Seizure for c1 students ppt usefull document

Usefull for seizure approach

1. Seizure and Epilepsy for c1 Abel M.( MD,Neurologist )

2. Seizure a paroxysmal event due to abnormal, excessive, hyper synchronous discharges from an aggregate of CNS neurons May not be observable objectively 5–10 % of the population will have at least one seizure Highest incidence early childhood and late adulthood

3. Cont… Epilepsy Recurrent seizures due to a chronic , underlying process. recurrent seizures due to correctable or avoidable conditions not included Epilepsy syndromes epilepsy with distinctive clinical and pathologic characteristics suggest a specific underlying etiology

4. ILAE-2017 Based Definition Seizures are transient events that include symptoms and/or signs of abnormal excessive or hyper synchronous neuronal activity in the brain . A seizure is a sudden change in behavior caused by electrical hyper synchronization of neuronal networks in the cerebral cortex . Epilepsy is the disorder of brain characterized by an enduring predisposition to generate epileptic seizures, and by the neurobiologic,cognitive,psychological,and social consequence of this condition.

5. Cont… Epileptic Seizure is a symptom of a disease but not a disease itself. A paroxysmal and transient event Due to an Abnormal Excessive or Hyper-synchronous electrical activity in the brain Manifested by clinical symptoms/signs or electro-cerebral signs Epileptic seizure could be: provoked/unprovoked Epilepsy to be considered as a disease of brain than a symptom It is known that the risk of seizure recurrence after two unprovoked seizures is greater than 60%.

6. The summary risk for an additional unprovoked seizure following a first unprovoked seizure is in the range of 40%. The summary risk for further unprovoked seizures approaches 60-80% in those who have experienced two (or more) unprovoked seizures . Seizures clustering within 24 h confer approximately the same risk for later seizures as does a single seizure.

7. Unprovoked seizure Unprovoked seizure refers to a seizure of unknown etiology as well as one that occurs in relation to a preexisting brain lesion or progressive nervous system disorder . Unprovoked seizures that are determined to be due to an underlying brain lesion or disorder are also referred to as remote symptomatic seizures. They carry a higher risk of future epilepsy compared with acute symptomatic seizures .

8. Cont… The term “unprovoked” implies absence of a temporary or reversible factor lowering the threshold and producing a seizure at that point in time. Provoked seizure is when induced by a transient factor acting on an otherwise normal brain to temporarily lower the seizure threshold . Reactive/Reflex seizure Acute symptomatic seizure. Recurrent reflex seizures represents provoked seizures that are defined as epilepsy. Acute symptomatic seizures: A seizure after a concussion Seizure occur with fever Seizure in association with alcohol-withdrawal

9. The Causes of Epilepsy can Sometimes Overlap with the Causes of Acute Symptomatic Seizures ACUTE SYMPTOMATIC SEIZURE EPILEPSY Provoked seizures Situation specific seizures Induced by an immediate underlying medical illness Two or more unprovoked seizures 24 hours apart No provoking immediate medical illness The medical illness must affect the brain Must happen at the time of the medical illness or be in closer time The medical illness must affect the brain Can begin many years after an inciting event Treating the underlying cause is enough No AEDs or Short term AEDs needed Long period of AEDs is needed Have Higher mortality Have Lower mortality

10. Acute symptomatic seizure   Seizure within one week of stroke, traumatic brain injury, anoxic encephalopathy, or intracranial surgery At first identification of subdural hematoma During the active phase of a central nervous system infection Within 24 hours of a severe metabolic derangement In population-based studies, acute symptomatic seizures make up 25 to 30 percent of first seizures.

