High Yield Topics

Seizures and Epilepsy

By admin



Ovid: 5-Minute Sports Medicine Consult, The


Seizures and Epilepsy
Nilesh Shah
Basics
  • Complications:
    • Status epilepticus: Recurrent generalized seizures without return to consciousness
  • Seizure types:
    • Generalized: Sudden onset involving an altered level of consciousness, usually bilateral and symmetrical
    • Partial: Either simple (no alteration of consciousness) or complex (alteration/loss of consciousness often with semipurposeful inappropriate movements)
Description
  • A seizure is an abnormal paroxysmal electrical discharge in the brain, usually with mental status changes.
  • Individuals who have 2 or more seizures are deemed to have epilepsy.
  • Synonym(s): Convulsions; Epilepsy; Fits; Spells
Epidemiology
  • >10% of the population will have at least one seizure during their lifetime.
  • ∼3% will have epilepsy by age 70.
  • 100,000 new cases of epilepsy per year in the U.S., many in pediatric patients (1)[C]
  • 70–80% of patients with epilepsy will go into remission (1)[C].
Risk Factors
  • Cerebrovascular disease
  • Brain tumors
  • Alcohol
  • Previous head injury
  • Malformations of cortical development
  • Infections
  • Idiopathic
  • Low seizure threshold is impossible to quantify. It may represent a genetic or acquired brain disorder.
Commonly Associated Conditions
  • Abrasions, lacerations, contusions: Occur from uncontrolled contact with objects during seizure
  • Tongue lacerations: Tongue is often bitten during a seizure.
  • Blunt head trauma
  • Syncope
Diagnosis
History
  • Actual account by 1st-hand observer is extremely helpful.
  • Previous history of seizure
  • Previous history of head trauma
  • Medications
  • Social/family history
Physical Exam
  • Fever: Suggests infectious etiology
  • Focal neurologic deficit: Possible localized trauma or tumor
  • Meningismus: May be present in meningitis
  • Papilledema: Secondary to increased intracranial pressure
  • Look for injuries that may have occurred during the seizure.
  • Look for evidence of acutely increased intracranial pressure, such as pupillary dilatation or posturing, indicating an emergency.
  • Expect postictal confusion that gradually clears after a seizure.
  • Thorough neurologic exam to document focal deficits
Diagnostic Tests & Interpretation
Lab
  • Electrolytes, including glucose, calcium, magnesium, and phosphorus
  • Liver function tests, including ammonia level
  • Blood toxicology
  • Urine toxicology
  • Anticonvulsant level: Inadequate levels are a significant cause of recurrent seizures.
Imaging
  • CT scan: Rule out acute bleeding or intracranial masses.
  • MRI: May better define posterior fossa tumors, vascular abnormalities, and temporal lobes
  • Electroencephalography (EEG): May define true seizure activity and focus, although a negative EEG result does not rule out seizure disorder. Sometimes a sleep-deprived patient EEG may be required.
Diagnostic Procedures/Surgery
Spinal tap to rule out infectious etiology, elevated intracranial pressure, some congenital etiologies
Differential Diagnosis
  • Alcohol withdrawal
  • Arteriovenous malformation
  • Electrolyte abnormalities (hypoglycemia, hyponatremia)
  • Fever
  • Hepatic failure
  • Idiopathic
  • Illicit drug use/abuse/withdrawal
  • Infection
  • Intracranial swelling/2nd-impact syndrome
  • Primary/secondary brain tumor
  • Posttraumatic (impact) seizure
  • Stroke
  • Syncope
  • Uremia
  • Vascular disease
Treatment
Immediate actions:
  • Supportive: ABCs
  • Keep area clear: Ensure that the patient does not injure self or others.
  • If in the setting of trauma, stabilize C-spine.
  • Once stable, workup begins as above.
ED Treatment
  • Immediate ED treatment includes benzodiazepines or other antiepileptic drugs if patient is in status epilepticus.
  • Workup as above for etiology
  • Consider neurology consultation.
Medication
  • A number of drugs are available.
  • Use depends on etiology of seizures.
First Line
Benzodiazepines for status epilepticus
Second Line
Depends on etiology of seizure
Additional Treatment
General Measures
  • If no reversible cause is found, place patient on antiepileptic drugs (AEDs).
  • Monitor levels of AEDs, especially in 1st couple months of training.
  • Follow up with neurologist.

