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2016-ACP-Review-Epilepsy.Pdf Annals of Internal Medicineᮋ In the Clinic® Diagnosis Epilepsy Prevention n epileptic seizure is defined by the Inter- Treatment national League Against Epilepsy (ILAE) Aas “a transient occurrence of signs and/or symptoms due to abnormal excessive or syn- Further Considerations chronous neuronal activity in the brain” (1). In 2014, the ILAE provided an operational (practi- cal) clinical definition of epilepsy as a disease of the brain defined as any of the following condi- tions: at least 2 unprovoked [or reflex] seizures occurring more than 24 hours apart; 1 unpro- voked [or reflex] seizure and a probability of further seizures similar to the general recur- rence risk [at least 60%] after 2 unprovoked sei- zures, occurring over the next 10 years; [and/or] a diagnosis of an epilepsy syndrome (2). The CME quiz is available at www.annals.org/intheclinic.aspx. Complete the quiz to earn up to 1.5 CME credits. Physician Writer doi:10.7326/AITC201602020 Kaarkuzhali B. Krishnamurthy, MD CME Objective: To review current evidence for diagnosis, prevention, treatment, and further considerations of epilepsy. Funding Source: American College of Physicians. Disclosures: Dr. Krishnamurthy, ACP Contributing Author, has disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterest Forms.do?msNum=M15-2484. With the assistance of additional physician writers, the editors of Annals of Internal Medicine develop In the Clinic using MKSAP and other resources of the American College of Physicians. In the Clinic does not necessarily represent official ACP clinical policy. For ACP clinical guidelines, please go to https://www.acponline.org/clinical_information/guidelines/. © 2016 American College of Physicians Downloaded From: http://annals.org/ by a University of Arkansas User on 09/02/2017 A seizure can cause isolated or fection (6). Because a first seizure combined sensory, motor, cogni- can lead to other events, an elec- tive, or emotional symptoms. The troencephalogram (EEG) is also ILAE defines reflex seizures as recommended at the time of initial those “that are objectively and presentation as identification of consistently demonstrated to be interictal abnormalities increases evoked by a specific afferent the risk for a second seizure, which stimulus or by activity of the pa- 1. Fisher RS, van Emde Boas may or may not lead to a diagnosis W, Blume W, Elger C, tient” (3). Epilepsy is a chronic of epilepsy (4). Genton P, Lee P, et al. Epileptic seizures and disorder that can have long- epilepsy: definitions pro- standing medical, psychological, The causes of epilepsy vary and posed by the International are identified in only about 30% League Against Epilepsy and social sequelae. (ILAE) and the Interna- of people with the disorder (see tional Bureau for Epilepsy Isolated seizures are common; (IBE). Epilepsia. 2005;46: the Box: Seizure Evaluation). 470-2. [PMID: 15816939] they are believed to occur in 1 in Common risk factors include pre- 2. Fisher RS, Acevedo C, Arzimanoglou A, Bogacz A, 10 persons over a lifetime. An iso- mature birth; complicated febrile Cross JH, Elger CE, et al. lated seizure should not be con- seizures; infections, such as men- ILAE official report: a prac- tical clinical definition of fused with epilepsy. The preva- ingitis or encephalitis, at any age; epilepsy. Epilepsia. 2014; lence of recurrent, unprovoked 55:475-82. [PMID: head trauma, which may be mi- 24730690] seizures, or epilepsy, is believed to nor, particularly if it is recurrent; 3. Illingworth JL, Ring H. Conceptual distinctions be 5–8 per 1000 persons in devel- and/or a family history of epi- between reflex and nonre- oped countries; higher (10/1000 flex precipitated seizures lepsy or neurologic illnesses. in the epilepsies: a sys- persons) in developing countries; Causes of epilepsy may include tematic review of defini- and higher still in rural areas, due tions employed in the structural lesions related to dis- research literature. Epilep- in part to infectious and traumatic turbances in intrauterine devel- sia. 2013;54:2036-47. [PMID: 24032405] causes (4). In low- and middle- opment, such as TORCH (toxo- 4. Moshe´ SL, Perucca E, income countries, other factors, Ryvlin P, Tomson T. Epi- plasmosis, other [syphilis, lepsy: new advances. including age and sex, can influ- varicella-zoster, parvovirus B19], Lancet. 