11. ILAE DEFINITION OF EPILEPSY: Second Definition A person with a single unprovoked seizure and with a risk of approximately 60% or more of having a second seizure in the next 10 years: Added in 2014 ILAE working group definition. E mphasizes the importance of neuroimaging and EEG in the evaluation of patients with a first-time seizure, as some of these patients will meet criteria for epilepsy at the time of a first seizure. Examples include: Patients with a single seizure occurring at least a month after a stroke A single seizure conjoined with a structural or remote symptomatic etiology An abnormal epileptiform electroencephalography Family history of seizure

12. ILAE DEFINITION OF EPILEPSY: Third Definition Epilepsy Syndromes even without Seizures: It is reasonable to consider children with Landau- Kleffner syndrome to have epilepsy even without clinical seizures Syndromes associated with persistent threshold alteration can be made after the occurrence of a single seizure. EEG features of Epileptic syndromes without clinical seizure

13. ILAE DEFINITION OF EPILEPSY Resolved Epilepsy A person who is seizure free for >10 years and off medications for 5 years. Seems to be based on “expert opinion” and seems arbitrary. Still has an annual seizure recurrence risk of 0.5% and 1%: 10-20 fold increase than general population Individualized determination of the time at which this definition is met, is required Factors that should be considered: Age Seizure type/s Persistence or resolution of EEG abnormalities.

14. Seizure Semiology Pre- Ictal: Events that occur immediately before the seizure, and include Aura and Prodromal symptoms/signs Ictal semiology is the sign and symptoms observed during and immediately after the seizure occurrence. Motor ; Sensory; Autonomic; Cognitive…. Post-Ictal features : Features occur after the seizure stops

15. Ictal semiology: Elementary Motor features

16. Vesrsive activity and Posturing in Tonic Seizures

17. Ictal semiology: Elementary Motor Features

18. Automatisms are repetitive motor activities that are more or less coordinated and resemble a voluntary movement but are not purposeful. Automatisms usually occur in association with Impaired Awareness and the individuals are usually amnesic to the ictal feature. Could be Preservative automatism or De novo automatisms Oro-alimentary automatism Manual or pedal automatism Gestural automatism Manipulative automatism or Non-manipulative Hyperkinetic automatism Gelastic and dacrystic automatism Ictal semiology: Complex Motor Features

19. Ictal semiology: Automatisms

20. Classifications of Seizures and Epilepsy Purpose : Accurately identify the etiology of seizure or epilepsy For initiation of treatment: Not all seizures and epilepsies are treated Select appropriate workup and treatment modality and drugs More than one type of seizure could exist at the same time

21. Rules for Classifying Seizures: ILAE 2017

22. ILAE 2017 Classifications of Epileptic Seizures Seizure classification starts with determination of the initial manifestations of the seizure at onset. Focal seizures originate within a neuronal network limited to one hemisphere that may be discretely localized or more widely distributed. Generalized seizures originate at some point within the brain and rapidly engage bilateral distributed networks. If the onset of the seizure is missed or is unclear, the seizure is of unknown onset.

23. ILAE 2017 Classifications of Epileptic Seizures The second step in the classification of seizures is clarifying the presence of impaired awareness. Awareness is defined as knowledge and understanding that something is happening or exists. When a person is having a focal seizure, his or her awareness is determined by whether the person knows who they are and what is going on in his or her surroundings during the seizure It does not refer to awareness of the seizure occurring. Awareness is also distinct from responsiveness.

24. Unclassified : Due to inadequate information or inability to place in other categories ILAE 2017 Classification of Seizure Types: Basic Version

25. ILAE 2017 Classification of Seizure Types: Expanded Version

26. Rules for Classifying Seizures: ILAE 2017

27. Motor onset features Clinical descriptions Tonic Motor seizures with increased tone or stiffening of the limb or neck. Myoclonic Irregular and non rhythmic fast and brief jerking of muscle groups Clonic Repeated, regularly spaced stereotypical jerking movements Atonic Sudden loss of tone in one body part Epileptic spasms Flexion of the waist and flexion or extension of the arms, usually in clusters Automatisms Coordinated but purposeless, repetitive motor activities that may appear normal in other circumstances. Focal Motor Seizures

28. Focal Non-motor Seizure Non motor Clinical Descriptions Autonomic Changes in heart rate, blood pressure, sweating, skin color, piloerection, or gastrointestinal sensations Behavioral arrest Characterized by cessation of movement, which should be the dominant feature throughout the entire seizure and not just a brief part of the seizure Clinical symptoms include a blank stare and cessation from talking or moving Cognitive Changes in language function, thinking, or associated higher cortical functions More specific examples include déjà vu, jamais vu or hallucinations Emotional Emotional changes such as dread, fear, anxiety, or pleasure. Sensory Changes in sensory phenomena such as taste, smell, hearing, vision, pain, numbness, or tingling.

