Joseph Breuner, MD
6/24/03
Goals
history rules!!!
Physical exam, lab and even EEG are way
less important than history
characterized by "negative"
symptoms and signs (such as
weakness or visual loss)
postictal state may include
lateralizing "negative" symptoms
such as weakness;
Is it a seizure?
If its not REM behavior disorder
Transient ischemic attack
Transient global amnesia, or
Migraine
its probably a seizure
Is it epilepsy?
Question 2: is it epilepsy?
Differentiate physiological and psychogenic
seizures from epileptic seizures
Is it epilepsy?
Why do I care about this?
Epilepsy treated with
anticonvulsants
Physiologic/psychogenic seizures
you treat the disorder
This evaluation will determine the
likelihood that a patient will have
additional seizures and assist in
the decision whether to begin
Is it epilepsy?
Is it epilepsy?
In epileptic seizures the EEG is abnormal
Is it epilepsy?
Physiologic seizures are caused by
hyper- and hypothyroidism
Hypoglycemia
Nonketotic hyperglycemia -focal
motor seizures
Is it epilepsy?
Physiologic seizures caused by:
Precipitous falls in serum sodiumhigh mortality
Hypocalcemia--neonates
Is it epilepsy?
Physiologic seizures:
Acute intermittent porphyria--also includes
abdominal pain and behavior changes
Cerebral anoxia--including brief
syncope, though these patiens
wont be post ictal
alcohol withdrawal:3-72 hrs post
last drink
Is it epilepsy?
Medication history: tricyclic antidepressants
can lower seizure threshold
Is it epilepsy?
PMH--head injury
stroke
alzheimers disease
history intracranial infection
alcohol/drug abuse
Is it epilepsy?
Family history
if positive, highly suggestive of epilepsy
especially for absence seizures and
myoclonic seizures
Is it epilepsy?
Physical exam/neuro exam
rarely helpful except in setting of acute
infection or hemorrhage
look for lateralizing abnormalities
Is it epilepsy?
Is it epilepsy?
Lumbar puncture--only useful if infection or
malignant metastasis to the meninges
Is it epilepsy?
Neuroimaging
unless obvious physiologic seizure, should
obtain MRI.
MRI better than CT for infarcts and tumors
the older the patient, the more likely you
will find a structural cause
Sleep deprivation
hyperventilation
intermittent photic stimulation
all increase the yield
usually okay to begin with awake eeg, sleep
deprive if high index of suspicion
status
Dont give meds unless youre in a setting
where you can control airway
ativan 2mg or valium 5mg IVP q 2-4
minutes PRN
load fosphenytoin 20 mg/kg iv
to icu
References
Up to date
evaluation of the first seizure, 12/02/01
treatment of chronic epilepsy
van donselaar, CA, value of the eeg in adult
patients, arch neurol 1992
cochrane database
swedish admit orders for status epilepticus