2015;385:884-98. ence morbidity and mortality re- [PMID: 25260236] rubella, cytomegalovirus, and 5. Wagner RG, Bottomley C, lated to epilepsy (5). Ngugi AK, Ibinda F, herpes) infections, abnormalities Go´mez-Olive´ FX, Kahn K, of neuronal migration, and fetal et al; SEEDS Writing Causes of isolated seizures can Group. Incidence, remis- include such toxic, metabolic, intracranial hemorrhage. Prema- sion and mortality of con- ture birth can lead to white mat- vulsive epilepsy in rural structural, and infectious factors northeast South Africa. as alcohol intoxication and with- ter and cortical damage in the PLoS One. 2015;10: e0129097. [PMID: drawal, hypoglycemia and hyper- developing brain, producing an 26053071] environment that is conducive to 6. Krumholz A, Wiebe S, glycemia, acute stroke, and me- Gronseth G, Shinnar S, ningoencephalitis. Thus, the the initiation and propagation of Levisohn P, Ting T, et al; seizures (7). Other acquired le- Quality Standards Sub- algorithm for evaluation of a first committee of the Ameri- seizure includes a thorough his- sions can serve as seizure foci, can Academy of Neurol- ogy. Practice parameter: tory and physical examination, a including benign and malignant evaluating an apparent intracranial or extra-axial tumors, unprovoked first seizure in blood glucose test, electrolyte adults (an evidence-based panels, a blood count, toxicology abscesses, cysts, hemorrhagic review): report of the Quality Standards Sub- screening, brain imaging (com- lesions, or strokes. Genetic causes committee of the Ameri- puted tomography [CT] or mag- have been identified for some id- can Academy of Neurology and the American Epilepsy netic resonance imaging [MRI]), iopathic epilepsy syndromes, and Society. Neurology. 2007; systemic illnesses, such as HIV in- 69:1996-2007. [PMID: and spinal fluid analysis in pa- 18025394] tients with fever or other symp- fection and malaria, can also lead 7. Robinson S. Systemic prenatal insults disrupt toms or signs of intracranial in- to chronic epilepsy (8). telencephalon develop- ment: implications for potential interventions. Epilepsy Behav. 2005;7: 345-63. [PMID: Diagnosis 16061421] What are the symptoms of 8. Bhalla D, Godet B, Druet- tingling, pain, or isolated motor Cabanac M, Preux PM. epilepsy? symptoms) or twitching, jerking, Etiologies of epilepsy: a comprehensive review. Symptoms of seizures vary or rhythmic or semirhythmic un- Expert Rev Neurother. widely. They can be isolated controlled movements. They can 2011;11:861-76. [PMID: 21651333] sensory symptoms (numbness, be purely psychic symptoms, ஽ 2016 American College of Physicians ITC18 In the Clinic Annals of Internal Medicine 2 February 2016 Downloaded From: http://annals.org/ by a University of Arkansas User on 09/02/2017 such as fear, sadness, elation, or creased intracranial pressure. laughing. Awareness may be al- Hemiatrophy of a limb or digit Seizure Evaluation tered, leading to an inability to suggests incomplete contralateral First seizure: interact normally. Although pa- cerebral development, such as tients may seem to be conscious, can be seen in patients who may Thorough history and physical difficulty responding verbally to have had intrauterine insults. examination questions and difficulty integrating Bloodwork: Serum glucose Several causes of altered behav- new memories, as well as auto- level, chemistry panel (so- ior should be considered in the matic behaviors such as lip smack- dium, calcium, phosphorus, differential diagnosis of pre- ing, chewing, or swallowing, can magnesium,) liver function sumed epilepsy (9). Syncope is a tests, blood urea nitrogen/ be signs of a seizure. Patients with commonly misidentified event that creatinine, pregnancy test for focal-onset epilepsy (in which the can occur with vascular insuffi- women, complete blood electrical disturbance spreads to ciency, cardiac dysrhythmias, hy- count, toxicology, alcohol involve wider areas of the cerebral povolemia, anemia, and auto- level cortex) may have other visible mo- nomic dysfunction. Sleep Lumbar puncture if febrile, tor manifestations, including stiff- disturbances; metabolic derange- nuchal rigidity, immune ening, jerking, or twitching on one ments, such as hypoglycemia; compromise or both sides of the body. Loss of movement disorders; and mi- tone, incontinence, and tongue Electroencephalogram graine can also lead to repetitive biting may occur. Confusion and Computed tomography or or stereotyped movements, al- disorientation may be seen for sev- magnetic resonance imaging tered awareness, and impaired Consider HIV test eral minutes afterward and, con- cognitive function. Altered aware- cordant with the duration of the ness in the context of delirium or Breakthrough seizure: seizure, resolution to normal cog- dementia can also be mistaken for History and examination nitive function may take hours or seizure activity, although the coin- days. Patients with absence sei- Bloodwork: As above, add in cidence of seizures in these medi- trough anticonvulsant levels zures may stare or blink repeti- cal conditions can be high. Finally, No need for neuroimaging tively with little else in the way of psychiatric and psychological
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