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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 (lower threshold), ASM/benzodiazepine/EtOH withdrawal, physical/mental/emotional stressors, hypo/hyperglycemia, significant electrolyte abnormalities (e.g. hyponatremia), CNS infections
  • EEG is necessary for spell capture
  • In pts with new seizures, important to work-up potential underlying etiology
  • 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)

  • Can be very difficult to distinguish from epileptic seizures

  • Not all NES are psychogenic, such as myoclonus, tremors, and syncope

  • Features more common in PNES

    • Retained awareness with bilateral extremity “seizing”

    • Opisthotonus (arching the back)

    • Talking during a spell

    • Excessively long spells (e.g. lasts hour or days)

    • Forced eye closure

    • Truncal Thrusting

    • Suppressibility to touch

    • Coachability during a spell or reacting to external stimuli

    • Heavy breathing during a spell with lots of rigorous movement

    • Immediately returning to normal after a spell

  • Features more common in epileptic seizures:

    • Seizures arising out of sleep

    • Highly stereotyped

    • Incontinence

    • Severe injuries (e.g. burns)

  • Management

    • Try to avoid excessive BZD use

    • 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.

Syncopal Convulsions

  • Very common, can present with posturing and tonic-clonic movements happening for a few moments after syncope

    • Should not last for more than 30 seconds

    • These are just related to syncope and do not typically require seizure medications

    • Can be associated with urinary incontinence

    • Workup:

      • Two-hour EEG and MRI (with and without contrast)

      • Infectious workup, BMP, CBC, blood glucose, toxicology/drug screen

      • If there is concern for convulsive syncope, (carefully) check orthostatic vitals