Clinical Evaluation of a 1st Seizure 1
-
Upload
umesh-babu -
Category
Documents
-
view
215 -
download
0
Transcript of Clinical Evaluation of a 1st Seizure 1
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
1/33
AnEvidenceBasedPractice
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
2/33
Theaimofthispresentationistohighlightthestandardinitialhistory,physicalandneurologicalexaminationandthemethodsandprocedureswhichcomplementtheevaluation
ofafirstseizureinanadult.
Neurology.2007;69:19962007
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
3/33
Seizuresareacommonpresentationintheemergency
care
setting
EpilepsyisdefinedasarecurrentunprovokedseizureUpto28%ofallepilepsypatientsrequiretreatmentin
emergencydepartment(EDs)annually.
AnnEmerg Med.2004;43:605625
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
4/33
ClassificationofSeizures:AccordingtoPresentation
AnnEmerg Med.2004;43:605625
AmFam Physician2007;75:13421347
GeneralizedSeizures:Involvesallareasofthe
brain(bothhemisphere) Generalizedtonicclonic Tonic Clonic Absence Myoclonic
PartialSeizures:Involvespartofbrain(focal).
Furtherclassifiedas:Simple:NolossofconsciousnessComplex:Lossofconsciousness
Afirstseizureistwiceaslikelytobegeneralizedseizuresasapartialseizure.
Mostgeneralizedseizuresoccurwhentheyareawake,
but
one
in
four
occur
when
they
are
asleep.
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
5/33
Classificationof
Seizures:
According
to
Etiology
SymptomaticSeizures:TheyhaveaRecognizableCause
AcuteSymptomatic Causedbyarecentorcurrentevent
RemoteSymptomatic Causedbyachronicabnormality like
stroke,trauma
or
anoxia
IdiopathicSeizures:Thereisnoabnormalityfound
AnnEmerg Med.2004;43:605625
AmFam Physician2007;75:13421347
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
6/33
NewOnsetEpilepsyisthemostcommoncause
of
a
first
Seizure
AmFam Physician2007;75:13421347
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
7/33
SomeMoreTermsforClassifyingSeizures:ProvokedSeizures:Resultofanacute
precipitating disorderviz. Meningitis IntoxicationsTrauma
Metabolicderangement:
(e.g.Hypoglycemia)
These
may
require
prompt
interventiontoreversepotentiallydamaging
dangerouscondition
UnprovokedSeizures:Seizureswithoutanapparentcauseor causesthatarenot
acuteprecipitating
conditions
requiringimmediateaction.
Theirbasis
may
be
Cryptogenic(noknowncause) Remotesymptomatic:duetoa
braininjury
,lesion,
tumor
or
stroke Idiopathic(genetic)
Neurology.2007;69:19962007
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
8/33
Recurrence&MortalityAssociatedwithSeizures
Inayearfollowinganacutesymptomaticseizurediagnosis,patientshaveaninefoldhigherriskofdeath
in
the
first
30
days
after
seizure,
thanthosewithoutthisdiagnosis.
Idiopathicseizuresarenotassociatedwithincreasedriskof
death.
Acutesymptomaticseizureswere80%lesslikely to
havesubsequent
unprovoked
seizures
over
thefollowing10yearscomparedwithpatientswith
firstunprovokedseizure
AmFam Physician2007;75:13421347
F1000MedicineReports2010,2:51
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
9/33
GoalsofImmediateEvaluationofaFirstSeizureAfter
apatient
who
presents
with
afirst
seizure
is
stabilizedandreturnstobaselinefunction,acarefuland
complete,physicalandneurologicalexaminationare
criticallyimportant
at
the
initial
presentation.
