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Slide 1-

C-Slide 1 Clinical Epilepsy American Epilepsy Society
Slide 2-

C-Slide 2 Definitions  Seizure: the clinical manifestation of an abnormal and excessive excitation and synchronization of a population of cortical neurons  Epilepsy: two or more recurrent seizures unprovoked by systemic or acute neurologic insults
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C-Slide 3 Epidemiology of Seizures and Epilepsy  Seizures Incidence: approximately 80/100,000 per year Lifetime prevalence: 9% (1/3 benign febrile convulsions)  Epilepsy Incidence: approximately 45/100,000 per year Point prevalence: 0.5-1%
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C-Slide 4 Partial Seizures  Simple  Complex  Secondary generalized
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C-Slide 5 Simple Partial Seizure Subclassification  With motor signs  With somatosensory or special sensory symptoms  With autonomic symptoms or signs  With psychic symptoms (disturbance of higher cerebral function)
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C-Slide 6 Complex Partial Seizures  Impaired consciousness  Clinical manifestations vary with site of origin and degree of spread Presence and nature of aura Automatisms Other motor activity  Duration (typically 1 minute)
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C-Slide 7 Secondarily Generalized Seizures  Begins focally, with or without focal neurological symptoms  Variable symmetry, intensity, and duration of tonic (stiffening) and clonic (jerking) phases  Typical duration up to 1-2 minutes  Postictal confusion, somnolence, with or without transient focal deficit
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C-Slide 8 EEG: Simple Partial Seizure Right temporal seizures with maximal phase reversal in the right sphenoidal electrodes Continued on C-Slide9
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C-Slide 9 EEG: Simple Partial Seizure Continuation of same seizure (C-slide-8) Right temporal seizures with maximal phase reversal in the right sphenoidal electrodes
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C-Slide 10 EEG: Absence Seizure
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C-Slide 11 Epilepsy Syndromes  Localization-related epilepsies Idiopathic Symptomatic Cryptogenic
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C-Slide 12 Epilepsy Syndromes (cont.)  Generalized epilepsies Idiopathic Symptomatic Cryptogenic  Undetermined epilepsies  Special syndromes
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C-Slide 13 Etiology of Seizures and Epilepsy  Infancy and childhood Prenatal or birth injury Inborn error of metabolism Congenital malformation  Childhood and adolescence Idiopathic/genetic syndrome CNS infection Trauma
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C-Slide 14 Etiology of Seizures and Epilepsy (cont.)  Adolescence and young adult Head trauma Drug intoxication and withdrawal*  Older adult Stroke Brain tumor Acute metabolic disturbances* Neurodegenerative *causes of acute symptomatic seizures, not epilepsy
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C-Slide 15 Questions Raised by a First Seizure  Seizure or not?  Focal onset?  Evidence of interictal CNS dysfunction?  Metabolic precipitant?  Seizure type? Syndrome type?  Studies?  Start AED?
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C-Slide 16 Seizure Precipitants  Metabolic and Electrolyte Imbalance  Stimulant/other proconvulsant intoxication  Sedative or ethanol withdrawal  Sleep deprivation  Antiepileptic medication reduction or inadequate AED treatment  Hormonal variations  Stress  Fever or systemic infection  Concussion and/or closed head injury
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C-Slide 17 Seizure Precipitants, con’t Metabolic and Electrolyte Imbalance  Low (less often, high) blood glucose  Low sodium  Low calcium  Low magnesium
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C-Slide 18 Seizure Precipitants, con’t Stimulation/Other Pro-convulsant Intoxication  IV drug use  Cocaine  Ephedrine  Other herbal remedies  Medication reduction
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C-Slide 19 Evaluation of a First Seizure  History, physical  Blood tests: CBC, electrolytes, glucose, Calcium, Magnesium, phosphate, hepatic and renal function  Lumbar puncture only if meningitis or encephalitis suspected and potential for brain herniation is ruled out  Blood or urine screen for drugs  Electroencephalogram  CT or MR brain scan
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C-Slide 20 EEG Abnormalities  Background abnormalities: significant asymmetries and/or degree of slowing inappropriate for clinical state or age  Interictal abnormalities associated with seizures and epilepsy Spikes Sharp waves Spike-wave complexes  May be focal, lateralized, generalized
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C-Slide 21 Medical Treatment of First Seizure Whether to treat first seizure is controversial  16-62% will recur within 5 years  Relapse rate might be reduced by antiepileptic drug treatment  Abnormal imaging, abnormal neurological exam, abnormal EEG or family history increase relapse risk  Quality of life issues are important Reference: First Seizure Trial Group. Randomized Clinical Trial on the efficacy of antiepileptic drugs in reducing the risk of relapse after a first unprovoked tonic-clonic seizure. Neurology 1993; 43 (3, part1): 478-483. Reference: Camfield P, Camfield C, Dooley J, Smith E, Garner B. A randomized study of carbamazepine versus no medication after a first unprovoked seizure in childhood. Neurology 1989; 39: 851-852.
