Transcript www.braininjurymn.org

Brain Injury and
Seizures
www.efmn.org
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1600 University Avenue West, Suite 300, St. Paul, MN 55104
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1.800.779.0777
A little bit about your presenters
• Amanda Pike- Epilepsy Foundation of MN
• Jeannine Conway- University of MN, EFMN
PAB
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Today’s Objectives
 Define epilepsy and discuss the correlation
between brain injuries and strokes with
seizures
 Identify the most common types of seizures
and describe appropriate response
 Discuss available treatment options
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Epilepsy is…
 A neurological disorder of the brain
characterized by the tendency to have
recurring seizures
 May also be called a Seizure Disorder
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Epilepsy Facts…
 Approximately 2.2 million Americans have epilepsy
 Epilepsy is the most common neurological condition in
children and the fourth most common in adults after
Alzheimer’s, stroke and migraines
 Approximately 1 in 26 people will develop epilepsy at
some point in their lives
 Over 60,000 people in MN & ND have epilepsy
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Epilepsy and stroke
• Number 1 cause of epilepsy in people older
than 50.
• Side effects of medicine can make the effects
of the stroke a little worse.
• Make sure you know about any other
medications and if it is safe to mix with any
epilepsy medications.
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What happens to the brain
during a seizure?
 Sudden electrical activity in the brain
 Most seizures are either partial or generalized
 Where the activity occurs in the brain will
determine how the seizure will look
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Possible Causes of Epilepsy
 Head Trauma
 Brain tumor and stroke
 Infection and maternal injury
 Some forms are genetic
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In 70% of the epilepsy cases –
there is no known cause
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Possible Seizure Triggers
 Assess the environment
 Failure to take medications
 Lack of sleep
 Stress / Anxiety
 Dehydration
 Photosensitivity – strobe lights
 Menstrual cycle / hormonal changes
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Seizure Classification
Partial Seizures (focal)
 Involves only part of brain
 Simple & complex forms
 Symptoms relate to the part of brain effected
Generalized Seizures
 Involves whole brain
 Convulsions, staring, muscle spasms, and falls
 Most common are absence & tonic-clonic
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Simple Partial Seizures
 Uncontrollable shaking movements of hand,
arm or legs
 Sensory Seizures – may see flashing lights in
peripheral vision, hear bells ringing, etc.
 Seizure usually lasts between 1 and 2 minutes
– no impairment of consciousness
 May be considered an aura
 No immediate action is needed other than
reassurance and emotional support
 A medical evaluation is recommended
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Complex Partial Seizures
 Most common seizure type
 Unaware of surroundings and unable to
respond
 Repetitive, purposeless movements such
as lip smacking, hand wringing, or wandering
- actions seem unusual
 Seizure usually lasts approximately three
minutes
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Complex Partial Seizures
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Appropriate Response
– Complex Partial
 Stay calm
 Track time
 Do not restrain
 Gently direct away from hazards
 Remain with the individual until they have
gained full awareness
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Absence Seizures (formerly petit mal)
 Usual onset between 4 and 12 years of age
 Characterized by brief staring – can be
confused with “daydreaming”
 Starts and ends abruptly - can happen several
times a day
 Quickly returns to complete awareness
 Appropriate response includes documentation
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Absence Seizures (formerly petit mal)
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Generalized Tonic Clonic
(formerly grand mal)
 NOT the most common type
 Completely unconscious – loss of control
 Characterized by a sudden fall
 May cry out or make some types of noise
 Onset of uncontrolled jerking or shaking of muscles
 May have irregular breathing
 Lasts 5 minutes or less
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Generalized Tonic Clonic
(formerly grand mal)
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Appropriate Response
– Generalized Tonic Clonic
 Stay calm
 Protect their head
 Turn on side to prevent choking *
 Track time
 Check for Seizure Disorder ID
 Move objects out of the way
* Do NOT put anything in the person’s mouth.
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Appropriate Response
– Generalized Tonic Clonic
 Remain with them until they have gained full
awareness
 If seizure lasts more than 5 minutes, call EMS
 Recovery period– post ictal state
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Call 911 if the person…
 Is injured
 Has diabetes
 Is pregnant
 Does not resume normal breathing
 Has a 1st time seizure
 Has a seizure in water
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Treatment Options
 Medication
 Brain Surgery
 Diet
 VNS
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Medications
Medications are most often the first line of
treatment:
 Approximately 60% of people achieve
seizure control after the 1st year
 15% achieve control at a later date
 25% continue to have seizures despite
treatment
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Common Side Effects of
Medication
 Lethargy
 Weight gain / weight loss
 Cognitive, concentration, memory difficulties
 Hyperactivity
 Emotional and/or behavioral changes
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Brain Surgery Options
 Lobectomy
• Partial Seizures
• Hope for result of seizure free
 Corpus Callosotomy
• Generalized Seizures
• Never seizure free, less frequent/ intense
seizures
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Medical Device Options
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Special Diets
 Ketogenic Diet
•
•
•
•
Burns fat instead of glucose (fasting induced)
Gets 80% of calories from fat
Gets 20% from carbohydrates and proteins
Must be strictly managed and maintained daily
– 1/3 become seizure free or almost seizure free
– 1/3 improve but still have some seizures
– 1/3 do not respond or find it too hard to comply
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Special Diets
 Modified Atkins Diet
• No fluid or calorie restriction, no protein restriction
• Foods not weighed and measured, carbohydrates
monitored
• Not fast induced
 Low Glycemic Index Treatment
• Glycemic Index: how high that food raises your blood
glucose
• Easier to maintain - based more on portion control
• Increase of carbohydrates with a low Glycemic Index
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Possible Impact of Epilepsy
 Depression, Anger,
Anxiety, Fear
 Cognitive Problems
 Developmental
Delays
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Relationships
Financial Costs
School/Employment
Driving
Recreational
Activities
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The Epilepsy Foundation of Minnesota leads the
fight to stop seizures, find a cure and
overcome the challenges created by epilepsy.
1.800.779.0777
www.efmn.org
www.efmn.org
|
1600 University Avenue West, Suite 300, St. Paul, MN 55104
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1.800.779.0777
ABOUT US

