Seizures

• Presentation given by Miranda LaCroix, PA, Spring 2022

Patient Case: H.B.

• A 38-year-old female with a past medical history of anxiety and hypertension presents to the ED with altered mental status
• According to her husband, she has been minimally responsive and refusing to move, eat, or care for herself for the last couple of days

AEIOUTRIPS Differential

• A useful acronym to run through a list of things to check with altered mental states:
  • Acidosis
  • Abuse of substances
  • Arrhythmias
  • Environmental
  • Electrolytes
  • Encephalopathy
  • Endocrine
  • Infection
  • Overdose
  • Underdose
  • Uremia
  • Trauma
  • Tumor
  • Respiratory
  • Insulin
  • Psychogenic
  • Poison
  • Stroke
  • Seizure
  • Shock
  • Syncope

Seizures

• Objectives include summarizing etiology, pathophysiology, and treatment of different categories of seizures
• Categories include:
  • Focal onset (motor vs non-motor)
  • Aware vs impaired awareness, focal to bilateral tonic-clonic
  • Generalized onset (non-motor/absence), motor
  • Unknown onset
  • Febrile seizure
  • Psychogenic non-epileptic seizure
• Focus on patient education for those with a seizure disorder

Definitions

• Seizure: A sudden change in behavior caused by electrical hypersynchronization of neuronal networks in the cerebral cortex
• Epilepsy
• At least two unprovoked seizures occurring more than 24 hours apart -One unprovoked seizure with a probability of further similar seizures -Diagnosis of an epilepsy syndrome
• Post-Ictal: The period after a seizure where the patient becomes unresponsive, fatigued, confused, or flaccid

Epidemiology

• Lifetime Seizure Risk: ~10%
• Lifetime Epilepsy Diagnosis Risk: ~4%
• Approximately 2 million people
• Slightly more common in males than females

Etiology

• Idiopathic accounts for 65%
• Vascular diseases account for 10.9%
• Pediatric (Metabolic disorders, gene disorders, congenital malformations, benign) account for 8%
• Trauma accounts for 5.5%
• Neoplastic accounts for 4.1%
• Degenerative diseases account for 3.5%
• Infectious diseases account for 2.5%
• Pre-eclampsia (pregnancy-hypomagnesemia)

Causes of Seizures by Age

• Neonates (<1 month): CNS infection, developmental disorders, drug withdrawal, genetic disorders, intracranial hemorrhage, metabolic disturbances, perinatal hypoxia/ischemia
• Infants and Children (>1 month - 12 years): CNS infection, developmental disorders, febrile seizures, genetic disorders, trauma
• Adolescents (12-18 years): Brain tumor, genetic disorders, illicit drug use, infection, trauma
• Young Adults (18-35 years): Alcohol withdrawal, autoantibodies, brain tumor, illicit drug use, trauma
• Older Adults (>35 years): Alcohol withdrawal, Alzheimer's disease, autoantibodies, brain tumor, cerebrovascular disease, metabolic disorders

Medications Associated with Seizures

• Analgesics (opioids), anticancer drugs, antimicrobials, hypoglycemic agents, immunosuppressants, psychiatric and pulmonary medications, stimulants, sympathomimetics, decongestants
• Decreased seizure threshold: antidepressants (bupropion, maprotiline), neuroleptics (phenothiazines, clozapine), Lithium, Baclofen, withdrawal of AEDs, supratherapeutic Phenytoin levels, Theophylline, analgesics, opioid withdrawal, benzo/barbiturate withdrawal

It may resemble a seizure, but probably isn't

• Apnea / ALTE
• Sleep disorders (nocturnal myoclonus, night terrors, narcolepsy/cataplexy)
• Migraine variants (esp. aura)
• Benign breath holding spells
• Syncope
• Movement disorders (tics, Tourette's, dystonia)
• ADD, GERD
• Temper tantrums
• Benign Paroxysmal Vertigo
• Substance use
• Functional Neurologic Disorder/Psychogenic Nonepileptic Seizure
• Epileptic Seizure

Psychogenic Nonepileptic Seizures (PNES)

• AKA pseudoseizures, functional neurologic disorder
• More common in females
• A psychiatric mechanism can sometimes cause a dissociative conversion, usually unconsciously
• Can be associated with physical and/or sexual abuse
• Approximately 50% respond to psychiatric treatment
• Distinguished signs of epileptic seizures: brief duration (1-2 min), typically open eyes, stereotyped synchronized motor activity, rate vocalization, rare incontinence, signs

