CHAIR SUMMIT 7TH ANNUAL #CHAIR2014. Master Class for Neuroscience Professional Development. September 11 13, Westin Tampa Harbour Island

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1 #CHAIR2014 7TH ANNUAL CHAIR SUMMIT Master Class for Neuroscience Professional Development September 11 13, 2014 Westin Tampa Harbour Island Sponsored by

2 #CHAIR2014 Name That Spell: A Film Festival Joseph I. Sirven, MD Mayo Clinic College of Medicine Phoenix, AZ

3 Joseph I. Sirven, MD Disclosures Research/Grants: NeuroPace, Inc.; MAP Consultant: Upsher-Smith Laboratories, Inc.; Acorda Therapeutics

4 #CHAIR2014 Learning Objective Accurately identify and document the seizure type or syndrome and seizure frequency from the patient history before initiating a treatment plan

5 Points to Consider When Evaluating Spells Precipitating/Ameliorating factors Description of behavior during event Is it stereotyped? Duration Aura or Prodrome When do they occur? Nature of recovery

6 Points to Consider When Evaluating a Spell Evaluate the spell from the perspective of having a beginning, middle, and end! Beginning Look for aura, warning, or prodrome! Middle Look for the clinical behavior, progression of symptoms and what parts of the body are involved. Assess cognition, language.! End Look for time to recovery back to baseline, duration of event, is there post-event confusion. Was there incontinence, tongue biting?

7 Definitions Seizure disturbances in the electrical activity of the brain Epilepsy two or more unprovoked seizures separated by at least 24 hours; re-defined 2014 Epilepsy is a spectrum of disorders:! Many different types of seizures! Many causes! Many syndromes and types of epilepsy Fisher RS, et al. Epilepsia. 2014;55(4):

8 Seizure Types Focal Seizures (part of the cortex is disrupted)! Awareness! Focality Generalized Seizures (all of the cortex is disrupted)! 7 types Sirven JI. Semin Neuro. 2002;22(3): PMID:

9 Seizure Types Focal Simple Focal Complex Focal Motor Sensory Autonomic Psychic Sirven JI. Semin Neuro. 2002;22(3): PMID:

10 Seizure Types Generalized Myoclonic Clonic Tonic Tonic-Clonic Atonic Unspecified Absence Atypical Typical Sirven JI. Semin Neuro. 2002;22(3): PMID:

11 Seizure Differential Diagnosis Non-epileptic Epilepsy Syncope Cardiovascular Migraine Cerebrovascular Metabolic Psychogenic Primary Focal & Generalized Age Dependent Genetic Family History Neurochem imbalance Non-lesional Epilepsy Syndromes Rowan AJ, et al. Neurology. 2005;64(11): Secondary Focal & Generalized Symptomatic Structural Lesions Progressive

12 Seizure vs. Non Epilepsy Seizures (NES) Clues Favoring Epilepsy Autonomic Changes! pupil dilation! incontinence! corneal reflex suppression Post-ictal Babinski sign Self Injury Not responsive during event Amnesia for the event Duration less than 2 minutes NES = Non-epileptic seizures Hoerth MT, et al. Neurologist. 2008;14(4): PMID: Brown RJ, et al. Epilepsy Behav Sep;22(1): PMID:

13 Seizure vs. Non Epileptic Seizures (NES) Clues Favoring NES Never witnessed or vice versa Provoked by emotional stress Variable form one event to another Screaming or vocalizing throughout the entire event Prolonged, greater than a couple of minutes Sudden termination of event No post-ictal confusion Induced by suggestion Responsive during event Usually NO injury Usually NO incontinence! Long QT syndrome on electrocardiogram! History or new onset metabolic disorder

14 Work Up for Other Etiologies EKG/event monitor Electrolytes during an event Blood sugar during an event Drug screen during an event Imaging/routine EEG Cardiac evaluation Psychiatric evaluation

15 Role of EEG Usually do not see events with routine EEG Spikes/sharps seen in patients without seizure Ambulatory EEG Do NOT over read routine EEG Gold Standard remains Epilepsy Monitoring Unit (EMU) Krumholz A, et al. Neurology. 2007;69(21): PMID:

16 Routine EEG Often over-interpreted 2% of adults and 3% of peds w/s/w but no seizure Persons with epilepsy (PWE) 50% normal with one EEG; if 4 normal EEGs not likely to see abnormality 10-20% PWE have normal EEG w/s/w = with spike and wave Krumholz A, et al. Neurology. 2007;69(21): PMID:

17 EEG During Seizure With loss of consciousness, should see changes:! Spikes! Sharps! Rhythmic theta/delta! Focal slowing/suppression May be normal with simple partial seizures and myoclonus May see evolving pattern before muscle Ictal activity obscured by muscle artifact Should see post-ictal slowing/suppression Krumholz A, et al. Neurology. 2007;69(21): PMID:

18 EEG During Non-Epileptic Seizures No evolving pattern Do NOT arise from sleep No post-ictal slowing or suppression Reprise Sudden discontinuation of event Fluctuating fields Normal background noted with altered loss of consciousness Krumholz A, et al. Neurology. 2007;69(21): PMID:

19 Clinical Connections Clues Favoring Epilepsy Autonomic Changes! pupil dilation! incontinence! corneal reflex suppression Post-ictal Babinski sign Self Injury Not responsive during event Amnesia for the event Duration less than 2 minutes NES = Non-epileptic seizures Clues Favoring NES Never witnessed or vice versa Provoked by emotional stress Variable form one event to another Screaming or vocalizing throughout the entire event Prolonged, greater than a couple of minutes Sudden termination of event No post-ictal confusion Induced by suggestion Responsive during event Usually NO injury Usually NO incontinence Long QT syndrome on EKG History or new onset metabolic disorder

20 Questions & Answers #CHAIR2014