* A seizure is an abnormal motor, sensory or mental function caused by a series of synchronous, high-frequency neurons discharged from the cortical or subcortical brain centers.
* Non-epileptic (secondary or reversible) seizures. Common causes: Benzodiazepine or alcohol withdrawal, meningitis, stroke, renal dialysis, high fever in children.
* Epileptic seizures (epilepsy)
* Primary disorder of recurrent seizures without a reversible metabolic cause.
* Diagnosis usually made when a patient has had two unprovoked seizures within 24 hours.
* Febrile seizures are tonic-clonic type seizures associated with fever above 38.8° C (101.8° F), which typically occur in children ages 3 months to 6 years.
CLASSIFICATION OF SEIZURES
* Primary generalized: Begin in one area of the brain; rapidly spread throughout both brain hemispheres and involve an alteration of consciousness.
* Tonic-clonic (grand mal) phases in order of occurrence:
* Aura: Abnormal sensations, emotions, altered vision, or hearing that frequently precede a tonic-clonic seizure.
* Tonic (stiffening) phase: Sudden loss of consciousness, skeletal muscle tension, and brief apnea.
* Clonic (jerking) phase: Violent, rhythmic muscle contractions alternating with muscle relaxation; respirations resume.
* Postictal phase: Transient confusion, drowsiness, and/or agitation, excessive salivation, and possible bowel or bladder incontinence.
* Recovery phase: Gradual return to consciousness; patients often sleep for several hours.
* Absence (petit mal)
* Occur primarily in children.
* “Blanking out” spells (brief, abrupt altered consciousness).
* Patient stares ahead and stops talking, responding, and performing activities for a few seconds.
* Classic 3 Hz “spike and wave” pattern seen on EEG.
* Intermittent brusque, brief, single, or multiple rapid muscular jerking movements.
* Involve a single muscle, part of a muscle, a localized site such as the face, trunk or an extremity, or the entire trunk musculature.
* No altered consciousness.
* Status epilepticus
* Life-threatening emergency.
* Prolonged seizure lasting longer than 5 minutes, or recurrent seizures without recovery of consciousness for longer than 5 minutes between episodes.
* May progress to coma and death.
* Partial (focal): Involve a single area of the brain in only one cerebral hemisphere; no spread to other brain areas.
* Simple partial
* May present with motor signs such as twitching, jerking movements of an extremity, the face, eyes, or other body area, or a sensory disturbance, such as flashing lights or gustatory hallucinations.
* May include autonomic features (pallor, flushing, sweating, piloerection, pupil dilation, salivation, or vomiting).
* No altered consciousness.
* Complex partial
* Bizarre, complex motor behaviors such as wandering about, chewing motions, lip smacking, or picking at clothing.
* Altered consciousness (dream-like state).
* History: Need to assess patient's current medications, such as psychotropics, opioids, antimicrobials, chemotherapeutic agents, stimulants, antiarrhythmics, antihistamines, bupropion, venlafaxine, or others that may lower seizure threshold.
* Past medical history: Head injury, stroke, Alzheimer disease, CNS infection, drug or alcohol abuse.
* In children: Assess illness (including fever), developmental delays, or perinatal injury.
* Determine compliance with medications if patient is known to be on antiseizure medication.
* Family history: Seizure in family member is highly suggestive of seizure disorder.
* Document if seizure was witnessed, by whom, with description of seizure activity and duration of symptoms.
* Physical exam:
* Vital signs: Patient may be febrile, which should alert clinicians to the possibility of fever and seizures from an infectious cause.
* Examine patient for potential traumatic injuries incurred during seizure activity, especially intraoral and head trauma.
* Neurologic examination should include complete cranial nerve examination, deep tendon and primitive reflex examination, and motor and sensory function of extremities. Complete a thorough examination to rule out any non-neurologic cause for seizure.
* All patients with new onset of seizures need a neurology consult.
* Studies should include:
* EEG: Essential in evaluation of seizure to examine brain wave activity; differentiate seizure type.
* Magnetic resonance imaging (MRI): Generally preferred over computed tomography (CT) to rule out structural brain abnormalities.
* CT: Rule out brain tumor, hemorrhage, stroke, or other intracranial abnormalities if MRI is contraindicated or unavailable.
* Lumbar puncture: If infectious cause is suspected.
* Positron emission tomography (PET) or single photon emission computed tomography (SPECT): May localize the site of seizure activity.
* CBC and chemistry panel: Identify any potentially treatable causes of seizures.
* Consider serum creatine phosphokinase levels, which can help distinguish between partial and tonic-clonic seizures.
* Pharmacotherapy is the mainstay of treatment, and must be individualized.
* Therapeutic goals: Prevent further seizure activity with minimal adverse drug reactions.
* Multiple medication options; selection based (in part) on seizure type.
* Monotherapy preferred; two or more medications may be combined if needed to control seizure activity.
* Monitor plasma drug levels for efficacy and/or toxicity.
* Lorazepam or diazepam are the initial drugs of choice for status epilepticus.
* Ethosuximide is the drug of choice for absence seizures.
* Carbamazepine is the least teratogenic; valproic acid is the most teratogenic.
* No treatment for febrile seizures except fever control (acetaminophen or ibuprofen).
* Surgical intervention may be considered if seizures are adversely affecting a child's life or development.
© 2013 American Academy of Physician Assistants.