Types of Seizures

• Generalized
• Tonic
• Clonic
• Tonic-Clonic
• Myoclonic
• Absence
• Focal (Partial)
• Simple
• Complex
• Secondary
• Specialized

Classification of Seizure Types (ILAE 2017)

• Focal Onset: Aware or impaired awareness, includes motor or nonmotor onset, can become focal to bilateral tonic-clonic
• Generalized Onset: Motor (tonic-clonic) or nonmotor (absence)
• Unknown Onset: Motor or nonmotor, can be unclassified

Seizure Activity

• Partial: Activity starts in one part of the brain
• Generalized: Activity involves the whole brain
• Simple: Person is alert during activity
• Complex: Person experiences awareness change
• Absence: Person is staring and blinking without falling, which involves the whole brain
• Myoclonic: Jerking movements of the body, which involves the whole brain
• Tonic-Clonic: Stiffening and jerking of the body, which involves the whole brain
• Tonic: Falling heavily to the ground, which involves the whole brain
• Atonic Seizures: loss of muscle tone

Types of Generalized Seizures

• Tonic: Muscle contraction leading to stiffening, ictal "cry," respiratory drive impairment, and increased heart rate and blood pressure
• Clonic: Jerking or twitching
• Tonic-Clonic: Wide-spread activity and neuronal discharge; also known as "Grand Mal" seizure; EEG: bilateral synchronous high voltage spikes (3/s)
• Myoclonic: Isolated "jerks"
• Absence: most common in children, sudden brief loss of consciousness without loss of muscle tone or post-ictal phase, plus staring spells; EEG - bursts of bilateral, synchronous 3Hz spike & wave activity

Types of Partial (Focal) Seizures

• Simple: No loss of awareness; Auras (see next slide)
• Complex: Impaired consciousness/level of awareness; Varying clinical manifestations base on origin & degree of spread (Jacksonian march); Amnesia for event & confusion after event; Typically lasts 30sec-3min
• Secondary Generalization: Begins focally, with or without focal neurologic symptoms; Variable symmetry, intensity, and duration of tonic and clonic phases; Typical duration of 1-3 minutes; Post-ictal confusion, somnolence, possible transient focal deficit; EEG - normal OR with slow waves/focal spikes corresponding to region of the brain

Seizure Auras

• Illusion; Memory; Vision; Sound; Self image; Time; and other types -Hallucination; Memory; vision; sound can be indicators

Lobes Where Seizures Begin

• Frontal Lobe: May cause loss of motor control, a change in behavior, or change in language expression
• Temporal Lobe: May cause a person to experience an odd smell, odd taste, buzzing/ringing in ears, fear/panic, déjà vu, or abdominal discomfort
• Occipital Lobe: May cause a person to experience multicoloured shapes (circles/flashes) and temporary loss of vision
• Parietal Lobe: May cause numbness/tingling, or burning/cold sensations

Febrile Seizures

• The most common neurological disorder of infants and young children is age-dependent, usually impacting children under five years
• Occurs in 2-4% of children under 5 (peak within the 12-18 months)
• Often defined as requiring an elevated temperature (greater than 38 degrees Celsius) for a child older than six months and younger than five years, and the absence of a central nervous system or acute systemic metabolic abnormality also helps confirm

Types of Febrile Seizures

• Simple: Majority of febrile seizures are <5 minutes AND not recurring within a 25-hour period. Occurs in 1/3 of children during early childhood and usually has a minimal risk in developing future epilepsy
• Complex: Focal, prolonged (>10-15 minutes), or multiple seizures within the first 24 hours. Carries a high risk of recurrence during early childhood and increased likelihood of future afebrile seizures

Febrile Status Epilepticus (FSE)

• Continuous seizures or intermittent seizures without neurologic recovery, lasting >5 minutes
• Historically determined if a seizure lasted 30 minutes or longer, updated in 201
• Persistently open and deviated eyes can indicate an ongoing focal seizure, even if convulsive motor activity has stopped.
• FSE does not include episodes of status epilepticus: children with fever due to meningitis, but distinguishing factors are difficult
• Lumbar puncture (LP) should be carefully considered

Management

• Majority of febrile seizures have ceased by the time the child is evaluated
• Antipyretics treat fever and is crucial.
• Febrile seizures >5 min in duration and ongoing will likely have Intravenous benzodiazepine treatment with the following options:
• Diazepam 0.1-0.2mg/kg OR lorazepam 0.05-0.1mg/kg
• Monitor respiratory and circulatory status
• Options also include Buccal Midazolam or intranasal lorazepam
• Most children with simple febrile seizures will not need to be admitted, and can discharge home once back to baseline

