Transcript Clinical Slide Set. Epilepsy - Annals of Internal Medicine

In the Clinic
Epilepsy
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (2): ITC2-1.
What are the symptoms of epilepsy?
 Sensory: numbness, tingling, pain
 Motor: twitching, jerking, rhythmic or semirhythmic
uncontrolled movements
 Psychic: fear, sadness, elation, laughing
 Automatic: lip smacking, chewing, swallowing
 Loss of tone, incontinence, and tongue biting
 Staring or repetitive blinking
 Altered awareness, impaired ability to interact normally
 Individual may be unaware seizure has occurred
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (2): ITC2-1.
Elements of history and physical
 History
 How do you know that a seizure is going to occur?
 What's the first thing that happens? Then what?
 Do you have any other intermittent movements or
feelings that occur without an apparent cause?
 Physical exam
 Look for focal findings
 Presence of intracranial structural disturbance?
 Blurred disc margins on an ocular exam? intracranial
mass lesion may be increasing intracranial pressure
 Hemiatrophy of a limb or digit? suggests incomplete
contralateral cerebral development
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (2): ITC2-1.
Seizure evaluation
 First seizure
 History and physical examination
 Labs: glucose level, chemistry panel, liver function tests,
BUN:creatinine, pregnancy test, CBC, toxicology, alcohol level
 Lumbar puncture if febrile, nuchal rigidity, immune compromise
 Electroencephalogram; CT or MRI
 Consider HIV test
 Breakthrough seizure
 History and physical examination
 Labs: As above, plus trough anticonvulsant levels
 Neuroimaging if new type or semiology or frequency changes
 EEG if patient does not return to baseline
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (2): ITC2-1.
Differential diagnosis
 Syncope from vascular insufficiency, anemia, cardiac
dysrhythmias, hypovolemia, autonomic dysfunction
 Conditions that may cause altered awareness, repetitive
or stereotyped movements, impaired cognitive function
 Sleep disturbances; Metabolic derangements
 Movement disorders; Migraine
 Delirium or dementia
 Psychiatric and psychological conditions
 Panic attacks, PTSD, pseudoseizures
 May be difficult to distinguish from epileptic seizures
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (2): ITC2-1.
What tests should be done to diagnose
epilepsy?
 EEG
 Routine
 Ambulatory outpatient or inpatient: if symptoms occur
frequently or can be provoked by reproducible situations
 Cardiac testing
 Routine ECG or ambulatory cardiac monitoring
 Echocardiography
 Neuroimaging
 Focal or space-occupying lesions
 Migrational disorders or vascular lesions
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (2): ITC2-1.
Do patients with epilepsy have related
comorbidities?
 Pneumonia, asthma, upper GI bleeding
 Hormonal imbalances
 Reproductive endocrine disorders
 Perimenstrual or periovulatory seizures or seizures
during entire second half of the menstrual cycle
 Low sexual function among men
 Cognitive impairment
 Mood disorders (depression, anxiety)
 Anticonvulsants can have adverse effects that
exacerbate concomitant medical conditions
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (2): ITC2-1.
CLINICAL BOTTOM LINE: Diagnosis...
 Careful history and physical exam
 Neuroimaging with MRI
 Ambulatory or continuous EEG monitoring
 Many comorbidities are associated with epilepsy
 From etiologic cause or from treatments for the condition
 Proper identification and management of these may
improve functioning and quality of life
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (2): ITC2-1.
How can epilepsy be prevented?
 Identify and avoid seizure triggers
 Soon after a seizure, patients should record events over
the past 24 h to identify possible patterns
 Insufficient sleep or alcohol use may trigger seizures
 Counsel on ways to improve sleep duration and quality and
on ways to avoid or limit alcohol use
 Impaired absorption of seizure medications (GI illness,
colonoscopy prep) may result in seizure
 Intermittent use of short-term benzodiazepines may
prevent progression into status epilepticus
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (2): ITC2-1.
CLINICAL BOTTOM LINE: Prevention...
 No proven strategies to avoid the development of epilepsy
 Careful history may identify triggers that can be avoided
 Sleep deprivation
 Use of alcohol
 Planned or inadvertent nonadherence to medication
 Providing patients with small quantity of low-dose oral
benzodiazepines may decrease the risk of recurrent seizures
in the setting of intercurrent illness
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (2): ITC2-1.
How should epilepsy be treated initially?
 Treatment typically initiated after the second seizure
 Prescribe pharmacotherapy
 >2 dozen anticonvulsants FDA-approved for epilepsy
 Identify ones with efficacy in the patient's type of epilepsy
 Consider potential adverse effects, interactions with other
medical conditions or medications, plans for childbearing
 Consider time to reach optimal dosing and dosing schedule
 Consider other lifestyle factors
 No evidence supports using one over another where both
medications have efficacy in epilepsy syndrome/seizure type
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (2): ITC2-1.
 Offer strategies for taking medication consistently
 If patients don’t respond to the first agent or have
unacceptable adverse effects, try a second agent
 Either as an adjunct to the first
 Or cross-taper to allow for resultant monotherapy
 Once effective dose is established, document serum
concentration
 If seizures continue while receiving 2 anticonvulsants:
Refer to a neurologist or a specialty center
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (2): ITC2-1.
What are the adverse effects of epilepsy
treatment?
 Fatigue, dizziness, blurred vision, incoordination, gait
imbalance
 Tend to be dose-dependent rather than idiosyncratic
 May be alleviated with slower dose-escalation plan or by
taking the medication on full stomach
 Increased tendency to suicidality
 As early as 1 week after initiation of treatment
 FDA warning: physicians must warn patients of risk for
suicidality and screen for depression or suicidality at
regular intervals during dose escalation
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (2): ITC2-1.
Are there devices to treat epilepsy?
 Vagus nerve stimulator
 Generator implanted subcutaneously in anterior chest wall
or axilla
 Lead is threaded subcutaneously from generator to left
vagus nerve
 Provides regular electrical impulses and can also deliver
impulses through external hand-held magnet
 Responsive neurostimulation system
 Stimulator implanted in the skull
 Leads extend from generator to surface of the brain or into
the brain parenchyma where seizures originate
 Can be programmed to respond to seizures directly,
sending electrical impulses to the seizure focus or foci
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (2): ITC2-1.
What is the role of surgery?
 For patients who have failed ≥ 2 anticonvulsants or have
intolerable adverse effects
 Refer to epilepsy center where the surgery may be done
 Risks: wound infections, meningitis, hemorrhagic
complications, neurologic deficits
 Transient postsurgical psychiatric disturbance may occur
 2/3 of patients with specific resections become free of all
but simple partial seizures
 Anticonvulsants may be reduced or withdrawn if patients
become seizure-free
 But risk for subsequent relapse is higher if all
anticonvulsant therapy is stopped
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (2): ITC2-1.
Is there a role for hormonal treatment of
epilepsy?
 Exogenously administered hormonal treatment
 For women with hormonally-sensitive seizures,
 Mitigates hormonal oscillations that trigger events
 May improve seizure control without additional
anticonvulsant therapy
 Requires extensive recordkeeping to identify a
catamenial pattern of events
 Serial blood work needed to identify hormonal
changes
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (2): ITC2-1.
CLINICAL BOTTOM LINE: Treatment...
 Many anticonvulsants are available for initial treatment
 If ≥ 2 fail in a patient, refer to neurologist or epilepsy center to
consider treatment options:
 Implantable devices
 Resective or minimally invasive surgery
 For women with catamenial epilepsy, hormonal
manipulation
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (2): ITC2-1.