1. Seizures and Epilepsy Dr.Isazadehfar

2. Seizures A seizure is as a sudden, disorderly discharge of cerebral neurons. Seizures involve a transient alteration in brain function involving motor, sensory, autonomic, or psychic clinical manifestations

3. Epilepsy Epilepsy is a group of related disorders characterized by a tendency for recurrent (2 or more) seizures. Every 5 – 10 persons per 1,000 people have epilepsy

4. Terminology  Aura: A partial seizure experience before the onset of a generalized seizure; often described as a ‘funny feeling’  Prodroma: Early clinical manifestations that may occur hours to a few days before the onset of a seizure (malaise, headache, or depression)  Tonic phase: A state of muscle contraction with increased muscle tone (associated with loss of consciousness)

5. Terminology cont.  Clonic phase: Alternating contraction and relaxation of muscles  Postictal phase: Time period immediately after the end of seizure activity

6. Types of Seizures  Seizures can be classified as either partial or generalized  The type of seizure as well as the signs and symptoms that accompany the seizure depend on the part of the brain in which the seizures occur

7. Types of Seizures - Partial  Partial Seizures are seizures that begin locally (in one part of the brain) i.Simple Partial seizure (consciousness not impaired) ii.Complex partial seizure (consciousness impaired) iii.Secondary generalized seizure (begins as partial and transitions into a generalized seizure)

8. Types of Seizures - Generalized  Generalized seizures are bilaterally symmetric; there is no local onset and although they involve the entire brain, physical control is rarely lost.  Types of GS include: i.Absence seizures (petit mal)- staring, slight body movement and short periods of unawareness ii.Myoclonic seizures- sudden jerks of arms and legs iii.Atonic seizures (drop attacks)- suddenly collapse or fall down iv.Tonic-clonic seizures (grand mal)- most severe type of seizure; characterized by loss of consciousness, body stiffening, shaking and sometimes tongue biting or bladder incontinence

9. Partial and Generalized Partial Seizure with Secondary Generalization Primary Generalized Seizure Partial Seizure

10. Etiology - Seizures  We all have the potential to have a seizure if the right conditions affect our neuronal environment; some people however, have a lower genetic threshold for seizures.  Causes include:  Cerebral lesions  Biochemical disorders  Cerebral trauma  Epilepsy

11. Etiology seizures cont.  hypoglycemia  fatigue or lack of sleep  emotional or physical stress  febrile illness  large amounts of water ingestion  constipation  use of stimulant drugs  withdrawal from depressants  hyperventilation Environmental stimuli that can trigger seizures include:  Blinking lights  Poorly adjusted lights  Loud noises  Certain music  Certain odors  Being startled Seizures may be precipitated by:

12. Etiology - Epilepsy  Metabolic defects  Congenital malformation  Genetic predisposition  Perinatal injury  Postnatal trauma  Myoclonic syndromes  Infection  Brain tumor  Vascular disease  Fever  Drug and/or alcohol abuse

13. Pathogenesis A seizure occurs when a burst of electrical impulses in the brain escape their normal limits (past threshold). They spread to neighboring areas and create an uncontrolled storm of cortical nerve cell electrical activity. The electrical impulses can be transmitted to the muscles, causing twitches or convulsions. A seizure can also be caused by a rapid increase in body temperature in children; these are called fever seizures

14. Clinical Manifestations  Signs and symptoms (S&S) can be categorized as pre-seizure, during, and post-seizure manifestations.  Seizures may involve some or all of the following list of symptoms depending upon the seizure type.

15. Pre-seizure S&S S&S include-  “Aura” symptoms: unusual smell, visual loss or blurring and/or feelings of deja-vu  Racing thoughts  Tingling feeling (most often felt in the stomach)  Fear and panic  Dizziness  Light-headedness  Numbness

16. S&S after the initial onset  Symptoms may be isolated to one side of the body or generalized throughout the body  Blackouts and loss of consciousness  Chewing movements, drooling, swallowing, tongue- biting, spitting, lip-smacking, tooth grinding  Difficulty talking, unusual sounds  Eyelid fluttering, eyes rolling back  Stiffness and/or inability to move

17. During seizure S&S cont.  Twitching movements, jerking, shaking or uncontrolled limb movements  Incontinence  Breathing difficulty -Older adults generally experience less exaggerated physical signs and symptoms than younger adults

18. Post-seizure S&S  Deep sleep  Memory loss  Confusion  Writing and speech difficulties  Weakness  Injuries, bruising, aching and pain from muscle activity -The above symptoms experienced after a seizure generally last longer in adults (postictal phase)

19. Diagnosis and Management of Seizures  Initial assessment  Airway  Breathing  Circulation  Call for help  Ask for more history  How long has the patient been seizing?  New-onset vs. known seizure disorder  Baseline seizure frequency, is this typical or not?  Events leading up to this episode  Meds/triggers  History of status

20. Diagnosis  FAMILY HISTORY!  Seizure, developmental delay, genetic/metabolic problems, consanguinity  Setting in which the seizure occurs:  Nocturnal? Medications? Illness/fever  What happened before the event?  Precipitants? Headache, anorexia, nausea, vomiting, breath-holding? Certain activities? Aura?  What happened after the event?  Immediate recovery? Confusion/somnolence? How long did this last? Ability to speak/follow commands? Not moving limbs?

21. Diagnosis  Has the patient had these episodes before?  What has been done to evaluate/treat these episodes? How many? How often? Has the patient ever been in status epilepticus?  Normal development? Social stressors? Previous history of neurological illness (infection, trauma)? Drug use? (especially in adolescents)

22. Diagnosis & Treatment  EEGs can be used to confirm diagnosis and determine type of seizure  An MRI may be ordered if the initial medications pt. is on fail to control seizures or a CT scan if pt. is an older adult  Plasma levels of electrolytes, glucose and calcium levels, renal function tests, liver function tests and even drug screening may be performed There are many different diagnostic tests that are used to determine and classify seizures and seizure disorders. Diagnostic tests include:

23. Diagnosis & Treatment cont.  If the pt. has already been diagnosed with epilepsy: anti-epileptic drug (AED) levels may be tested to ensure that the dosage levels are accurate  An ECG can exclude cardiac cause of symptoms or seizure  CSF may be tested for infection

24. Diagnosis & Treatment cont. Current treatment methods can control seizures for approximately 66% of people with epilepsy. Treatments include:  Anti-epileptic drugs are the most common form of treatment  Brain surgery is performed if seizures originate in a small, defined area in the temporal or frontal lobes, but is not common otherwise due to added risk of damaging vital brain functions

25. Diagnosis & Treatment cont.  Vagus nerve stimulation- a vagus nerve stimulator is implanted into the chest beneath the collarbone, wraps around the vagus nerve and stimulates the brain to inhibit seizures  Children (and some adults) who don’t respond to medicinal treatment have been prescribed a high-fat, high-protein and low carbohydrate diet to produce ketones, which allow the body to use fat instead of glucose for energy. The exact mechanism for why this works is unknown.

26. Witness Response When you see someone having a seizure you should:  Loosen their clothing  Move surrounded objects that the seizing individual could hurt him/herself on  Stay until seizure ends to make sure the person is okay and can get up

27. Status Epilepticus  A patient is in status epilepticus if seizure activity has lasted > 30 minutes or there are multiple seizure episodes with failure to regain consciousness between episodes