Acute Management of Seizures KURT HECOX M.D. PH.D. CHIEF OF PEDIATRIC NEUROLOGY BAUMAN ENDOWED CHAIR IN PEDIATRIC EPILEPSY Outline Management Principles Categorizing the event Key elements to the history What data to gather and immediate actions Pathophysiology Imaging Future Management Principles Seizures are common Most seizures do not need chronic anticonvulsant management When not properly managed seizures can cause brain damage Not all seizures are alike, nor are all therapies equally effective The therapeutic approach should be driven by the acuity of the situation, the type of seizure and complicating systemic issues 1
Is It a Seizure? Stereotyped, impaired responsiveness, rhythmic when motor activities Errors can happen frontal lobe seizures can be flailing, arrhythmic especially during sleep; patients in fugue states can be fully ambulatory but clearly confused; difficult to distinguish post-ictal phase from transition to non-convulsive seizures (present in up to 30% of newborns). Diagnosis of non-epileptogenic or psychogenic seizures must only be made after thorough evaluation DB As Acquired 2
D B CURRY Single Stationary Dipole Analysis (Right and Top Views) History Taking Prior seizures? Duration of current event? If chronic seizures, any missed doses of AED? Head trauma? Current infections? Recent changes in behavior? Possible exposure to non-prescription drugs? Recent change in motor skills, headaches or school performance? Family history? 3
4
Immediate Actions/Data Needed Pulse Respiratory rate Blood Pressure Temperature O2 Sats Electrolytes, glucose Secure access Position the patient History 5
Special Considerations Respiratory compromise - avoid multiple doses of benzos or loading dose of phenobarb, if possible. Keppra, VPA, Fosphenytoin are safer True allergic reactions cross reacting Pheno, Dilantin, Lamictal, Tegretol, Trileptal if allergic to any, avoid others when possible If cause is a SCN variant (eg Dravets) avoid sodium channel meds Drop attacks or multi-focal EEGs, in the past, signal the need to avoid focal meds While not as potent an anticonvulsant, Keppra is very safe and rarely causes complications even in high doses Rescue Meds Rectal Diazepam Nasal Versed Clonazepam ODT Must consider age, support system and history of AED responsiveness 6
Schematic of Activation During Seizures 7
PET Scans : Sensitive to Chronic Hypo- Perfusion Imaging Approaches CT has largely been replaced by MRI for structural characterization and PET reflects dynamic physiological changes To these modalities have been added MRI morphometry, diffusion tensor imaging, MRSI, merging of fmri/eeg, PET/MRI, EEG/ESI, MEG, MEG source images MRI Findings 8
How Accurate are the Current Methods The ability of MEG, EEG/ESI, Spect and PET to predict correct hemisphere and whether there was focality varied from 70-85% in patients who ended with invasive electrodes. However the agreement as to whether to proceed with invasive studies was only 56%. We clearly do not yet have consensus on whose data shows sufficient convergence to warrant moving to an invasive phase II study. Sensitivity/Specficiity SPECT has strongest sensitivity (TLE) of nearly 85% for ictal and 60% for interictal, except when MRI is normal when it looses 20% points PET has the second highest sensitivity. While MRS and SISCOM perform at a lower level. PET and ADC of DTI are more accurate than MRI and fractional anisotropy fmri is particularly helpful in defining eloquent cortex for surgical planning High resolution MRI, voxel based intensity analysis, and MRI morphometry have increased the yield on patients with cortical dysplasia Various forms of quantitative MRI, merged EEG/MRI, co-registered source localized data with PET or MRI, with MEG playing a mounting(for example in basal temporal sites) role. 9
The Future 10
MRI and Source Reconstruction Merge Multi-channel system 11
Talking to the Patient and Family 12
2/26/18 13