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Seizure Disorders

Seizure Disorders is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Seizure: sudden and transient symptoms (altered level of consciousness, motor manifestations) due to abnormal or synchronous electrical activity of neuronal networks
  • Epilepsy: enduring preposition to generate epileptic seizures; defined as two or more unprovoked seizures apart in a >24-hour period
  • Status epilepticus: epileptic seizure that lasts >5 minutes or multiple seizures without returning to normal between them. Classification: generalized, simple and complex partial, absence, nonconvulsive. Treatment varies depending of type.
  • ILAE seizure classification, based on three key features:
    • Seizure origin: focal (previously partial), focal to bilateral, generalized
    • Awareness: aware, focal impaired awareness, generalized
    • Clinical features: motor, nonmotor (absence, behavior, cognitive, autonomic)
  • System(s) affected: nervous
  • Synonym(s): convulsion; attacks; spells

Pediatric Considerations
Breastfeeding is not contraindicated. Sedation of the infant should be monitored.

Pregnancy Considerations
  • Preconception: Certain antiepileptic drug (AED) (P450 inducers) may cause hormonal contraceptive failure.
  • Pregnancy: Avoid valproate as possible, due to increased teratogenicity and worse developmental outcomes. Epileptic patients should notify their neurologist before conception, if possible. During pregnancy, monitor AED levels every trimester for dose adjustment, continue folic acid supplementation, and screen for congenital abnormalities.
  • Levetiracetam, topiramate, lamotrigine are alternatives for women of childbearing potential (1).

Epidemiology

Incidence
  • 200,000 new cases of epilepsy are diagnosed in the United States annually, with 45,000 new cases in children <15 years of age.
  • Pediatric (<2 years of age) and older adults (>65 years of age) more commonly present with new-onset seizures
  • Predominant sex: male = female

Prevalence
  • 2.7 million with seizure disorder
  • 4 million people have had ≥1 seizures.
  • 326,000 children (≤14 years of age) and 600,000 adults (>65 years of age) have a seizure disorder.

Etiology and Pathophysiology

  • Synchronous and excessive firing of neurons, resulting in an imbalance of regulatory mechanisms in favor of excitatory activity. Seizures may be triggered by metabolic/medical conditions, but such seizures do not necessarily define the presence of epilepsy.
  • Idiopathic
  • Hippocampal sclerosis and other neurodevelopmental abnormalities of the brain
  • Acute infection (meningitis, abscess, encephalitis)
  • Metabolic and endocrine disorders
  • Trauma
  • Drug and alcohol withdrawal
  • Tumor
  • Vascular disease, including stroke and vasculitis
  • Familial/genetic, infantile, and pediatric seizure syndromes (e.g., Lennox-Gastaut, benign familial, myoclonic epilepsy of infancy)
  • Other etiologies (by age of onset)
    • Infancy (0 to 2 years)
      • Hypoxic-ischemic encephalopathy/other injury to cerebral cortex
      • Metabolic: hypoglycemia, hypocalcemia, hypomagnesemia, vitamin B6 deficiency, phenylketonuria
    • Childhood (2 to 10 years): absence or febrile (usually <6 years) seizure
    • Adolescent (10 to 18 years): arteriovenous malformation
    • Late adulthood (>60 years)
      • Prevalence increases with age and is the highest >65-year-old patients.
      • Degenerative disease, including dementia
      • Most common causes for symptomatic seizures in elderly patients are acute stroke, metabolic disturbances (hypoglycemia, uremia, hepatic failure, electrolyte abnormality), and drugs. Initial diagnostic testing should be focused on these common etiologies.

Genetics
Family history increases risk 3-fold.

Risk Factors

History of congenital brain malformations, CNS infections, head trauma, stroke, tumors, neurocognitive degenerative diseases

General Prevention

Take measures to prevent head injuries. Avoid sleep deprivation. Avoid excessive alcohol intake.

Commonly Associated Conditions

Genetic syndromes (Angelman, tuberous sclerosis, Sturge-Weber), infections, tumors, drug abuse, alcohol and drug withdrawal, trauma, metabolic disorders

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Citation

Stephens, Mark B., et al., editors. "Seizure Disorders." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116552/all/Seizure_Disorders.
Seizure Disorders. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116552/all/Seizure_Disorders. Accessed March 22, 2019.
Seizure Disorders. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116552/all/Seizure_Disorders
Seizure Disorders [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 March 22]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116552/all/Seizure_Disorders.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Seizure Disorders ID - 116552 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116552/all/Seizure_Disorders PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -