•10/15/2015
Seizure types and epilepsy syndromes for Primary Care
Justin Meuse, MD Department of Neurology Oregon Health & Science University October 23-24, 2015
Disclosures
• None
Traveling Neurosciences CME
• Evidence Based Antiepileptic Medication Selection for the PCP Paul V. Motika, MD
• Surgical Treatment of Epilepsy for Neurologists David C. Spencer, MD
• Background on Epilepsy Victoria Wong, MD
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Topics
• Introduction • Classifying seizures • Epilepsy syndromes • Seizure mimics • Initial evaluation • Anti-seizure medications • Epilepsy counseling
Introduction to Epilepsy
• Seizure: • Paroxysmal, excessive, and disorderly electrical neuronal discharges in the brain
• Epilepsy: • More than one unprovoked seizure • A tendency for recurrent seizures
Introduction to Epilepsy
• Epidemiology: • Incidence is bimodal: • Highest under age 2 and over age 65
• By 20 years old: • 1% of the population has epilepsy
• By 75 years old: • 3% have epilepsy • 10% will have experienced a seizure
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Seizure Types & Epilepsy Types
• International League Against Epilepsy (ILAE) • Classification system • Last major revision: 2010
Classification of Seizures
• Focal / partial / localization-related • Originating within networks limited to one hemisphere • Focal seizures can secondarily generalize
• Generalized: • Involving bilaterally distributed networks
Focal Seizure
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Generalized Seizure
Classification of Seizures
• Under age 10: • Generalized seizures more common
• After age 10: • >50% of all new epilepsy cases are of focal epilepsy
Focal Seizures Descriptors
• Focal/partial seizures: • Simple: no impairment of consciousness • An aura is a simple partial seizure.
• Complex: impaired consciousness
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Focal Seizures Descriptors
• Onset location • Temporal lobe (most common) • Frontal lobe • Parietal lobe • Occipital lobe
Temporal Lobe Epilepsy
• Most common: 30 to 50%
• Symptoms (30 to 120 seconds) • Aura: • Epigastric feeling, déjà vu, fear, smell • Behavioral arrest, staring • Automatisms: • Hands: picking, fidgeting, fumbling • Mouth: chewing, lip smacking • Post-ictal confusion
Generalized Seizure Descriptors
• Example of a complex partial seizure:
• http://www.youtube.com/watch?v=hyj7MSdaLqw
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Focal Seizures Descriptors
• Frontal lobe: • Short duration (<30 seconds) • Hyper-motor • Nocturnal
• Parietal lobe • Somatosensory auras
• Occipital lobe • Visual phenomena: lights, distortions, complex hallucinations
Generalized Seizure Descriptors
• Tonic-clonic • Absence • Myoclonic • Tonic • Clonic • Atonic
Generalized Seizure Descriptors
• Tonic-clonic seizures • No longer termed “grand mal”
• Abrupt loss of consciousness • Tonic contraction • “Ictal cry” • Mouth closes, tongue biting • Eyes deviate up • Clonic phase • Gasping respirations • Urinary incontinence • Post-ictal state
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Generalized Seizure Descriptors
• Example of secondarily generalized tonic-clonic seizure:
• http://www.youtube.com/watch?v=Nds2U4CzvC4
Generalized Seizure Descriptors
• Absence seizures • No aura • 10 seconds or less • May have associated automatisms • No post-ictal symptoms • Age of onset: 5 to 12 years old • Frequently end in teen years
Generalized Seizure Descriptors
• Example of absence seizure:
• http://www.youtube.com/watch?v=H3iLQi6wt94
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Generalized Seizure Descriptors
• Others: • Myoclonic • Brief sudden muscle contractions • May not have loss of consciousness
• Atonic • Sudden loss of muscle tone • Can range from brief head drop to complete fall • http://www.youtube.com/watch?v=9obFVWW47NE
Generalized Seizure Descriptors
• Others: • Tonic • Sudden increased muscle tone with loss of consciousness • Typical onset 1 to 7 years
• Clonic • Sudden hypotonia with loss of consciousness • Bilateral rhythmic jerking • Typical onset 1 to 3 years
Describing Epilepsy
• Symptomatic: • Known etiology • Usually structural lesion
• Idiopathic: • No structural lesion • Used to be unknown etiology • Now with a presumed genetic etiology
• Cryptogenic: • “Probably symptomatic”
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Describing Epilepsy
• Example: • A patient with a left Posterior Cerebral Artery stroke • Now with right hemi-field visual seizures • One progressed to a generalized tonic clonic seizure
• Symptomatic occipital lobe epilepsy • With focal seizures • And secondary generalization
Epilepsy Syndromes
• “A complex of signs and symptoms that define a unique epilepsy condition.”