Thegoalsofimmediateevaluationare:
o Toknowwhetheritwasaseizureoracondition
mimickingseizure(Pseudoseizure orSyncope).oToknowwhetheritwasthefirstseizure.oTo
determine
the
possible
cause
of
the
seizure.
o Classifyingseizuretype&possibleseizuresyndromeo Assessingrecurrencerisk
Neurology.2007;69:19962007
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
10/33
OutlinesforSeizureAssessment:Featuresofaseizure
Associatedfactors Age
Medicalhistory previoushistoryofsimilarepisodes,
prior
stroke,
brain
tumor,
systemic
illness,
mental
illness,drugoralcoholabuse Familyhistory
Developmentalstatus
Behavior Healthatseizureonset febrile,ill,exposedtoillness,
symptomsof
infection
viz.
stiff
neck,
fever,
headache.
Precipitatingeventsotherthanillness trauma,alcohol,medications,illicitdrugs,toxins,sleepdeprivation
AdaptedfromHertzetal.Neurology.2000;55:616623
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
11/33
OutlinesforSeizureAssessment:Featuresofaseizure(Contd)
Symptomsduringseizure(ictal)
Aura:Subjective
sensations
Behavior: Moodorbehavioralchangesbeforetheseizure
Preictal symptoms: Describedby
patient
or
witnessed
Vocal: Cryorgasp,slurringofwords,garbledspeech Motor: Headoreyeturning,eyedeviation,posturing,
jerking(rhythmic),
stiffening,
automatisms
(purposeless
repetitivemovementssuchaspickingatclothing,
lipsmacking);generalizedorfocalmovements
AdaptedfromHertzetal.Neurology.2000;55:616623
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
12/33
OutlinesforSeizureAssessment:Featuresofaseizure(Contd)
Symptomsduringseizure(ictal)
Respiration: Changein
breathing
pattern,
cessation
of
breathing,cyanosis Autonomic: Pupillary dilation,drooling,changein
respiratoryor
heart
rate,
incontinence,
pallor,
vomiting
Lossofconsciousness orinabilitytounderstandorspeak
AdaptedfromHertzetal.Neurology.2000;55:616623
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
13/33
OutlinesforSeizureAssessment:Featuresofaseizure(Contd)
Symptomsfollowingaseizure(postictal)
Amnesiafor
events
ConfusionLethargy
SleepinessHeadachesandmuscleachesTransientfocalweakness(Toddsparesis)
Nauseaor
vomiting
Bitingoftongue
AdaptedfromHertzetal.Neurology.2000;55:616623
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
14/33
DifferentialDiagnosis
of
a
Seizure
Pseudoseizure Syncope
MigraineDrugReactionorIntoxication
Neurology.2007;69:19962007
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
15/33
Nonepileptic
seizures
(NES)
are
events
resembling
epilepticattacks,butlackingtheircharacteristicclinicalandelectrographicfeatures.
Theyhave
been
referred
to
as
pseudoseizures,
hystericalseizuresandpsychogenicseizures.
Nonepileptic
attack
disorder
(NEAD) has
also
been
used,butnonepilepticseizuresisnowgenerallypreferred.
20%ofpatientsdiagnosedwithepilepsyactuallyhavepseudoseizures
Seizure(2005)14,293303
AmFam Physician2007;75:13421347
Seizures&Pseudoseizures
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
16/33
EEG/video isthegoldstandardfordiscriminatingbetweenepilepticandnonepilepticattacks.
AccordingtotheAmericanAcademyofNeurology(AAN),serumprolactin measurement,ifobtainedwithin
1020
mins of
the
event,
is
useful
in
differentiating
seizurefrompseudoseizure.(Sensitivityofanelevatedprolactin levelis60%forgeneralized
tonicclonicseizuresand46%forcomplexpartialseizures).
DifferentiatingSeizuresfromPseudoseizures
AmFam Physician2007;75:13421347
Neurology,2005;65:668675
Duetononavailabilityofthetesttoallclinicians,routine
diagnosis
largely
remains
restricted
to
clinical
judgment
onthebasisofhistorical featuressuggestiveofseizures.
Somehistoricalfeaturesofseizures:tonguebiting,
presenceof
an
aura,
sensation
of
epigastric
fullness,
postictalconfusionandfocalneurologicalsigns.
Tonguebiting
especially
lateral
is
highly
specific
but
not
sensitiveforgeneralizedseizures.
