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Clinical Pearls of Epilepsy PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "You’ve Got Nerve: Clinical Pearls of Epilepsy" by Akilah Mikel, MSN, FNP-BC.
This medical PowerPoint presentation talks about seizures and epilepsy, two related but distinct medical conditions.
A seizure is a sudden, uncontrolled electrical disturbance in the brain that can cause changes in behavior, movements, and sensations. Seizures can be caused by a variety of factors, including brain injury, infections, genetics, and drug or alcohol abuse. There are many types of seizures, including focal seizures, generalized seizures, absence seizures, and tonic-clonic seizures.
Epilepsy, on the other hand, is a neurological disorder characterized by recurrent seizures. A person is diagnosed with epilepsy if they have had two or more unprovoked seizures. Epilepsy can be caused by a variety of factors, including genetic mutations, brain tumors, head injuries, and infections.
Treatment for seizures and epilepsy depends on the underlying cause and the type and frequency of seizures. Medications, surgery, and lifestyle changes, such as avoiding triggers, can help manage seizures and prevent epilepsy. It is important for anyone experiencing seizures or epilepsy to seek medical attention to receive proper diagnosis and treatment.

Tags : seizures, epilepsy, focal seizures, generalized seizures, absence seizures, tonic-clonic seizures, neurological disorder, recurrent seizures, Neurology PowerPoint presentation

Published on : Mar 21, 2023 | Views : 848 | Downloads : 2

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Slide 1-

You’ve Got Nerve: Clinical Pearls of Epilepsy Akilah Mikel, MSN, FNP-BCPediatric Specialists of Virginia Neurology Nurse Practitioner
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No Disclosures
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Objectives Describe seizures and epilepsy according to standard classification Discuss common types of seizures Explain the diagnostic evaluation of seizures Gain some familiarity with anti-seizure treatment Discuss safety and management of seizures
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Seizures have been documented since the earliest civilizations An account of a boy with epileptic-like seizures is recorded in 3 of the 4 gospels of the bible using phrases like “possessed by a spirit”, “a spirit seizes him (Matthew 17:14–18; Mark 9:14–29; Luke 9:38–42) The word epilepsy comes from the Greek verb epilambanein (over seize), derived from the notion that gods take hold or “seize” a person
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Neuron
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Definitions Seizure – a disturbance in the electrical activity of the brain Epilepsy – two or more unprovoked seizures separated by more than 24 hours Proposed ILAE (International League Against Epilepsy) definition – one seizure and risk for additional seizures >60%
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Epilepsy Epidemiology 2.2 million people in the United States and more than 65 million people worldwide 150,000 new cases of epilepsy are diagnosed in the United States annually 1 in 26 people in the United States will develop epilepsy at some point in their lifetime
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New Onset Seizure Evaluation Electrolytes? Lumbar puncture? EKG? Neuroimaging? EEG? Other?
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Seizure Differential Diagnosis Syncope Pseudo-seizures Breath-holding Sandifer syndrome-related to reflux Migraine Movement Disorder TIA Sleep myoclonus
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History Pre-monitory Ictal Post-ictal Other spells Tongue biting Incontinence
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Neuroimaging Almost always indicated for seizure evaluation MRI (Magnetic Resonance imaging) preferred 3 Tesla (T) epilepsy protocol Look for signs of tumors, stroke, infection, structural abnormalities in the brain such as hydrocephalus and vascular malformations that would indicate a cause for seizures
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MRI
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Neuroimaging Immediate noncontrast CT is possibly useful for emergency patients presenting with seizure to guide appropriate acute management especially where there is an abnormal neurologic examination, predisposing history, or focal seizure onset.
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EEGElectroencephalogram A non-invasive procedure that detects abnormalities in the brain waves, or in the electrical activity of the brain. It records the brains electrical activity as a series of traces. Each trace corresponds to a different region of the brain Activation procedures: Photic stimulation (flashing lights) and hyperventilation (breathing fast for 3 min)
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EEG Electrodes consisting of small metal discs with thin wires are pasted onto the scalp.