29. Focal Onset Seizure Focal seizures can be further classified as to whether they evolve to a bilateral tonic-clonic seizure or not. Replaces secondary generalized tonic-clonic naming to avoid any confusion between generalized and focal seizures. These seizures start in one area of the brain (as with all focal seizures) and then spread to both sides of the brain. This spread is typically clearly seen on EEG.

30. Focal Onset Seizure Evolving to a Bilateral Tonic-Clonic seizure start as focal aware or focal impaired awareness seizure. They manifest initially as focal motor or focal non motor feature before progressing to bilateral tonic-clonic seizure. Typical findings which differentiates focal from primary generalized forms of seizures include: Presence of Aura or Aura continua Presence of post ictal Todd’s paralysis Jacksonian march progression of focal motor activity Asymmetric ictal activity Presence of unilateral versive activity Focal Onset Seizure Evolving to a Bilateral Tonic-Clonic seizure

31. Generalized Seizures Generalized seizures originate at some point within the brain and rapidly engage bilateral distributed networks. Patients will have impaired awareness or lose their consciousness at the onset of the seizure. Similar to focal seizures, generalized seizures are classified according to motor or non-motor manifestations occurring in symmetric fashion. Broadly, motor seizures are either tonic-clonic or other motor seizures. Non-motor generalized seizures primarily refer to absence seizures.

32. GTCS are dramatic, the best recognized and the most common forms. Do not have an Aura, but they may be preceded by a prodrome—the vague sense a seizure will occur—lasting up to several hours (PRE-ICTAL) Seizure onset is abrupt, most often with loss of consciousness and a generalized and often bilateral tonic contraction which immediately followed by clonic phase (ICTAL) The tonic phase includes an upward eye deviation with eyes half open and the mouth open; ictal cry or moaning; cyanosis with vibratory epileptic tonic spasms: Lasts for few seconds to minutes The clonic phase showed the frequency of clonic jerks decreases, and the amplitude may initially increase but later decreases just before the Sz stops: Followed by flaccid limbs and sometimes incontinence Confusion; exhausted; muscle ache; memory loss; headache….. (POST-ICTAL) Generalized Seizures: GTCS

33. Unknown Onset Seizures and Unclassified Seizures If the onset of the seizure is missed or is unclear, the seizure is of unknown onset. Seizures of unknown onset can be classified by: Motor: tonic-clonic or epileptic spasms Non-motor: behavior arrest If information is inadequate or if the seizure cannot be categorized, then the seizure is considered unclassified.

34. A child has seizures with stiffening of the right arm and leg, during which responsiveness and awareness are retained. Old = simple partial seizures New = focal aware tonic/motor seizures EXAMPLES

35. Cont… A 25 year old woman describes seizures beginning with 30 seconds of an intense feeling that “familiar music is playing.” She can hear other people talking, but afterwards realizes that she could not determine what they were saying. She didn’t fall down but wanders around the house After an episode, she is mildly confused, and has to “re-orient herself.” Old = complex partial seizures New = focal auditory/sensory unaware seizures with automatism

36. Cont… A woman awakens to find her husband having a seizure in bed. The onset is not witnessed, but she is able to describe unilateral limb stiffening followed by bilateral shaking. He is unresponsive during the episode Old = partial onset, secondarily generalized seizure New = focal tonic/motor to bilateral tonic-clonic seizure

