David Lee Gordon, MD, FAHA

Update in Stroke 2007

ASSESSMENT & TREATMENT OF SEIZURES 2016 Jeanne Ann King, MD Clinical Associate Professor Department of Neurology The University of Oklahoma Health Sciences Center

OU Neurology

ASSESSMENT & TREATMENT OF SEIZURES Under Accreditation Council for Continuing Medical Education guidelines disclosure must be made regarding relevant financial relationships with commercial interests within the last 12 months.

Jeanne Ann King, MD I have no relevant financial relationships or affiliations with commercial interests to disclose.

OU Neurology

Learning Objectives n1. List the different types of seizures n2. Correlate partial seizure symptoms & neuro-anatomic localization n3. Describe the differential diagnosis for seizures n4. Describe the principles of selection & implementation of antiepileptic drug therapy OU Neurology

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David Lee Gordon, MD, FAHA

Update in Stroke 2007

US EPILEPSY STATISTICS PREVALENCE:

INCIDENCE:

n 4-7/1000 people/year n 2.2 million people in (.5-1%) the United States with epilepsy n 150,000 new cases/year n 10,000 people in Oklahoma alone n Single seizure: 9% >65 million people worldwide Statistics from Institute of Medicine Report 3/2012

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THE LIFE OF AN EPILEPTIC n I’ve had seizures all of my life, so it’s been an adventure, to balance the living of today, and fear of the future. n It effects every aspect of living; your career, fun, and even raising children; from holding a baby to driving a car, you learn that nothing is for certain. n Working is often difficult, your life is like a yoyo, no matter how good of a worker you are, a few seizures and they let you go. OU Neurology

THE LIFE OF AN EPILEPTIC (Cont.) nMy friends have helped a lot, by learning about me, the person; they accept the individual, without any reservation. nIf we could educate the world, give them the chance to know, epileptics are ordinary people; good friends and happy lives are our goals.

OU Neurology

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David Lee Gordon, MD, FAHA

Update in Stroke 2007

OU Neurology

OVERVIEW nDefinitions nDiagnosis nClassification nTreatment

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DEFINITIONS nA seizure is a sign or symptom of cerebral paroxysmal discharge. nEpilepsy is a tendency to have recurrent seizures. nThe Epilepsies are syndromes or diseases characterized by a tendency to have recurrent seizures along with other clinical characteristics. OU Neurology

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David Lee Gordon, MD, FAHA

Update in Stroke 2007

Old Definition of Epilepsy nA disorder of the brain characterized by an enduring tendency to have epileptic seizures and by the neurobiologic, cognitive, psychologic, and social consequences nDiagnosis based on at least 2 unprovoked seizures more than 24 hours apart ILAE 2005

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ILAE (International League Against Epilepsy) Definition

Epilepsy is defined as one or more seizures with a high likelihood of recurrence, not due to another immediately triggering cause, such as low blood sugar.

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WHAT HAPPENED?

Credit to John DeToledo, MD

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David Lee Gordon, MD, FAHA

Update in Stroke 2007

Clinical question #1: Was it a seizure? n Careful history is the most important Ø The patient may be the least helpful in some cases

ØEye-witness if at all possible ØPrior spells? n Conditions That Can Mimic Epileptic Seizures ØHyperventilation, syncope ØMigraine, TIA (transient ischemic attack) ØPanic attack, psychogenic seizures OU Neurology

DISORDERS THAT MAY MIMIC EPILEPSY n Gastroesophageal Reflux n Breath-holding n Migraine Ø Confusional Ø Basilar Ø With recurrent abdominal pain and cyclic vomiting

n Sleep disorders (especially parasomnias) n Cerebrovascular events Ø Ø Ø Ø

Pallid infantile syncope Vasovagal attacks Vasomotor syncope Cardiac arrhythmias

n Movement disorders Ø Stuttering attacks Ø Paroxysmal choreoathetosis Ø Nonepileptic myoclonus Ø Tics and habit spasms

n Psychological disorders Ø Ø Ø Ø

Panic disorder Hyperventilation Rage Pseudoseizures

OU Neurology

Clinical question #2: Does the patient have epilepsy? nPrecipitated seizures ØMetabolic: Uremia, hypoglycemia, hyperglycemia, hepatic failure ØToxic: Drug overdose or withdrawal ØInfectious: Meningitis/encephalitis

OU Neurology

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David Lee Gordon, MD, FAHA

Update in Stroke 2007

Seizure vs Epilepsy Seizures Nonepilepsy (precipitated) Cardiovascular Drug related Syncopal Metabolic Toxic Poison Infectious Febrile Pseudosz

Epilepsy (recurrent sz)

Idiopathic (primary)

Symptomatic (secondary)

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SEIZURE DIAGNOSIS n Physical/Neurological Exam n EEG Ø Photic stimulation Ø Hyperventilation Ø Sleep deprivation

n Anatomic studies Ø CT Ø MRI

n Special studies Ø SPECT Ø PET

n Intensive CCTV/EEG monitoring

K.Penry 1992

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Laboratory Evaluation of Patients with Seizures nGlucose, oxygen nElectrolytes, BUN nCalcium, magnesium nDrug screen nLumbar puncture nScreen for inborn errors ( 6 months): Ø No driving car (or operating high risk power equipment) Ø No swimming alone or bathing in a closed-drain tub Ø No climbing on ladders (or other high places) n Avoid sleep deprivation & alcohol n Avoid alcohol n Mood Ø High rates of depression & suicidal thoughts Ø AEDs sometimes can contribute n Urge compliance with AED Ø Daily schedule, pill box Ø Expected side effects OU Neurology

EMERGING AEDS (NONAPPROVED) n stiripentol n talampanel n n n n n n n n n

losigamone remacemide SGB-017 (ADCI) PNU-151774E (or NW1015) fluorofelbamate JZP-4 propylisopropylacetamide (PID) M-TMCD VX-765

n valrocemide n n n n n n n n n n n n

ganaxolone (CCD 1042) carisbamate YP3089 2-deoxyglucose (2DG) NAX-5055 huperzine T-2000 tonabersat sulthiame ICA-105665 seletracetam *everolimus OU Neurology

NON-MEDICATION OPTIONS nSurgery nVagus Nerve Stimulation nDeep Brain Stimulation ØNeuropace

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David Lee Gordon, MD, FAHA

Update in Stroke 2007

Referral to neurologist nWhen the diagnosis is in question nWhen the patient has failed to respond to two seizure medications (drug resistant) nIf you are uncomfortable for any reason

OU Neurology

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