Christos Lambrakis MD 1 September 20 th 2014 How is Epilepsy Diagnosed Recognizing Types of Seizures a nd Imitators of Epilepsy 2 3 Brain Weight 3 lbs Made of 75 water ID: 774961
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Northeast Regional Epilepsy Group Christos Lambrakis M.D.
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Slide2September 20
th, 2014How is Epilepsy DiagnosedRecognizing Types of Seizuresand Imitators of Epilepsy
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Slide4Brain
*Weight: 3 lbs*Made of 75% water* 2% of body weight
* 20% of energy requirements*Contains 100 billion neurons*Each neuron has 1000 to 10,000 synapses*100,000 miles of blood vessels*Likes: Oxygen, Glucose, Cute cat videos
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Slide9What is a Seizure?
A seizure is caused by abnormal electrical activity between cells of the brain (neurons) A seizure can temporarily disturb many of the brains normal functions.This abnormal electrical activity results in the clinical manifestations of the seizure.
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Slide10What is a Seizure?
The clinical manifestations of the seizure are determined by the region of the brain where the abnormal electrical activity is located. Clinical manifestations of a seizure are varied depending on the region of the brain involved. Examples include changes in movement, sensation, behavior or awareness.
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Slide11EEG (Normal)
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Slide12EEG (Seizure)
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Slide13What is Epilepsy?
Epilepsy is the term applied to the state of recurrent seizures.Epilepsy is a condition of the brain, of various causes, which predisposes the patient to recurrent epileptic seizures.Epilepsy is a tremendously variable condition in terms of its cause, seizure types and response to treatment.
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How is Epilepsy Diagnosed?
Slide15Epilepsy Diagnosis
C
linical description of the seizure events provides very important information.
What was seen? (Confusion, Loss of consciousness, Body movements, Head turning, Eye deviation, Right side/Left side or both)
What was felt by the patient? (At the start of the seizure (Aura) or as seizure evolves)
**Helps us to localize the seizure (where in the brain did it originate from).
Slide16Epilepsy Diagnosis
Precipitating factors:Lack of sleep, fever, current illness, medications, flashing lights, hyperventilation.Predisposing factors:Past medical history (head trauma, stroke), Family history**Helps us to better understand why the seizures occurred (Etiology).
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Slide17Epilepsy Diagnosis
Physical ExaminationVitals (Fever)General (Head size, dysmorphic features, skin lesions, stiff neck).Neurologic Examination (Confusion, memory loss, speech difficulty, motor weakness, sensory loss)
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Slide18Epilepsy Diagnosis
Acute Symptomatic SeizuresChronic Symptomatic SeizuresIdiopathic Seizures
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Slide19Epilepsy Diagnosis-Etiology
Acute Symptomatic Seizures (Seizures caused by a suspected acute reason).Trauma (Head injury)Metabolic (Electrolyte imbalance, Uremia)Toxic (Ingestion, Medication)Infectious (Meningitis, Encephalitis, Sepsis)Vascular (Stroke, Hemorrhage)
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Slide20Epilepsy Diagnosis-Etiology
Chronic Symptomatic Seizures (Seizures caused by preexisting conditions which favor the development of seizures).Remote injury (Past head injury, Birth trauma)Developmental (Cortical dysplasia)Degenerative Disorders (Alzheimer’s)Metabolic (Amino and organic acid disorders)
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Slide21Epilepsy Diagnosis-Etiology
Idiopathic Seizures (Etiology is unclear)The cause of the seizures cannot be determined from our current knowledge or conventional testing.Approximately 50% of patients will fall under this category.
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Slide22Epilepsy DiagnosisDiagnostic Studies
Blood work (Electrolytes such as Sodium, Potassium, Calcium; Glucose, Kidney and Liver function)Electro-diagnostic (EEG)Imaging (CT, MRI, SPECT, PET and MEG)
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Slide23Electroencephalogram (EEG)
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Slide24ElectroencephalogramEEG
Represents a record of the small shifting brain electrical potentials from the surface of the brain recorded over the scalp.
As seizures are caused by a disturbance of electrical activity, the EEG is uniquely suited to further our understanding of a patients seizures.
Slide25Goals of Video-EEG Monitoring
Is it really an epileptic seizure? (Epilepsy vs. non-epileptic events)What type of seizure is it? (Characterize epilepsy type)Where does the seizure originate from? Is it focal? (i.e. does it come from one specific region?)
Slide26Electrodes
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Slide32Video-EEG Monitoring
Long term inpatient monitoring allows for recording of seizure events.
Clinical and electroencephalographic features can be reviewed aiding in seizure characterization and localization.
Baseline EEG may be helpful in determining risk of future seizures.
Slide33Inpatient Video-EEG
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Slide34Outpatient Ambulatory Video-EEG
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Slide35Brain MRI
Provides a structural assessment of the brain.
We look for developmental abnormalities, strokes, tumors or scar tissue that could be focus for electrical irritation that could cause a seizure.
Slide36Brain MRI
Slide37Recognizing Types of Seizures
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Slide38Seizure Classification
Two major categories:GeneralizedPartial
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Slide39Generalized Seizures
Slide40EEG (Seizure)
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Slide41Seizure Classification
Generalized Seizures
Tonic/
Clonic
Absence
Myoclonic
Atonic
Tonic
Slide42Generalized SeizuresTonic/Clonic
Electrically the entire brain is affected all at once.
Patients loses consciousness at the onset of the seizure.
Stiffening (tonic) and rhythmic jerking movements (
clonic
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Cyanosis, tongue biting and loss of bladder control are common.
Slide43Generalized SeizuresAbsence
Results in a brief period of staring (5-10 sec).
Patient is usually unaware of his surroundings.
