PANCE Blueprint Neurology (7%)

Generalized seizures (ReelDx + Lecture)

600 REEL-DX-ENHANCED

seizure disorder reeldx

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

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 seizure

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

Todd’s paralysis: Brief paralysis after 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.

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.
IM_NUR_TypesofSeizures_V1.1_ There are numerous types of seizures, but the most common type is the tonic-clonic seizure or grand mal. It has phases of tonicity, followed by a clonic phase, where there is jerking. Children can have absence or petit mal seizures, described as a brief staring spell. Myoclonic seizures are described as a sudden jerk of the body or extremity, while an atonic seizure is where there is excessive tonicity, or a loss in tone leading to a “drop attack.” Focal parts of the brain can be affected in partial or focal seizures, which may or may not lead to impaired consciousness.

Types of Seizures Picmonic

IM_NUR_Carbamazepine_V1.5_ Carbamazepine (Tegretol) is an anticonvulsant medication that decreases seizure activity caused by high-frequency neuronal discharge. This drug is primarily indicated for seizures but is also used to treat trigeminal neuralgia and symptoms associated with bipolar disorder. Neurological side effects such as blurred vision, vertigo, and headache are common.

Severe side effects include Stevens-Johnson Syndrome (SJS),  toxic epidermal necrolysis (TEN), hepatotoxicity, and blood dyscrasias such as aplastic anemia. Monitor the patient for signs of water retention. Grapefruit juice increases serum carbamazepine and should be avoided. It is teratogenic and should be avoided in pregnancy

Carbamazepine (Tegretol) Picmonic

IM_PHM_Ethosuxamide_v2.1_ Ethosuximide is an anticonvulsant medication used to treat absence seizures, or petit mal seizures, which are mostly seen in school-age children. This drug is a first line agent for this neurological disorder, and is preferred over similar drugs because it does not cause hepatotoxicity. The mechanism of action for ethosuximide is blocking thalamic t-type Ca2+ channels, leading to decreased neuronal transmission.

Side effects of this drug include Stevens-Johnson Syndrome (SJS), which is a life-threatening skin and mucous membrane hypersensitivity reaction, fatigue, and diarrhea, while constipation can occur in some.

Ethosuximide Picmonic

IM_PHM_ValproicAcid_v1.7_ Valproic acid (Depakote), or valproate, is an anticonvulsant and mood-stabilizing drug that works by increasing GABA concentration and blocking Nachannels. It is mainly indicated for epilepsy, bipolar disorder, and migraine prophylaxis. This drug increases levels of the neurotransmitter GABA by inhibiting the enzyme GABA transaminase, which acts to break down GABA. Also, valproic acid decreases repetitive neuronal firing by blocking voltage-gated Na+ channels, inactivating them.

This medication is known for causing GI distress, as well as being hepatotoxic and sometimes leading to pancreatitis. Valproic acid is contraindicated in pregnant patients, as it is teratogenic and a folate antagonist, and can lead to neural tube defects (spina bifida).

IM_PHM_Phenytoin_v1.10_ Phenytoin is an antiepileptic medication used to treat generalized tonic-clonic (grand mal) seizures and during status epilepticus. This drug works by blocking sodium channel activation in neuronal membranes, leading to an inhibition of glutamate release and resultingly, enhanced GABA release. Phenytoin is categorized as and also has use as a Class IB antiarrhythmic medication.

There are numerous side effects related to phenytoin use. It is known to be teratogenic, and can cause fetal hydantoin syndrome. It induces cytochrome p450, and decreases folate levels, leading to megaloblastic anemia. Phenytoin can prompt drug-induced lupus, which is an autoimmune disorder that can sometimes arise from a drug reaction. Neurological symptoms can present in various forms, depending on acute and chronic usage of this medication, and hirsutism is often seen in women who use phenytoin long term. Gingival hyperplasia may also be seen.

Phenytoin Picmonic

Question 1
A child exhibits short staring spells at school, which are sometimes accompanied by loss of postural tone. Episodes last less than a minute. Electroencephalography reveals bilateral 3-Hz spike-and-wave pattern. What is the medication of choice?
A
carbamazepine
Hint:
Carbamazepine, phenobarbital, and phenytoin are indicated for tonic–clonic (grand mal) or partial focal seizures.
B
ethosuximide
C
phenobarbital
Hint:
Carbamazepine, phenobarbital, and phenytoin are indicated for tonic–clonic (grand mal) or partial focal seizures.
D
phenytoin
Hint:
Carbamazepine, phenobarbital, and phenytoin are indicated for tonic–clonic (grand mal) or partial focal seizures.
Question 1 Explanation: 
Absence, or petit mal, seizures are best treated with either ethosuximide or valproic acid. Clonazepam is also effective but can be habit forming.
Question 2
Which of the following is the most common known cause of epilepsy in young adults?
A
Strokes
B
Head trauma
C
Tumors
D
Infection
Question 2 Explanation: 
In a substantial number of cases, the cause of epilepsy remains unknown. Identified causes tend to vary with patient age. Inherited syndromes, congenital brain malformations, infection, and head trauma are leading causes in children. Head trauma is the most common known cause in young adults. Strokes, tumors, and head trauma become more frequent in middle age, with stroke becoming the most common cause in the elderly, along with Alzheimer disease and other degenerative conditions.
Question 3
Which of the following types of seizures consist of brief episodes (< 20 sec) of impaired consciousness with no aura or postictal confusion?
A
Myoclonic seizures
B
Atonic seizures
C
Absence seizures
D
Primary generalized tonic-clonic seizures
Question 3 Explanation: 
Absence seizures are brief episodes of impaired consciousness with no aura or postictal confusion. They typically last less than 20 seconds and are accompanied by few or no automatisms. Myoclonic seizures consist of brief arrhythmic jerking motor movements that last less than 1 second and often cluster within a few minutes. If the seizures evolve into rhythmic jerking movements, they are classified as evolving into a clonic seizure. Clonic seizures consist of rhythmic jerking motor movements with or without impairment of consciousness; they can have a focal origin. Focal seizures are classified as simple or complex partial seizures. The typical generalized clonic seizures simultaneously involve the upper and lower extremities. Tonic seizures consist of sudden-onset tonic extension or flexion of the head, trunk, and/or extremities for several seconds. These seizures typically occur in relation to drowsiness, shortly after patients fall asleep, or just after they awaken. Atonic seizures are also called "drop attacks." These seizures typically occur in people with clinically significant neurologic abnormalities (although they may occur in developmentally normal children as part of an idiopathic epilepsy syndrome) and consist of brief loss of postural tone, often resulting in falls and injuries (hence, some patients need helmets).
Question 4
Which of the following is the criterion standard for classifying the type of seizure or syndrome or for diagnosing pseudoseizures?
A
MRI
B
CT scanning
C
Positron emission tomography (PET) scanning
D
Video electroencephalography (video EEG)
Question 4 Explanation: 
Video EEG monitoring is the criterion standard for classifying the type of seizure or syndrome or for diagnosing pseudoseizures. This study can be performed to rule out an epileptic etiology with a high degree of confidence if the patient has demonstrable impairment of consciousness during the spell in question, without abnormality on the EEG. Video EEG is also used to characterize the type of seizure and epileptic syndrome to optimize pharmacologic treatment and for presurgical workup.
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