•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 •1 •10/15/2015 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 •2 •10/15/2015 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 •3 •10/15/2015 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 •4 •10/15/2015 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 •5 •10/15/2015 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 •6 •10/15/2015 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 •7 •10/15/2015 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” •8 •10/15/2015 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 •9 •10/15/2015 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: •10 •10/15/2015 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 •11 •10/15/2015 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 •12 •10/15/2015 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 •13 •10/15/2015 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 •14 •10/15/2015 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 •15 •10/15/2015 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 •16 •10/15/2015 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 •17 •10/15/2015 Thanks for listening! • June 20, 2015 • http://www.nwrunwalk.org/ •18.