1. Seizure Disorders
Basics
Description
• Seizure: Sudden change in cortical electrical activity,
manifested through motor, sensory, or behavioral changes,
+/- an alteration in consciousness.
• System(s) affected: Nervous
• Synonym(s): Epilepsy; Convulsion; Attacks; Spells
Geriatric Considerations
Fractures from falls are more common in the osteopenic age range.
Pediatric Considerations
Breast-feeding is not contraindicated. Sedation in the infant should
be monitored.
Pregnancy Considerations
• Monitor serum levels of antiepileptic drugs (AEDs).
• There is a twofold increase in congenital malformations in
children born to mothers taking anticonvulsants, depending
on the anticonvulsant. Some expectant mothers can be taken
off anticonvulsants safely for the 1st trimester or initial 6
week period (organogenesis.) Avoid Depakote. Epilepsy
patients should notify their neurologist before conception if
possible.
• Recommend against use of category C or D AEDs during
pregnancy/nursing.
Epidemiology
Incidence
• Approximately 200,000 new cases of epilepsy are diagnosed
in the US each year.
• 45,000 new cases in children <15 years of age
• Pediatric (<2 years) and older adults (>65 years) more
commonly present with new-onset seizures.
• Predominant sex: Male = Female
Prevalence
• 2.7 million with seizure disorder
• 4 million people have had 1 or more seizures.
• 326,000 children (≤14 years) and 600,000 adults (>65 years)
have a seizure disorder.
Risk Factors
Children delivered breech have a prevalence rate of 3.8%
compared with 2.2% in vertex deliveries.
Genetics
Family history increases risk threefold.
General Prevention
Acetaminophen to prevent febrile seizures. Take measures to
prevent head injuries. Reduce exposure to lead-containing
products. Avoid excessive alcohol use/abuse.

2. Pathophysiology
Synchronous and excessive firing of neurons resulting in
impairment of normal control of CNS
Etiology
• Brain tumor
• Cerebral hypoxia
• Cerebrovascular accident
• Convulsive or toxic agents (e.g., lead, alcohol, picrotoxin,
strychnine)
• Drug or alcohol overdose/withdrawal
• Eclampsia
• Exogenous factors, triggers (e.g., sound, light, cutaneous
stimulation)
• Fever, acute infection, or metabolic disturbance
• Head injury
• Heat stroke
Commonly Associated Conditions
Infections, tumors, drug abuse, alcohol and drug withdrawal,
trauma, metabolic disorders
Diagnosis
• Differentiate first between epileptiform seizures and
nonepileptiform seizures (NESs).
• If NES are psychogenic; often are associated with history of
sexual abuse
o Psychogenic NES is usually associated with a history of
psychiatric conditions. Physiologic seizures are true
cortical events and often require acute intervention.
 Hyperthyroidism
 Hypoglycemia
 Nonketotic hyperglycemia
 Hyponatremia
 Uremia
 Porphyria
 Hypoxia
 Confusional migraine
 Transient ischemic attack
 Narcolepsy/sleep disorder
 Toxin
• International classification of seizures:
o Generalized seizures:
o Absence
o Atonic
o Juvenile myoclonic
 Myoclonic: Repetitive muscle contractions
 Tonic–clonic: Tonic phase: Sudden loss of
consciousness; clonic phase: sustained
contraction followed by rhythmic contractions of
all 4 extremities; postictal phase: headache,

3. confusion, fatigue; clinically, hypertensive,
tachycardic, and otherwise hypersympathetic
o Febrile seizures:
 Age between 3 months and 5 years
 Fever without evidence of any other defined
cause for seizures
 Recurrent febrile seizures probably do not
increase the risk of epilepsy
o Symptomatic focal epilepsies
o Complex partial seizures
o Nonconvulsive status epilepticus: Most commonly seen
in ICU patients-no tonic clonic activity seen so must
diagnose with bedside EEG
o Status epilepticus: Repetitive generalized seizures
without recovery between seizures; considered a
neurologic emergency.
History
• Eyewitness descriptions of event
• Patient impressions of what occurred before, during, and
after the event
• Screen for etiologies.
• Provoking or ameliorating factors for the event including
sleep deprivation
• Ask about bowel or bladder incontinence, tongue biting,
other injury, automatisms.
Physical Exam
Thorough neurologic exam
Diagnostic Tests & Interpretation
A negative EEG does not rule out a seizure disorder.
• Sleep deprivation is helpful prior to EEG to identify positive
spike wave formations.
• Video EEG monitoring is used to differentiate psychomotor
NES from true cortical events
Lab
Initial lab tests
• Serum tests: Glucose, sodium, potassium, calcium,
phosphorus, magnesium, BUN, ammonia
• AED levels
• Drug and toxic screens: Include alcohol.
• Complete blood count (CBC): Rule out infection.
Follow-Up & Special Considerations
• Consider an arterial blood gas determination.
• Drugs that may alter lab results: AED therapy may affect the
EEG results dramatically.