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C-Slide 22 Choosing Antiepileptic Drugs  Seizure type  Epilepsy syndrome  Pharmacokinetic profile  Interactions/other medical conditions  Efficacy  Expected adverse effects  Cost
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C-Slide 23 Choosing Antiepileptic Drugs (cont.) Partial onset seizures carbamazepine phenytoin felbamate primidone gabapentin tiagabine lamotrigine topiramate levetiracetam valproate oxcarbazepine zonisamide phenobarbital
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C-Slide 24 Choosing Antiepileptic Drugs (cont.) AEDs that have shown efficacy for Absence seizures: Ethosuximide Lamotrigine Levetiracetam Topiramate Valproate Zonisamide
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C-Slide 25 Choosing Antiepileptic Drugs (cont.) AEDs that have shown efficacy for myoclonic seizures: Clonazapam Lamotrigine Levetiracetam Topiramate Valproate Zonisamide
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C-Slide 26 Choosing Antiepileptic Drugs (cont.) AEDs that have shown efficacy for Tonic Clonic seizures:  Carbamazepine  Phenytoin  Felbamate  Topiramate  Lamotrigine  Valproate  Levetiracetam  Zonisamide  Oxcarbazepine
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C-Slide 27 Antiepileptic Drug Monotherapy  Simplifies treatment, reduces adverse effects  Conversion to monotherapy from polytherapy Eliminate sedative drugs first Withdraw antiepileptic drugs slowly over several months
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C-Slide 28 Antiepileptic Drug Interactions  Drugs that induce metabolism of other drugs: carbamazepine, phenytoin, phenobarbital  Drugs that inhibit metabolism of other drugs: valproate, felbamate  Drugs that are highly protein bound: valproate, phenytoin, tiagabine, carbamazepine  Other drugs may alter metabolism or protein binding of antiepileptic drugs
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C-Slide 29 AED Serum Concentrations  AED serum concentrations are simply to be used as a guide.  Serum concentrations are useful when optimizing AED therapy, assessing compliance, pregnancy, or teasing out drug-drug interactions.
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C-Slide 30 AED Serum Concentrations  AED serum concentrations can be useful for documenting compliance and steady-state serum level.  Individual patients define their own “therapeutic” and “toxic” ranges.
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C-Slide 31 Dose Initiation and Monitoring  Discuss likely and unlikely but important adverse effects  Discuss likelihood of success  Discuss recording/reporting seizures, adverse effects, potential precipitants
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C-Slide 32 Evaluation After Seizure Recurrence  Progressive pathology?  Avoidable precipitant?  If on AED Problem with compliance or pharmacokinetic factor? Increase dose? Change medication?  If not on AED Start therapy?
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C-Slide 33 Discontinuing AEDs  Seizure freedom for  2 years implies overall >60% chance of successful withdrawal in some epilepsy syndromes  Favorable factors Control achieved easily on one drug at low dose No previous unsuccessful attempts at withdrawal Normal neurologic exam and EEG Primary generalized seizures except JME “Benign” syndrome  Consider relative risks/benefits (e.g., driving, pregnancy)
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C-Slide 34 Non-Drug Treatment/ Lifestyle Modifications  Adequate sleep  Avoidance of alcohol, stimulants, etc.  Avoidance of known precipitants  Stress reduction — specific techniques
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C-Slide 35 Ketogenic Diet  Main experience with children, especially with multiple seizure types  Anti-seizure effect of ketosis (beta hydroxybutyrate)  Low carbohydrate, low protein, high fat after fasting to initiate ketosis  Long-term adverse effects unknown
