Seizures

Seizures: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter

Linda M. Savory

Seizures are a common serious neurologic disorder in the outpatient setting. In the United States, approximately 4 million patients suffer at least one seizure and 2 million have suffered two or more. Approximately 10% of these suffer more than one seizure per month despite treatment. No gender or geographic predominance is seen (1).

Approach.

 Seizures must be precisely categorized to be treated. Seizures are categorized as primary or secondary, generalized or focal, and simple or complex.

 A. Seizure types

 1. Primary generalized seizures include absence (seconds of staring, lid fluttering with no postictal state); atony (sudden falling); febrile (short seizures associated with rising temperature); myoclonus (short spells of jerking at awakening); and major motor (tonic flexion, followed by rhythmic flexion and extension, and postictal phase).

 2. Simple partial seizures include focal motor seizures (contractions of one limb or side with no loss of consciousness, starting in the frontal lobes).

a. Complex partial seizures involve a change in sensorium and au-tomatisms (repetitive stereotyped movements), and psychologic phenomena like crying.

 b. Secondary seizures are associated with infectious, metabolic, or structural causes.

 c. Status epilepticus, an unrelenting seizure activity or multiple seizures in rapid succession, is a life-threatening emergency (2).

 B. Special concerns. Generally, the older the patient, the more chance of structural (tumor) or metabolic brain abnormality (3). Jacksonian march, progressive involvement of one or both lobes of the brain, is strongly associated with tumors.

History.

Seizures can be confused with migraines and syncope.

A. Characteristics of the seizure

1. What was witnessed? Does the patient fall? Is there urinary or fecal incontinence, tongue biting, or loss of consciousness? Is there a postictal period? Is there staring, lip smacking, or automatisms? Seizure activity in neonates may present with subtle activities such as apnea, tremors, grimacing, or spasms.

 2. What can the patient remember? Are there associated sensations (odors, lights, emotions, tactile input)? Is there an aura?

 3. At what age was seizure onset? What is the frequency of the spells?

4. What is the setting? Is there evidence supporting anoxia or hypoxia? Was there a sudden rise in temperature (4)? Did the seizure follow flashing lights, exercise, sleeplessness, fasting, or menses?

5. Red flags include adult age at onset, changing pattern, and regression of motor skills.

 B. Chronology of the seizure. Most seizures present a characteristic pattern. A pattern of change or worsening of seizures can indicate new causation.

 C. Family history. Febrile, myoclonic, primary idiopathic seizures, and genetic syndromes with seizures often present a familial pattern.

 D. Psychosocial aspects. Ask how the family, teachers, employers interact with the patient.

 E. Other information. Important data include use of alcohol or drugs, medications that lower seizure threshold, toxic occupational or recreational chemicals, and severe physical [previous head trauma, central nervous system (CNS) infection, chronic illness] or psychosocial stressors.

Physical examination (PE)

A. Focused neurologic examination. Examine level of consciousness, pupils, fundi, cranial nerves, reflexes, gait, muscle strength, general sensory, coordination, and Romberg’s sign (4). Look for abnormal motor activity and test for abnormal reflexes.

B. Additional PE

 1. Look for signs of systemic illness: cardiac disease (cyanosis, pallor, irregular rhythm, cool extremities) and chronic alcoholism (ascites, jaundice, caput medusae, and bruising).

 2. Look for residual signs of trauma or limb asymmetry.

3. Look for dysmorphic manifestations of heritable disease: vascular malformations (Sturge–Weber), adenoma sebaceum (tuberous sclerosis), or café au lait spots and subcutaneous nodules (neurofibromatosis).

4. Gingival hypertrophy suggests phenytoin therapy.

Testing

A. Clinical laboratory tests. Choice of tests is dictated by the patient’s age, history, physical findings, and type of seizure.

1. In evaluating a child, consider a random glucose, calcium, magnesium, electrolytes, and, possibly, a lead level and an electroencephalogram (EEG). In a child aged less than 5 years with one or two short generalized seizures associated with fever, no neurologic abnormality, and normal bloodwork, no imaging study is generally necessary (5).

2. In adults, obtain glucose, sodium, calcium, and consider thyroid function tests, heavy metal screen, and porphyrins.

3. Obtain a lumbar puncture when acute or chronic infection of subdural is suspected.

4. An abnormal EEG supports the diagnosis of seizure and hints at the cause and classification. A normal EEG does not exclude seizure.

B. Diagnostic imaging

1. In newborns, ultrasound or computerized tomography (CT) imaging may reveal intracerebral hemorrhage or structural abnormality.

2. Adolescents and adults should have a magnetic resonance imaging scan (or CT) to rule out focal and structural lesions.

C. Special studies include prolonged closed-circuit video EEG to distinguish psychogenic seizures or in a patient with continuing seizures and multiple normal EEGs.

Diagnostic assessment.

The key to diagnosis is the history and neurologic examination. A history with a focal component indicates a high likelihood of structural pathology. A recent febrile illness with seizure, headache, change in mental status, or confusion suggests acute CNS infection. A history of headache or change in mental function with seizure and abnormal neurologic examination suggests mass lesion. A clear, focal onset of the event (staring or head turning) may aid in distinguishing seizure from syncope. Emotional lability and a history of psychiatric treatment in a patient whose neurologic workup is negative may suggest a diagnosis of pseudoseizures. A pregnant patient near term who seizes may have pregnancy-induced hypertension or declining drug levels.

References

1. Dichter MA. The epilepsies and convulsive disorders. In: Braunwald E, Fauci AS, Isselbacher DL, et al., ed. Harrison’s principles of internal medicine, 13th ed. New York: McGraw-Hill, 1995:2223.

2. Bradford JC, Kyriakedes CG. Evaluation of the patient with seizures: an evidence based approach. Emerg Med Clin North Am 1999;17(1):203–220, ix–x.

3. Hauser WA. Seizure disorders: the changes with age. Epilepsia 1992;33(4):S6–S14.

4. Roth HL, Drislane FW. Seizures. Neurol Clin 1998;16:257–284.

5. Berg, AT, Shinnar S. The risk of seizure occurrence following a first unprovoked seizure: a quantitative review. Neurology 1991;41:965–972.

Book Source Details

• Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
• Author(s): Robert B. Taylor (editor)
• Year of Publication: 2000
• Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter Authors: Robert B. Taylor (editor) Publisher: Lippincott Williams & Wilkins Copyright: 2000 ISBN: 0-78172-094-X

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