4. • Inadequate AED levels: May be altered by many medications,
such as erythromycin, sulfonamides, warfarin, cimetidine,
and alcohol.
• Disorders that may alter lab results: Pregnancy decreases
serum concentration.
• Consider HLA testing in Asian patients.
Imaging
Imaging is recommended for new onset seizures when localization-
related epilepsy is known or suspected, when the epilepsy
classification is in doubt, or when an epilepsy syndrome with
remote symptomatic cause is suspected. MRI is preferred to CT
because of its superior resolution, versatility, and lack of radiation
Initial approach
• Brain MRI: Superior in evaluation of the temporal lobes
• CT scan of brain: Indicated routinely as initial evaluation esp
in ER
• Bone scan to determine bone mineral density (BMD) –
generally done if pt on older AEDs such as Dilantin and
Tegretol
Diagnostic Procedures/Surgery
LP for spinal fluid analysis may be necessary especially if fever or
impairment of consciousness
Pathological Findings
MRI may identify a nidus for seizure activity.
Differential Diagnosis
• General:
o Idiopathic
o Acute infection
o Trauma
o Drug and alcohol withdrawal
o Tumor
o Conversion disorder: Pseudoseizure
o NES
o Vascular disease
• Additionally:
o Infancy (0–2 years):
 Perinatal hypoxia
 Metabolic: Hypoglycemia, hypocalcemia,
hypomagnesemia, vitamin B6 deficiency,
phenylketonuria
o Childhood (2–10 years): Febrile seizure
o Adolescent (10–18 years):
 Arteriovenous malformations
o Late adulthood (>60 years):

5.  Degenerative disease including dementia
 Metabolic: Hypoglycemia, uremia, hepatic
failure, electrolyte abnormality
Treatment
• 50-60% presenting with an initial unprovoked seizure
will not have a recurrence; 40–50% will have a
recurrence within two years (2)[A].
• Starting antiepileptic medications reduces recurrences of
seizures, but does not alter long term outcomes (3)[A].
• Evidence is conflicting whether or not to routinely start AEDs
in patients with an initial seizure and no focal abnormalities
on exam or imaging, though many recommend deferring
treatment until a second seizure has occurred (4)[A].
Medication
• AEDs of choice: Select from seizure groups below, with
attention toward potential side effects.
• Choice of AED is based on type of seizure
• Monotherapy is preferred whenever possible. Systemic
reviews found insufficient evidence on which to base a 1st- or
2nd-line choice among these drugs in terms of seizure
control.
• Treatment options include:
o Carbamazepine (Tegretol) 100–200 mg/d in 1–2 doses;
therapeutic range: 4–12 mg/L
o Phenytoin (Dilantin) 200–400 mg/d in 1–3 doses;
therapeutic range 10–20 mg/L
o Valproic acid (Depakene) 750–3,000 mg/d in 1–3 doses
to begin at 15 mg/kg/d; therapeutic range 50–150 mg/L
o Lamotrigine (Lamictal) 25–50 mg/d; adjust in 100-mg
increments every 1–2 weeks to 300–500 mg/d in 2
divided doses.
o Oxcarbazepine (Trileptal) 300 mg b.i.d., increase to
300 mg/3 days; maintenance 1,200 mg/d
o Topiramate (Topamax) 50 mg/d; adjust weekly to
effect; 400 mg/d in 2 doses, maximum 1,600 mg/d
o Pregabalin (Lyrica)
o Lacosamide (Vimpat), particularly if refractory
seizures
• Alternative drugs (in addition to any of the preceding):
o Phenobarbital: 50–100 mg b.i.d.–t.i.d.; therapeutic
range 15–40 mg/L
o There is evidence to suggest long-term use of
phenobarbital may impair cognitive ability.
o Primidone (Mysoline) 100–125 mg qhs; adjust to
maximum of 2,000 mg/d in 2 doses.
• Contraindications: Refer to manufacturer's profile of each
drug.

