Seizure without Status Epilepticus¶
Background¶
- Risk factors: birth trauma, prematurity, TBI with loss of awareness > 1 hour, strokes/tumors/abscesses, history of meningitis/encephalitis
- Key for seizures: stereotyped event with sudden onset/offset
- Generally, if full body systems are involved (e.g., jerking or tonic activity, then there will also be loss of awareness)
Evaluation¶
- A clear description or recording of seizure semiology is helpful
- Provoked seizures can develop with medications, hypo/hyperglycemia, significant electrolyte abnormalities (e.g. hyponatremia), and CNS infections
- EEG is necessary for spell capture
- MRI brain with and without contrast once stable
Management¶
| AED | Side effects |
|---|---|
| Levetiracetam (Keppra) (PO/IV) | Sedation and agitation, worsening of underlying mood disorders. Can trial B6 supplementation to help with mood effects |
| Valproic acid (Depakote) (PO/IV) | Sedation, hirsutism, PCOS, P450 inhibitor, nausea, liver injury, hyperammonemia |
| Phenytoin (Dilantin) (PO/Fosphenytoin IV) | Sedation, gingival hyperplasia |
| Lacosamide (Vimpat) (PO/IV) | Heart block, dizziness, ataxia |
| Topiramate (Topamax) (PO) | Kidney stones, metabolic acidosis, paresthesias, weight loss, cognitive slowing |
| Carbamazepine (Tegretol) (PO) | Hyponatremia, SJS (in Han Chinese check HLA), bone marrow suppression (rare) |
| Oxcarbazepine (Trileptal) (PO) | Similar to carbamazepine |
| Lamotrigine (Lamictal) (PO) | SJS/TEN, nausea. Least sedating |
| Zonisamide (Zonegran) (PO) | Sedation, ataxia, nausea, confusion |
Non-Epileptic Spells (aka PNES, psychogenic non-epileptic spells)¶
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Can be very difficult to distinguish from epileptic seizures
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Features more common in PNES
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Retained awareness with bilateral extremity “seizing”
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Opisthotonus (arching the back)
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Talking during a spell
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Excessively long spells (e.g. lasts hour or days)
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Forced eye closure
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Coachability during a spell or reacting to external stimuli
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Heavy breathing during a spell with lots of rigorous movement
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Immediately returning to normal after a spell
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Features more common in epileptic seizures:
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Seizures arising out of sleep
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Highly stereotyped
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Incontinence
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Severe injuries (e.g. burns)
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Management
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Try to avoid excessive BZD use
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This requires good clinical judgement as you wouldn't want to withhold Ativan and discover that the pt was having true atypical seizures. The compromise would be: do not repeatedly administer BZDs when there is suspicion for PNES as well as no evidence of response to prior BZD administration.
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Syncopal Convulsions¶
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Very common, can present with posturing and tonic-clonic movements happening for a few moments after syncope
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Should not last for more than 30 seconds
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These are just related to syncope and do not typically require seizure medications
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Workup:
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Two-hour EEG and MRI (with and without contrast)
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Infectious workup, BMP, CBC, blood glucose, toxicology/drug screen
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If there is concern for convulsive syncope, (carefully) check orthostatic vitals
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