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Brain Injury and Seizures www.efmn.org | 1600 University Avenue West, Suite 300, St. Paul, MN 55104 | 1 1.800.779.0777 A little bit about your presenters • Amanda Pike- Epilepsy Foundation of MN • Jeannine Conway- University of MN, EFMN PAB 2 Today’s Objectives Define epilepsy and discuss the correlation between brain injuries and strokes with seizures Identify the most common types of seizures and describe appropriate response Discuss available treatment options 3 Epilepsy is… A neurological disorder of the brain characterized by the tendency to have recurring seizures May also be called a Seizure Disorder 4 Epilepsy Facts… Approximately 2.2 million Americans have epilepsy Epilepsy is the most common neurological condition in children and the fourth most common in adults after Alzheimer’s, stroke and migraines Approximately 1 in 26 people will develop epilepsy at some point in their lives Over 60,000 people in MN & ND have epilepsy 5 Epilepsy and stroke • Number 1 cause of epilepsy in people older than 50. • Side effects of medicine can make the effects of the stroke a little worse. • Make sure you know about any other medications and if it is safe to mix with any epilepsy medications. 6 What happens to the brain during a seizure? Sudden electrical activity in the brain Most seizures are either partial or generalized Where the activity occurs in the brain will determine how the seizure will look 7 Possible Causes of Epilepsy Head Trauma Brain tumor and stroke Infection and maternal injury Some forms are genetic 8 In 70% of the epilepsy cases – there is no known cause 9 Possible Seizure Triggers Assess the environment Failure to take medications Lack of sleep Stress / Anxiety Dehydration Photosensitivity – strobe lights Menstrual cycle / hormonal changes 10 Seizure Classification Partial Seizures (focal) Involves only part of brain Simple & complex forms Symptoms relate to the part of brain effected Generalized Seizures Involves whole brain Convulsions, staring, muscle spasms, and falls Most common are absence & tonic-clonic 11 Simple Partial Seizures Uncontrollable shaking movements of hand, arm or legs Sensory Seizures – may see flashing lights in peripheral vision, hear bells ringing, etc. Seizure usually lasts between 1 and 2 minutes – no impairment of consciousness May be considered an aura No immediate action is needed other than reassurance and emotional support A medical evaluation is recommended 12 Complex Partial Seizures Most common seizure type Unaware of surroundings and unable to respond Repetitive, purposeless movements such as lip smacking, hand wringing, or wandering - actions seem unusual Seizure usually lasts approximately three minutes 13 Complex Partial Seizures 14 Appropriate Response – Complex Partial Stay calm Track time Do not restrain Gently direct away from hazards Remain with the individual until they have gained full awareness 15 Absence Seizures (formerly petit mal) Usual onset between 4 and 12 years of age Characterized by brief staring – can be confused with “daydreaming” Starts and ends abruptly - can happen several times a day Quickly returns to complete awareness Appropriate response includes documentation 16 Absence Seizures (formerly petit mal) 17 Generalized Tonic Clonic (formerly grand mal) NOT the most common type Completely unconscious – loss of control Characterized by a sudden fall May cry out or make some types of noise Onset of uncontrolled jerking or shaking of muscles May have irregular breathing Lasts 5 minutes or less 18 Generalized Tonic Clonic (formerly grand mal) 19 Appropriate Response – Generalized Tonic Clonic Stay calm Protect their head Turn on side to prevent choking * Track time Check for Seizure Disorder ID Move objects out of the way * Do NOT put anything in the person’s mouth. 