Febrile Status Epilepticus Management

• Treat with benzodiazepines, like normal febrile seizure management
  • Likely need additional antiseizure medication
  • Fosphenytoin indicated
• Lower fever using antipyretics or a cooling blanket
• Will likely always require admission for monitoring

Risk Factors for Recurrent Febrile Seizures

• Overall recurrence rate is 30-35%
• Increased Recurrence
• Young age at onset (<1 year old)
• History of febrile seizure in first-degree relative
• Low-degree fever while in the emergency department
• Brief duration between onset of fever and initial seizure
• Complex features are not necessarily associated with a high risk of recurrence. Other factors are an abnormal development, recurrence of seizures within the same illness or many illnesses

Diagnosis/Evaluation

• Physical Exam -Aura: metallic taste, abnormal smell, sense of impending doom -Ictal: automatisms, tonic, clonic, impaired consciousness -Post-ictal phase
• Evolution
• Labs: electrolytes, glucose, calcium, magnesium, complete blood count, renal function tests, liver function tests, urinalysis, (and toxicology screens)
• Electrocardiogram (ECG)
• Electroencephalogram (EEG)
  • Normal EEG does not rule out seizure
• Neuroimaging study (CT, MRI)
• Lumbar puncture (?)

Seizure Management

• Treatment with Antiepileptic drugs (AED) are an option
• Examples include Carbamazepine, Phenobarbital, Phenytoin, Lamotrigine, Levetiracetam, Oxcarbazepine , Topiramate, and Valproic Acid
• Risks & Side Effects: hyponatremia, increased suicidality, and some AED’s are teratogenic.

Common and Rare AED Side Effects

• Rare/serious side effects: hypersensitivity, leukopenia, severe neuropsychiatric effects, acute toxic reaction,
• Common: Systematic and neurological side effects

AED Treatment Initiation

• Generally, treatment is not provided after the 1st seizure.
• Starts with unprovoked cases, in which an estimated chance higher than 60% can influence treatment. Other examples can be abnormal MR, electroencephalogram, focal finding etc.
• Provoked cases of AED treatment can occur if a prolonged seizure, an active underlying disease, acute brain injury or strokes are present.

Managing 1st Unprovoked Seizure In Adults

• Patients are checked for seizure history, as well as any neurological issues
• Followed by suggested recommendations

Provoked vs Unprovoked

• Recommendations to tell them apart for care.
• Followed by suggested algorithms

AED Treatment Initiation After 2nd Seizure

Epilepsy Management

• Focal epilei: lamotrigine, levetiracetam, oxcarbazepine, carbamazepine, lacosamide
• Generalized epilei: valproate, lamotrigine, levetiracetam, topiramat
• Absence seizures: ethosuximide, valproate, lamotrigine

Patient Education

Education

• Safety measures
• When to call 911
• Medication knowledge
• Doctor knowledge
• Driving regulations

Key steps in Seizure First Aid include staying, safe and calling

• STAY with the affected person during initial seizure and recovery until they are alert
• Keep the person SAFE by moving away any harm.
• If in danger of aspiration, turn the person into SIDE as they are not awake and alert.
• Call if longer than 5 Minutes

Status Epilepticus

• Varying definitions, commonly accepted definition is longer than 5 min of activity
• Includes hypoxia, acidosis, cerebral edema, fever, and death if longer than 30min

Status Epilepticus Managemen

• Secure ABC’s(Airway, Breathing, Circulation) for the patient, with consideration for intubating if issues arise.
• Labs, CMP, CBC, AED levels are then tested
• IV BENZODIAZEPINE! given as medication
• Fosphenyotol/Depakote are another source for medication
• Continues EEC and Neuro consult

Neurologic Infections

• Objectives include being able to summarize the etiology, pathophysiology, and treatment of these infections.
• Infections include Encephalitis/Meningitis of chronic bacterial, viral, aseptic and Lyme disease.
• Prevention recommendations and understanding impact areas between encephalitis vs meningitis is also another objective.