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C-Slide 36 Vagus Nerve Stimulator  Intermittent programmed electrical stimulation of left vagus nerve  Option of magnet activated stimulation  Adverse effects local, related to stimulus (hoarseness, throat discomfort, dyspnea)  Mechanism unknown  Clinical trials show 26% effective and <10% seizure free  May improve mood and allow AED reduction  FDA approved for partial onset seizure
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C-Slide 37 Patient Selection for Surgery: Criteria  Epilepsy syndrome not responsive to medical management Unacceptable seizure control despite maximum tolerated doses of 2-3 appropriate drugs as monotherapy  Epilepsy syndrome amenable to surgical treatment
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C-Slide 38 Evaluation for Surgery  History and Exam: consistency, localization of seizure onset and progression  MRI: 1.5 mm coronal cuts with sequences sensitive to gray-white differentiation and to gliosis  Other neuroimaging options: PET, ictal SPECT  EEG: ictal and interictal, special electrodes  Neuropsychological battery  Psychosocial evaluation  Intracarotid amobarbital test (Wada)
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C-Slide 39 Surgical Treatment  Potentially curative Resection of epileptogenic region (“focus”) avoiding significant new neurologic deficit  Palliative Partial resection of epileptogenic region Disconnection procedure to prevent seizure spread — corpus callosotomy Multiple subpial transection
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C-Slide 40 Epilepsy Surgery Outcomes Temporal Extra Lesional Hemispheric Callosotomy Temporal Seizure Free 68% 45% 66% 45% 8% Improved 23% 35% 22% 35% 61% Not improved 9% 20% 12% 20% 31% Total 100% 100% 100% 100% 100% Reference: Engel, J. NEJM, Vol 334 1996, 647-653
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C-Slide 41 Status Epilepticus  Definition More than 30 minutes of continuous seizure activity or Two or more sequential seizures spanning this period without full recovery between seizures
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C-Slide 42 Status Epilepticus  A medical emergency Adverse consequences can include hypoxia, hypotension, acidosis and hyperthermia Know the recommended sequential protocol for treatment with benzodiazepines, phenytoin, and barbiturates. Goal: stop seizures as soon as possible
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C-Slide 43 Status Epilepticus Treatment Time post onset Treatment Onset Ensure adequate ventilation/O2 2-3 min. IV line with NS, rapid assessment, blood draw 4-5 min. Lorazepam 4 mg (0.1 mg/kg) or diazepam 10 mg (0.2 mg/kg) over 2 minutes via second IV line or rectal diazepam 7-8 min. Thiamine 100 mg, 50% glucose 25 mg IV Phenytoin or fosphenytoin 20 mg/kg IV (phenytoin PE) at  50 mg/per minute phenytoin or 150 mg per minute fosphenytoin ( 0.75 mg/kg/min) Pyridoxine 100-200 mg IV in children under 18 mo.
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C-Slide 44 Status Epilepticus Treatment (cont.) Time post onset Treatment 10 min. Can repeat lorazepam or diazepam if seizures ongoing 30-60 min. EEG monitoring unless status ended and patient waking up 40 min. Phenobarbital 20 mg/kg at  5 mg per minute (0.75 mg/kg per minute) continued Reference: Lowenstein DH, Alldredge BK, Status Epilepticus. NEJM 1998; 338: 970-976.
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C-Slide 45 Status Epilepticus Treatment (cont.) Time post onset Treatment 70 min. Pentobarbital 3-5 mg/kg load, 1 mg/kg per hour infusion, increase to burst- suppression OR Propofol 3-5 mg/kg load, 5-10 mg/kg/hr initial infusion then 103 mg/kg/hr OR Midazolam 0.2 mg/kg load, .25-2 mg/kg infusion Reference: Lowenstein DH, Alldredge BK, Status Epilepticus. NEJM 1998; 338: 970-976.
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C-Slide 46 Neonatal Seizures  Incidence: 1.6 – 3.5 per 1000 live births  Major risk factors are prematurity, low-birth weight, HIE  Association with increased morbidity and mortality  May be symptomatic of treatable, serious condition (hypoglycemia, meningitis)  Diagnosis: observation with vs. without EEG References: Ronen, J Pediatr, 1999; Lanska, Neurology, 1995; Saliba, Am J Epidemiol, 1999.