We serve Minnesota and Eastern North Dakota

Offices in St. Paul, Rochester, Duluth, St. Cloud,
and Fargo

Funding Sources: used clothing, individual/corporate
donations, special events and grants

The Epilepsy Foundation is the only organization in MN
or ND that works exclusively with people affected by
seizures.
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PROGRAMS THAT
EDUCATE
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Seizure Smart Communities

Seizure Recognition & Response Training

Seizure Smart Schools

Conferences & Workshops
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PROGRAMS THAT
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Camp Oz
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CONNECT
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PROGRAMS THAT
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EMPOWER
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Make A Difference!
Help us educate, connect and empower those
impacted by epilepsy!
- Visit us online at www.efmn.org/giving
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(United Way, Community Health Charities or
Combined Federal Campaign)
- Attend EFMN events
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Anticonvulsants and Brain Injury
Objectives
• Describe the elements of epilepsy treatment
including:
– Available treatments
– Desired outcomes
– Describe medication choices
Indications for AEDs
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•
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•
•
•
•
•
Epilepsy
Headache
Psychiatric disorders
Neuropathic pain
Behavior
Weight loss
Movement disorders
Spasticity
Goals of Epilepsy Care
• Eliminate seizures with no side effects;
alternatively
– Reduce the number
– Decrease the severity
– Minimize side effects
• Optimize quality of life
Chronology of AED Development
Year
1912
1938
1947
1954
1960
1968
1974
1975
1978
1st generation AEDs
Drug
Phenobarbital
Phenytoin
Mephenytoin (no
longer available)
Primidone
Ethosuximide
Diazepam
Carbamazepine
Clonazepam
Valproate
Year
2009
2011
2012
2nd generation AEDs
Year
Drug
1993
1994
1994
1996
1997
1999
1999
2000
2005
2009
2009
2011
3rd generation AEDs
Drug
Lacosamide
Ezogabine
Perampanel
Felbamate
Gabapentin
Lamotrigine
Topiramate
Tiagabine
Oxcarbazepine
Levetiracetam
Zonisamide
Pregabalin
Rufinamide
Vigabatrin
Clobazam
Normal CNS Function
Excitation
Glutamate
Aspartate
Inhibition
GABA
Abnormal Excitation
Glutamate
Aspartate
Excitation
Inhibition
GABA
Furthermore, membrane depolarization leads
to enhanced excitatory receptor function and
reduced GABA-receptor function. This pattern
of ‘voltage-dependence’ leads to an even
greater level of excitation.
AEDs Act By Restoring Balance
Inhibition
Excitation
Reduce excitation
Phenytoin (PHT)
Carbamazepine (CBZ)
Valproic acid (VPA)
Felbamate (FBM)
Lamotrigine (LTG)
Topiramate (TPM)
Oxcarbazepine (OXC)
Zonisamide (ZNS)
Levetiracetam (LEV)
Increase inhibition
Phenobarbital (PB)
Benzodiazepines (BDZ)
VPA
FBM
TPM
ZNS
Tiagabine
Vigabatrin
Drug Choices for the Treatment of New Onset
Seizures
Seizure Type
First line therapy
Partial Onset
Carbamazepine
Gabapentin
Lamotrigine
Oxcarbazepine
Phenobarbital
Phenytoin
Topiramate
Valproic Acid
Generalized
Lamotrigine
Topiramate
Valproic Acid
Absence
Lamotrigine
Ethosuximide
Valproic Acid
Medication Selection
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•
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Seizure type
Co-medications
Medical conditions
Age of the patient
Insurance coverage
Allergies
Adherence challenges
