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Epilepsy and Seizures Clinical Characteristics and Evaluation

Epilepsy and Seizures Clinical Characteristics and Evaluation. R. Eugene Ramsay, M.D. Professor of Neurology Director, Epilepsy Institute Ochsner Health System New Orleans. Seizures vs Epilepsy.

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Epilepsy and Seizures Clinical Characteristics and Evaluation

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  1. Epilepsy and SeizuresClinical Characteristics and Evaluation R. Eugene Ramsay, M.D. Professor of Neurology Director, Epilepsy Institute Ochsner Health System New Orleans

  2. Seizures vs Epilepsy • Seizure - The subjective and/or objective symptoms or behaviors produced by an abnormal uncontrolled synchronous discharge of a group of neurons • Seizure Syndrome - Clinical manifestations related to seizure arising from a single focal cortical area. • Epilepsy – seizures occurring as a result of a primary CNS process • Epilepsy Syndrome - Characterized by similar seizure type(s), EEG, age of onset & remission, family history, prognosis, and response to medication. Ramsay

  3. Epilepsy Characteristics • Good/Detailed history is paramount • Aura – localized onset of seizure • Etiology varies with age • Risk factors • Pregnancy, febrile seizures, head trauma, CNS infection, psychiatric disease, family hx • Epileptic seizures • Stereotyped • Anatomically correct • Limited presentation in an individual Ramsay

  4. Evaluation of a First Seizure • History • Physical • Neurological Exam – Look for focal findings • Blood tests: CBC, chemistries, glucose, Ca++, Mg++ • Blood or urine screen for drugs • MRI (or CT) • EEG (urgently if possible) • Lumbar puncture • Fever • Immunocompromised Browne TR. NEJM 2001;344(15):1145-1151. Epilepsy: a comprehensive textbook. 1997.

  5. Possible Seizure Precipitants • Low (less often, high) blood glucose • Low sodium • Low calcium • Low magnesium • Stimulant/other pro-convulsant intoxication • Sedative withdrawal • Severe sleep deprivation Brodie M et al. Epilepsy Fast Facts. 2001. Epilepsy: a comprehensive textbook. 1997.

  6. Electroencephalogram (EEG) • Graphical depiction of cortical electrical activity, usually recorded from the scalp • ~50% of patients with epilepsy show no abnormality • Clinical applications • Seizures/epilepsy • Sleep • Altered consciousness • Focal and diffuse disturbances in cerebral functioning Browne TR. NEJM 2001;344(15):1145-1151. Epilepsy: a comprehensive textbook. 1997.

  7. Imaging for Epilepsy • CT Scan • Quick • Low resolution • Useful in emergent situation • MRI • High resolution • Image the entire brain, use thin sections • fMRI – localizes function areas of the cortex (eg. language) • PET • Brain Metabolism • Epileptic focus • Hypometabolisminterictal • Hypermetabolism during seizure Ramsay

  8. Ramsay

  9. Seizure Epilepsy Non-epileptic Syncope Cardiovascular Migraine Cerebrovascular metabolic psychogenic Primary Secondary Partial & Generalized Partial & Generalized Age Dependent Genetic Family History Neurochem imbalance Non-lesional Epilepsy Syndromes Symptomatic Structural Lesions Progressive Ramsay Ramsay

  10. Early Childhood (1-5 years) Lennox-Gaustaut Syndromeb & Febrile seizuresa Infancy — West’s Syndromea Later Childhood(5-10 years)—Typical Absence Epilepsya, Landau-Kleffner Syndromea& Benign Rolandic Epilepsya Adolescence —JuvenileMyoclonic Epilepsyc —Juvenile Absence Selected Syndrome Typesin Different Age Groups aAppleton R, Baker G, Chadwick D, Smith D. Epilepsy 2nd edn. Martin Dunitz: London, UK;1992. bGenton P, Dravet C. Epilepsy: A Comprehensive Textbook, Vol 1 (Engel J, Pedley T, eds)Lippincott Raven Publishers: Philadelphia, USA, 1997; pp 2355–2366. cJanz D. Acta Neurol Scand. 1985;72:449-459. Ramsay

  11. Ramsay

  12. Seizure & Epilepsy Syndromes Localization Related • Temporal Mesial Lateral • Frontal • Sensory-Motor • Motor Association • Cingulate • Frontal Polar • Orbital • Parietal • Occipital Ramsay

  13. Localization Related Seizures Hippocampus/Amygdala Mesial TLE Aura Epigastric sensationFearEnvironmental Distortion (deja vu, micropsia) Olfactory Hallucination Ictus Blank StareSimple Automatisms oral facial/handsReactive Automatisms postictal DisorientedDysphasic/Amnestic Ramsay