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C-Slide 47 Recognition of Neonatal Seizures  Observation of abnormal, repetitive attacks of movements, postures or behaviors  Classification subtle tonic clonic myoclonic autonomic  Evaluation for cause(s) of seizures  Confirmation/support by EEG
Slide 48-

C-Slide 48 Examples of Acquired Conditions That May Provoke Neonatal Seizures  Hypoxia-ischemia  Physical trauma  Toxic-metabolic  Inborn errors of metabolism  Systemic or CNS infections  Intracranial hemorrhage
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C-Slide 49 Acute Treatment of Neonatal Seizures  Phenobarbital loading dose: 20 mg/kg  Fosphenytoin loading dose: 20 mg/kg PE@ 1  Diazepam first dose about 0.25 mg/kg  Lorazepam first dose about 0.05 to 0.1 mg/kg
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C-Slide 50 Selected Pediatric Epilepsy Syndromes  Epileptic Encephalopathies West Syndrome — infantile onset, hypsarrhythmic EEG, tonic/myoclonic seizures; idiopathic vs. symptomatic Lennox-Gastaut Syndrome — childhood onset, slow spike-wave EEG, tonic, atypical absence, atonic and other seizure types Myoclonic epilepsies of infancy and early childhood — heterogeneous
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C-Slide 51 Selected Pediatric Epilepsy Syndromes (cont.)  Febrile convulsions — 6 mo.-5 yrs. Simple: Duration less than 15 minutes, generalized, and do not recur within 24 hours Complex: Duration longer than 15 minutes, focal in nature or recur within 24 hours  Febrile convulsions: Risk Factors for development of epilepsy: Complex febrile seizures Neurodevelopmental abnormalities Afebrile seizures in first-degree relatives Recurrent febrile seizures Febrile seizures following brief and low grade fever Febrile seizure onset in first year
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C-Slide 52 Selected Pediatric Epilepsy Syndromes (cont.)  Benign epilepsy with centrotemporal spikes — nocturnal oropharyngeal simple partial, rare secondarily generalized seizures  Childhood epilepsy with occipital paroxysms — visual phenomena, at times with secondary generalization
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C-Slide 53 Selected Pediatric Epilepsy Syndromes (cont.)  Idiopathic generalized epilepsies Childhood absence epilepsy — absence, occasionally with tonic-clonic seizures Juvenile myoclonic epilepsy — myoclonic, tonic-clonic, at times absence
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C-Slide 54 AEDs in Pediatrics  Extrapolation of efficacy data from adult studies  Importance of adverse effects relative to efficacy  Susceptibility to specific adverse effects (valproate hepatotoxicity, lamotrigine rash)  Age-related pharmacokinetic factors  Neonate: low protein binding, low metabolic rate, possible decreased absorption if given with milk/formula  Children: faster metabolism
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C-Slide 55 Differential Diagnosis of Non-epileptic Events  Syncope  Migraine  Cerebral ischemia  Movement disorder  Sleep disorder  Metabolic disturbance  Psychiatric disturbance  Breath-holding spells
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C-Slide 56 Psychogenic Nonepileptic Seizures  10-45% of patients referred for intractable spells  Females > males  Psychiatric mechanism — disassociation, conversion  Common association with physical, emotional, and sexual abuse  Spells with non-epileptic etiology  Non-ictal patern on EEG
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C-Slide 57 Psychogenic Nonepileptic Seizures (cont.)  Represents psychiatric disease  Once recognized, approximately 50% respond well to specific psychiatric treatment  Epileptic and nonepileptic seizures may co-exist  Video-EEG monitoring often required for diagnosis
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C-Slide 58 Syncope  Characteristic warning, usually gradual (except with cardiac arrhythmia)  Typical precipitants (except with cardiac arrhythmia)  Minimal to no postictal confusion/somnolence  Convulsive syncope — tonic>clonic manifestations, usually < 30 sec; usually from disinhibited brainstem structures (only rarely from cortical hypersynchronous activity)
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C-Slide 59 Pregnancy and Epilepsy  Most pregnancies in mothers with epilepsy produce normal children  Fetal anomalies (up to 10% of pregnancies) are multifactorial Drug effects Consequences of the mother’s underlying diseases Consequence of maternal seizures during pregnancy  All antiepileptic drugs carry teratogenic risks  Polytherapy increases risk Reference: Practice Parameter: Management issues for women with epilepsy (summary statement): Report of the Quality of Standards Subcommittee of the American Academy of Neurology. Neurology 1998; 51: 944-948.
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C-Slide 60 Pregnancy and Epilepsy Guidelines for Management  All women of child-bearing potential should receive education and carefully considered management before and during pregnancy to optimize the chances of a good outcome for both mother and child. Reference: Liporace J, D’Abreu. Epilepsy and Women’s Health: Family Planning, Bone Health, Menopause, and Menstrual Related Seizures. Mayo Clinic Proceedings 2003; 78: 497-506.
