Seizures

Seizure without Status Epilepticus

Background

  • Risk factors: birth trauma, prematurity, TBI with loss of awareness > 1 hour, strokes/tumors/abscesses, history of meningitis/encephalitis
  • Key for seizures: stereotyped event with sudden onset/offset
    • Generally, if full body systems are involved (e.g., jerking or tonic activity, then there will also be loss of awareness)

 

Evaluation

  • A clear description or recording of seizure semiology is helpful
  • Provoked seizures can develop with medications, hypo/hyperglycemia, significant electrolyte abnormalities (e.g. hyponatremia), and CNS infections
  • EEG is necessary for spell capture
  • MRI brain with and without contrast

 

Management

  • Common AEDs with indications and typical side effects (SE):
    • Levetiracetam/Keppra (PO/IV): general or focal sz. SE: sedation and agitation, can worsen underlying mood disorders
    • Valproic acid/Depakote (PO/IV): general or focal sz. SE: sedation, hirsutism, PCOS like symptoms, P450 inhibitor, nausea, liver injury, hyperammonemia
    • Phenytoin/Dilantin (PO/fosphenytoin is IV): focal or general sz. SE: sedation, unsteadiness, gingival hyperplasia 
    • Lacosamide/Vimpat (PO/IV): focal or general. SE: heart block (don’t use if pt has pre-existing blocks), dizziness, ataxia
    • Topiramate/Topamax (PO) –general or focal sz. SE: kidney stones, metabolic acidosis, paresthesia’s, weight loss, cognitive slowing
    • Carbamazepine/Tegretol (PO) –focal and general sz. SE: hypoNa, in Han Chinese HLA testing is recommended due to risk of SJS, rare reports of bone marrow suppression
    • Oxcarbazepine/Trileptal (PO) –focal and general sz. SE similar to carbamazepine, hypoNa
    • Lamotrigine/Lamictal (PO) –general or focal sz. Benefit of mood stabilization. SE: SJS/TEN, nausea. One of the least sedating AEDs
    • Zonisamide/Zonegran (PO) –general and focal. SE: somnolence, ataxia, nausea, confusion

 

 

Non-Epileptic Spells (aka PNES, psychogenic non-epileptic spells)

  • Can be very difficult to distinguish from epileptic seizures
  • Retained awareness with bilateral extremities “seizing” is very unusual for epileptic sz’s
  • Other red flags: opisthotonus (arching the back), talking during a spell, excessively long spells (if historically patient has “seizures lasting for hours or days” at home), forced eye closure, coachability during a spell or reacting to external stimuli, very heavy breathing during a spell with lots of rigorous movement, immediately returning to normal after a spell
  • Things that are hard to be non-epileptic: seizures arising out of sleep, highly stereotyped, incontinence, severe injuries (e.g. burns)
  • If high concern for PNES, try to avoid excessive BZD use. This requires good clinical judgement as you wouldn't want to withhold Ativan and discover that the pt was having true atypical seizures. The compromise would be: do not repeatedly administer BZDs when there is suspicion for PNES as well as no evidence of response to prior BZD administration.
  • Notably, syncopal convulsions are very common, with posturing and tonic-clonic movements happening for a few moments after syncope
    • Should not last for more than 10-15 seconds
    • These are just related to syncope and do not typically require seizure medications
    • Workup:
        • Two-hour EEG and MRI (with and without contrast)
        • Infectious workup, BMP, CBC, blood glucose, toxicology/drug screen
        • If there is concern for convulsive syncope, (carefully) check orthostatic vitals