Epilepsy resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: , Fahimeh Shojaei, M.D., Moises Romo, M.D.

Synonyms and keywords: Epilepsy management, Epilepsy workup, Epilepsy approach, approach to Epilepsy, Epilepsy treatment

## Overview

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Epilepsy is a common chronic neurological disorder that is characterized by recurrent unprovoked seizures. These seizures are transient signs and/or symptoms due to abnormal, excessive or synchronous neuronal activity in the brain. Epilepsy can be diagnosed based on history, symptoms and physical examination of a patient with seizure complain. Among the patients who present with clinical signs of seizures, the EEG is the most efficient test for diagnosis. Anti-seizure medications for epilepsy include drugs that affect voltage-dependent Na+ channels, drugs that affect Ca currents, drugs that affect GABA activity, drugs that affect glutamate receptor, and drugs with multiple mechanisms of action.

## Causes

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### Life-threatening Causes

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Life-threatening causes of epilepsy include:[1][2][3][4][5][6]

* Head trauma
* Brain tumor
* Brain hemorrhage
* Encephalitis
* Hypoglycemia
* Hypoxic encephalopathy
* Stroke

### Common Causes

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Common causes of epilepsy may include:[7][8][9][10][11][12]

* Cerebral palsy
* Electrolyte disturbances
* Epileptic encephalopathy - Lennox-Gastaut type
* Febrile seizures
* Huntington's disease
* Intoxication
* Uremia

## Diagnosis

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Shown below is an algorithm summarizing the diagnosis of Epilepsy according the the ESC guidelines:

| Clinical presentation|

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| Loss of consciousness|

| No|

| Yes

| • Transient?
• Rapid onset?
• Short duration?
• Spontaneous recovery?

Falls|

| Altered consciousnes|

| Yes|

| No

| Coma|

| Aborted SCD|

| Others

| T-LOC|

| Non-Traumatic|

| Traumatic|

Syncope|

| Epileptic seizure|

| Psychogenic|

| Rare causes|

• Reflex syncope
• Orthostatic hypotension
• Cardiac syncope|

| • Tonic
• Clonic
• Tonic-clonic
• Atonic|

| • Pseudo-epileptic
• Pseudo-syncopal|

## Treatment

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Shown below is an algorithm summarizing the treatment of epilepsy according the the American Epilepsy Society guidelines:[13]

| Patient with convulsive status epilepticus|

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| 1\. Stabilize the patient (airway, breathing, circulation, disability, neurological examination
2\. Time seizure from its onset and monitor vital signs
3\. Assess oxygenation and give supplemental oxygen or intubate if necessary
4\. Initiate ECG monitoring
5\. Collect fingerstick blood glucose. If less than 60 mg/dl: Adults: 100 mg thiamine IV then 50 ml of dextrose 50% IV. Children ≥ 2 years: 2 ml/kg dextrose 25% IV Children < 2 years: 4 ml/kg dextrose 12.5% IV
6\. Attempt IV access and collect electrolytes, hematology, toxicology screen, (if appropriate) anticonvulsant drug levels)|

| Does seizure continue?|

| No|

| Yes|

| If patient at baseline, then symptomatic medical care|

| A benzodiazepine is the initial therapy of choice (Level A):

1\. Choose one of the following 3 equivalent first-line options with dosing and frequency:

• Intramuscular midazolam (10 mg for > 40 kg, 5 mg for 13-40 kg, single dose,
Level A) OR

• Intravenous lorazepam (0.1 mg/kg/dose, max: 4 mg/dose, may repeat dose
once, Level A) OR

• Intravenous diazepam (0.15-0.2 mg/kg/dose, max: 10 mg/dose, may repeat dose
once, Level A)

2\. If none of the 3 options above are available, choose one of the following:

• Intravenous phenobarbital (15 mg/kg/dose, single-dose, Level A) OR

• Rectal diazepam (0.2-0.5 mg/kg, max: 20 mg/dose, single dose, Level B) OR

• Intranasal midazolam (Level B), buccal midazolam (Level B)|

| Does seizure continue?|

| No|

| Yes|

| If patient at baseline,

then symptomatic

medical care|

| There is no evidence based preferred second therapy of choice (Level U):

1\. Choose one of the following second line options and give as a single dose

• Intravenous fosphenytoin (20 mg PE/kg, max: 1500 mg PE/dose, single dose,
Level U) OR

• Intravenous valproic acid (40 mg/kg, max: 3000 mg/dose, single dose,
Level B) OR

• Intravenous levetiracetam (60 mg/kg, max: 4500 mg/dose, single-dose, Level U)

2\. If none of the options above are available, choose one of the following (if not given already)

• Intravenous phenobarbital (15 mg/kg, single dose, Level B)|

| Does seizure continue?|

| No|

| Yes|

| If patient at baseline,

then symptomatic

medical care|

| There is no clear evidence to guide therapy in this phase (Level U):

