Neuroimaging and Seizure Management Quiz

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Questions and Answers

What is the primary reason for hospitalization in patients with seizures?

First seizure without any obvious risk factors

Presence of a mild headache

First unprovoked seizure with a short post-ictal state

Status Epilepticus (correct)

When is Antiepileptic Drug (AED) therapy generally indicated?

If there is a high risk of recurrent seizures (correct)

After a patient has had multiple migraines

Only after a third seizure occurs

After the first provoked seizure that resolves

Which factor increases the likelihood of seizure recurrence?

History of significant head trauma (correct)

Normal neurologic exam following the first seizure

A single brief seizure with no identified cause

A normal EEG result after the first seizure

What diagnostic tool is considered preferred for evaluating potential seizure pathology?

Brain MRI is the preferred modality Signup and view all the answers

Which patient profile is considered high risk for seizure recurrence?

Patients with a history of serious brain injury Signup and view all the answers

What feature differentiates partial seizures from generalized seizures?

Partial seizures may involve a focal area of the brain. Signup and view all the answers

Which of the following is a common risk factor for developing epilepsy?

History of head injury Signup and view all the answers

Which of the following seizure types is classified under generalized seizures?

Absence Seizures Signup and view all the answers

What is the primary purpose of a neurologic exam after the first seizure in adults?

To look for focal features and musculoskeletal trauma Signup and view all the answers

What is considered a common diagnostic study in the evaluation of epilepsy?

Magnetic Resonance Imaging (MRI) Signup and view all the answers

What is the defining characteristic of status epilepticus?

Continuous seizures or repetitive seizures without recovery of consciousness lasting 5 minutes or longer Signup and view all the answers

Which of the following is the most common cause of status epilepticus?

Withdrawal or non-adherence to anticonvulsant drugs Signup and view all the answers

Which first generation anticonvulsant does NOT induce enzyme activity that affects the efficacy of OCPs?

Valproate Signup and view all the answers

What is the recommended approach for patients on AEDs during pregnancy?

Folate supplementation of 1-4 mg per day Signup and view all the answers

What characterizes non-convulsive status epilepticus?

A wide variety of clinical manifestations including confusion and hallucinations Signup and view all the answers

Which of the following AEDs is specifically noted for decreasing the efficacy of oral contraceptive pills (OCPs)?

Felbamate Signup and view all the answers

What is a common risk associated with seizures during pregnancy?

Increased chance of fetal malformations Signup and view all the answers

In the classification of seizures, what is a key aspect of simple partial status epilepticus?

Seizures are localized to the part of the body in which they originate Signup and view all the answers

Study Notes

Diagnostic Studies

Brain MRI is the preferred modality for neuroimaging.
CT brain is used in emergency settings to rule out acute pathology, but MRI should be used if possible.
Lab studies include CBC, serum glucose, Calcium, Magnesium, renal function studies, and drug and toxicology screens.
Lumbar puncture is performed if an infectious process is suspected.

EEG

A positive EEG is helpful in diagnosing epilepsy.
A normal EEG does not eliminate the possibility of epilepsy.
The EEG is more sensitive if the patient is sleep-deprived.

Hospitalization

Hospitalization is recommended for first seizures with a prolonged post-ictal state or unusual features.
Status Epilepticus warrants immediate hospitalization.
Hospitalization is also recommended for seizures associated with a systemic illness or a history of significant head trauma.

Single Unprovoked Seizures

4% of the population will experience a seizure by age 80.
30-40% of patients with a first seizure will experience a second unprovoked seizure (epilepsy).
Risk factors for seizure recurrence include a history of neurological insult, focal lesions on MRI, epileptiform EEG, and family history of epilepsy.
Adult patients with these risk factors have a 60-70% chance of seizure recurrence.

Antiepileptic Drug Therapy (AED)

AED therapy is not necessary if a first seizure is provoked by factors that resolve.
AED therapy may be indicated for persistent brain injury, such as stroke or tumor.
AED therapy is generally started if there is a high risk of recurrent seizures.

High Risk Patients

A history of serious brain injury increases the risk of recurring seizures.
Lesions on CT or MRI that could promote recurrent seizures indicate a higher risk.
Focal neurologic exam findings suggest increased risk.
Mental retardation is a risk factor for seizure recurrence.
Partial seizure as the first seizure indicates a higher risk of recurrence.
Abnormal EEG findings increase the risk of recurrent seizures.
Absence, myoclonic, and atonic seizures are more likely to recur.