  14. Localization Related SeizureHippocampus/Amygdala Ramsay

  15. Left Temporal Onset Seizure Ramsay

  16. Localization Related Seizures Lateral Temporal Neocortex Lateral TLE Aura Vestibular Hallucinations simple & complex auditoryReceptive AphasiaFace/arm motor or sensory Ictus Blank StareSimple AutomatismsReactive Automatisms postictal DisorientedDysphasic/Amnestic Ramsay

  17. Localization Related SeizureLateral Temporal Neocortex Ramsay

  18. No/minimal DOC Bladder Function Guttural Sounds Clouded consciousness Head & Axial Mvts 4 Limb posturing Complex Verbalizations Complex Automatisms Autonomic symptoms Olfaction Ramsay

  19. Localization Related Seizures Frontal - Motor Association Asymmetric Tonic Posturing Vocalizations - Elemental Brief Mood changes Consciousness clouded or impaired No postictal confusion Infrequent secondary generalization Ramsay

  20. Localization Related SeizureFrontal – Motor Association Ramsay

  21. Localization Related SeizureFrontal – Motor Association Ramsay

  22. Localization Related Seizures Frontal - Posterior Mesial Cingulate Prominent Motor Activity Bimanual/Bipedal movements Vocalizations Abnormal respiration Axial movements Adversive / Fencing postures Nocturnal Brief, occur in clusters Minimal to clouding of consciousness No/brief post-ictal confusion Ramsay

  23. Localization Related SeizureFrontal – Posterior Mesial Cingulate Ramsay

  24. Localization Related Seizures Frontal - Anterior Mesial - Cingulate Complex Motor Activity Vocalizations (Profanities) Urinary incontinence Mood changes Consciousness clouded No post-ictal confusion Rapid secondary generalization Ramsay Ramsay

  25. Localization Related SeizureFrontal – Anterior Mesial Cingulate Ramsay

  26. Localization Related SeizureFrontal – Anterior Mesial Cingulate Ramsay

  27. Localization Related Seizures Frontal - Orbital Prominent Autonomic signs Salivation Flushing tachycardia Alimentary symptoms Olfactory hallucinations Vocalizations (infrequent) hand/eye deviation (infrequent) Spread to GTC (infrequent) Ramsay

  28. No/minimal DOC Bladder Function Guttural Sounds Clouded consciousness Head & Axial Mvts 4 Limb posturing Complex Verbalizations Complex Automatisms Autonomic symptoms Olfaction Ramsay

  29. Localization Related Seizures Parietal Somatosensory (pain rare) Asomatognosia body part absent loss of awareness of body Urge to move body part Visualization (ill defined) Vertigo Aphasia Choking sinking sensation (inferior/lateral parietal) Ramsay

  30. Localization Related Seizures Occipital Visual hallucinations Elemental (colored lights) Complex (1-2 digit numbers) Visual loss (partial or complete) Visual illusions micropsia, palinopsia metamorphopsia Spread to Temporal lobe Ramsay Ramsay

  31. Seizure & Epilepsies Syndromes Primary Generalized h Childhood Absence h Adolescent Absence h Juvenile Myoclonic Absence h GTC upon Awakening h Adult Myoclonic Epilepsy D. Janz - "the age of onset is the strongest single indication of a biologic difference between the four major syndromes of the Idiopathic Generalized Epilepsies" Ramsay Ramsay

  32. Atonic Seizure Ramsay

  33. Atonic Seizure Pattern Ramsay

  34. Primary Generalized EpilepsyAdolesence Absence Ramsay

  35. Primary Generalized EpilepsyTonic Clonic Ramsay D. Janz - "the age of onset is the strongest single indication of a biologic difference between the four major syndromes of the Idiopathic Generalized Epilepsies"

  36. FP1-A1 FP2-A2 F3-A1 F4-A2 C3-A1 C4-A2 P3-A1 P4-A2 O1-A1 O2-A2 Primary Generalized Pattern Ramsay

  37. Seizure & Epilepsy SyndromesGeneralized Convulsion Ramsay

  38. Juvenile Myoclonic Epilepsy of Janz Incidence 4.3% Female/Male 3/1 Seizure Onset PM (5yrs) Myocl (14 yrs) TC/CTC (15 yrs) IQ/Exam nl / nl EEG Poly S/W 10-16 Hz Spikes Remission 10% FHx 25% 1st Treatment VPA, LTG, ZNA, ?LEV, ?TPM Ramsay

  39. AED Selection by Seizure Type Secondary Primary LennoxGastaut InfantileSpasms Absence TonicClonic Myoclonic Simple & . Complex TonicPartial Clonic phenytoin ethosuximide Felbemate Lamotrigine Rufinamide TopiramateValproic Acid ACTH FelbamateVigabatrin benzodiazepinefelbamate carbamazepinegabapentinoxcarbazepinephenobarbphenytointiagabine Lamotrigine, Levetiracetam, Topiramate, Valproate & Zonisamide Ramsay

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