Case 1: Issues in this case. Generalized Seizures. Seizure Rounds with S.Khoshbin M.D. Disclosures: NONE
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1 Disclosures: NONE Seizure Rounds with S.Khoshbin M.D. Case 1: 45 yo male while jogging with his wife stopped,acted strangely for a while then fell to the ground and had a convulsion.emt s were called by a passerby and he was brought to the ER Was this a seizure? Epilepsy? Driving and Epilepsy Sleep deprivation and seizures Treating the first seizure Workup of the first seizure Generalized Seizures (Loss of consciousness, convulsive, nonconvulsive) Generalized tonic-clonic convulsions Clonic Tonic Absence (simple, complex) Myoclonic Atonic Standard AEDs Phenytoin (Dilantin) Carbamazepine (Tegretol) Valproate (Depakote) Clonazepam (Klonopin) Ethosuxamide (Zarontin) Phenobarbital (Luminal) Primidone (Mysoline) New AEDs Fosphenytoin (Cerebyx) Felbamate (Felbatol) Gabapentin (Neurontin) Lamotrigine (Lamictal) Tiagabine (Gabitril) Topiramate (Topamax) Oxcarbazepine (Trileptal) Levetiracetam (Keppra) Zonisamide (Zonegran)
2 Broad spectrum AED s Drug Benefit Disadvantage Valproate (VPA) Lamotrogine (LTG) Zonisamide (ZNS) Topiramate (TPM) IV,PR forms Migraine/bipol ar qd/bid dosing qd/bid dosing Interaction:few bid dosing Interaction:few Interaction:PB,LTG,Hep Toxic,wt gain,hair loss teratogenic Drug rash Slow titration Interaction:PB,,PHT,VPA Renal stones Cognitive difficulties, Renal stones,bcp Evaluation Blood work - CSF Electroencephalography Special leads Activation (HV, PS, sleep, drug withdrawal) Long-term monitoring (video EEG) Cortical mapping Neuroimaging (MRI, fmri, CT, PET, SPECT) Neuropsychological evaluation Case 2: 75 yo male noticed an unusual sensation in his left leg reflex difference while driving. He then entered a paint store dragging his foot, his foot started jerking uncontrolabely for a few seconds Issues in this Case Seizure vs TIA Stroke and Epilepsy Epilepsy in the elderly Anticonvulsant use in the elderly Simple Partial Seizures (Consciousness not impaired) Simple motor (Jacksonian, march) Adversive Simple sensory Special sensory Somatosensory Autonomic Psychic Case 3: 21 yo Nursing student working in the hospital was found unconscious in the medication room
3 Seizures vs cardiogenic syncope Epilepsy in women Epilepsy in Women Special issues at menarche-during menstrual cycles Adolescent issues-sexual function-contraception Pregnancy -conception-aed teratogenicity-postpartum Menopause-HRT-bone density Case 4: 23 yo Medical Student collapsed while observing surgery Seizures vs vaso-vagal syncope Epilepsy and alcohol Epilepsy and substance abuse Case 5: 35 yo car salesman ha had a number of episodes of sudden nausea.at one point did not respond to a customer during a test drive. His employer wants a Medical clearance Seizures vs Migraine Imaging in Epilepsy
4 Case 6: 28 yo shoe store clerk starts groaning while on the phone.he then starts wandering aimlessly.he assaults a coworker who tries to help him. Epilepsy and aggression Ictal Behaviour Interictal Behaviour Complex Partial Seizures (Consciousness impaired) CPS with motor symptomatology (frontal-temporal) absence, automatisms, adversion CPS with sensory symptomatology (parietaltemporal- occipital) somatosensory, primitive visual, dizziness CPS with cognitive symptomatology (temporaloccipital-limbic) amnesia, deja vu, jamais vu, macropsia, micropsia, teleopsia CPS with affective symptomatology (temporallimbic) fear, depression, sexual excitement, rage Case 7: 15 yo high school student treated for seizures since age 2 with carbamazepine has had increasing frequency of seizures.phenytoin and Valproate have been added with no improvement Epileptic vs non epileptic seizures Polypharmacy Refractory Epilepsy Epileptic Ictally unresponsive Brief Injury common Urinary incontinence All ages Male > Female Speech arrest Epileptic cry Bilateral movements Symmetric Unprovoked Prolactin Non-epileptic Ictally responsive Prolonged Injury uncommon Fecal incontinence years of age Female > Male Appeal to emotions Conversant Alternating movements Pelvic thrusting Suggestible Negative Babinski
5 Behavioral Symptom Analysis Prodromal (long duration days before seizure) Ictal (brief duration, consciousness, motor, sensory, and autonomic symptoms) Postictal (brief to long duration, sleep and headache) Interictal (intermittent, episodic, or persistent) Forced normalization (with cessation of seizure and normal EEG) Geschwind s Syndrome Van Gogh s Malady Hypergraphia Religiosity Aggressivity Altered sexuality Viscosity Surgery Topectomy (cortex) Lobectomy (cortex, subcortical), (mesial temporal sclerosis) Collostomy (multifocal) Hemispherectomy (catastrophic epilepsy, Rasmusen Encephalitis) Differential Diagnosis Syncope (cardiac, non-cardiac) Migraine TIA Transient global amnesia Sleep disorders Movement disorders Episodic toxic/metabolic disorders Episodic psychiatric disorders Behavioral seizures
6
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