37. NEW CLASSIFICATION OF EPILEPSY SYNDROME The epilepsy syndrome is a new addition to the current classification system and is defined as “a cluster of features incorporating seizure types, EEG, and imaging features that tend to occur together. Factors that contribute to epilepsy syndrome include age of onset, remission, triggers, diurnal variation, intellectual and psychiatric dysfunction, EEG findings, imaging studies, family history, and genetics. Epilepsy syndromes are grossly classified as: Idiopathic or Genetic Generalized Epilepsy Syndromes Reflex Epilepsy Syndromes Focal Epilepsy Syndromes

38. Epilepsy syndromes

39. Common Epilepsy Syndromes and EEG Findings

40. Etiologic Classifications of Epileptic Seizures Six etiologic categories have been defined: Structural Genetic Infectious Metabolic Immune Unknown When multiple potential etiologies are present, priority should be given to the etiology with more relevant management issues.

41. Etiologic Classifications of Seizure: Based on age Trauma ; Genetic disorders; Infection; Brain tumor; Illicit drug use; Unknown/ Idiopathic 12-18 yrs Trauma; Alcohol withdrawal; Illicit drug use ; Brain tumor; Unknown 18-35 yrs Cerebro-vascular disease ; Brain tumor; Alcohol withdrawal Metabolic disorders (uremia, hepatic failure, electrolyte abnormalities, hypoglycemia, hyperglycemia) Alzheimer's disease and other degenerative CNS diseases Idiopathic/Unknown > 35 yrs Some causes occur at any age: Metabolic, Trauma, CNS infection, Unknown

42. Pathophysiology of Seizure and Epilepsy Mechanism of Epileptogenesis Transformation of a normal neuronal network into one that is chronically hyper-excitable state. Mainly from remote or permanent neurologic injury Mechanism of Seizure Initiation Burst activity and hyper-syncronization of hyper-excitable area Mechanism of Seizure Propagation Recruitment of surrounding neurons; long tracts and fibers AEDs control seizures by acting on Sz initiation and propagation.

43. Some patients with epilepsy report seizure precipitants that will not trigger seizures in unaffected individuals. More than 50% of subjects with epilepsy reported at least one precipitant Emotional stress and Sleep deprivation were the most common Nocturnal seizures: Seizures could occur only during sleep Other precipitants were excessive fatigue, fever or illness, flickering light, and menstruation. Drugs reduce threshold for seizure episode like TCAs, tramadol, antibiotics, anti-histamines….. Breakthrough seizure occurs with missed AEDs dose Seizure Precipitants

44. DDX Syncope Transient ischemic attack (particularly in older adults) Migraine Panic attack and anxiety Psychogenic nonepileptic seizure Transient global amnesia (rare before the age of 50 years) Narcolepsy with cataplexy Paroxysmal movement disorders

45. FEATURES SEIZURE SYNCOPE Immediate PPT factors Usually none Emotional stress valsalva Premonitory symptoms Usually aura; prodrome Tiredness; dizziness; nausea Posture at onset Variable Often erect Transition to LOC Often immediate Gradual over seconds Duration of LOC Minutes or more Seconds Duration of convulsion Seconds to few minutes Not more than 15 seconds Facial appearance at ictal Cyanosis; frothing on mouth Pallor Disorientation post event Many minutes to hours Less than five minutes Muscle aching post event Frequent Sometimes Tongue bite Common Rare Headache Common Sometimes Incontinence Sometimes Rare

46. True seizure vs. PNES

47. Evaluation of First Onset Seizure ABC rule recognize and manage Life-threatening conditions History and P/E No history of earlier seizures Confirm seizure determine the cause of the seizure risk factors decide whether anticonvulsant therapy is required treatment of underlying illness.