Sometimes accompanied by eye blinking or chewing movements.
Prompt recovery.
Commonly seen in childhood and may be mistaken for day-dreaming.
Slide44Generalized SeizuresOther Less Frequent
Myoclonic seizure: Brief jerk like contractions which can be localized or generalized.Atonic seizure: Drop attacks
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Slide45Partial SeizuresComplex
Slide46Slide47Partial Seizures
Seizures originate from a specific (focal) region of the brain. Depending on what area of the brain is stimulated a variety of clinical presentations can occur.
Seizures are often stereotypic to the patient.
Examples include changes in awareness, sensation, rhythmic jerking or stiffening of a specific limb, visual hallucinations.
Slide48Partial Seizures
Can progress to a Generalized Tonic/Clonic seizure ‘Secondary Generalization’.Often associated with aura.Often associated with automatisms (coordinated involuntary, non-purposeful movements). Examples would include lip smacking, picking, rubbing etc.
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Slide49Partial Seizures
Two Types: Simple and Complex
Simple Partial: No impairment of consciousness.
Complex Partial: Impairment of consciousness.
Slide50Partial SeizuresMotor
Slide51Partial SeizuresComplex
Slide52Generalized vs Partial Seizures
Sudden onset with no warning/auraSymmetrical movementsLoss of consciousness
May begin with aura (subjective symptoms experienced by the patient)Asymmetric or focal motor movementsAlteration of awareness.
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Slide53Imitators of Epilepsy
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Slide54Differential Diagnosis
Seizures can produce sudden neurologic symptoms.Many diseases can produce sudden neurologic symptoms.** Many neurologic diseases can be mistaken for epilepsy and vice-versa.
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Slide55Differential Diagnosis
Non-Epileptogenic events can be secondary to organic or psychogenic etiologies
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Slide56Differential Diagnosis
How do we differentiate between events that are seizure related and those that are caused by a non-epileptic medical or psychiatric condition?** Capturing an episode on EEG and demonstrating abnormal electrical activity during the event.
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Slide57Differential Diagnosis
In general episodes stemming from non-epileptic neurologic issues are NOT associated with EEG changes.CaveatsSome partial seizures can remain electrical silent (i.e. not obvious on EEG).Some neurologic diseases can cause changes on the EEG (Migraine, Syncope)
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Slide58Seizure ImitatorsLoss of Consciousness
Cardiac (heart failure, heart attack, arrhythmias)Hypoglycemia (fasting, excess insulin)Hypovolemia (dehydration)Hypoxia (lung disease)Panic attack (vasovagal response)Syncope (orthostatic)
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Slide59Syncope
Decreased delivery of oxygenated blood to the brain resulting in loss of consciousness.Very common with many etiologiesSudden and unpredictableRecurrentStereotypicPremonitory symptoms (nausea, sweating)‘Convulsive’-type movements
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Slide60Syncope Work-Up
Video-EEG monitoringIctal (during event)Inter-Ictal (between episodes)EKG/ Holter MonitorCarotid UltrasoundTilt Table Testing
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Slide61Seizure ImitatorsConfusion
Cerebrovascular (TIA, Stroke, TGA)Endocrine (Hypo/Hyperglycemia, Thyroid Disease)Migraine Headaches (complicated)Metabolic (hepatic or renal encephalopathy
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Slide62Seizure ImitatorsMotoric or Behavioral Change
Movement Disorders (Tics, Tremors, RLS)Panic AttacksSleep Disorders (Night terrors/ Sleep walking, Benign myoclonus, Sleep apnea)Psychogenic Non-Epileptic Seizures (PNES)
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Slide63Psychogenic Non-epileptic Seizures
Resemble epileptic seizures but lack EEG correlate.Can mimic any type of epileptic seizures.Very common (~25% of patients referred to Video-EEG monitoring for evaluation of intractable epilepsy).
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Slide64Psychogenic Non-epileptic Seizures
Psychiatric manifestationSomatoform/Conversion Disorder (most common)Unconscious production of physical symptoms due to psychological factors. A psychological defense mechanism to keep internal stress out of conscious awareness.Factitious DisorderConsciously determined symptoms driven by a powerful unconsciously determined need.MalingeringWillful production of symptoms for a specific external incentive. *
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Slide65Psychogenic Non-epileptic Seizures
Often difficult to distinguish clinically from epileptic seizures.Clues: Resistance to AEDsEmotional Triggers (stress)Bilateral clonic movements without loss of consciousnessAbsence of post-event confusion/lethargy.Video-EEG is very helpful in diagnosis.
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Slide66Psychogenic Non-epileptic Seizures
Many clinical patterns:Migratory motor activity (most common)Generalized motor activityUnilateral (less common)Alteration of awareness (Common)** Can be difficult to distinguish from frontal lobe seizures.
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Slide67Psychogenic Non-epileptic Seizures
Characteristics of PNESVariable responsiveness or preserved awareness.Out of phase movements of extremities.Discontinuous motor activityPelvic thrusting.Side to side head movements. Eye closure/eye flutter
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Slide68Psychogenic Non-epileptic Seizures
Characteristics of PNESVaried character of eventsSuggestibilityEmotional triggersPrompt recovery (Absence of post-ictal state)Poor response to anti-epileptic medications
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Slide69Psychogenic Non-epileptic Seizures
Although such findings as urinary incontinence, tongue biting and injuries are often attributed to epileptic seizures they can also be seen in PNES.
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Slide70Psychogenic Non-epileptic Seizures
~20 % of patients with PNES will also have coexistent epileptic seizures.Latency between manifestation of PNES and diagnosis is ~ 7years.Prompt diagnosis is crucial to avoid iatrogenic morbidity (Exposure to unnecessary medication ~80%, Intubation ~50%).
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