Seizure disorders

A 16-year-old girl presented to the ED after an episode of loss of consciousness (LOC) and involuntary repetitive movements of the extremities occurring over approximately 3 minutes. Bystanders recorded video of the incident showing that the patient had generalized spasms and LOC that spontaneously resolved. After the episode, the patient reported headache and confusion. Her vital signs were normal, and she denied any similar previous episodes, fever, and substance use. GENERAL FEATURES Seizures occur due to abnormal electrical activity in the brain. Epilepsy is categorized as two or more unprovoked seizures more than 24 hours apart. The postictal state (time after the seizure) is characterized by: Confusion Drowsiness Headache An aura is an alert sign that occurs prior to seizures and is part of seizure itself. Auras can manifest as the feeling of déjà vu, sudden fear, anxiety, joy, anger, paresthesia, an abnormal smell, or restlessness. Focal seizures Unilateral abnormal brain activity May be classified by level of awareness and by initial observable features Motor seizure types Tonic: prolonged muscle contraction Atonic: loss of muscle tone Automatisms: coordinated, recurrent, purposeless repetitive motor actions such as lip smacking, chewing, or swallowing Myoclonic: sudden localized muscle contractions Nonmotor seizure types Autonomic: may include gastrointestinal symptoms (epigastrium symptoms, nausea, need for bowel movement), heart rate changes (tachycardia to asystole), and/or ocular changes (tearing, pupil size changes) Emotional: laughing, fear, crying, anxiety, bliss, anger Behavior-arrest: movement stops Sensory: auditory (buzzing, ringing), visual (flashing lights), olfactory (odor), sensations of heat/cold Cognitive: aphasia/dysphasia, anomia, hallucination, intrusive thoughts, dyscalculia, and dysgraphia Generalized seizures Originate in both hemispheres Impaired awareness Motor seizures Tonic-clonic: a type of contraction of muscles followed by jerking Other seizure types: tonic, clonic, myoclonic, atonic, epileptic spasms, and combinations Nonmotor seizures Absence: a sudden lapse in consciousness Status epilepticus is defined as continuous seizure activity that lasts 5 or more minutes and/or an episode in which two or more seizures occur without the patient regaining full consciousness or experiencing resolution of postictal confusion between them. Nonconvulsive status epilepticus is categorized as an altered level of consciousness that lacks major motor signs, with electroencephalogram (EEG) showing continuous epileptiform activity. CLINICAL ASSESSMENT Obtain history Apparent triggers Symptom onset and duration Any previous episodes and family history. Review any available recordings of a patient's episode(s). Conduct neurologic examination. Box 1DIAGNOSIS EEG Brain MRI or CT scan Causes (VITAMINS mnemonic, plus “G”) Vascular Infection Trauma Autoimmune Metabolic Idiopathic Neoplastic Substances Genetic (Dravet syndrome, Angelman syndrome, Rett syndrome, and long QT syndrome, among others) TREATMENT Nonacute seizure treatment is guided by an epilepsy specialist. Medications for nonacute seizure treatment: Absence seizures: ethosuximide, valproic acid, lamotrigine Focal onset seizures: common first-line options are lamotrigine and levetiracetam; other options include carbamazepine, esclicarbazepine, pregabalin, gabapentin, lacosamide, cenobamate, phenobarbital, primidone, stiripentol, tiagabine, vigabatrin, brivaracetam Both focal and generalized seizures: lamotrigine, levetiracetam, topiramate, zonisamide, valproate, rufinamide, perampanel, felbamate, clobazam Common medication side effects: Drowsiness Double vision Aggression Agitation Sleep difficulties Cardiac arrhythmias Ataxia Myoclonic seizures (associated with lacosamide) Providers should note that some medications carry precautions for women of childbearing age. Driving precautions and restrictions vary from state to state. In cases of status epilepticus, providers should: Stabilize the patient (blood pressure, oxygen, heart rate and rhythm) Time the seizure Oxygenate if appropriate Check glucose. If below 60 mg/dL, consider1: In adults, thiamine 100 mg via IV, then 50% dextrose solution (dosage depends on weight) via IV Consider naloxone during an opioid overdose In children over 2 years of age, 25% dextrose solution (dosage depends on weight) via IV In children under 2 years of age, 4 mL 12.5% dextrose solution via IV If seizure lasts longer than 5 minutes: IV administration is the preferred method of treatment delivery. If IV access is available, utilize one of the following: Midazolam Lorazepam Diazepam Phenobarbital (generally lower on the list of preferred medications, as it typically acts more slowly than the others) If IV access is not available, consider: Rectal diazepam Intranasal midazolam or diazepam Buccal midazolam or clonazepam If seizure lasts longer than 10 minutes: IV access is required for administration of one of the following: Fosphenytoin Valproic acid Levetiracetam Phenobarbital If IV access is not available, consider: Rectal diazepam Intranasal midazolam or diazepam Buccal midazolam or clonazepam CASE RESOLUTION The patient was urgently referred to a neurologist for a brain MRI and EEG. Further laboratory tests were ordered, including a complete blood cell count, a comprehensive metabolic panel, and ECG. The patient was cautioned to avoid driving until laboratory results were obtained and to avoid swimming, baths, and high-altitude areas until she could be seen by a neurologist.Box 2