48. Cont… G oals of the history: To characterize the event as a seizure, R ule out alternative diagnoses , D etermine whether similar events have happened in the past, and E valuate for underlying risk factors for seizures in the past medical history, family history, and medications . known history of epilepsy identification of the underlying cause precipitating factors adequacy of the patient's current therapy

49. Cont…   For focal seizures, some behaviors have localizing and/or lateralizing value. For example, versive head turning or eye deviation to the left suggests onset in the right frontal lobe U nilateral sensory disturbance suggests contralateral parietal lobe onset, and P rominent dysphasia suggests involvement of the dominant hemisphere.

50. P ostictal period: typically include confusion and suppressed alertness . Focal Neurologic Deficient : may also be present, often referred to as Todd paralysis or postictal paresis , aphasia, hemianopia, or numbness . Alcohol intoxication or withdrawal and drugs of abuse should not be overlooked as a potential cause of seizure . Focal-onset seizures are less likely to be drug-induced than generalized tonic-clonic seizures .

51. Systematic approach to patients with new-onset seizure.

52. Laboratory Studies Routine blood studies screen for toxins in blood and urine Serum Lactate,LDH,CPK,WBCs,Cortisol,Neuron specific enolase and serum Prolactin level within 2-6 hrs. of seizure(GTCS VS PNES). lumbar puncture if there is any suspicion of meningitis or encephalitis in all patients infected with HIV, even in the absence of symptoms or signs suggesting infection Brain Imaging Almost all patients with new-onset seizures MRI is superior to CT

53. Electroencephalography (EEG) EEG is a graphic representation of voltage change on the brain cells over time. EEG is useful for epileptic seizures: Diagnosis of epileptic activity Classification of seizure and epilepsy Identify causes of epileptic seizures For selection and response to treatment Prognosis Continuous video EEG when compared with inter-ictal EEG.

54. Electrophysiologic Studies ICTAL-EEG Always abnormal during generalized tonic-clonic seizures A bsence of EEG seizure activity does not exclude a seizure disorder Inter-ectal EEG Cannot establish the diagnosis of epilepsy

55. If the New Onset Seizure is due to Epilepsy: Consider Epilepsy Evaluation For Possible Causes

56. Treatment Treatment of underlying conditions Avoidance of precipitating factors Suppression of recurrent seizures antiepileptic medications or surgery Addressing psychological and social issues

57. Treatment of Underlying Conditions If due to metabolic disturbance or medications reverse the metabolic problem or avoid the drug antiepileptic drugs usually unnecessary structural CNS lesion removal of the structural lesion (surgery, radiation, medical or other therapies ) antiepileptic medication for at least 1 year

58. Avoidance of Precipitating Factors Patients can identify particular situations that precipitate seizure sleep deprivation alcohol intake video game monitor, Music voice stres s

59. The main reasons for poor control of seizures are multi-factorial: Reassess for the diagnosis of seizure to be sure its truly an epileptic activity Reclassify the type of epileptic activity and assess whether the AEDs used are the right choice: Don’t forget multiple Sz. Assess in detail adequacy and proper choice of AEDs, adherence for medication; for missed doses: Breakthrough seizures Look for provoking factors like drugs; alcohol; sleep history and others Evaluation of Recurrent Seizure on Treatment

60. Breakthrough Seizures A breakthrough seizure is defined as one that occurs despite the use of antiseizure medications that have otherwise successfully prevented seizures in the patient in the past. DDx: Reflex epilepsies are those in which seizures are provoked objectively and consistently by specific stimuli or activities in patients who otherwise lack spontaneous seizures . Acute symptomatic seizures occur in patients with or without epilepsy and are provoked at the time of an acute, and usually severe, epileptic insult

61. Breakthrough Seizures Breakthrough seizures are common: A Ugandan study estimated prevalence in a sample of 267 patients, of which 74% experienced breakthrough seizures. In an English sample of more than 2000 patients in a prospective, observational trial, the incidence of breakthrough seizures was 37%. Risk factors for Breakthrough Seizures include: Poor adherence Suboptimal dose of AEDs Antiseizure medication instability and Interactions Seizure Precipitants Proconvulsants drugs