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
17/33
Seizures&SyncopeSyncope
may
be
difficult
to
differentiate
from
seizures,
particularlyiftheeventwasunwitnessed.
Up
to
90%
of
patients
with
syncope
have
myoclonic or
other
seizurelikemovementswhileunconscious.
Events
precipitated
by
an
emotional
stressful
event
or
precededbylightheadedness,sweating,prolonged
standing,chestpain,palpitationsorslowheartratearemore
likelytobesyncopal.
AccordingtoAAN,serumprolactin levelcannotbeusedto
differentiatebetweenseizureandsyncope
AmFam Physician2007;75:13421347
Neurology,2005;65:668675
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
18/33
Somedisorderscausingseizuresrequirepromptdiagnosis
and
acute
treatment.
Also,
some
causes
of
seizures
influence
the
prognosis
andthedecisionsregardinginitiationandmaintenanceofantiepilepticdrugtherapy.
Goalofimmediateevaluation:To
know
the
Cause
of
the
Seizure
Neurology.2007;69:19962007
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
19/33
CriticalQuestionsRegardingAppropriateDiagnostic
Tools
While
Evaluating
first
Seizure
inanAdult
Neurology.2007;69:19962007
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
20/33
Question1:ShouldanEEGberoutinelyorderedinanadultpresentingwithan
apparentunprovoked
first
seizure?
Neurology.2007;69:19962007
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
21/33
AccordingtotheAmericanAcademyofNeurology
(AAN)
EEGsweresignificantlyabnormalin8%to50%
(average29%)
of
the
patients
(n=1766).However,itisalsoclearfromtheevidencesthatanormal
EEGdoesnotexcludethepresenceofaseizuredisorder
(Onan
average
about
50%
of
individuals
clinically
diagnosed
with
a
seizurehaveanormalEEG)
Also,it
was
estimated
that
the
probability
of
seizure
recurrenceinpatientswithepileptiformEEG
abnormalitiesisof49.5%comparedtoonly27.4%in
individualswhose
EEGs
are
completely
normal
RecommendationsbyAAN:1. The
EEG
(routine)
should
be
considered
as
part
of
theneurodiagnosticevaluationoftheadultwithanapparentunprovokedfirstseizurebecauseithasa
substantialyield.
2.TheEEG(routine)shouldbeconsideredaspartoftheneurodiagnostic evaluationoftheadultwithan
apparentunprovoked
first
seizure
because
it
has
valueindeterminingtheriskforseizurerecurrence.
Neurology.2007;69:19962007
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
22/33
Also,
EmergentEEGisindicatedifthereisconcern
about
status
epilepticus.
Non
convulsive
or
subtle
convulsivestatusepilepticus maybedifficultto
diagnoseclinicallyandmaybemistakenfora
prolongedpostictal
state.
Onefourthofpatientswithtreatedstatusepilepticus whoappeartobe
seizure
free
continue
to
have
seizure
activity
that
is
only
detectablewithEEG.
AmFam Physician2007;75:13421347
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
23/33
Question2:Shouldabrainimagingstudy(CTorMRI)beroutinelyorderedinanadult
presentingwith
an
apparent
unprovoked
firstseizure?
Neurology.2007;69:19962007
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
24/33
AmFam Physician2007;75:13421347
Patientsatanincreasedriskofacuteintracranialpathologyneedimmediateneuroimaging.
AjointconsensusstatementfromtheAmericanCollegeofEmergencyPhysicians(ACEP)andAmericanAcademyofNeurology(AAN)statesthatimmediateneuroimaging is
indicatedwhen
aserious
structural
brain
lesion
is
suspected
and
alsoshouldbeconsideredforpatientswithpartialonsetseizuresandforthosewhoareolderthan40years
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
25/33
MRIisthepreferredimagingmethodbecauseithas
greatersensitivityfordetectingabnormalitiesthanCT.
