Updated: 8/24/2018

Seizures

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Snapshot
  • A 16-year-old woman presents to the emergency department with a recent convulsive episode. The mother reports that this episode occured a few hours after awakening, described her movements as myoclonic, and involving the upper extremity. As time progressed, her myoclonus evolved into a generalized tonic-clonic seizure that lasted 3-4 minutes. The patient reported to sleeping only a few hours per night due to upcoming examinations. Physical exam is unremarkable. EEG shows 5-Hz polyspike and slow-wave discharges. (Juvenile myoclonic epilepsy)
Introduction
  • Clinical definition
    • synchronized and high-frequency neuronal depolarization that results in
      • abnormal behavior and patient experience
    • this is different from epilepsy, which can be simply described as
      • a tendency to have recurrent seizures that are unprovoked
        • febrile seizures are not considered to be epilepsy
  • Other definitions
    • ictal
      • during the seizure
    • postictal
      • after the seizure
    • interictal
      • between seizures
    • aura
      • simple partial seizures that are brief and have
        • no outward behavioral manifestations
      • for example, patients may describe a rising epigastric visceral sensation in
        • a seizure affecting the medial temporal limbic structures
    • status epilepticus
      • life threatening seizure episode that occurs
        • continuously or in rapid successions
  • Etiology
    • can be divided into provoked and unprovoked causes
      • provoked
        • substance abuse (e.g., cocaine and MDMA)
        • space occupying lesion (e.g., malignancy and abscess)
        • stroke (e.g., ischemic and hemorrhagic)
        • meningitis and encephalitis
        • hypo- or hyperglycemia
        • hyponatremia
        • hypocalcemia
        • hypomagnesemia
        • medication withdrawal (e.g., benzodiazepine and alcohol)
      • unprovoked
        • underlying neurological disorder (e.g., childhood absence epilepsy and neurofibromatosis)
  • Seizure classification
    • classification is based on the International League Against Epilepsy (ILAE)
    • seizures can be initially divided into
      • partial and generalized
Partial (Focal) Seizures
  • Clinical definition 
    • abnormal neuronal activity in a localized (focal) part of the brain
  • Partial seizures can
    • secondarily generalize
    • be subdivided into
      • simple partial seizures
      • complex partial seizures
 
Partial (Focal) Seizure Types
Seizure Type
Clinical Features
Simple partial seizures
  • Consciousness is spared
  • Symptoms are dependent on the anatomical location of the seizure
    • e.g., abnormal shapes or flashes when there is a seizure in the primary visual cortex
  • Typically no postictal deficits in brief simple partial seizures
Complex partial seizures 
  • Consciousness is impaired
    • this can be complete or mild
  • Symptoms are dependent on the anatomical location of the seizure
  • May have automatisms
  • Most common location is in the
    • temporal lobes
 
Generalized Seizures
  • Clinical definition
    • abnormal neuronal activity in both hemispheres of the brain
  • Generalized seizures
    • is almost always associated with impaired consciousness
    • generalized tonic-clonic (grand mal) seizures is
      • the most common type of generalized seizure
 
Generalized Seizure Types
Seizure Type
Clinical Features
Absence (petit mal seizures)
  • Most commonly occurs in children
  • Can occur many times in a day
  • Brief episodes (~10 seconds) of unresponsiveness
    • parents may report the patient had a blank stare
    • can occur many times in a day
  • No postictal deficits and automatisms
  • Characteristic EEG finding is
    • generalized 3-4-Hz spike and wave discharges
Myoclonic
  • Patients can present with quick and repetitive jerks
Tonic-clonic
  • Typically begins with a tonic phase
    • contraction of all muscles for 10-15 seconds
      • leads to a fall "like a tree"
  • The clonic phase follows the tonic phase
    • rhythmic jerking of the bilateral extremities
  • There are postictal deficits
Tonic
  • Patients can present with stiffening
Atonic
  • Patients can present with "drop" seizures
    • can be mistaken as fainting
 
 

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Questions (2)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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