62. Antiepileptic Drug Therapy Mainstay of treatment for most patients with epilepsy Goal Completely prevent seizures without causing any side effects P referably with a single medication E asy dosing schedule for the patient

63. When to Initiate? Recurrent seizures of unknown etiology Recurrent seizures of irreversible cause Single seizure with An abnormal neurologic examination, Presenting as status epilepticus Postictal Todd's paralysis Strong family history of seizures Abnormal EEG

64. Which drug ? Factors influencing the choice of an initial medication include The efficacy Convenience of dosing Potential side effects All of the commonly used antiepileptic drugs can cause similar, dose-related side effects such as sedation, ataxia, and diplopia Absence , myoclonic, and atonic seizures or mixed Valproic acid Carbamazepine and phenytoin can worsen the above seizures Ethosuximide Effective for absence seizures

65. Initiation and Monitoring Optimal dose is often a matter of trial and error Seizure frequency Side effects Start low go slow This process may take months or longer Increases in dose should be made only after achieving a steady state with the previous dose i.e., after an interval of five or more half-lives . Mild sedation, changes in cognition, or imbalance resolve within a few days

66. Cont… What to Monitor? Clinical response Medication side effects and drug interactions Evaluation of Re-occurrence of a previously medical responsive seizure Identification of Drug resistant epilepsy

67. Monitoring After Start of AEDs: Clinical response Clinical response can be assessed by checking the frequency of seizure occurred after treatment initiated. ILAE defines seizure free or medically responsive epilepsy as seizure freedom for 12 months or 3 times the longest previous inter-seizure interval, whichever is longer: “Rule of three” If no response titrate the first drug to maximum tolerable dose and then add second alternative treatment and titrate similarly If there is a response with the second drug, slowly taper the first drug and withdraw slowly. If there is no response with the second drug: RAP R eevaluate the patient for adherence, drug dose and interaction, provoking factors A dd a third drug P erform EEG again

68. Cont… If seizures continue despite the maximum tolerated dose and documented compliance Switch to another antiepileptic drug Maintaining the patient on the first drug while a second drug is added Second drug adjusted First drug gradually withdrawn (usually over weeks)

69. History of rash Avoid Lamotrigine Rash because of carbamazepine: Avoid also phenytoin and phenobarb Use levetiracetam, gabapentin, pregabalin and valproate Weight gain and obesity Avoid valproic acid, gabapentin, pregabalin or carbamazepine Preferred to use topiramate and zonisamide Monitoring After Start of AEDs: Side effects

70. Some drugs are more likely to produce behavioral problems Others with mood-stabilizing properties might be helpful in patients with concomitant psychiatric illness. Carbamazepine, lamotrigine, oxcarbazepine, and valproate can be used in mood disorders Avoid levitracetam and phenobarbital In elderly preferable to titrate slowly and to lower target doses specially protein bound AEDs Selective Issues: Comorbidities

71. Ovulatory issues Avoid or reduce hepatic enzyme inducers; use newer AEDs Supplement Vitamin D and calcium Avoid valproate Pregnancy issues Avoid valproate and topiramate Use monotherapy Lamotrigine ??? Supplement folic acid Selective Issues: Women

72. Patients with renal insufficiency or who require dialysis often require lower doses of renal excreted AEDs Post Dialysis dosing Avoid or reduce levetiracetam, gabapentin, and pregabalin. Those with reduced hepatic function may require lower doses of medications that are hepatic metabolized. Avoid valproate and felbamate Reduce most AEDs Monitoring After Start of AEDs: Side effects

73. Combination therapy Combination of drugs required in one-third of patients Focal epilepsy related to an underlying structural lesion Those with multiple seizure types Developmental delay Potential drug interactions should be recognized Myoclonic seizures resistant to Valproic acid Add clonazepam Non responsive absence seizures Add Valproic acid A third drug can be added if no response

74. Surgical Treatment of Refractory Epilepsy 20–30% of patients with epilepsy are resistant to medical therapy S urgery can be extremely effective Temporal lobectomy Lesionectomy Hemispherectomy or Multilobar resection Corpus callosotomy Not all medically refractory patients are suitable candidates for resective surgery Vagus nerve stimulation (VNS)