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C-Slide 61 Pregnancy and Epilepsy Guidelines for Management  Education Most women with epilepsy have normal children Risk of fetal malformations is increased AED teratogenicity is related to exposure in the first trimester of pregnancy Prenatal diagnosis of fetal malformations is possible Seizures may be deleterious to the fetus Compliance with AED treatment is important
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C-Slide 62 Pregnancy and Epilepsy Guidelines for Management  Before pregnancy Attempt AED monotherapy with lowest effective dose Folate supplementation (at least 1 mg/day orally)  During pregnancy Monitor AED dose requirements to maximize seizure control Continue folate supplementation Consider prenatal diagnosis of fetal malformations Vit K (10 mg/day orally) starting at 36 weeks General prenatal care
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C-Slide 63 Driving and Epilepsy  Regulation varies state by state regarding: Reporting requirements Required seizure-free period Favorable/unfavorable modifiers  Insurance issues  Employment issues Resource: www.efa.org
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C-Slide 64 First Aid Tonic-Clonic Seizure  Turn person on side with face turned toward ground to keep airway clear, protect from nearby hazards  Transfer to hospital needed for: Multiple seizures or status epilepticus Person is pregnant, injured, diabetic New onset seizures  DO NOT put any object in mouth or restrain
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C-Slide 65 Appendix References for Nurses Reprinted with permission from the American Association of Neuroscience Nurses
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C-Slide 66 Appendix References for Nurses Journals  Clinical Nursing Practice in Epilepsy  Epilepsia (the Journal of the International League Against Epilepsy).  Epilepsy Currents (Bimonthly Journal for American Epilepsy Society. Also on www.aesnet.org)  Epilepsy USA Magazine, published by the Epilepsy Foundation. Also available on www.epilepsyfoundation.org.  The Journal of Neuroscience Nursing (the Journal of the American Association of Neuroscience Nurses). There is a yearly index in the December issue by author and by topic (epilepsy) for easy reference.  Seizure
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C-Slide 67 Appendix References for Nurses Books  A Guide to Understanding and Living with Epilepsy, Devinsky, O, F.A. Davis Company, 1994.  Anticonvulsant Prescribing Guide, PDR second edition, 1998, Ortho-McNeil.  Clinical Epilepsy, Duncan, J.S., Shorvon, S.D., Fish, D.R., Churchill Livingstone, 1995.  Core Curriculum for Neuroscience Nursing, third ed., American Association of Neuroscience Nursing.  Epilepsy A to Z: A Glossary of Epilepsy Terminology, Kaplan PW, Loiseau P, Fischer RS, Jallon P, Demos Vermande, 1995.  Epilepsy in Clinical Practice: A Case Study Aproach, Wilner, A., Demos, 2000.  Managing Seizure Disorders: A Handbook for Health Care Professionals, Santilli, N., Lippincott-Raven, 1996.
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C-Slide 68 Appendix References for Nurses Books, Cont’d Seizures and Epilepsy in Childhood A guide for parents, second edition, Freeman JM, Vining EPG, Pillas DJ, Johns Hopkins Press, 1997.  The Epilepsy Diet Treatment An introduction to the Ketogenic Diet, Freeman JM, Kelly MT, Freeman JB. Demos, 1994.  Childhood Seizures, Shinnar, S., Amir N, Branski D, Karger, 1995.  Students with Seizures A manual for school nurses, Santilli N, Dodson WE, Walton AV. Health Scan Publications, 1991. (*there is a section in this book that lists references for specific groups.)  Treatment of Epilepsy: Principles and Practice, Wyllie, E Videos  The Epilepsy Foundation Catalog contains many videos that can be used for education for nurses, families and schools. The “First Aid” video is a good one. (800) EFA-1000 or www.epilepsyfoundation.org. (Spanish videos also available)
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C-Slide 69 Appendix References for Nurses Networking  American Association of Neuroscience Nurses (AANN), 4700 W. Lake Avenue, Glenview, IL 60025-1485, (847) 375-4733, http://www.aann.org. The professional organization for nurses specializing in the neurosciences.  American Epilepsy Society, 342 North Main Street, West Hartford, CT 06117-2507, (860) 586-7505, www.aesnet.org. A membership society of professionals interested in epilepsy. Within the society are special interest groups including a nurses group. Contact the Society for more information.  Association of Child Neurology Nurses (ACNN), 1000 West County Road East, Suite 290, St. Paul, MN, 55126, (651) 486-9447. A membership organization of nurses interested in child neurology.  Epilepsy Foundation, eCommunities. Chat rooms for four different groups: Women and Epilepsy; Parents Helping Parents; The Teen Chat Room; and Living Well with Seizures. Located at www.epilepsyfoundation.org
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C-Slide 70 Appendix References for Nurses  Web Sites  American Association of Neuroscience Nurses http://www.aann.org  American Child Neurology Nurses http://www.acnn.org  American Epilepsy Society http://www.aesnet.org  Epilepsy Foundation (National Office) http://www.epilepsyfoundation.org or http://www.efa.org/education.firstaid.html  First Aid for Epilepsy http://www.epinet.org.an/info/general.asp  Nursing Care Implications http://www.nurseweek.com/ce/191-sb1.html  Nursing CEUs for Neurological Nursing http://www.nursecen.com/nur.htm  Nursing Case Studies http:www.webclinics.org (log in as AED and use password NURSE)
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C-Slide 71 Clinical Epilepsy Case Studies American Epilepsy Society
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C-Slide 72 Medical Student Cases Case 1: 5 year-old female with episodes of “Blanking Out”
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C-Slide 73 Case Study 1  A 5 y/o female is brought to your office because of episodic “ blanking out” which began 1 month ago. The patient has episodes in which she abruptly stops all activity for about 10 seconds, followed by a rapid return to full consciousness. The patient’s eyes are open during the episodes and she remains motionless with occasional “ fumbling” hand movements.
