EPILEPSY/ STATUS EPILEPTICUS

EPILEPSY
Epilepsy is a paroxysmal neurological disorder and is characterized by recurrent episodes of convulsive movements or other motor activity, loss of consciousness, sensory disturbances, and other behavioral abnormalities.

Because epilepsy occurs in more than 50 diseases, it is considered a syndrome rather than a disease.

Convulsive seizures are the most common forms of attacks of epilepsy. Seizures occur with abnormal electrical discharges from brain cells, and these discharges are caused by the movement of ions across the cell membrane.

Although seizures are the dominant manifestation of epilepsy, patients can have a seizure and not have epilepsy.

Status epilepticus is a clinical or electrical seizure lasting at least 30 minutes, or a series of seizures without complete recovery over the same period of time. Pseudoseizures are the physical appearance of seizure activity without the cerebral electrical activity.

CAUSES
A. Central nervous system (CNS) disorders 1. potential mass effect (tumor, abscess, atrioventricular malformation, aneurysm, or hematoma) 2. strokes, especially those that are embolic. B. Metabolic or systemic disorders 1. acute overdose 2. acute drug withdrawal (especially CNS depressants, alcohol, benzodiazepines, and barbiturates) 3. febrile states 4. Hypoxia 5. Hyperosmolarity 6. hypertensive encephalopathy 7. Hyperthermia 8. electrolyte disturbances C. Idiopathic origins

classifications
I. PARTIAL (FOCAL, LOCAL) SEIZURES
A. Simple partial seizures: No impairment of consciousness B. Complex partial seizures: Impaired consciousness, frequently include automatisms C. Partial seizures that secondarily generalize

II. SEIZURES: All have impairment of consciousness

A. Absence (previously known as petit mal) of blank stare; generally in children B. Myoclonic seizures: Short, abrupt muscular contractions C. Clonic seizures: Muscle contraction and relaxation D. Tonic seizures: Abrupt increase in muscle tone E. Tonic-clonic seizures (previously known as grand mal): quick, bilateral, severe jerking movements F. Atonic seizures (drop attacks): Abrupt loss of muscle

III. Unclassified epileptic seizures: Inadequate or incomplete data to identify classification

DIAGNOSTICS HIGHLIGHTS
Test Magnetic resonance imaging (MRI) Normal Result Abnormality with Condition Explanation Structural brain changes such as sclerosis, tumors, infarcts, or atrophy can lead to seizures
Assesses the central Normal nervous system for brain structures changes in brain

structure such as atrophy of certain areas or brain tumors Assesses the central nervous system for changes in brain structure such as atrophy of certain areas or brain tumors

Electroencephalogram (EEG)

Normal patterns of electrical activity

Recording of electrical potentials based on distribution of waveforms generated by cerebral cortex of brain; waveforms demonstrate abnormal patterns during seizures; they are not useful in the acute management of status epilepticus

Other Tests: Computed tomography (CT) scans, positron emission tomography (PET), and skull x-rays; serum laboratory data to explore possible causes include glucose; calcium; blood urea nitrogen (BUN); and electrolyte, toxic, and metabolic screens

DIAGNOSTICS HIGHLIGHTS
Medicatio n or Drug Class Dosage Description Rationale

Anticonv ulsants

Varies with drug

Multiple drug therapies are available: Phenytoin sodium (Dilantin), phenobarbitol, lorazepam (Ativan), diazepam (Valium).

Lorazepam (Ativan) or diazepam (Valium) may be used to stop seizures quickly. Phenytoin (Dilantin) is preferred maintenance anticonvulsant for status epilepticus. A newer drug, fosphenytoin (Cerebyx), has been developed that is safer for parenteral administration. Phenobarbitol may be given if seizures occur after phenytoin loading.

Other: Thiamine 100 mg and 50 ml of 50% dextrose in water may be administered in an emergency to rule out seizures because of thiamine deficiency or hypoglycemia. Other Information about Anticonvulsants: The primary treatment for epilepsy is one or more of the multitude of antiepileptic drugs (AED) or anticonvulsants. The choice of AED or combination of AEDs depends on seizure type, patient tolerance, and cost. Carbamazepine (Tegretol) is a widely used and cost-effective anticonvulsant. Valproic acid, primidone (Mysoline), clonazepam, and ethosuximide are prescribed, depending on the seizure type. Lamotrigine (Lamictal) is a new AED approved as adjunctive therapy and single therapy for partial seizures.

Surgical Treatment
1. A proportion of the pts with intractable epilepsy will benefit from surgery. 2. Epilepsy surgery procedures: Curative (removal of epileptic focus) and palliative (seizure-related risk decrease and improvement of the QOL) 3. Curative (resective) procedures: Anteromesial temporal resection, selective amygdalohippocampectomy, extensive lesionectomy, cortical resection, hemispherectomy. 4. Palliative procedures: Corpus callosotomy and Vagal nerve stimulation (VNS).

STATUS EPILEPTICUS
SE is a common medical and one of the most serious neurological emergency associated with high mortality and morbidity. SE refers to a condition in which there is a failure of the normal factors that serve to terminate a typical seizure. SE may be classifies based solely on the presence or absence of convulsions into convulsive SE (CSE) and non-convulsive SE (NCSE).

ALGORITHM FOR TREATMENT OF CONVULSIVE STATUS EPILEPTICUS

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