20 Appropriate Response – Generalized Tonic Clonic Remain with them until they have gained full awareness If seizure lasts more than 5 minutes, call EMS Recovery period– post ictal state 21 Call 911 if the person… Is injured Has diabetes Is pregnant Does not resume normal breathing Has a 1st time seizure Has a seizure in water 22 Treatment Options Medication Brain Surgery Diet VNS 23 Medications Medications are most often the first line of treatment: Approximately 60% of people achieve seizure control after the 1st year 15% achieve control at a later date 25% continue to have seizures despite treatment 24 Common Side Effects of Medication Lethargy Weight gain / weight loss Cognitive, concentration, memory difficulties Hyperactivity Emotional and/or behavioral changes 25 Brain Surgery Options Lobectomy • Partial Seizures • Hope for result of seizure free Corpus Callosotomy • Generalized Seizures • Never seizure free, less frequent/ intense seizures 26 Medical Device Options 27 Special Diets Ketogenic Diet • • • • Burns fat instead of glucose (fasting induced) Gets 80% of calories from fat Gets 20% from carbohydrates and proteins Must be strictly managed and maintained daily – 1/3 become seizure free or almost seizure free – 1/3 improve but still have some seizures – 1/3 do not respond or find it too hard to comply 28 Special Diets Modified Atkins Diet • No fluid or calorie restriction, no protein restriction • Foods not weighed and measured, carbohydrates monitored • Not fast induced Low Glycemic Index Treatment • Glycemic Index: how high that food raises your blood glucose • Easier to maintain - based more on portion control • Increase of carbohydrates with a low Glycemic Index 29 Possible Impact of Epilepsy Depression, Anger, Anxiety, Fear Cognitive Problems Developmental Delays Relationships Financial Costs School/Employment Driving Recreational Activities 30 The Epilepsy Foundation of Minnesota leads the fight to stop seizures, find a cure and overcome the challenges created by epilepsy. 1.800.779.0777 www.efmn.org www.efmn.org | 1600 University Avenue West, Suite 300, St. Paul, MN 55104 | 31 1.800.779.0777 ABOUT US We serve Minnesota and Eastern North Dakota Offices in St. Paul, Rochester, Duluth, St. Cloud, and Fargo Funding Sources: used clothing, individual/corporate donations, special events and grants The Epilepsy Foundation is the only organization in MN or ND that works exclusively with people affected by seizures. www.efmn.org | 1600 University Avenue West, Suite 300, St. Paul, MN 55104 | 32 1.800.779.0777 PROGRAMS THAT EDUCATE Seizure Smart Communities Seizure Recognition & Response Training Seizure Smart Schools Conferences & Workshops www.efmn.org | 1600 University Avenue West, Suite 300, St. Paul, MN 55104 | 33 1.800.779.0777 PROGRAMS THAT Camp Oz Regional Events Shining Star Program Information & Referral Program Peer Groups & Online Communities www.efmn.org | CONNECT 1600 University Avenue West, Suite 300, St. Paul, MN 55104 | 34 1.800.779.0777 PROGRAMS THAT Stroll for Epilepsy Creative Arts Advocacy Volunteering Youth Advisory Council Winning Kid www.efmn.org | EMPOWER 1600 University Avenue West, Suite 300, St. Paul, MN 55104 | 35 1.800.779.0777 Make A Difference! Help us educate, connect and empower those impacted by epilepsy! - Visit us online at www.efmn.org/giving - Participate in your employee giving campaign (United Way, Community Health Charities or Combined Federal Campaign) - Attend EFMN events - Donate your used clothing 36 Anticonvulsants and Brain Injury Objectives • Describe the elements of epilepsy treatment including: – Available treatments – Desired outcomes – Describe medication choices Indications for AEDs • • • • • • • • Epilepsy Headache Psychiatric disorders Neuropathic pain Behavior Weight loss Movement disorders Spasticity Goals of Epilepsy Care • Eliminate seizures with no side effects; alternatively – Reduce the number – Decrease the severity – Minimize side effects • Optimize quality of life Chronology of AED Development Year 1912 1938 1947 1954 1960 1968 1974 1975 1978 1st generation AEDs Drug Phenobarbital Phenytoin Mephenytoin (no longer available) Primidone Ethosuximide Diazepam Carbamazepine Clonazepam Valproate Year 2009 2011 2012 2nd generation AEDs Year Drug 1993 1994 1994 1996 1997 1999 1999 2000 2005 2009 2009 2011 3rd generation AEDs Drug Lacosamide Ezogabine Perampanel Felbamate Gabapentin Lamotrigine Topiramate Tiagabine Oxcarbazepine Levetiracetam Zonisamide Pregabalin Rufinamide Vigabatrin Clobazam Normal CNS Function Excitation Glutamate Aspartate Inhibition GABA Abnormal Excitation Glutamate Aspartate Excitation Inhibition GABA Furthermore, membrane depolarization leads to enhanced excitatory receptor function and reduced GABA-receptor function. This pattern of ‘voltage-dependence’ leads to an even greater level of excitation. AEDs