Neurology

 6.4b   Dr.  Pineda  

Seizures  and  Epilepsy  (Cases)   February  27,  2015  
  CASE  1   § Abnormal   EEG:   1.5-­‐3-­‐fold   increase   in   risk   of   recurrence   (vs.  
• A  23  year  old  male  engineer  had  a  weekend  off  and  spent  it  at  home.   patients  with  normal  EEG)  
st
While   having   merienda,   he   was   suddenly   seen   to   have   his  head   slightly   § 1   seizure   +   underlying   neurological   condition:   2x   risk  
turned   to   the   right   with   the   eyes   turned   upward.   His   upper   recurrence  (vs  idiopathic)  
extremities   were   stiff   and   in   the   extended   position.   As   he   fell    
backwards,   he   started   to   have   tonic-­‐clonic   movements   of   all   2. While   waiting   for   your   preferred   examination   to   be   completed,  
extremities.     would  you  start  the  patient  on  an  AED?  Explain  your  reasons.  
1. What  is  the  first  thing  that  needs  to  be  done?  Outline  the  first  aid   § At   this   point   you   can   start   meds,   epilepsy   is   the   clinical  
given  to  patients  having  seizures.     diagnosis  because  of  the  presence  of  2  unprovoked  seizures.  
§ Refer  to  Dr.  Pineda’s  notes  on  First  aid  for  seizure  patient.   § You  do  not  wait  for  the  patient  to  seize  again.      
• First,   position   the   patient   on   his   side   to   prevent    
aspiration     3. If  you  were  to  start  an  AED,  what  will  be  your  basis  for  choosing  
• Most   patients’   will   be   continuously   drooling   or   vomiting.   the  appropriate  AED?  Explain.    
So  you  want  to  protect  their  airway   § Seizure  Type!  
§ Loosen   clothing   and   remove   anything   that   can   impede   § The   first   step   is   to   correctly   identify   the   seizure   type   then  
circulation   initiate  the  first  line  AED  for  the  appropriate  seizure  type  
• Loosen  buttons,  belt,  etc.     § This  patient’s  seizure  type:  generalized  tonic-­‐clonic  seizures.  
§ Protect  the  head  –  place  soft  pillow  or  towel  under  the  head   That  is  the  basis  
§ It   is   not   good   anymore   to   smack,   throw   water,   or   put   § Other  factors:  age,  cause,  gender,  co  morbidities  
something  in  the  mouth  to  protect  the  tongue   § AED  selection  depends  on:  
• Can  fracture  your  finger!   • Proven   efficacy   in   particular   seizure   type   or   syndrome  
§ Time  the  seizure  –  most  of  time  the  seizures  will  stop.  Time  it   and  spectrum  of  efficacy  
for  instances  of  status  epilepticus   • Tolerability  and  log-­‐term  retention  of  each  AED  
  • Individual  patient  circumstance  and  preference  
2. Would  you  treat  with  anti-­‐convulsants?  Why  and  why  not?   • Individual  clinician  preference  
§ No.   This   is   the   first   seizure,   no   history   of   prior   seizures   or   § Goals  of  AED  Treatment  
known  co-­‐morbidities.   • Seizure   freedom   -­‐   50%   seizure   reduction   is   of   little  
§ For   the   first   seizure   you   have   to   investigate,   unless   there   is   benefit  
history   of   post   cortical   injury   –   post   stroke,   post   trauma,   • No  adverse  effects  
neoplasm.   • Normal  lifestyle  maintained  
§ In   the   ER   setting,   your   main   question   is   the   chance   of   • Morbidity  and  mortality  reduced  