6. • Precautions: Doses should be based on individual's response
guided by drug levels.
• Consider cautioning about increased risk of suicide, but risk
of untreated seizures is far greater than increased risk of
suicide (5)[A].
• Patients are susceptible to SUDEP (sudden unexpected death
in epilepsy) possibly due to cardiac arrhythmia
Additional Treatment
Issues for Referral
• Patients should be referred to and followed by a specialist
regularly.
• Frequency of visits is based on severity and patient's wishes;
maximum of 1 year between visits.
Complementary and Alternative Medicine
• There is no evidence that any complementary medicines
improve seizures, but they may induce serious drug
interactions with prescribed AEDs.
• Psychological therapies may be used in conjunction with AED
therapy. Cognitive-behavioral therapy, relaxation,
biofeedback, and yoga all may be helpful as adjunctive
therapy (6)[C].
• Patients with NES should be referred for psychotherapy.
Surgery/Other Procedures
• Resection for seizures that fail traditional therapy
• Vagus nerve stimulation
In-Patient Considerations
Initial Stabilization
• Protect the airway, and if possible, protect the patient from
physical harm; do not restrain.
• Administer acute AEDs.
Admission Criteria
Outpatient therapy is usually sufficient except for status
epilepticus.
Ongoing Care
Follow-Up Recommendations
• Maintain adequate drug therapy; ensure compliance
and/or access to medication.
• Drug therapy withdrawal may be considered after a seizure-
free 2-year period. Expect a 33% relapse rate in the following
3 years.
Patient Monitoring
• Monitoring of drug levels and seizure frequency
• CBC and lab values (e.g., calcium, vitamin D) as indicated,
BMD

7. • Monitor for side effects and adverse reactions.
• All patients currently taking any AED should be monitored
closely for notable changes in behavior that could indicate
the emergence or worsening of suicidal thoughts or behavior
or depression.
Diet
Ketogenic diet may be beneficial in children in conjunction with
AED therapy.
Patient Education
• Stress the importance of medication compliance and the
avoidance of alcohol and recreational drugs.
• Individuals with uncontrolled seizures should be encouraged
to avoid heights and swimming.
• State driving laws: epilepsyfoundation.org – most states
require a minimum of 6 months seizure free
• http://epilepsy.org
Prognosis
• Depends on type of seizure disorder
• ∼70% will become seizure-free with initial appropriate
treatment, but 30% will continue to have seizures. The
number of seizures within 6 months after first presentation
is the most important factor for remission.
• Approximately 90% who are seen for a first unprovoked
seizure attain a 1–2 year remission within 4 or 5 years of the
initial event (2)[A].
• Life expectancy is shortened in persons with epilepsy.
• The case-fatality rate for status epilepticus may be as high as
20%.
Complications
Drug toxicity.
References
1. Gaillard WD, Chiron C, Cross JH, et al. Guidelines for imaging
infants and children with recent-onset epilepsy. Epilepsia.
2009;50:2147–53.
2. Berg AT, et al. Risk of recurrence after a first unprovoked
seizure. Epilepsia. 2008;49(1):13–8.
3. Arts WF, Geerts AT, et al. When to start drug treatment for
childhood epilepsy: the clinical-epidemiological evidence. Eur J
Paediatr. Neurol. 2009;13:93–101.

8. 4. Haut SR, Shinnar S, et al. Considerations in the treatment of a
first unprovoked seizure. Semin Neurol. 2008;28:289–96.
5. Hesdorffer DC, Kanner AM. The FDA alert on suicidality and
antiepileptic drugs: Fire or false alarm? Epilepsia. 2009;50:978–
86.
6. Marson A, Ramaratnam S. Epilepsy. Clin Evid Concise.
2005;13:362–4.
7. Levy R, Cooper P. Ketogenic diet for epilepsy. Cochrane
Database of Systematic Reviews. 2003;3: CD001903.
DOI:10.1002/14651858.CD001903.
Seizures, Febrile; Status Epilepticus
Codes
ICD9
• 345.90 Epilepsy, unspecified, without mention of intractable
epilepsy
• 779.0 Convulsions in newborn
• 780.39 Other convulsions
Snomed
• 128613002 seizure disorder (disorder)
• 84757009 epilepsy (disorder)
• 87476004 convulsions in the newborn (disorder)
Clinical Pearls
• Encourage helmet usage to minimize head injuries.
• In order for the patient to be allowed to drive, he or she must
be seizure-free from a minimum of 3 months up to a year
depending on state requirements.
• Drug initiation after a single seizure will decrease risk of
early seizure recurrence (8)[A] but does not affect long-term
prognosis of developing epilepsy (9)[A].