Act By Restoring Balance Inhibition Excitation Reduce excitation Phenytoin (PHT) Carbamazepine (CBZ) Valproic acid (VPA) Felbamate (FBM) Lamotrigine (LTG) Topiramate (TPM) Oxcarbazepine (OXC) Zonisamide (ZNS) Levetiracetam (LEV) Increase inhibition Phenobarbital (PB) Benzodiazepines (BDZ) VPA FBM TPM ZNS Tiagabine Vigabatrin Drug Choices for the Treatment of New Onset Seizures Seizure Type First line therapy Partial Onset Carbamazepine Gabapentin Lamotrigine Oxcarbazepine Phenobarbital Phenytoin Topiramate Valproic Acid Generalized Lamotrigine Topiramate Valproic Acid Absence Lamotrigine Ethosuximide Valproic Acid Medication Selection • • • • • • • Seizure type Co-medications Medical conditions Age of the patient Insurance coverage Allergies Adherence challenges Optimize Therapy • Titrate dose or serum concentration to response • Increase dose until seizure control is attained or until unacceptable side effects occur • Consider adding 2nd AED if first is not effective Monitoring AED Treatment • Efficacy – Seizure control • Toxicity – Side effects – Serum concentrations Toxicity • Acute side effects – Concentration dependent • Common, bothersome, generally not life threatening • Reversible by decreasing the serum concentration • Examples: dizziness, ataxia, headache – Idiosyncratic • Rare, may be serious and life threatening • Generally involve organ hypersensitivity • Examples: hepatic failure, rash, aplastic anemia Toxicity • Chronic Side Effects – Due to long term exposure to the medication – Occur regardless of serum concentration levels – Examples: Alopecia, weight gain, behavior change, cognitive impairment Challenges in using anticonvulsants • • • • Age Gender Illness Drug interactions Types of Drug Interactions • Drug-drug: Valproic acid and lamotrigine • Drug-food: Carbamazepine and grapefruit juice • Drug-dietary supplement: Calcium and phenytoin • Drug-herbal: indinavir and St. John’s Wort • Drug-disease: medications that lower the seizure threshold and epilepsy Removing medication from body • Elimination is two processes: – Metabolism: a chemical reaction that changes the drug so the body can get rid of it – Excretion: removing the drug from the body • Blood moves drug to liver and kidney to be “disposed of” • Even if drug moves into non-eliminating tissues (like brain), it must get back to blood and moved to the liver and kidney’s for disposal Metabolism Changes one chemical (drug) into another for removal from the body via enzymes Enzymes are proteins that help chemical reactions along If you know how a drug is metabolized =Help predict interactions http://www.cincinnatichildrens.org/svc/alpha/l/liver/liver-anatomy.htm Major Liver Enzymes P450 Enzyme Examples of Drug That Use The Enzyme CYP1A2 Caffeine, Theophylline CYP2B6 CYP2C9 Bupropion Warfarin, Phenytoin, Phenobarbital, NSAIDs CYP2C19 Omeprazole, Phenytoin, S-Mephenytoin CYP2D6 Metoprolol, Fluoxetine Codeine, Dextromethorphan Carbamazepine, Zonisamide, Tiagabine, Ethosuximde, Cyclosporin, Triazolam, Amlodipine, Atorvastatin, Erythromycin CYP3A4 http://medicine.iupui.edu/flockhart/ Excretion Drug is removed from the body in urine http://www.nlm.nih.gov/medlineplus/ency/imagepages/1101.htm Not everyone is the same No 2D6=lack of pain relief CYP 2D6 Codeine (inactive) Morphine (active) Approximately 7-10% of the US population is deficient in CYP 2D6 Codeine glucuronide (inactive) As we age…. • Absorption – – – – Blood flow to stomach and intestines acidity stomach emptying intestinal motility • Distribution – muscle – fat • Metabolism – blood flow to liver – size of liver • Excretion – blood flow to kidneys – size of kidneys – ability to filter As a result drug interactions can change over time Summary • Many medication options available • Medication choice driven by several factors – Seizure type – Medical conditions – Other medications • Drug interactions can usually be proactively managed AED abbreviations 1st generation AEDs Year Drug PB Phenobarbital PHT Phenytoin PRM Primidone ESM Ethosuximide DZP Diazepam CBZ Carbamazepine Clonazepam VPA Valproate 2nd generation AEDs Year Drug FBM Felbamate GBP Gabapentin LTG Lamotrigine TPM Topiramate TGB Tiagabine OXC Oxcarbazepine LEV Levetiracetam ZNS Zonisamide PGB Pregabalin RUF Rufinamide VGB Vigabatrin CLB Clobazam 3rd generation AEDs Year Drug LAC Lacosamide EZG Ezogabine