Epilepsy Syndromes
• Important syndromes • Lennox-Gastaut syndrome • Childhood absence epilepsy • Juvenile absence epilepsy • Juvenile myoclonic epilepsy
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Epilepsy Syndromes
• Lennox-Gastaut syndrome • Onset between 2 to 5 years old
• Significant cognitive impairment
• Multiple seizure types • Tonic • Atonic • Absence • Others
• Seizures are very refractory
Normal EEG
Slow spike-and-wave:
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Tonic Seizure:
Epilepsy Syndromes
• Absence epilepsy • Childhood or juvenile • Onset 3 to 12 years, can be later • Infrequent convulsions • 60 to 90% go into remission in teens
Normal EEG
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Absence Seizure:
Epilepsy Syndromes
• Juvenile myoclonic epilepsy (JME) • Begins in adolescence • Most common generalized epilepsy • Myoclonus upon awakening • Generalized tonic clonic seizures upon awakening • Good prognosis but requires lifelong treatment
Myoclonus on EEG
Myoclonus time-locked to spike-and-wave discharge
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Provoked Seizures
• Epilepsy: • More than one unprovoked seizure • A tendency for recurrent seizures
• Provoked seizures are NOT epilepsy • Reverse underlying cause
Provoked Seizures
• Acute stroke • Traumatic brain injury • Meningitis • Anoxic encephalopathy • Hypo/hyperglycemia • Low Na, Ca, Mg • Renal failure • Hyperthyroidism • Drug toxicity • Withdrawal states
Initial Seizure Evaluation
• Is it a seizure? • Syncope • Narcolepsy (cataplexy) • Migraine equivalent • Transient ischemic attack (TIA)
• Psychogenic non-epileptic seizure
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Initial Seizure Evaluation
• Is it a seizure? • Triggers • Aura • Impairment of consciousness • Tongue biting • Urinary incontinence • Post-ictal state
Non-Epileptic Seizures
• Clinically resembles an epileptic seizure
• Not a result of abnormal neuronal discharges
• Frequently misdiagnosed as epilepsy • ~25% of pts with “refractory epilepsy” actually have non-epileptic seizures
Non-Epileptic Seizures
• Involuntary
• Common
• Risk factors: • Specific traumatic event • Psychiatric comorbidity • Chronic pain or fibromyalgia
• Treatment: • Treat psychiatric comorbidities • Cognitive behavioral therapy
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Non-Epileptic Seizures
• Example of a non-epileptic seizure:
• http://www.youtube.com/watch?v=GVIrGYSYiZk
Initial Seizure Evaluation
• Rule out provoking causes
• Brain imaging • 3T MRI, epilepsy protocol
• EEG • Routine EEG • Sleep-deprived EEG • Prolonged EEG • 24-hour ambulatory EEG • Epilepsy monitoring unit admission
Management
• Narrow-spectrum AEDs: • Effective in simple partial, complex partial, and secondarily generalized
• Broad-spectrum AEDs: • Effective in all seizure types
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Management
• Narrow-spectrum AEDs: • Effective only in simple partial, complex partial, and secondarily generalized
• Carbamazepine (Tegretol) • Oxcarbazepine (Trileptal) • Eslicarbazepine (Aptiom) • Gabapentin (Neurontin) • Lacosamide (Vimpat) • Phenobarbital (Luminal) • Phenytoin (Dilantin) • Pregabalin (Lyrica) • Primidone (Mysoline) • Felbamate (Felbatol) • Perampanel (Fycompa)
Management
• Broad-spectrum AEDs: • Effective in all seizure types
• Lamotrigine (Lamictal) • Levetiracetam (Keppra) • Topiramate (Topamax) • Valproate (Depakote) • Zonisamide (Zonegran) • Ethosuximide (Zarontin)
Counseling Patients
• Seizure precautions • Water safety, heights, heavy machinery • Childcare safety
• Driving • Oregon DMV
• Women with epilepsy • Folate, bone health, endogenous and exogenous hormones • Pregnancy: 6 month advance notice
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Summary
• Seizures classification is important for syndrome identification and management
• Under the age of 10, generalized seizures are more common.
• After age 10, most new epilepsy cases are focal/partial epilepsy. Of these, temporal lobe epilepsy is most common.
Summary
• Syncope, migraine equivalents, TIA, psychogenic non-epileptic seizures, and other conditions can resemble seizures.
• Taking a good clinical history helps.
• In treating epilepsy, make sure the epilepsy type is known, or a broad-spectrum AED is being used.
References
• UpToDate • Handbook of Epilepsy, Browne et al., 4 th ed. • AAN Continuum: Epilepsy, 2010 • Epilepsy.com • Epilepsyfoundation.org
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Thanks for listening!
• June 20, 2015 • http://www.nwrunwalk.org/
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