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C-Slide 74 Case Study 1  After the episode the patient resumes whatever activity she was previously engaged with no awareness that anything has occurred  She has 30 episodes per day  No convulsions
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C-Slide 75 Case Study 1  Past medical, physical and developmental histories are unremarkable.  No history of previous or current medications; No allergies  Family history is pertinent for her father having similar episodes as a child.
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C-Slide 76 Case Study 1  General physical and neurological examination is normal.  Hyperventilation in your office replicates the episodes.
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C-Slide 77 Case Study 1 EEG for Case Study 1
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C-Slide 78 Case Study 1  What additional studies do you perform, if any?  What is the diagnosis?  How do you initiate medication? If so, Which?  Would you counsel the family regarding prognosis?
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C-Slide 79 Medical Student Cases Case 2: “Nervous” Disorder?
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C-Slide 80 Case Study 2  25 year-old right-handed marketing executive for a major credit card company, began noticing episodes of losing track of conversations and having difficulty with finding words.  These episodes lasted 2-3 minutes.  At times, the spells seemed to be brought on by a particular memory from her past.  No one at her job noticed anything abnormal.
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C-Slide 81 Case Study 2  Patient had no significant past medical history, and took no medicines except for the birth control pill.  She was in psychotherapy for feelings of depression and anxiety, but was not taking medications for mood or anxiety disorder  Her therapist notes that she has been under significant stress from the breakup with her boyfriend.
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C-Slide 82 Case Study 2  What is your differential diagnosis at this point?
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C-Slide 83 Case Study 2  A careful medical history revealed that she had one febrile seizure at age three; no family members had epilepsy.  The psychiatrist prescribed a benzodiazepine sleeping pill to be used as needed, and scheduled her for an electroencephalogram (EEG).
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C-Slide 84 Case Study 2  Prior to the EEG, the patient had an episode while on a cross country business trip, in which she awoke on the floor near the bathroom of her hotel room.  She had a severe headache and noted some blood in her mouth, along with a very sore tongue. She called the hotel physician and was taken to the local emergency room.
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C-Slide 85 Case Study 2  What is your differential diagnosis now? How would you classify her event?  How would you evaluate the patient in the ER if you saw her after this episode?
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C-Slide 86 Case Study 2  In the ER, a diagnosis of nocturnal convulsion was made.  A head computerized tomographic (CT) scan was normal.  Laboratory tests including a CBC, chemistries and toxicology screen were normal.
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C-Slide 87 Case Study 2  She was given fosphenytoin 1000 mg PE intravenously and observed.  She was discharged home on phenytoin 300 mg per day and referred to a neurologist.  What would the continued evaluation and treatment consist of?
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C-Slide 88 Case Study 2  Neurologist took a complete neurologic and medical history and found patient had an uncomplicated febrile seizure as a toddler, but no other seizures.  There was no family history of epilepsy in her immediate family members.  Medical history is otherwise benign and she has no medication allergies. She had regular menstrual periods since age 13 and has never been pregnant, although she wants to have children.  General and neurologic examination was normal.
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C-Slide 89 Case Study 2  EEG showed right anterior temporal spike and wave discharges.  An MRI of the brain was normal.  Complaint of persistent sedation led to change from phenytoin to lamotrigine, at a dose starting at 50 mg BID increasing by 50 mg/day every two weeks to reach a target dose of 300 mg/day.
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C-Slide 90 Case Study 2  Side effects were explained to the patient. She was also started on folic acid 1 mg per day and was advised to take a multivitamin daily.
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C-Slide 91 Case Study 2 What are the most reasonable choices of antiseizure treatment for this patient? Was an appropriate choice made? What considerations must be made since she is a woman of child-bearing potential?
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C-Slide 92 Case Study 2 Are there considerations regarding the oral contraceptive pill? What is the reason for the extra folic acid and multivitamin? What advice should be given regarding lifestyle (sleep habits, alcohol intake) and driving?
