes
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EEG: Absence Seizure

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Questions Raised by a First Seizure

 Seizure or not?
 Seizure type? Syndrome type?
 Causes?
 Start AED?
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Medical Treatment of First Seizure

Whether to treat first seizure is controversial
 16-62% will recur within 5 years
 Relapse rate might be reduced by
antiepileptic drug treatment
 Abnormal imaging, abnormal neurological
exam, abnormal EEG or family history
increase relapse risk
 Quality of life issues are important
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Treatment
• Most neurologists begin drug therapy
after two unprovoked seizures.
• Each drug has its own set of
indications and adverse effects.
• Monotherapy is a goal of antiepileptic
therapy; most patients’ seizures are
well controlled on one medication.
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Choosing Antiepileptic Drugs

 Seizure type
 Epilepsy syndrome
 Pharmacokinetic profile
 Interactions/other medical conditions
 Efficacy
 Expected adverse effects
 Cost
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Choosing Antiepileptic Drugs

Partial onset seizures
carbamazepine phenytoin
felbamate primidone
gabapentin tiagabine
lamotrigine topiramate
levetiracetam valproate
oxcarbazepine zonisamide
phenobarbital
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Choosing Antiepileptic Drugs

AEDs that have shown efficacy for
Absence seizures:

 Ethosuximide
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Choosing Antiepileptic Drugs

AEDs that have shown efficacy for
generalized seizures:
• Valproic acid
• Phenobarbital
• Lamotrigine
• Topiramate
• Levetiracetam
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Antiepileptic Drug Monotherapy

 Simplifies treatment effects

 Conversion to monotherapy from

polytherapy
▫ Eliminate sedative drugs first
▫ Withdraw antiepileptic drugs
slowly over several months
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AED Serum Concentrations

 AED serum concentrations are simply
to be used as a guide.
 Serum concentrations are useful when
optimizing AED therapy, assessing
compliance, pregnancy, or teasing out
drug-drug interactions.
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Non-Drug Treatment/
Lifestyle Modifications
 Adequate sleep

 Avoidance of alcohol, stimulants, etc.

 Avoidance of known precipitants

 Stress reduction — specific techniques

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Patient Selection for Surgery: Criteria

 Epilepsy syndrome not responsive to
medical management
▫ Unacceptable seizure control despite
maximum tolerated doses of 2-3
appropriate drugs as monotherapy

 Epilepsy syndrome amenable to surgical

treatment
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Status Epilepticus
 Definition
▫ More than 5 minutes of uncontinuous
seizure activity or
▫ Two or more sequential seizures spanning
this period without full recovery between
seizures
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Status Epilepticus
 A medical emergency
▫ Adverse consequences can include hypoxia,
hypotension, acidosis and hyperthermia
▫ Know the recommended sequential protocol
for treatment with benzodiazepines, phenytoin,
and barbiturates.
▫ Goal: stop seizures as soon as possible
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Subtypes of status epilepticus

• Generalized convulsive status epilepticus

(GCSE) (e.g. , persistent, generalized
electrographic seizures, coma, and tonic-
clonic movements)
• Non-convulsive status epilepticus (e.g.,
persistent absence seizures or partia
seizures, confusion or partially impaired
consciousness)
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Assess the ABCS: airway, breathing,

Treatment circulation
Check fingerstick glucose
Establish IV access

Send blood laboratory studies

Give 100 mg IV thiamine, followed by 50%
dextrose infusion

Lorazepam 0.1 mg/kg IV or diazepam

10mg (0.2 mg/kg over 2 minutes IV )
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Phenytoin 20 mg/kg IV

If status epilepticus
continues

Intubate if not already done

Phenobarbital 20 mg/kg IV

If status epilepticus
continues

Induce coma with bartiturate, midazolam,

or propofol
Institute continuous bedside EEG
monitoring
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Clinical Epilepsy
Case Studies
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Medical Student Cases

Case 1: 5 year-old female with episodes of
“Blanking Out”
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Case Study 1
 A 5 y/o female is brought to the office because
of episodic “ blanking out” which began 1 month
ago. The patient has episodes in which she
abruptly stops all activity for about 10 seconds,
followed by a rapid return to full consciousness.
The patient’s eyes are open during the episodes
and she remains motionless with occasional
“ fumbling” hand movements.
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Case Study 1
 After the episode the patient resumes whatever
activity she was previously engaged with no
awareness that anything has occurred
 She has 30 episodes per day
 No convulsions
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Case Study 1
 Past medical, physical and developmental
histories are unremarkable.
 No history of previous or current medications;
No allergies
 Family history is pertinent for her father having
similar episodes as a child.
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Case Study 1
 General physical and neurological examination
is normal.
 Hyperventilation in the office replicates the
episodes.
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Case Study 1

EEG for
Case
Study 1
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Case Study 1
 What additional studies do you perform, if any?
 What is the diagnosis?
 How do you initiate medication? If so, Which?