recurrence   § AEDs  Locally  available  
nd
§ After  a  first  seizure,  the  risk  of  having  a  2  seizure  is  43%  at  5   • Standard   AEDs:   Phenobarbital,   Phenytoin,  
years.   Carbamazepine,  Valproic  acid  
§ After   a   second   seizure,   the   risk   of   having   another   seizure   is   • New   AEDs:   Lamotrigne,   Oxcarbazepine,   Topiramate,  
72%  at  5  years.   Gabapentin,  Levebracetam,  Pregablin,  Zonisamide  
§ Predict   the   individual   risk   of   seizure   recurrence.   Increased   • Know   the   mechanism   of   action   of   the   standard   and   most  
risk  if  there  is/are:   common  EEG  
• Brain  lesions  or  neurological  abnormality   • Don’t  need  to  know  the  doses,  but  be  familiar  with  what  
• Partial  seizure  -­‐  presentation  is  partial.   is  the  best  AED  to  use  per  seizure  type.  
• Family  history    
• EEG  abnormalities   CASE  2  
§ Two-­‐year  risk  of  recurrence   • A   65   year   old   hypertensive   diabetic   male   had   a   thrombotic   infarct,  
• Idiopathic  +  normal  EEG:  24%   right   frontoparietal   area   in   May   2005   which   left   him   with   a   mild   left  
• Underlying  neurologic  conditions  +  abnormal  EEG:  65%   hemiparesis.   Four   weeks   ago,   he   had   an   episode   of   a   sudden  
  contraction-­‐relaxation   of   the   left   upper   extremity   with   deviation   of  
• A   week   later,   the   patient   was   seen   by   his   brother   to   have   two   his  head  to  the  left.  He  then  fell  backwards  and  developed  contraction-­‐
consecutive   episodes   of   generalized   tonic-­‐clonic   seizures   while   relaxation   movements   of   all   extremities.   The   event   lasted   for   two  
sleeping,   each   lasting   for   one   minute,   with   a   two   minute   interval   minutes  and  he  was  fully  awake  after  30  minutes.  He  decided  to  seek  
between   each   episode.   He   wakes   up   with   a   headache   but   is   again   fully   medical   consult   and   goes   to   you.   Your   examination   shows   the   same  
alert.  He  decides  to  seek  consult.     degree  of  left-­‐sided  weakness  as  2005    
1. If   you   were   the   first   doctor   consulted,   what   is   your   diagnostic   1. If   you   were   the   first   doctor   consulted,   what   is   your   diagnostic  
plan?   Outline   your   diagnostic   plan   and   explain   the   rationale   for   plan?   Outline   your   diagnostic   plan   and   explain   the   rationale   for  
each.   each.  
§ In   an   ER   setting   the   most   important   tests   are   RBS   (to   rule   out   § CT  scan/  MRI  -­‐  to  localize  the  lesion  
hypoglycemia),   and   electrolytes   (to   rule   out   hypoglycemia   § EEG  -­‐  to  document  presence  of  seizure    
and   electrolyte   imbalances),   sodium.   Do   not   miss   out   on   § Blood  glucose  -­‐  to  monitor  hyperglycemia  or  hypoglycemia    
these  tests.   § Serum  sodium  -­‐  changes  may  account  for  seizure    
§ These   are   not   the   only   ones   you   ask   for,   depending   on   the   § Blood  workup  -­‐  for  borderline  values  and  monitoring    
history  of  the  patient  you  request  the  appropriate  tests   § Neuro   exam   -­‐   to   determine   the   neurological   status   of   the  
§ EEG  is  undoubtedly  the  most  sensitive,  indeed  indispensable   patient    
tool  for  the  diagnosis  of  epilepsy    