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C-Slide 93 Medical Student Cases  Case 3: 70 yo man with his first seizure
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C-Slide 94 Case Study 3  70 y/o male presents to the ER with a history of a single seizure.  His wife was awakened at 5:30 am by her husband making an odd gurgling noise with his head deviated to the left and left arm tonically stiffened.  This was followed by generalized body jerking  Patient was unresponsive  Event lasted 2 minutes with 10 minutes until full recovery
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C-Slide 95 Case Study 3  In the ER, initially the patient is weaker in the left hand than the right side and is fully responsive and his wife feels that he has returned to baseline.  PMH: Non-insulin dependent diabetes  Family history: Negative for seizures  Social history: No smoking or alcohol use.  Neurological examination: Normal
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C-Slide 96 Case Study 3  Current medications: Glyburide 5 mg/day  Vital signs: BP 200/130, HR 75 ( regular)  RR 14, Temp 100.1
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C-Slide 97 Case Study 3  Sodium 141 meq/L  Potassium 4.2 meq/L  Chloride 99 meq/L  Bicarbonate 27 meq/L  BUN 8 mg/dL  Cr 0.7 mg/dL  Glucose 60 mg/dL  Hematocrit 44%  Hemoglobin 15.4 g/dL  WBC 12,000/  80% Neutrophils  Platelets 180,000
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C-Slide 98 Case Study 3  Urine analysis: 15 WBC/HPF, nitrite positive  ABG: pH 7.3, pCO2- 36, pO2- 86, O2 saturation 93%  CT scan: normal  EEG: minimal bitemporal slowing
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C-Slide 99 Case Study 3 CT Scan
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C-Slide 100 Case Study 3  What work-up is needed after a single seizure?  What are the causes of seizures, including what conditions lower the seizure threshold?  Would you treat this patient or not? If you choose to start a medication, which drug would you choose and why?  What are the predictors of seizure recurrence?
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C-Slide 101 Medical Student Cases  Case 4: A 62 yo male with Continuous Seizures
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C-Slide 102 Case Study 4  A 62 y/o male without significant previous history of seizures presents to the E R following one generalized tonic-clonic seizure.  Initial assessment after the first seizure revealed poorly reactive pupils, no papilledema or retinal hemorrhages and a supple neck.
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C-Slide 103 Case Study 4  Oculocephalic reflex is intact.  Respirations are rapid at 22/min and regular, heart rate is 105 with a temperature of 101.  As you are leaving the room, the patient had another seizure.
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C-Slide 104 Case Study 4  What should the initial management be?  What initial investigations should be performed in this setting?  What is the appropriate management with continued seizures if initial therapy does not terminate the seizures?
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C-Slide 105 Case Study 4  Laboratory study results: CBC  WBC- 13.1  HGB 11  Plt 200,000  Creatinine- 1.0  Mg 1.0  Na- 132  K- 4.5  Ca- 9.0  Glucose- 90
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C-Slide 106 Case Study 4 What are indications for lumbar puncture in this case?  CSF color- clear  Cell count tube # 1 – 500 RBC/ 35 WBC- 100% Neutrophils  Tube # 3 - 100 RBC/ 11 WBC  Protein 65  Glucose 60
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C-Slide 107 Case Study 4  Urinalysis- (+) ketones  No White Blood Cells or bacteria  Tox screen: negative for alcohol positive for benzodiazepines
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C-Slide 108 Case Study 4 You obtain an MRI of the brain with the following images
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C-Slide 109 Case Study 4
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C-Slide 110 Case Study 4  Which of the above studies helps to explain the current seizures?  Would you ask for other studies?  What are the CSF findings during repeated convulsions?
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C-Slide 111 Case Study 4  Define Status Epilepticus.  Describe the systemic manifestations of status epilepticus.  What causes status epilepticus?  What is the role of EEG in status epilepticus management?
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C-Slide 112 Medical Student Cases  Case 5: 51 year old female with frequent seizures
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C-Slide 113 Case Study 5  Seizure History: Her birth was unremarkable except that she was born with syndactyly requiring surgical correction.  Early developmental milestones were met at appropriate ages.  She had her first convulsive episode at age 2 in the setting of a febrile illness.
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C-Slide 114 Case Study 5  How would you evaluate and treat a patient with a febrile seizure?  What clinical features are important in guiding your evaluation?
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C-Slide 115 Case Study 5  She began to develop a new type of episode in the third grade.  The attacks consisted of her seeing a pink elephant that was sitting on various objects and waving to her.  The patient has subsequently found a ceramic model of an elephant that was the same as the elephant that she saw during her seizures.
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C-Slide 116 Case Study 5  How are her symptoms different from most patients with schizophrenia?
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C-Slide 117 Case Study 5  She was not diagnosed with seizures until the age of 15.  Initially, the seizures were controlled with medicine.  After a few years, however, the attacks re-occurred despite treatment with anticonvulsants.
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C-Slide 118 Case Study 5  At age 20, the seizures changed in character to the current pattern.  The seizures begin with an aura of “a chilling sensation starting at the lower back with ascension to the upper back over the course of 10-20 seconds”.
