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98 Cards in this Set
- Front
- Back
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What % of pts can be maintained on 1 antiepileptic drug?
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50-70%
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Can some pts eventually d/c antiepileptic drug therapy?
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yes
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What is epilepsy?
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a disorder that is best viewed as a symptom of disturbed electrical activity in the brain
chronic disorder characterized by recurrent unprovoked seizures |
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What is the focus of drug tx for seizures?
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abolition of seizures
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What % of population will have at least 1 seizure in their lifetime?
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8%
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Can a pt have a seizure and not have epilepsy?
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yes
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Do febrile seizures constitute epilepsy?
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no, only associated with fever
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How many new epilepsy cases/year?
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125,000
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What % of new epilepsy cases are in pts younger than 18 years?
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30%
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When does the first seizure occur?
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bimodal: 2 peaks
one peak in newborns and young children, 2nd peak in pts older than 65 years |
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What makes a seizure occur?
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a group of cortical neurons discharge abnormally in sychrony
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What pts are at increased risk of seizure?
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mental retardation, cerebral palsy, head injury, stroke
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What induces seizures in the elderly?
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strokes, neurodegenerative disorders (Alzheimers), and other conditions
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What is idiopathic etiology?
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suspected primary generalized seizures
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What is cryptogenic etiology?
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no obvious cause for partial onset seizures
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Is idiopathic etiology higher in older or younger pts?
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younger
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What factors can precipitate seizures?
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hyperventilation, sleep, sleep deprivation, sensory stimuli, emotional stress, hormonal changes
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What drugs may provoke seizures?
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theophylline, alcohol, high dose phenothiazines, antidepressants, street drugs
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What are risk factors for development of partial-onset seizures?
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perinatal injuries, small gestational weight at birth
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Are immunizations associated with increased risk of epilepsy?
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no
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What do seizures result form?
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excessive excitation of a large population of cortical neurons
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What do absence seizures result from?
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disordered inhibition of a large population of cortical neurons
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How is a seizure reflected on an EEG?
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a sharp wave or spike
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What mechanisms might contribute to synchronolus hyperexcitability?
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-alterations in the distribution, number, type and biphysical properties of ion channels in the neuronal membranes
-biochemical modifications of receptors -modulation of second messaging systems and gene expression changes in extracellular ion concentrations -alterations in neurotransmitter uptake and metabolism in glial cells -modifications in the ratio and function of inhibitory circuits |
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What is the main excitatory NT?
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glutamate
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What is the main inhibitory NT?
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GABA
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What are the neuromodulators?
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acetylcholine, NE, 5-HT
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Can imbalances of the main NT and neuromodulators precipitate seizures?
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yes
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How do AEDs work?
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elevating the threshold of neurons to electrical or chemical stimuli or by limiting the propagation of the seizure discharge from its origin
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What does raising the threshold involve?
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stabilization of neuronal membranes
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What does limiting the propagation involve?
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depression of synaptic transmission and reduction of nerve conduction
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What can continued exposure to glutamate lead to?
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neuronal damage
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Do individual seizures cause decrease in intelligence?
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no, suffering from a large number (100) generalized tonic clonic seizures and multiple episodes of status epilepticus can cause caognitive declines
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Where to partial (focal) seizures begin?
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one hemisphere of the brain
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How do partial (focal) seizures present?
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asymmetric motor manifestation unless they become secondarily generalized
alterations in motor functions, sensory or somatosensory symptoms, or automatisms |
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What are partial seizures with no loss of consciousness classified as?
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simple partial
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What are auras?
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"warning" somatosensory symptoms to the development of a GTC seizure that are actually simple partial seizures
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What are partial seizures with an alteration of consciousness?
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complex partial seizures
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What symptoms for complex partial seizure?
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automatisms, periods of memory loss, aberrations of behavior, amnestic to these events
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What can complex partial seizures progress to?
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generalized tonic clonic seizures
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What is involved in generalized seizures?
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involvement of both hemispheres
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What symptoms of generalized seizure?
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bilateral motor manifestations, loss of consciousness
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What is a secondarily generalized seizure?
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partial seizure that becomes generalized
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What are generalized absence seizures manifested by?
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sudden onset, interruption of ongoing activities, a blank stare, and possibly a brief upward rotation of the eyes
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Who usually gets generalized absence seizures?
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young children through adolescence
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What manifestations from generalized tonic clonic seizure?
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sudden tonic contraction of muscles followed by a period of rigidity and clonic movements
pt may cry or moan, lose sphincter control, bite the tongue, or develop cyanosis |
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What s/s after a generalized tonic clonic seizure?
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altered consciousness, drowsiness, confusion for a variable period of time (postictal period), deep sleep
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Can tonic and clonic seizure occur separately?
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yes
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What are myoclonic jerks?
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brief shock-like muscular contractions of the face, trunk, and extremities
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What is a atonic seizure?
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a sudden loss of muscle tone
head drop, dropping of a limb, slumping to the ground |
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What is idopathic?
