Seizures and other such Spells

Seizures and other such Spells

27th Annual Family Medicine Review

Austin, Texas APRIL 2011

Jeffrey Clark, D.O.

things that come and go

• SZ• Migraine• TIA/Syncope

HypoglycemiaIntoxicationPsychiatric (spells) NarcolepsyBPPV

Spells

The Significance of Syncope

The only difference between

syncope and sudden death

is that in one you wake up.1

1 Engel GL. Psychologic stress, vasodepressor syncope, and sudden death. Ann Intern Med 1978; 89: 403-412.

Neurally-mediated syncope

Absence of cardiological disease

Long history of syncope

After sudden unexpected unpleasant sight, sound, smell or pain

Prolonged standing or crowded, hot places

Nausea, vomiting associated with syncope

During the meal or in the absorptive state after a meal

With head rotation, pressure on carotid sinus (as in tumors, shaving, tight collars)

After exertion

Syncope due to orthostatic hypotension

After standing up

Temporal relationship with start of medication leading to hypotension or changes of dosage

Prolonged standing especially in crowded, hot places

Presence of autonomic neuropathy or Parkinsonism

After exertion

Cardiac syncope

Presence of definite structural heart disease

During exertion, or supine

Preceded by palpitation

Family history of sudden death

Cerebrovascular syncope

With arm exercise

Differences in blood pressure or pulse in the two arms

1 Day SC, et al. Am J of Med 1982;73:15-23.2 Kapoor W. Medicine 1990;69:160-175.3 Silverstein M, Sager D, Mulley A. JAMA. 1982;248:1185-1189.4 Martin G, Adams S, Martin H. Ann Emerg Med. 1984;13:499-504.

• Some causes of syncope are potentially fatal• Cardiac causes of syncope have the highest mortality rates

The Significance of Syncope

0%

5%

10%

15%

20%

25%

Syn

cop

e M

ort

alit

y

Overall Due to Cardiac Causes

Structural Cardiac Abnormalities

• Hx of MI / Ischemic injury

• CHF / decreased EF

• Valvular abnormalities

• Outflow obstruction

• Wall motion abn.

Bradycardia• Sick sinus• AV block

Tachycardia• VT

• SVT

Long QT Syndrome

Cardiac Rhythm Abnormalities

Test/Procedure Yieldbased on mean time to

diagnosis of 5.1 months7

History and Physical (including carotid sinus massage)

49-85% 1, 2

ECG 2-11% 2

Electrophysiology Study without SHD*

11% 3

Electrophysiology Study with SHD 49% 3

Tilt Table Test (without SHD) 11-87% 4, 5

Ambulatory ECG Monitors:

• Holter 2% 7

• External Loop Recorder(2-3 weeks duration)

20% 7

• Insertable Loop Recorder(up to 14 months duration)

65-88% 6, 7

Neurological †

(Head CT Scan, Carotid Doppler)0-4% 4,5,8,9,10

* Structural Heart Disease† MRI not studied

1 Kapoor, et al N Eng J Med, 1983.2 Kapoor, Am J Med, 1991.3 Linzer, et al. Ann Int. Med, 1997.4 Kapoor, Medicine, 1990.

5 Kapoor, JAMA, 19926 Krahn, Circulation, 19957 Krahn, Cardiology Clinics, 1997.8 Eagle K,, et al. The Yale J Biol and Medicine. 1983; 56: 1-8.

9 Day S, et al. Am J Med. 1982; 73: 15-23.10 Stetson P, et al. PACE. 1999; 22 (part II): 782.

Arch aortogram initially shows apparent absence of left vertebral artery . However, delayed imaging on the same patient, the left vertebral artery (green) fills retrogradely to supply the left subclavian artery, (confirming left subclavian steal phenomenon secondary to a severe stenosis of the proximal left subclavian artery)

(b) Delayed Image(a) aortogram

SubclavianStenosis

SubclavianStenosis

Your Patient

• 21 year old college student who “keeps blacking out without seizure activity”…

• Evaluated in the ED this afternoon, phenytoin (Dilantin) level is “normal”...

• What other tests do you want?…

• What are these spells (? Seizures ?)• If so, what type of seizure is it (? And, does it matter ?)• How do you know they are not in status epilepticus?• What should your evaluation include?• How does the AED level help direct your plan?• What will you do if seizures continue in spite of management?

Will it happen again? (risk of recurrence)

If it does…

Seizures: Focal vs. Generalized Onset

Generalized Onset(primarily generalized)

Focal Onset(partial onset)

• Absence • Atonic• Myoclonic• Generalized tonic-clonic

• Partial motor• Partial sensory• Complex partial• Generalized tonic clonic

Epilepsy syndromes

• Juvenile myoclonic epilepsy

• Benign neonatal familial convulsions

• Childhood & Juvenile absence

• Febrile seizures

• West syndrome

• Lennox-Gastaut syndrome

• Rolandic epilepsy

Absence• Warning (aura) Often no• Duration 30-120 sec 10-20 sec• Occur (#) 1-3/day 10-20/day• Automatisms Often Occas.• Amnestic (for spell) Partially Totally• Post-ictal (tired) YES no• Focal abn (ex or scan) Often no• Family hx no YES

ComplexPartial

• Phenobarbital (1912) • Dilantin (1938)• Ethosuximide (1955)• Tegretol (1974)• Valproate (1978)

• Neurontin (1993)• Felbatol (1993)• Lamictal (1994)• Topamax (1996)• Gabitril (1997)• Keppra (1999)• Trileptal (2000)• Zonegran (2000)• Lyrica (2004)• Vimpat (2008)• Sabril (2009)Vagus Nerve Stimulator (1997)

Sz free firstdrug

Sz free 2nddrug

Sz free 3rd ormult. drugs

Not sz free

47 %

13 %

36 %

4 %

Success of AEDs in Previously Untreated Epilepsy Pts. (470)

NEJM 2000;342:314-319. Kwan P, Brodie MJ.

Not Controlled

First Drug Tried

Second Drug

Dilantin dose increased from 400 to 500 per day

What you should now know:

• SPELLS of… Vision, consciousness, weakness, etc… • Avoid terms such as “Blacking Out”, “Passing Out”, “Fell Out”• Syncope definition, evaluation, prognosis• Epilepsy, Tx & eval of epilepsy, Control of epilepsy• “Normal” AED Level• Therapeutic AED level• Toxic Level• “Post-ictal”• “Petit Mal” (Absence) sz• Convulsive syncope• Tussive Syncope & Micturation Syncope• “Hypoglycemia” spells• “Drop Attacks” due to “V-B Insufficiency” or “Subclavian Steal”• Carotid dz (? Causing syncope/spells with LOC)• Bank Robberies and other complex activity during seizures or

somnambulism