However,patientswithacuteseizuresinitiallyshouldundergoCTbecauseitmoreaccuratelydetectsacute
bleedingand
is
reasonably
sensitive
in
detecting
other
abnormalities
AmFam Physician2007;75:13421347
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
26/33
AccordingtotheAmericanAcademyofNeurology CT
or
MRI
were
significantly
abnormal
in
1%
to
47%
(average10%)ofthepatients(n=1092).
Thesignificant
abnormalities
affected
patient
managementandincludedpreviouslyunrecognizedbraintumors,vascularlesionsandcerebralcysticercosis
orotherstructurallesion.
Recommendations:BrainimagingusingCTorMRIshouldbeconsideredas
part
of
the
neuro
diagnostic
evaluation
of
adults
presentingwithanapparentunprovokedfirstseizure
Neurology.2007;69:19962007
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
27/33
Question3: Shouldbloodcounts,bloodglucose,electrolytepanelsandothertest
beroutinely
ordered
in
an
adult
with
an
apparentunprovokedfirstseizure?
Neurology.2007;69:19962007
A di t th A i A d f N l
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
28/33
AccordingtotheAmericanAcademyofNeurologyData
from
studies
showed
that
in
adults
presenting
withanapparentunprovokedfirstseizure,
althoughsomeabnormallaboratoryresultsare
reported,there
is
not
sufficient
evidence
to
support
orrefuterecommendingroutinetestingofblood
glucose,blood
counts,
or
electrolyte
panels.
Thenecessityforsuchstudiesshouldbeguidedby
specificclinical
circumstances
based
on
the
history,
physical,andneurologicexamination.
Neurology.2007;69:19962007
Recommendations:
In
the
adult
initially
presenting
with
an
apparent
unprovokedfirstseizure,bloodglucose,bloodcounts,andelectrolytepanels(particularlysodium)maybe
helpfulin
specific
clinical
circumstances,
but
there
are
insufficientdatatosupportorrefuteroutine
recommendationofanyoftheselaboratorytests
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
29/33
Question4:Shouldalumbarpunctureberoutinelyperformedinanadultpresenting
withan
apparent
unprovoked
first
seizure?
Neurology.2007;69:19962007
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
30/33
Alumbar
puncture
is
indicated
for
patients
with
a
historyorexaminationresultssuggestiveofcentral
nervous
system
infection
and
in
patients
who
are
immunocompromised.
Newonset
seizures
may
be
the
only
symptom
of
centralnervoussysteminfectioninpatientswith
humanimmunodeficiencyvirus.
AmFam Physician2007;75:13421347
A di t th A i A d f N l
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
31/33
Datafromthestudiesrevealedsignificant
abnormalitiesinupto8%ofamixedgroupofpatientspresentingtoanemergency
departmentwith
afirst
seizure.
Neurology.2007;69:19962007
Recommendations:
Inthe
adult
initially
presenting
withanapparentunprovokedfirstseizure,lumbarpuncturemaybehelpfulinspecificclinical
circumstances,such
as
patients
who
are
febrile,
but
thereareinsufficientdatatosupportorrefuterecommendingroutinelumbarpuncture
AccordingtotheAmericanAcademyofNeurology
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
32/33
Question4:Shouldtoxicologic screeningberoutinelyorderedinanadultpresentingwith
anapparent
unprovoked
first
seizure?
Neurology.2007;69:19962007
-
8/13/2019 Clinical Evaluation of a 1st Seizure 1
33/33
Seizuresarereportedasaconsequencesofdrug
intoxication
particularly
with
tricyclicantidepressants,cocaineandotherstimulants.
Inaseries
of
event
with
acute
medical
complicationsofcocaineintoxication,seizures,
often
first
seizures,
accounted
for
10%
of
the
presentingsymptoms.
Severalstudies
of
emergency
department
admissionforfirstseizures,indicatedthatabout3%
ofseizures
may
relate
to
drug
toxicity
or
abuse.
RecommendationsbyAAN:Intheadultpresentingwithan
apparentunprovokedseizure,toxicologyscreening
may
be
helpful
in
specific
clinical
circumstances,butthereareinsufficientdatato
supportorrefutearoutinerecommendationfor
toxicologyscreening
Neurology.2007;69:19962007