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2. If  you  were  to  start  an  AED  in  this  patient,  what  would  be  your   • The   patient   is   planning   to   get   married   soon.   She   brings   her   fiancé   to  
AED  of  choice?  Explain  the  rationale  behind  your  choice  of  AED.   your   clinic   for   joint   counseling.   Her   fiancé   is   worried   about   possible  
§ Choice  between  lamotrigine  and  gabapentin     effects  of  the  AEDs  to  the  eventual  pregnancy  and  wants  to  stop  AEDs.  
§ Lamotrigine   1. How  would  you  advice  the  patient’s  fiancé?  
• Effective   and   well   tolerated   in   elderly   patients   with   § First,   he   must   be   informed   that   the   patient   needs   a  
epilepsy     maintenance   drug   for   prevention   of   attacks.   Second,   there  
• Blocks   the   sodium   channel   receptors   to   decrease   the   are   AED’s   that   may   be   given   to   patients   with   epilepsy   who  
sodium   influx   to   prevent   cellular   swelling   to   inhibit   wishes  to  get  pregnant.  
seizure  onset    
§ Gabapentin   2. What  is  your  therapeutic  plan  for  this  patient?  Explain.    
• Elderly   patients   are   more   likely   to   have   unwanted   § Maintain   her   on   Lamotrigine   and   Folic   acid.   Advise   on   the  
effects   (e.g,   problems   with   balance   or   walking,   swelling   importance  of  strict  compliance  and  follow-­‐up  regularly.  
in   the   feet   or   legs)   and   age-­‐related   kidney   problems,    
which   may   require   caution   and   an   adjustment   in   the   CASE  4  
dose  for  patients  receiving  gabapentin   • A   5   year   old   female   was   brought   to   the   office   due   to   blanking   out  
• Binds  to  the  α2δ  subunit  and  has  been  found  to  reduce   which  began  1  month  ago  with  episodes  in  which  she  abruptly  stops  all  
calcium  currents  after  chronic  but  not  acute  application   actions   for   about   10   seconds   followed   by   a   rapid   return   to   full  
via   an   effect   on   trafficking   of   voltage-­‐dependent   calcium   consciousness.  The  patient’s  eyes  are  open  during  the  episode  and  she  
channels  in  the  central  nervous  system.   remains  motionless  with  occasional  fumbling  hand  movements.  After  
  the  episode,  the  patient  resumes  whatever  activity  she  was  previously  
• The   patient   has   been   seizure   free   since   starting   AED.   You   see   him   six   engaged   in   with   no   awareness   that   the   activity   has   occurred.   She   has  
months  later  and  he  has  gained  weight  and  was  given  instructions  for   30  episodes  per  day.  No  convulsions.    
an  increase  in  his  AED.  However,  two  weeks  later,  the  patient  decided   • (-­‐)  history  of  previous  /  current  medications,  (-­‐)  allergies,    
to  discontinue  his  AED,  he  had  a  seizure  of  the  same  description.   • Father  with  similar  episodes  as  a  child  
1. What  do  you  think  happened  in  this  case?  What  is  the  most  likely   • General  physical  and  neuro  exam  was  normal    
cause  of  the  seizure?  Explain.     • Hyperventilation  in  office  replicates  episodes    
§ The   patient   had   an   abrupt   recurrence   of   his   seizures   due   to   • EEG:  3Hz  spike  and  wave  discharges  
abrupt  discontinuation  of  his  AED.  Non-­‐compliance  is  a  major   1. What  additional  studies  does  your  patient  need  if  any?  
cause  of  recurrent  seizures.   § CBC  -­‐  to  rule  out  infection  
  § Random   Blood   Sugar   -­‐   to   rule   out   hypoglycemia   or  
2. What   is   your   long-­‐term   plan   for   this   patient?   Explain   the   hyperglycemia  
rationale  for  this  plan.     § Electrolytes  -­‐  to  rule  out  electrolyte  imbalance  
§ Patient   education   regarding   his   condition   and   the   proper   § BUN  -­‐  to  rule  out  uremia  
usage  and  maintenance  of  AEDs.     § Creatinine  -­‐  to  rule  out  renal  issues  like  drug  toxicities  
• Warning  signs  of  seizures     § Creatine  kinase  
• Importance  of  compliance  to  AEDs     • In   one   retrospective   study,   total   CPK   (not   cardiac  
• The  possible  side  effects   isoenzymes)   measured   at   least   three   hours   after   the  
§ If   patient   does   not   tolerate   current   medication,   we   may   opt   event  correlated  with  generalized  seizures.  
to  change  to  felbamate.     § Prolactin  
  • Prolactin  is  released  during  periods  of  significant  stress.  
CASE  3   Serum   levels   are   elevated   following   generalized   motor  
• A   24   year   old,   female   was   seen   at   the   UERM   epilepsy   clinic   for   seizures   in   approximately   90%   of   cases,   and   following  
recurrent   generalized   tonic-­‐clonic   seizures   since   6   months   prior   to   complex  partial  seizures  in  about  70%  of  cases.  
consult.   Work   up   supports   idiopathic   primary   generalized   epilepsy.   § ECG  
She   was   started   on   phenytoin   at   6mg/kg/day.   She   has   had   regular   § ABG  -­‐  to  rule  out  hypoxia  
follow   ups   and   has   been   seizure   free.   On   her   last   checkup   she,   she   • If   an   arterial   blood   gas   analysis   (ABG)   is   obtained   in   a  
complained  of  gum  pain  and  gum  bleeding.  The  PE  showed  presence  of   convulsing   patient   (and   this   is   not   routinely   indicated),   it  
slight  mustache  and  increase  in  hair  distribution  over  her  arms.     will   show   an   anion   gap   metabolic   acidosis,   usually  
1. Do  you  think  the  patient  needs  further  follow  up?  Explain.   secondary   to   lactic   acidosis.   In   cases   of   prolonged  
§ No.   The   symptoms   experienced   by   the   patient   are   known   seizures,   an   ABG   can   provide   information   regarding  
side   effects   of   Phenytoin.   Moreover,   the   patient   has   been   hypercarbia  and  oxygenation.  
 
