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Seizures and other such Spells
27th Annual Family Medicine Review
Austin, Texas APRIL 2011
Jeffrey Clark, D.O.
things that come and go
Spells
• SZ
• Migraine
• TIA/Syncope
Hypoglycemia
Intoxication
Psychiatric (spells)
Narcolepsy
BPPV
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
The Significance of Syncope
• Some causes of syncope are potentially fatal
• Cardiac causes of syncope have the highest mortality rates
Syncope Mortality
25%
20%
15%
10%
5%
0%
Overall
1
Day SC, et al. Am J of Med 1982;73:15-23.
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.
2
Due to Cardiac Causes
Structural Cardiac
Abnormalities
• Hx of MI / Ischemic
injury
• CHF / decreased EF
• Valvular
abnormalities
• Outflow obstruction
• Wall motion abn.
Cardiac Rhythm
Abnormalities
Bradycardia
• Sick sinus
• AV block
Tachycardia
• VT
• SVT
Long QT
Syndrome
Test/Procedure
Yield
based on mean time to
diagnosis of 5.1 months7
History and Physical
(including carotid sinus massage)
ECG
49-85% 1, 2
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%
•
External Loop Recorder
(2-3 weeks duration)
20% 7
•
Insertable Loop Recorder
(up to 14 months duration)
Neurological †
(Head CT Scan, Carotid Doppler)
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.
7
65-88% 6, 7
0-4%
4,5,8,9,10
9 Day S, et al. Am J Med. 1982; 73: 15-23.
Kapoor, JAMA, 1992
10 Stetson P, et al. PACE. 1999; 22 (part II): 782.
Krahn, Circulation, 1995
7 Krahn, Cardiology Clinics, 1997.
8 Eagle K,, et al. The Yale J Biol and Medicine. 1983; 56: 1-8.
5
6
*
†
Structural Heart Disease
MRI not studied
Subclavian
Stenosis
Subclavian
Stenosis
(a) aortogram
(b) Delayed Image
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)
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
Focal Onset
(primarily generalized)
(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
• Warning (aura)
Complex
Partial
Often
• Duration
30-120 sec
• Occur (#)
1-3/day
• Automatisms
Often
Occas.
Partially
Totally
• Post-ictal (tired)
YES
no
• Focal abn (ex or scan)
Often
• Amnestic (for spell)
• Family hx
no
Absence
no
10-20 sec
10-20/day
no
YES
•
•
•
•
•
Phenobarbital (1912)
Dilantin (1938)
Ethosuximide (1955)
Tegretol (1974)
Valproate (1978)
Vagus Nerve Stimulator (1997)
•
•
•
•
•
•
•
•
•
•
•
Neurontin (1993)
Felbatol (1993)
Lamictal (1994)
Topamax (1996)
Gabitril (1997)
Keppra (1999)
Trileptal (2000)
Zonegran (2000)
Lyrica (2004)
Vimpat (2008)
Sabril (2009)
Sz free first
drug
47 %
First Drug Tried
36 %
Not Controlled
Sz free 2nd
drug
Sz free 3rd or
mult. drugs
Not sz free
4%
13 %
Second Drug
Success of AEDs in Previously Untreated Epilepsy Pts. (470)
NEJM 2000;342:314-319. Kwan P, Brodie MJ.
Dilantin dose increased
from 400 to 500 per day
What you should now know:
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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