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syndromes presumably genetic, also those with no underlying etiology documented or suspected
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What do symptomatic cases involve?
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evidence of brain damage or a known underlying cause
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What is a cryptogenic syndrome?
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symptomatic of an underlying condition that can't be documented
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What is unknown or undetermined?
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no cause can be identified
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What s/s for complex partial seizures?
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somatosensory or focal motor features, altered consciousness
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What s/s for absence seizures?
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almost nondetectable, only very brief (seconds) periods of altered consciousness
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What s/s of generalized tonic clonic seizures?
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major convulsive episodes and loss of consciousness
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Are there any signs between seizures?
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no
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What labs for seizure diagnosis?
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none, sometimes after GTC or CP seizures prolactin will be elevated
rule out treatable causes of seizures: hypoglycemia, altered electrolyte concentrations, infections |
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Is epileptiform EEF found in all epilepsy pts?
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no, only about 50%
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Is MRI or CT more useful in evaluation for epilepsy?
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MRI
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How many pts become seizure free from older AED monotherapy?
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50%
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What % of pts are refractory to tx?
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30-35%
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When is an AED considered ineffective?
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pt experienced unacceptable AE with continued seizures
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Is monotherapy preferred in epilepsy tx?
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yes, 50-70% can be maintained on monotherapy
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What type seizure has the best prognosis for 12 month seizure free period?
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generalized tonic clonic
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What type seizure has the worst prognosis for 12 month seizure free period?
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complex partial seizure
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What % of pts will be refractory to tx?
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20%
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What is the single most common reason for tx failure?
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medication noncompliance
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How many seizures before a pt should be started on AED?
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generally 2 or more, some start after 1st, some prophylaxis
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In reducing polypharmacy, what drug is d/c?
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the considered less appropriate for the seizure type or most responsible for AE
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What factors favor successful withdrawal of AEDs?
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seizure free period of 2-4 years, complete seizure control within 1 year of onset, onset of seizures after age 2 but before age 35, normal neurologic exam and EEG
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What factors are associated with a poor prognosis in d/c AEDs?
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history of a high frequency of seizures, repeated episodes of status epilepticus, combination of seizure types, development of abnormal mental functioning
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What activity in children is linked to a high relapse rate?
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irregular generalized spike and wave activity in EEG recording
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How long of a seizure free period for absence and rolandic epilepsy before d/c?
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2 year
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How long of a seizure free period in simple partial, complex partial, and absence seizures before d/c?
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4 years
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When is AED withdrawal not recommended?
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juvenile myoclonic epilepsy, absence with clonic-tonic-clonic seizures, or clonic-tonic-clonic seizures
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When can d/c of AED?
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seizure free for 2-5 years, history of a single type of a partial seizure or primary GTC seizure, normal neurologic exam, normal IQ, EEG has been normalized with tx
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What can occur with sudden withdrawal of AED?
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status epilepticus
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What agents are withdrawal seizures of particular concern?
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BDZ, barbiturates
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How long should AEDs be withdrawn to prevent relapse?
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6 months
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What nonpharm for seizures?
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diet, surgery, vagus nerve stimulation
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What is a vagal nerve stimulator?
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implanted medical device, FDA approved for adjunctive tx in reducing the frequency of seizures in adults and adolescents older than 12 years with partial onset seizures refractory to AEDs
off label use for generalized epilepsy |
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How dose vagal nerve stimulator work?
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change CSF concentrations of inhibitory and stimulatory NT and activates specific areas of the brain that generate or regulate cortical seizure activity through increased blood flow
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What does the long term intermittent antiepiletpic effects of vagal nerve stimulation involve?
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NT and neurochemicals
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What AE from VNS?
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relatively safe, common SE: hoarseness, voice alteration, increased cough, pharyngitis, dyspnea, dyspepsia, nausea
serious SE: infection, nerve paralysis, hypoesthesia, facial paresis, left vocal cord paralysis, left facial paralysis, left recurrent laryngeal nerve injury, urinary retention, low grade fever |
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What is the tx of choice in selected pts with refractory focal epilepsy?
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surgery
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What is success rate of surgery?
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80-90%
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What benefits from surgery?
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reduces risk of epilepsy associated death, may improve depression and anxiety in refractory pts
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What absolute requirements for surgery?
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absolute diagnosis of epilepsy, failure of adequate trial of drug therapy, definition of the electroclinical syndrome
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What location of surgery has best outcome?
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focus in the temporal lobe, extratemporal foci can be excised successfully in more than 75% pts
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What AE from surgery?
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learning and memory impaired postop, general intellectual abilities also affected
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Is AED still needed after surgery?
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yes for a period of time, can use a lower dose
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What is the ketogenic diet?
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high in fat, low in carbs and protein which leads to acidosis and ketosis
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What are most of the calories in the ketogenic diet provided from?
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heavy cream and butter
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Is sugar used in the ketogenic diet?
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no
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What can be substituted for dietary fats in the ketogenic diet?
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medium chain triglycerides
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What long term AE from ketogenic diet?
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kidney stones, increased bone fractures, AE on growth
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