Seizures/Convulsions

Seizures are a symptom of some identifiable underlying cause or are idiopathic. Epilepsy is recurrent unprovoked seizures. Seizures may or may not be associated with convulsive activity. Correct classification of the seizure type helps to suggest etiology and treatment.

Differential Diagnosis

• Partial seizure (involve only part of the brain)
  –Simple (no altered consciousness)
  –Complex (with altered consciousness)
• Generalized seizure (involve both hemispheres)
  –Tonic-clonic
  –Atonic
  –Tonic
  –Myoclonic
  –Absence
• Epilepsy
  –Recurrent unprovoked seizures of any or multiple types, which may be idiopathic or symptomatic
  • Secondary seizure
    –Metabolic abnormalities (e.g., electrolyte disturbances, hypoglycemia)
    –Drug effects, intoxication, or withdrawal
    –Head injury/trauma
    –Febrile seizures in children
    –Structural lesions (e.g., tumor, subdural hematoma)
    –Cerebrovascular etiologies (e.g., cerebral infarct, intracerebral hemorrhage, subarachnoid hemorrhage
    –Hypoxic-ischemic encephalopathy
    –Infection (e.g., meningitis, encephalitis)
    –Hypoxia
  • Nonepileptic seizure
    –Not associated with abnormal electrical activity in the brain
    –Patients with loss of consciousness secondary to cerebral hypoperfusion (fainting, syncope) may occasionally exhibit brief periods of twitching or convulsive movements resembling seizure activity
    –Psychological disturbances (pseudoseizure)
  • Inborn errors of metabolism
    –Disorders of amino acid metabolism
    –Organic acidemias
    –Urea cycle disorders
    –Mitochondrial disorders
    –Peroxisomal disorders
    –Glycogen storage disorders
    –Disorders of sugar metabolism
  • Rasmussen's encephalitis
    –Causes seizures and progressive hemispheric dysfunction in infants

  Workup and Diagnosis

  • History and physical examination
    –In many instances, the most useful history is obtained from a witness of the seizure rather than the patient him- or herself, because seizures commonly cause altered consciousness and may result in postictal confusion
    –Appropriate classification of seizure type may help to suggest etiology and treatment (e.g., a partial seizure resulting in isolated clonic jerking of the right arm is suggestive of pathology in the left frontal lobe)
    –Evidence of postictal paralysis on examination may also help to suggest the part of the brain involved
  • Initial labs should include CBC, electrolytes, glucose, O₂ saturation, calcium, magnesium, glucose, and BUN/creatinine
  • CT is suitable for emergent evaluation, but MRI is more sensitive
  • CSF examination if CNS infection (e.g., meningitis) or subarachnoid hemorrhage is suspected
  • Drug screen and ethanol level
  • EEG
  • Video EEG monitoring may be useful in cases of refractory epilepsy as part of evaluation for epilepsy surgery or suspected nonepileptic seizures

  Treatment

  • Generalized status epilepticus (continuous or recurrent seizure activity without a return to baseline for >30 minutes) is a medical emergency and should be treated aggressively with IV antiepileptic medications
  • Remove offending intoxicants or medications
  • Correct metabolic abnormalities as necessary
  • Numerous anticonvulsant medications are available for acute and chronic use
    –Select the most appropriate agent on the basis of the clinical situation, seizure type, and side effect profile
    –Combination anticonvulsant therapy may be effective for patients refractory to a single agent
• Vagus nerve stimulators are effective in patients refractory to anticonvulsant therapy
• Epilepsy surgery also may be effective in controlling seizures in carefully selected surgical candidates who are refractory to chronic anticonvulsant medication
• Lifestyle modification and avoidance of triggers (e.g., sleep deprivation, alcohol)

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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