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C-Slide 119 Case Study 5  Observers then note a behavioral arrest.  She tends to clench her teeth and breath heavily, such that her breathing sounds “almost as if she were laughing”.  She is unable to fully respond to people for 5-10 minutes.  Typically, she experiences 4-5 seizures per month.
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C-Slide 120 Case Study 5  She has had several EEGs in the past; the most recent available report is from seven years ago, which revealed mild, diffuse slowing of background elements with no abnormalities noted during three minutes of hyperventilation and photic stimulation.  She had an MRI 13 years ago with no reported abnormalities.
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C-Slide 121 Case Study 5  She has tried several different medications, but is currently maintained on carbamazepine and lamotrigine. Her carbamazepine dose is 700 mg/day and Lamotrigine 125 mg/day with BID dosing.  She feels excessively tired on higher doses.  She has been on carbamazepine 32 years and on lamotrigine for four years.  She states that she has had some success with the lamotrigine.
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C-Slide 122 Case Study 5  In the past, she has been unsuccessfully tried on phenobarbital, primidone, valproate, gabapentin, phenytoin and ethosuximide.  She had marked weight gain while taking valproate.  She hated having seizures in public and she “felt like a prisoner in my own home”.  Upon hearing of seizure surgery, she requested a referral for evaluation.
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C-Slide 123 Case Study 5  When are seizures “medically refractory”?  When should you consider an inpatient video EEG evaluation?  What might you learn from such an evaluation?
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C-Slide 124 Case Study 5 Past Medical History: 1) Migraine headaches (with the last one occurring four years ago) 2) status-post hysterectomy with removal of one ovary 25 years ago 3) history of syndactyly at birth with surgical corrections; 4) partial thyroidectomy 32 years ago during pregnancy.
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C-Slide 125 Case Study 5 Social History:  She currently lives with her mother.  She works as a sales clerk.  She completed twelve years of school and finished one semester of college.  She has not driven a car after being reported to the DMV by her doctor 23 years ago.
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C-Slide 126 Case Study 5  She tells you that she still has her driver’s license. 1) What are your legal and ethical obligations as a physician? 2) What are some of the employment issues experienced by people with epilepsy?
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C-Slide 127 Case Study 5  Family History: She has a cousin with a history of ”grand mal” seizures who died at age 12.  Habits: She does not use of alcohol, tobacco, or illicit drugs.  Medications: Carbamazepine 600/400 mg/day BID, Lamotrigine 50/75 mg/day BID, Conjugated estrogens 1.25 mg PO qd, thyroxine100 mcg PO qd, and sumatriptan PRN.  Neurologic Examination: Normal
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C-Slide 128 Case Study 5  Impression Possible Mesial Temporal Lobe Epilepsy Auras of forced recall and rising autonomic experience Complex Partial Seizure Seizures refractory to multiple antiepileptic medications  Recommendation Epilepsy Surgery Evaluation
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C-Slide 129 Case Study 5  The patient underwent video-EEG monitoring.
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C-Slide 130 Case Study 5  During 5 days of video EEG, she had 3 typical CPS.  Her seizures began with her typical aura followed by lip smacking and left hand automatisms. Right hand had tonic posture  She had a brief post-ictal aphasia
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C-Slide 131 Case Study 5 EEG onsets consisted of a rapid build up of rhythmic theta frequency activity over the left temporal region (Arrows)
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C-Slide 132 Case Study 5  MRI reveals an atrophic L. Hippocampus
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C-Slide 133 Case Study 5 Pre-surgical Evaluation:  Neuropsychological Testing Performance and Verbal IQ normal  Wada (Intracarotid amobarbital) test Language on Left side only No memory difference with left and right injections
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C-Slide 134 Case Study 5 Pre-surgical Evaluation: Conclusions  She has complex partial seizures refractory to anticonvulsant treatment  Clinical and EEG features are compatible with seizure origin from the left, language- dominant temporal lobe  MRI suggests mesial temporal sclerosis is the underlying pathology  She has an excellent chance for a seizure-free outcome with a left anterior temporal lobe resection
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C-Slide 135 Case Study 5 Surgery  Surgery under local anesthesia  Language map determined by electrical stimulation  Language areas (green arrow) and epileptogenic tissue (white arrow) labeled on next slide
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C-Slide 136 Case Study 5  MRI showing language areas
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C-Slide 137 Case Study 5 Surgery  Anterior temporal lobe resected (arrow)  Amygdala and hippocampus also resected
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C-Slide 138 Case Study 5 Follow-up  Immediately following surgery she had mild dysnomia  At three months post-op, cognitive testing confirmed no change from pre-op  She has had no seizures for two years. She declines a trial off of anticonvulsants for fear of recurrent seizures. She drives to her appointment in a new car.  She writes, “I’m now having a life I never knew was possible”