P.527


Additional Therapies
Transfer to ED if the patient has no known seizure disorder.
In-Patient Considerations
  • Hospitalization recommended for immediate care of uncontrolled seizures
  • Abnormal mental status associated with seizures
  • Ongoing studies (ie, sleep study or 24-hr EEG monitoring)
IV Fluids
  • IV drug administration
  • Correction of electrolyte abnormalities
  • Correction of dehydration
Ongoing Care
Follow-Up Recommendations
If no reversible cause is found, the patient should be referred to a neurologist for an initial visit and EEG.
Patient Education
Recommendations on specific sports (2)[C]:
  • Activities to be avoided:
    • Scuba diving
    • Parachuting
    • High-altitude climbing
    • Gliding
    • Hand-gliding
    • Aviation
    • Motor-racing
    • Boxing
  • Activities requiring precautions or supervision:
    • Water-skiing
    • Swimming
    • Canoeing
    • (Wind) surfing
    • Sailing
  • Activities requiring knowledge of seizure type and sports:
    • Cycle racing
    • Skating
    • Horse-riding
    • Gymnastics
Prognosis
Prognosis is generally good with well-controlled seizures.
Complications
Preparticipation Physical Evaluation (PPE) clearance for some sports in cases of uncontrolled or poorly controlled seizure disorders.
References
1. Arida RM, Cavalheiro EA, da Silva AC, et al. Physical activity and epilepsy: proven and predicted benefits. Sports Med. 2008;38:607–615.
2. van Linschoten R, Backx FJ, Mulder OG, et al. Epilepsy and sports. Sports Med. 1990;10:9–19.
3. Dimberg EL, Burns TM. Management of common neurologic conditions in sports. Clin Sports Med. 2005;24:637–662, ix.
Additional Reading
Cantu RV, Cantu R. Epilepsy and athletics. Clin Sports Med. 1998;17:61–69.
Fountain NB, May AC. Epilepsy and athletics. Clin Sports Med. 2003;22:605–616, x–xi.
Howard GM, Radloff M, Sevier TL. Epilepsy and sports participation. Curr Sports Med Rep. 2004;3:15–19.
Miele VJ, Bailes JE, Martin NA. Participation in contact or collision sports in athletes with epilepsy, genetic risk factors, structural brain lesions, or history of craniotomy. Neurosurg Focus. 2006;21:e9
Sirven JI, Varrato J. Physical activity and epilepsy— what are the rules? Physician Sports Med. 1999;27:63, 64, 67–70.
Codes
ICD9
  • 345.10 Generalized convulsive epilepsy, without mention of intractable epilepsy
  • 345.11 Generalized convulsive epilepsy, with intractable epilepsy
  • 780.39 Other convulsions
Clinical Pearls
  • There is no definitive evidence of any relationship between repetitive minor head injury and deterioration of the epileptic patient; therefore, most collision/contact sports are acceptable (but no boxing). Swimming is acceptable only with a certified lifeguard who should be made aware of the situation. Motor sports should be undertaken only by individuals with well-controlled seizures. Sports in which falling is a potential (eg, gymnastics, rock climbing, hang gliding) should be judged on an individual basis based on the type and frequency of seizure.
  • Sports need not be avoided for children who experience seizures. Improving overall health may reduce the number of seizures experienced by a child. He or she also may benefit from the increased self-esteem and social integration, so important to all youngsters, available with participation in sports. Children will obtain all the physiologic benefits of exercise, including increased cardiovascular fitness, stronger muscles, and weight control.
  • Many antiepileptic medications have side effects that may impair concentration or coordination. Most are approved by the NCAA and IOC.
  • The following questions need to be asked when deciding if participation in sports is OK (3)[C]:
    • Are there any other impairments to modify the athlete's participation (ie, ventricular shunts or vascular malformations)? What type of seizures occur? How often do seizures occur?
    • Do AEDs significantly impair the athlete's perception and alertness?
    • Overall, the decision is individualized, but the physiologic and psychological benefits of sport and exercise usually far outweigh the risk to athletes or their competitors.
  • Risk factors of exercise include fatigue, psychic stress, hypoxia, hyperhydration, hyperthermia, and hypoglycemia.
    • Hypoxia is usually an issue at high altitudes (>2,000 m).
    • Hyperhydration can occur with vigorous hydration in combination with sodium loss.
    • Hyperthermia, a known seizure trigger, can occur with exercise in the heat, especially with high humidity.
    • Certain AEDs can place athletes at risk for heat illnesses as well.
    • Hyperventilation is a common trigger of seizures but is rarely seen as a trigger in exercise because this is a compensatory mechanism owing to exercise, and respiratory alkalosis does not occur.


Continue Reading
You might also like More from author

This website uses cookies to improve your experience. We'll assume you're ok with this, but you can opt-out if you wish. Accept Read More