Optimize Therapy
• Titrate dose or serum concentration to
response
• Increase dose until seizure control is attained
or until unacceptable side effects occur
• Consider adding 2nd AED if first is not
effective
Monitoring AED Treatment
• Efficacy
– Seizure control
• Toxicity
– Side effects
– Serum concentrations
Toxicity
• Acute side effects
– Concentration dependent
• Common, bothersome, generally not life threatening
• Reversible by decreasing the serum concentration
• Examples: dizziness, ataxia, headache
– Idiosyncratic
• Rare, may be serious and life threatening
• Generally involve organ hypersensitivity
• Examples: hepatic failure, rash, aplastic anemia
Toxicity
• Chronic Side Effects
– Due to long term exposure to the medication
– Occur regardless of serum concentration levels
– Examples: Alopecia, weight gain, behavior change,
cognitive impairment
Challenges in using anticonvulsants
•
•
•
•
Age
Gender
Illness
Drug interactions
Types of Drug Interactions
• Drug-drug: Valproic acid and lamotrigine
• Drug-food: Carbamazepine and grapefruit
juice
• Drug-dietary supplement: Calcium and
phenytoin
• Drug-herbal: indinavir and St. John’s Wort
• Drug-disease: medications that lower the
seizure threshold and epilepsy
Removing medication from body
• Elimination is two processes:
– Metabolism: a chemical reaction that changes
the drug so the body can get rid of it
– Excretion: removing the drug from the body
• Blood moves drug to liver and kidney to be
“disposed of”
• Even if drug moves into non-eliminating tissues
(like brain), it must get back to blood and moved
to the liver and kidney’s for disposal
Metabolism
Changes one chemical (drug)
into another for removal from
the body via enzymes
Enzymes are proteins that
help chemical reactions
along
If you know how a drug is
metabolized
=Help predict interactions
http://www.cincinnatichildrens.org/svc/alpha/l/liver/liver-anatomy.htm
Major Liver Enzymes
P450 Enzyme
Examples of Drug That Use The Enzyme
CYP1A2
Caffeine, Theophylline
CYP2B6
CYP2C9
Bupropion
Warfarin, Phenytoin, Phenobarbital, NSAIDs
CYP2C19
Omeprazole, Phenytoin, S-Mephenytoin
CYP2D6
Metoprolol, Fluoxetine
Codeine, Dextromethorphan
Carbamazepine, Zonisamide, Tiagabine,
Ethosuximde, Cyclosporin, Triazolam,
Amlodipine, Atorvastatin, Erythromycin
CYP3A4
http://medicine.iupui.edu/flockhart/
Excretion
Drug is removed from
the body in urine
http://www.nlm.nih.gov/medlineplus/ency/imagepages/1101.htm
Not everyone is the same
No 2D6=lack of pain relief
CYP 2D6
Codeine
(inactive)
Morphine
(active)
Approximately 7-10% of the US
population is deficient in CYP 2D6
Codeine glucuronide
(inactive)
As we age….
• Absorption
–
–
–
–
 Blood flow to stomach and intestines
 acidity
 stomach emptying
 intestinal motility
• Distribution
–  muscle
–  fat
• Metabolism
–  blood flow to liver
–  size of liver
• Excretion
–  blood flow to kidneys
–  size of kidneys
–  ability to filter
As a result drug interactions can
change over time
Summary
• Many medication options available
• Medication choice driven by several factors
– Seizure type
– Medical conditions
– Other medications
• Drug interactions can usually be proactively
managed
AED abbreviations
1st generation AEDs
Year
Drug
PB Phenobarbital
PHT
Phenytoin
PRM
Primidone
ESM
Ethosuximide
DZP
Diazepam
CBZ
Carbamazepine
Clonazepam
VPA
Valproate
2nd generation AEDs
Year
Drug
FBM
Felbamate
GBP
Gabapentin
LTG Lamotrigine
TPM
Topiramate
TGB
Tiagabine
OXC
Oxcarbazepine
LEV Levetiracetam
ZNS Zonisamide
PGB
Pregabalin
RUF
Rufinamide
VGB
Vigabatrin
CLB
Clobazam
3rd generation AEDs
Year
Drug
LAC
Lacosamide
EZG
Ezogabine