distinguishing types of seizures - cme...
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Joseph I. Sirven, MD Mayo Clinic College of Medicine Phoenix, AZ
Distinguishing Types of Seizures
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Accurately identify and document the seizure type or syndrome and seizure frequency from the patient history before initiating a treatment plan
Learning Objective
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Points to Consider When Evaluating Spells
● Precipitating or ameliorating factors ● Description of behavior during event ● Is it stereotyped? ● Duration ● Aura or Prodrome ● When do they occur? ● Nature of recovery
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Definitions
● Seizure: the clinical manifestation of an abnormal, excessive excitation and synchronization of a population of cortical neurons ● Epilepsy: recurrent seizures (two or more)
which are not provoked by systemic or acute neurologic insults
Fisher RS, et al. Epilepsia. 2014;55(4):475-482.
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Practical Definitions
● Seizure – disturbances in the electrical activity of the brain ● Epilepsy – two or more unprovoked
seizures separated by at least 24 hours ● Epilepsy is a spectrum of disorders: – Many different types of seizures – Many causes – Many syndromes and types of epilepsy
Sirven JI. Semin Neuro. 2002;22(3):237-246. PMID: 12528049.
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ILAE Classification of Seizures
Seizures
Generalized Absence
Myoclonic
Atonic
Tonic
Tonic-Clonic
Focal
Simple Partial
Complex Partial
Secondary Generalized
ILAE – International League Against Epilepsy Sirven JI. Semin Neuro. 2002;22(3):237-246. PMID: 12528049.
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ILAE Classification of Seizures
Seizures
Generalized Focal
Simple Partial
Complex Partial
Secondary Generalized
Sirven JI. Semin Neuro. 2002;22(3):237-246. PMID: 12528049.
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Seizure Differential Diagnosis
Rowan AJ, et al. Neurology. 2005;64(11):1868-1873. PMID: 15955935.
Non-epileptic Epilepsy
Primary Secondary Syncope Cardiovascular Migraine Cerebrovascular Metabolic Psychogenic
Age dependent Genetic Family History Neurochemical imbalance
Non-lesional Epilepsy Syndromes
Symptomatic Structural Lesions Progressive
Focal & Generalized
Focal & Generalized
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Seizure vs. Non Epilepsy Seizures (NES)
Hoerth MT, et al. Neurologist. 2008;14(4):266-270. PMID: 18617856. Brown RJ, et al. Epilepsy Behav. 2011 Sep;22(1):85-93. PMID: 21450534.
Clues Favoring Epilepsy ● Autonomic changes – Pupil dilation – Incontinence – Corneal reflex
suppression ● Post-ictal Babinski sign ● Self injury ● Not responsive during event ● Amnesia for the event ● Duration less than 2 minutes
Clues Favoring NES ● Never witnessed or vice versa ● Provoked by emotional stress ● Variable form one event to
another ● Screaming or vocalizing
throughout the entire event ● Prolonged, greater than a
couple of minutes ● Sudden termination of event ● No post-ictal confusion ● Induced by suggestion ● Responsive during event ● Usually NO injury ● Usually NO incontinence
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Routine EEG and Role in Diagnosing Seizures
● Often over-interpreted ● 2% adults and 3% pediatrics without spike
wave but no seizure ● Persons with epilepsy (PWE): 50% normal
with one EEG; if 4 normal EEGs not likely to see abnormality ● 10-20% PWE have normal EEG
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AAN Recommendations for First Seizure
● Adults presenting with an unprovoked first seizure should be informed that the chance for a recurrent seizure is greatest within the first 2 years after a first seizure (21%-45%) (Level A).
● Clinicians should also advise such patients that clinical factors associated with an increased risk for seizure recurrence include a prior brain insult such as a stroke or trauma (Level A), an EEG with epileptiform abnormalities (Level A), a significant brain-imaging abnormality (Level B), or a nocturnal seizure (Level B).
Krumholz A, et al. Neurology. 2015; 84(16 ):1705-1713. PMID: 25901057.
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AAN Recommendations for First Seizure ● Clinicians should advise patients that, although
immediate anti-epileptic drug therapy (AED), as compared with delay of treatment pending a second seizure, is likely to reduce the risk for a seizure recurrence in the two years subsequent to a first seizure (Level B); it may not improve QOL (Level C).
● Clinicians should advise patients that over the longer term (> 3 years) immediate AED treatment is unlikely to improve the prognosis for sustained seizure remission (Level B).
● Patients should be advised that their risk for AED adverse effects ranges from 7% to 31% (Level B) and that these adverse effects are predominantly mild and reversible.
Krumholz A, et al. Neurology. 2015;84(16 ):1705-1713. PMID: 25901057.
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Questions & Answers