PANCE Blueprint Neurology (7%)

17 y/o with confusion and disorientation following a 5-minute seizure

Patient will present as → a 22-year-old man is brought to the emergency department by his wife. While he was raking leaves in the backyard, he suddenly lost consciousness, became rigid, and fell to the ground. His respirations temporarily ceased. This lasted for approximately 45 seconds and was followed by a period of jerking of all four limbs lasting 2 or 3 minutes. The patient then remained unconscious for 3 or 4 minutes.

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Generalized (both hemispheres)

• Start midbrain or brainstem and spreads to both cortices

"A seizure is a single occurrence, whereas epilepsy is a neurological condition characterized by two or more unprovoked seizures"

Absence seizure (petit mal)

• Characterized by brief impairment of consciousness with an abrupt beginning and ending.  At times involuntary movements may occur, but they are uncommon and the patient has no recollection and witnesses commonly miss them
• Start around age 3
• Lasts less than 15 seconds, occurs frequently
• EEG: during an event would show symmetric 3-Hz spike and wave activity
• TX absence seizures with Ethosuximide

Tonic-Clonic (Grand mal)

• Tonic phase: very stiff and rigid 10-60 seconds.
• Clonic phase: generalized convulsions and limb jerking
• Postictal phase: confused state
• Evaluate with glucose, standard blood workup, and a CT scan
• EEG: generalized high-amplitude, rapid spiking on EEG
• TX with Phenytoin (Dilantin)

Myoclonic: muscle jerking, but not the tonic phase, occurs in the morning

Tonic: extreme rigidity then immediate LOC, but not followed by a clonic phase

• Tonic seizures are characterized by facial and truncal muscle spasms, flexion or extension of the upper and lower extremities, and impaired consciousness.

Atonic attack (drop attack): looks like syncope, sudden loss of muscle tone

• Atonic seizures (drop attacks) are not seen in many children. Without warning, a child abruptly loses consciousness, collapses and falls to the floor. There is no convulsion, but children may hit their heads as they fall. After a few seconds, the child regains consciousness and can stand and walk again.

Additional types

Febrile Seizure: A convulsion associated with an elevated temperature greater than 38°, > 6 mos < 5 years, absence of central nervous system infection or inflammation

• Febrile seizures that continue for more than five minutes should be treated with IV benzodiazepines (diazepam or lorazepam)

Todd’s paralysis: Brief paralysis after a seizure. Subsides after 48 hrs.

"Did you know: patients who may be taking Valproate (Depakote) should have LFTs monitored as Valproate may be toxic to the liver as well as cause thrombocytopenia."

*Seizures that develop during adolescence and adult life are predominantly due to tumor, trauma, drug use, or alcohol withdrawal.

Diagnostic approach: check electrolytes, glucose, pregnancy test, ECG, EEG, neuroimaging for adults with first seizure (CT/MRI)

• EEG helps to establish the diagnosis and localize the lesion
• Seizures that develop during adolescence and adult life are predominantly due to tumor, trauma, drug use, or alcohol withdrawal - In addition to blood work obtain a CT scan

Carbamazepine, phenobarbital, and phenytoin are indicated for tonic-clonic (grand mal) or partial focal seizures

• Absence, or petit mal, seizures are best treated with either ethosuximide or valproic acid. Clonazepam is also effective but can be habit-forming