1\. Choices include: repeat second line therapy or anesthetic doses of either thiopental,

midazolam, pentobarbital, or propofol (all with continuous EEG monitoring)|

## Do's

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* Adults with an unprovoked first seizure should be informed that their risk of recurrence is higher within the first 2 years.[14]
* Treat with immediate antiepileptic therapy from the first unprovoked seizure in adults, since it has been seen that it reduces recurrences, as compared with the delay of treatment pending a second seizure. This may not improve quality of life.[14] Benefits and risks of psychological and medical side effects of AED should be evaluated when treating children with an unprovoked first seizure.[15]
* Use Gabapentin in patients aged ≥60 years with new-onset focal epilepsy, as it is as effective and better tolerated than other drugs.[16]
* Lamotrigine should be used to decrease seizure frequency in patients aged ≥60 years.[16]
* Vagus nerve stimulation may be used to reduce seizure frequency over time for periods greater than 6 months and as long as 12 years. In adult patients receiving VNS for epilepsy, improvement in mood may be an additional benefit.[17][18]
* Adjust dose of antiepileptic drugs in pregnant, since pregnancy may increase the risks of seizure.[19]
* Adjust dosage of antiepileptics such as phenytoin and valproic acid in patients with HIV taking certain antivirals.[20]

## Don'ts

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* Do not restrain a person with a seizure to try to stop his or her movements.[21]
* Do not put anything object in a person’s mouth during a seizure, since it may injure his teeth or the jaw.[21]
* Do not give water or food to a person with a seizure until he or she is fully alert.[21]
* Do not use cannabinoids in epilepsy. Although, marihuana has been suggested to decrease seizure frequency in epilepsy, there is insufficient studies to support or refute its efficacy.[22][23]