Definition

• Meningitis is a purulent infection in subarachnoid space causing inflammation where the brain and spinal cord meet at the meninge.
• Encephalitis is inflammation of the brain parenchyma, usually associated with viral infection

Meningitis Diagram

• Meningitis is inflammation/swelling of the thin tissue surrounding both the brain and spinal cord.
• While Encephalitis is simply a inflammation of the brain itself.
• Meningoencephalitis is inflammation of both the brain and meninges

Meningitis Etiologies

• Viral/Aseptic
• Bacterial
• Chronic
• Fungal

Viral (Aseptic) Meningitis

• Includes: HSV-1
• Enterovirus
• HIV
• West Nile Virus
• EBV
• Mumps
• Influenza
• Varicella (zoster)
• Measles
• Mild symptoms than Bacterial Meningitis

Bacterial Meningitis

• Include Streptococcus pneumonia & Neisseria meningitidis
• Typically due to close places - college students, military barracks
• Listeria Monocytogene In Infants, Immunocompromised, & Eldery
• Haemophilus influenzae type in Children
• Gram-negative bacillary meningitis (Pseudomonas) are also prevalent
• Head trauma + Neurosurgery creates opportunity

Bacterial Meningitis risk factors

• Pneumococca
• Does not require treatment
• Risk factor -Recent Otitis/URI/PMA -Trauma -Diabetes -Alcohol use -History of meningitis - Endocarditis - Asplenic

Other Bacterial Meningitis Considerations

• In adults, the use of second meningitis in children with medication like rocephin/rifampin must be a requirement, for the household/roommates
• Those in long contact with an infected can take precaution . Recent UR, winters bring risk
• College or school can be spread faster.

Bacterial Meningitis Vaccine

-Haemophilus influenzae vaccination was previously important in cause of meningitis for children until recently. -Prophylactic use for household members and long term exposure needs caution. Unvaccinated , children and elders and pregnant needs particular attention for vaccine

Chronic Meningitis

• Arbitrarily lasting for weeks and is complex.
• Both infectious and non can be the causes
• Symptoms:Usually have a recent headache and nausea, with varying clinical treatments.
• Potential causes can include: Infection from various bacterial and viral loads, neoplastic causes, drug indued meningitis and rheumatoid arthritis.

Fungal Meningitis

• Typically, HIV load can cause increased CSF production
• Intracranial pressuring can influence.
• Treatments include IV and antifungal fluconazole

Meningitis Features

• Include mild fever
• Headache and light sensitivity
• Neck and muscle aches
• Rashes, seizures

Physical Exam for Diagnosis

• HEENT
• CV
• Neuro: CN, DTRs, Brudzinski, Kernig
• Physical Exam, neurological assessments and physical examinations are all key

Meningitis Diagnosis

• CT scan should be completed to identify risks for spinal tap
• Some factors include:
• Altered Mental, immunocompromised, deficit focal and recent seizures.

Spinal Tap

• Spinal tap (Lumbar puncture) can extract medicine
• It test fluid for cell and test

Values and Readings via Testing

• Adults CSF volumes are 150mm
• Pressure should be between 70/-180 mmH2 to measure pressure

Chart of What to Look For

• A cerebrospinal Fluid Chart can show signs of pressure for a normal and bacterial body.

Meningitis - Gram Stain

• Test for: Streptococcus pneumoniae, Group B Streptococcus, and Listeria monocytogenes
• GRAM NEGATIVE forNeisseria meningitidis and Haemophilus influenza

What To Do

• Treat with immediacy when a patient is suspected
• Regimen Antibiotics are based on age. 3rd generation cephalosporin + vancomycin, and +/- ampicillin.

Meningitis Treatment (Steroid)

• I.e dexamethasone helps lower rate of heart loss . Must be present for antibiotics to work
• Should be used in 2-4 days
• Should be discontinued if some bacteria or fluids have been treated.

Meningococcal Vaccinations

• Meningococcal vaccinatio like Haemophilus influenzae
• PCV (Pneumococcal Conjugate Vaccine), is given to all infants at: 2 months 4 months months, PRP-T/PRP-OMI
• PCV (Pneumococcal Conjugate Vaccine), is also given to all Adults over the age of 65, at: 2mo,4mo

Encephalitis Virus

• Viral infectio with inflammation that creates Aphasia and seizures. MRI testing for high patterns,

Lyme Disease

• Transmitted by Borrelia burgdorferi from ixodes ticks
• Can be transmitted in NE or midwest.

Lyme Disease-Clinical

• Early signs show red marks on the skin as well as fatigue and fever. 3- 30 days after.
• Migrating/arthrisis, with eye issues. Can cause av nodal blockage. If treated, Ms spreads and can cause arthritic symptoms.

Lyme diagnosis includes confirmation to look for infections, rash as well as lab testing ELISA as indicators

• A positive indicator requires a high diagnosis that can include many factors.

The Lyme disease infection is treated with proper antibiotics and support

• Treating with antibiotics , a proper removal process needs to be implemented

Ticks are removed at the surface as direct as possilbe

• Pulling up with Steady pressure will remove the tick
• The area should be cleaned by soap and water with alcohol

Lyme prevention education would require insect and boot treatment for a long treatment.

Wear long sleeves or special locations where ticks can attach often