seizure   free   since   onset   of   medical   therapy   which   indicates  
her  responsiveness  to  the  drug.   2. What  is  the  diagnosis?  Explain.  
  § Absence   or   petit   mal   seizure   since   the   patient   met   its  
2. What   would   be   your   therapeutic   plan   for   the   patient,   will   you   description.    
switch  AEDs?  If  so,  what  AED  will  you  start?  Explain.   • Blanking   out   in   which   she   abruptly   stops   all   actions   for  
§ The   plan   is   to   switch   to   another   AED   to   prevent   or   avoid   about   10   seconds   followed   by   a   rapid   return   to   full  
recurrence  of  the  symptoms  presented.  Since  the  patient  was   consciousness   (brief   staring   spells;   3-­‐20   seconds;   sudden  
diagnosed   with   generalized   (tonic-­‐clonic)   epilepsy,   the   first   onset  and  sudden  resolution)  
line   drugs   are   CARBAMAZEPINE,   LAMOTRIGINE,   AND   • Eyes   are   open   during   the   episode   and   she   remains  
VALPROATE.   Among   these,   she   could   be   given   Lamotrigine   motionless   with   occasional   fumbling   hand   movements  
since   she   is   of   reproductive   age   and   the   other   drugs   are   (brief  staring  spells)  
usually  avoided  when  pregnancy  is  anticipated.   • No  awareness  that  the  activity  has  occurred  (impairment  
  of  awareness)  
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   Neurology  6.4b  
 
• Patient  is  5  y/o  (onset  of  absence  is  typically  between  4  
and  14  y/o)  
• Hyperventilation   in   office   replicates   episodes   (often  
provoked  by  hyperventilation)    
• EEG:  3Hz  spike  and  wave  discharges  (EEG:  generalized  3  
Hz  spike-­‐wave  discharges)  
• General   physical   and   neuro   exam   was   normal   (normal  
development  and  ntelligence)    
 
3. How  would  you  initiate  medication?  If  so,  what?  
§ Factors   to   consider   in   selecting   an   AED   include:   control   of  
seizure,   tolerability,   pharmacokinetic   properties,   patient  
characteristics,   drug   interactions   and   the   cost,   and   the   most  
important   thing   to   consider   is   the   type   of   seizure.   For  
absence  type,  the  drug  of  choice  is  Ethosuximide.  
 
4. Would  you  counsel  the  family  regarding  the  prognosis?  
§ Counsel   the   family   that   this   type   of   seizure   usually   resolves  
by  18  y/o.  
 
REFERENCES  
1. Dra.  Pineda’s  powerpoint  
2. https://www.ebmedicine.net/topics.php?paction=showTopicSeg&
topic_id=112&seg_id=2173  
 

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