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EEG Useful for evaluating new onset seizure: Prognosis Focal vs. generalized Epilepsy syndrome 25-60% chance of catching abnormal discharges on routine EEG A negative EEG does not exclude the possibility of seizures Prolonged video EEG when indicated
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Epilepsy classification
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Seizure classification
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Generalized Seizures-affect the entire brain Tonic Clonic (rigid/jerking) Absence (starring spell) Other motor including: Myoclonic (muscle jerks) Atonic (drop seizure) Epileptic Spasms
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Focal seizure-affect part of the brain Aware: Alert, involuntary movement, odd taste/smell, fear/happiness, sweating/goose bumps Impaired awareness: Aura, unconscious, lip smacking, meaningless movements, picking at clothing, wandering around, repeating words
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Examples of Seizures Generalized seizure: Focal Seizure:
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Febrile Seizures 2-5% of children (Hauser 1975, Nelson 1978, Offringa 1991) between 6 months and 6 years of age Simple vs complex Complex: Duration > 15 minutes Focal features ≥ 2 in 24 hours
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Febrile Seizures: management Anti-pyretics do not decrease risk for febrile seizures with subsequent illness However, they (acetaminophen) may decrease risk for febrile seizures within the same illness (9% vs 24%) (Murata et al., 2018)
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Febrile Seizures: Prognosis Overall, 1/3 have recurrence of FS ~10% have ≥3 FS 1% without risk factors will develop epilepsy by age 7 Compared to 10% with 2/3 risk factors – complex, preexisting neurological abnormality, family history of afebrile seizures Nelson & Ellenberg (1978)
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Infantile Spasms Clinical – usually trunk flexion and extremity extension in clusters 50-60% continue to have seizures (mostly LGS) 71-81% MR West syndrome = spasms, psychomotor deterioration, and hypsarhythmia Tx Corticotropin (ACTH) or high dose steroids, alternatively Vigabatrin
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Hypsarhythmia
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Infantile Spasms
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Absence seizures Starring spells <30-40 seconds No post-ictal Multiple per day 3 Hz spike-wave Can be triggered by hyperventilation
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Absence seizures
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Benign Epilepsy with Centrotemporal Spikes (BECTS) Onset 3-14 years old; most outgrow by 16 years Most common focal childhood epilepsy Seizures from rolandic cortex 80% have < 6 seizures Classically, unilateral face, tongue, and/or hand/arm clonic jerking/ parasthesia in early morning or while asleep – may be on either side; often retained awareness but expressive aphasia in ictal/ post-ictal phase Seizures may generalize Central-temporal spikes, activated by drowsiness/ sleep
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Juvenile Myoclonic Epilepsy Most common generalized epilepsy in adolescents Myoclonic, absence, and GTC seizures usually after morning awakening, provoked by sleep deprivation, alcohol Myoclonic jerks necessary for diagnosis, predominate in upper limbs 4-5 Hz generalized polyspike and slow wave discharges; photosensitive Most easily treated; 16% pharmacoresistant
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Pseudo-seizure Also known as: psychogenic non-epileptic seizures (PNES), conversion disorder, functional neurologic disorder A non-epileptic seizure: no abnormal electrical activity in the brain correlating with the event Tx: Cognitive behavioral therapy, psychiatric evaluation, PT/OT
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Pseudo-seizure Risks in children: history of abuse, depression, anxiety, school phobia, mood disorders, separation anxiety, ADHD, panic disorder, PTSD, cognitive impairment, learning disability, epilepsy Video EEG is the gold standard for diagnosis Common reason for admission to EMU; about 20-30% with refractory “seizures” have been misdiagnosed and most are PNES
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Status Epilepticus Single seizure ≥ 30 minutes Multiple seizures without regaining consciousness Impending status epilepticus (Chen JWY and Wasterlain CG, 2006) or early status epilepticus (Shorvon S, 2001) = 5 minutes Status epilepticus: Convulsive Non-convulsive Incidence 20 episodes per 100,000 per patient-year 1/3-1/2 present with SE as their first seizure
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Status Epilepticus Etiology Missed medications (history of epilepsy) Febrile status epilepticus Meningitis/ encephalitis Electrolyte disturbance, hypoglycemia Traumatic brain injury Toxin/ overdose Stroke, Tumor, other lesion Eclampsia
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SUDEP Sudden Unexpected Death in Epilepsy Each year about 1 in 1000 adults and about 1 in 4,500 childeren with epilepsy dies from SUDEP No known cause of SUDEP Risk increases with poorly controlled epilepsy (particularly GTC seizures) Best prevention is to control seizures
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Management ABCs High flow O2 via non-rebreather mask Do not put anything in the mouth Do not restrain the patient, but ensure they are in a safe place May need to help keep the airway open Turn patient on his/her side when possible to prevent aspiration Check blood sugar, electrolytes (more important if no history of epilepsy)