75. When to Discontinue 70% of children and 60% of adults can eventually discontinue therapy Good patient profile for drug withdrawal Complete medical control of seizures for 1–5 years Single seizure type Normal Neurologic examination Normal EEG If the epileptogenic cause is treated

76. Cont … A ttempt withdrawal of therapy after 2 years in a patient who meets all of the above criteria R educe the dose of the drug gradually over 4–6 months Most recurrences occur in the first 3 months A dvised to avoid potentially dangerous situations during discontinuation Patient is motivated to stop Patient profile is assessed

77. STATUS EPILEPTICUS It is a neurologic emergency. It can be convulsive or nonconvulsive. Convulsive status epilepticus is 5 minutes or more of continuous seizure activity or two or more sequential seizures without full recovery of consciousness between the seizures. Nonconvulsive status epilepticus is a range of conditions in which greater than 30 minutes of recurrent electrographic seizure activity results in nonconvulsive clinical symptoms or electrographic seizure activity persists for greater than 30 minutes in the absence of visible convulsion.

78. Cont… Neurocritical Care Society is defined it as 5 minutes or longer of continuous clinical and/or electrographic seizure activity or recurrent seizure activity without recovery between seizures. Refractory status epilepticus: Clinical or electrographic seizures that persist after adequate doses of an initial benzodiazepine and an acceptable second-line antiseizure drug. Super-refractory status epilepticus: Seizures continue to recur 24hours or more after the onset of anesthetic therapy.

79. Causes Anticonvulsant withdrawal or noncompliance Metabolic disturbances &electrolyte abnormalities Drug toxicity CNS infection CNS tumors Refractory epilepsy and head trauma Anoxic brain injury Alcohol withdrawal Traumatic brain injury Idiopathic

80. Treatment The goal of treatment for convulsive status epilepticus is to achieve seizure control as quickly and safely as possible. Initial steps should always be to stabilize the patient with special attention to airway, breathing, and circulation. Admit the patient in the ICU or Neurocritical Care facility Administer oxygen and secure the airway as needed .

81. Cont … Initiate ECG monitoring, perform finger-stick glucose, and screen for any immediate life-threatening causes such as meningitis and intracranial mass lesions. Attempt IV access and send blood for electrolytes, hematology, and toxicology screen. Emergent AEDs.

82. GUIDELINES FOR TREATMENT OF SE

83. Catamenial Epilepsy Marked increase in seizure frequency around the time of menses Some women E ither the effects of estrogen and progesterone C hanges in antiepileptic drug levels Treatment Acetazolamide :started 7–10 days prior to the onset of menses and continued until bleeding stops I ncrease in antiepileptic drug dosages during this time C ontrol of the menstrual cycle

84. Pregnancy Most women have an uncomplicated gestation and deliver a normal baby Seizure frequency during pregnancy Unchanged in ~50% of women Increase in 30% Decrease in 20% See patients at frequent intervals during pregnancy

85. Cont … Monitor serum antiepileptic drug levels Incidence of fetal abnormalities in children born to mothers with epilepsy is 5–6%, compared to 2–3% in healthy women Teratogenic effects of antiepileptic drugs A syndrome comprising facial dysmorphism , cleft lip, cleft palate, cardiac defects, digital hypoplasia, and nail dysplasia Risk increases with the number of medications used

86. Cont… Pregnant women should be maintained on effective drug therapy Monotherapy at the lowest effective dose, especially during the first trimester Patients should also take folate (1–4 mg/d) Mother should be treated with oral vitamin K (20 mg/d) in the last 2 weeks of pregnancy The infant should receive vitamin K (1 mg) at birth. Encouraged breast-feeding

87. Contraception Carbamazepine , phenytoin, phenobarbital, Antagonize the effects of oral contraceptives Consider alternative forms of contraception

88. Questions????