## References

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1. ↑ Annegers JF, Coan SP (October 2000). "The risks of epilepsy after traumatic brain injury". Seizure. 9 (7): 453–7. doi:10.1053/seiz.2000.0458. PMID 11034867.
2. ↑ Englot DJ, Chang EF, Vecht CJ (2016). "Epilepsy and brain tumors". Handb Clin Neurol. 134: 267–85. doi:10.1016/B978-0-12-802997-8.00016-5. PMC 4803433. PMID 26948360.
3. ↑ Faught E, Peters D, Bartolucci A, Moore L, Miller PC (August 1989). "Seizures after primary intracerebral hemorrhage". Neurology. 39 (8): 1089–93. PMID 2761703.
4. ↑ Misra UK, Tan CT, Kalita J (August 2008). "Viral encephalitis and epilepsy". Epilepsia. 49 Suppl 6: 13–8. doi:10.1111/j.1528-1167.2008.01751.x. PMID 18754956.
5. ↑ Sloper JJ, Johnson P, Powell TP (September 1980). "Selective degeneration of interneurons in the motor cortex of infant monkeys following controlled hypoxia: a possible cause of epilepsy". Brain Res. 198 (1): 204–9. PMID 7407585.
6. ↑ Chung JM (May 2014). "Seizures in the acute stroke setting". Neurol. Res. 36 (5): 403–6. doi:10.1179/1743132814Y.0000000352. PMID 24641717.
7. ↑ Diaconu G, Burlea M, Grigore I, Frasin M (2003). "[Epilepsy in different types of cerebral palsy]". Rev Med Chir Soc Med Nat Iasi (in Romanian). 107 (1): 136–9. PMID 14755984.CS1 maint: Unrecognized language (link)
8. ↑ Riggs JE (February 2002). "Neurologic manifestations of electrolyte disturbances". Neurol Clin. 20 (1): 227–39, vii. PMID 11754308.
9. ↑ Markand ON (2003). "Lennox-Gastaut syndrome (childhood epileptic encephalopathy)". J Clin Neurophysiol. 20 (6): 426–41. PMID 14734932.
10. ↑ Shinnar S, Glauser TA (January 2002). "Febrile seizures". J. Child Neurol. 17 Suppl 1: S44–52. doi:10.1177/08830738020170010601. PMID 11918463.
11. ↑ Cendes F, Andermann F, Carpenter S, Zatorre RJ, Cashman NR (January 1995). "Temporal lobe epilepsy caused by domoic acid intoxication: evidence for glutamate receptor-mediated excitotoxicity in humans". Ann. Neurol. 37 (1): 123–6. doi:10.1002/ana.410370125. PMID 7818246.
12. ↑ D'Hooge R, Pei YQ, Marescau B, De Deyn PP (October 1992). "Convulsive action and toxicity of uremic guanidino compounds: behavioral assessment and relation to brain concentration in adult mice". J. Neurol. Sci. 112 (1–2): 96–105. PMID 1469446.
13. ↑ "New Guideline for Treatment of Prolonged Seizures in Children and Adults | American Epilepsy Society".
14. ↑ 14.0 14.1 Krumholz, A.; Wiebe, S.; Gronseth, G. S.; Gloss, D. S.; Sanchez, A. M.; Kabir, A. A.; Liferidge, A. T.; Martello, J. P.; Kanner, A. M.; Shinnar, S.; Hopp, J. L.; French, J. A. (2015). "Evidence-based guideline: Management of an unprovoked first seizure in adults: Report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society". Neurology. 84 (16): 1705–1713. doi:10.1212/WNL.0000000000001487. ISSN 0028-3878.
15. ↑ Hirtz, D.; Berg, A.; Bettis, D.; Camfield, C.; Camfield, P.; Crumrine, P.; Gaillard, W. D.; Schneider, S.; Shinnar, S. (2003). "Practice parameter: Treatment of the child with a first unprovoked seizure: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society". Neurology. 60 (2): 166–175. doi:10.1212/01.WNL.0000033622.27961.B6. ISSN 0028-3878.
16. ↑ 16.0 16.1 Kanner, Andres M.; Ashman, Eric; Gloss, David; Harden, Cynthia; Bourgeois, Blaise; Bautista, Jocelyn F.; Abou-Khalil, Bassel; Burakgazi-Dalkilic, Evren; Llanas Park, Esmeralda; Stern, John; Hirtz, Deborah; Nespeca, Mark; Gidal, Barry; Faught, Edward; French, Jacqueline (2018). "Practice guideline update summary: Efficacy and tolerability of the new antiepileptic drugs I: Treatment of new-onset epilepsy". Neurology. 91 (2): 74–81. doi:10.1212/WNL.0000000000005755. ISSN 0028-3878.
17. ↑ Morris, G. L.; Gloss, D.; Buchhalter, J.; Mack, K. J.; Nickels, K.; Harden, C. (2013). "Evidence-based guideline update: Vagus nerve stimulation for the treatment of epilepsy: Report of the Guideline Development Subcommittee of the American Academy of Neurology". Neurology. 81 (16): 1453–1459. doi:10.1212/WNL.0b013e3182a393d1. ISSN 0028-3878.
18. ↑ Kuba, Robert; Brázdil, Milan; Kalina, Miroslav; Procházka, Tomáš; Hovorka, Jiří; Nežádal, Tomáš; Hadač, Jan; Brožová, Klára; Sebroňová, Věra; Komárek, Vladimír; Marusič, Petr; Ošlejšková, Hana; Zárubová, Jana; Rektor, Ivan (2009). "Vagus nerve stimulation: Longitudinal follow-up of patients treated for 5 years". Seizure. 18 (4): 269–274. doi:10.1016/j.seizure.2008.10.012. ISSN 1059-1311.
19. ↑ Harden, C. L.; Hopp, J.; Ting, T. Y.; Pennell, P. B.; French, J. A.; Hauser, W. A.; Wiebe, S.; Gronseth, G. S.; Thurman, D.; Meador, K. J.; Koppel, B. S.; Kaplan, P. W.; Robinson, J. N.; Gidal, B.; Hovinga, C. A.; Wilner, A. N.; Vazquez, B.; Holmes, L.; Krumholz, A.; Finnell, R.; Le Guen, C. (2009). "Practice Parameter update: Management issues for women with epilepsy--Focus on pregnancy (an evidence-based review): Obstetrical complications and change in seizure frequency: Report of the Quality Standards Subcommittee and Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and American Epilepsy Society". Neurology. 73 (2): 126–132. doi:10.1212/WNL.0b013e3181a6b2f8. ISSN 0028-3878.
20. ↑ Birbeck, G. L.; French, J. A.; Perucca, E.; Simpson, D. M.; Fraimow, H.; George, J. M.; Okulicz, J. F.; Clifford, D. B.; Hachad, H.; Levy, R. H. (2012). "Evidence-based guideline: Antiepileptic drug selection for people with HIV/AIDS: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Ad Hoc Task Force of the Commission on Therapeutic Strategies of the International League Against Epilepsy". Neurology. 78 (2): 139–145. doi:10.1212/WNL.0b013e31823efcf8. ISSN 0028-3878.
21. ↑ 21.0 21.1 21.2 "Seizure First Aid | Epilepsy | CDC".
22. ↑ . doi:10.2165/11539000-000000000-00000. Check `|doi=` value (help). Missing or empty `|title=` (help)
23. ↑ Raichlen, D. A.; Foster, A. D.; Gerdeman, G. L.; Seillier, A.; Giuffrida, A. (2012). "Wired to run: exercise-induced endocannabinoid signaling in humans and cursorial mammals with implications for the 'runner's high'". Journal of Experimental Biology. 215 (8): 1331–1336. doi:10.1242/jeb.063677. ISSN 0022-0949.

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