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New Onset Seizure: To Treat or Not to Treat? Effect on long-term prognosis Generally do not treat first unprovoked seizure Recurrence risk- 50% within 2 years after 1st unprovoked
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Risk of Recurrence after Unprovoked Seizure
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Common Anti-Epileptic Drugs Medications: Broad-spectrum – levetiracetam, lamotrigine, valproic acid, phenobarbital, etc Focal – oxcarbazepine, carbamazepine, phenytoin, etc Absence – ethosuximide
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New AEDs Cannabidiol (Epidiolex-Lennox Gastaut, Dravet syndrome) Brivaracetam (Briviact-Focal) Steripentol (Diacomit-Dravet syndrome)
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Medication Management To avoid side effects, medications are gradually titrated to a goal dose based on weight. There is a risk for seizure during this titration period. Ensure that medications are taken at the same time twice daily (use alarm/pill box for reminders) Labs are generally checked at trough levels Unless otherwise instructed contact your neurology team with every seizure
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Medication Management Vaccinations are generally recommended including the flu shot (except for the nasal spray) Please do not stop medications abruptly without contacting your neurology team If seizure free for 2 years, your neurologist may discuss weaning seizure medication if patient has a normal EEG
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Non-medication therapies Vagus Nerve Stimulator (VNS)-prevents seizures by sending regular, mild pulses of electrical energy to the brain via the vagus nerve Deep Brain Stimulation (DBS)-electrodes placed in target areas in the brain provide brain stimulation to help stop the spread of seizures Ketogenic Diet- 3-4 gms of fat for every 1 gm carb and protein
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Vagus Nerve Stimulator
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Vagus Nerve Stimulator
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Vagus Nerve Stimulator Magnet can be swiped once a minute 3-5 times Needs to be turned off if getting MRI
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Deep Brain Stimulation
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SAFETY & RESPONSEWhat to do during a seizure
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When to call 911 Seizure lasts longer than 5 min > 3 seizures in 1 hour Patient does not resume normal breathing once seizure stops Respiratory distress Serious injury during seizure Water was inhaled
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Rescue Medications Diastat/Diazepam (rectal) Ativan/Lorazepam (buccal) Klonopin/Clonazepam Tab or ODT (buccal) Versed/Midazolam (nasal spray)
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Seizure Triggers Illness, fever, diarrhea, vomiting Sleep deprivation Missed medications Stress – worry, anxiety, anger Flashing lights – if photosensitive Alcohol or drug abuse Menstrual cycle in women
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Safety Never swim alone No bathing without supervision (showers are fine) Sports-helmet with bike riding, wear protective gear for each sport, use buddy system, stay hydrated Make sure coaches and referees are aware of the possibility of seizures In Virginia must be seizure free for 6 months to drive
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Activities to Avoid Hang gliding Sky diving Rock/mountain climbing Scuba diving
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The International League Against Epilepsy (ILAE) has proposed to expand the definition of remission to 10 years seizure-free with the last 5 years off antiepileptic drugs (AEDs). Seizure Remission
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Caleb is a 3 month old male who presents to your clinic with his parents. They state over the past couple of weeks Caleb has been having “weird movements”. Upon further questioning they report that the movements consist of flexion of his trunk and extension of his extremities in clusters particularly upon early morning wakening. A: Reassure them that babies sometimes have strange movements B: Refer them immediately to neurology for workup including an EEG and to consider ACTH or high dose steroids C: Start them on Keppra and give them Diastat for emergencies Case Study 1
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Brady is a 7 yo male who was brought into your clinic for evaluation of inattention. His parents state he will often stop and stare for about 30 seconds as if he is day dreaming. It occurs multiple times a day and his teacher is reporting he is not listening in class and his grades are dropping. A: put him on Adderall for ADHD B: tell him they need to discipline him better C: Refer him to neurology for an EEG and to consider treatment with Ethosuximide Case Study 2
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Caroline is a 16 yo female with a hx of abuse and depression. She presents to the office for concerns for seizures. Upon further questioning the movements consist of a violent thrashing of her body, the arm and leg movements are out of phase, her eyes are closed, and she turns her head from side to side. She sometimes falls but never has hurt herself. A: Send her to neurology for a video EEG to distinguish between epileptic seizures and non-epileptic events B: Tell her parents she must be faking it C: Start her on Keppra and give her Diastat for rescue Case Study 3
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Questions
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Thank You!!