Treatment Approach

Treatment is typically reserved for individuals who have experienced at least two seizures.
Treatment after a first seizure may be appropriate in certain circumstances.

Glossary

Seizure: an alteration in behavior, sensation, or awareness caused by abnormal neuronal discharge in the brain.
Epilepsy: a recurring tendency to have seizures, excluding an underlying reversible cause.

Epilepsy

Epilepsy is a chronic disorder characterized by recurrent seizures.
Seizures are episodes of brain dysfunction resulting from abnormal discharge of cerebral neurons.

Epidemiology

Approximately 50 million people worldwide live with epilepsy.
The estimated proportion of the general population with active epilepsy is 4-10 per 1000 people.
An estimated 2.4 million people are diagnosed with epilepsy annually.

Classification of Seizures

Partial (Focal) Seizures:
- Simple Partial Seizures
- Complex Partial Seizures
- Partial seizures secondarily generalized
Generalized Seizures:
- Generalized Tonic-Clonic Seizures
- Absence Seizures
- Tonic Seizures
- Atonic Seizures
- Clonic Seizures
- Myoclonic Seizures
- Infantile Spasms

Evaluation of the First Seizure in Adults

History:
- Was the event a seizure?
- Are there witnesses?
- What were the circumstances surrounding the event?
- Is there an obvious provoking cause?
- Were there any signs like tongue biting, incontinence, post-ictal state, or muscle soreness?
- Medication history
- Past Medical history - Risk factors for epileptic seizures include a history of head injury, stroke, alcohol and drug abuse
- Family history - Absence and myoclonic seizures may be inherited
Physical and Neurologic Examination:
- Look for focal features during the neurologic exam.
- Screen for musculoskeletal trauma (fractures, etc.).
- Consider the possibility of aspiration pneumonia.

AED Special Considerations

OCPs:
- First-generation AEDs, except valproate, may interfere with OCP effectiveness.
- AEDs such as felbamate, topiramate, and oxcarbazepine induce enzyme activity, decreasing OCP efficacy.
- Women on enzyme-inducing AEDs should use an OCP with at least 50 mcg of estrogen.

AEDs in General

Enzyme-Inducing Drugs:
- Phenytoin
- Carbamazepine
- Phenobarbital
- Felbamate
- Topiramate
- Oxcarbazepine

Pregnancy Considerations

Consider withdrawing AEDs if the patient is a good candidate.
Use monotherapy whenever possible.
Supplement with folate (1–4 mg daily) for all women on AEDs.
Increased risk of fetal malformations in pregnant women on AEDs.
Seizures during pregnancy can induce miscarriage.
Seizures during pregnancy can be harmful to the mother or fetus.

Status Epilepticus (SE)

Generalised convulsive and non-convulsive SE:
- Neurological and medical emergency.
- Defined as ≥ 5 minutes of continuous seizure activity or repetitive seizures without intervening recovery of consciousness.
Simple partial SE:
- Usually does not involve alteration of consciousness.
- Seizures are typically localised to the part of the body where they originate, and motor activity can last for hours, days, or even longer.

SE Etiology

Causes of SE are varied.
Any neurological insult or systemic abnormality capable of inducing a seizure can trigger SE.
The most common cause of SE is non-adherence or withdrawal from anticonvulsant medication.

SE Classification

Generalized Convulsive SE:
- Paroxysmal or continuous tonic or clonic motor activity, which may be symmetrical or asymmetrical.
- Includes primary and secondary generalized seizures.
Non-convulsive SE:
- Variety of clinical manifestations, such as coma, confusion, disorientation, altered affect, bizarre behavior, delusions, hallucinations, and paranoia.
- Subdivided into:
  - Absence SE
  - Complex partial SE.
Simple partial SE:
- Seizures localised to the body part where they originate.
- Focal clonic activity or subjective changes alone.

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Description

Test your knowledge on diagnostic studies related to neuroimaging and seizure management. This quiz covers the preferred imaging modalities, EEG significance, and guidelines for hospitalization in seizure cases. Assess your understanding of the clinical approach to neurological emergencies.