Section VIII. Seizure and Epilepsy

Answer c.

The scenario is typical for juvenile myoclonic epilepsy

(JME). Patients with JME often present as developmentally

normal teenagers. Patients have a combination of myo-

clonic, GTC, and absence seizures. Myoclonic seizures often

occur shortly after waking. GTC seizures occur in more than

90% of patients with JME. Conversely, absence seizures are

present in only about one-third of JME patients. The EEG

typically shows generalized 4- to 6-Hz polyspike-and-wave

discharges interictally. Generalized discharges and myo-

clonic seizures are photosensitive in about 30% of patients.

Answer a.

West syndrome is clinically characterized by infantile

spasms and developmental arrest or regression. Infantile

spasms are a type of epileptic spasms that occur during

infancy and often occur in clusters. In patients with West

syndrome, the interictal EEG shows hypsarrhythmia, which

consists of high-amplitude, asynchronous slow waves with

multifocal spikes and sharp waves (Figure 81.6).

Electrodecrement is typically seen on EEG during spasms.

Answer b.

In patients with autosomal dominant nocturnal frontal lobe

epilepsy, seizures begin in late childhood or adolescence and

persist into adulthood. This syndrome is associated with an

autosomal dominant mutation in the genes coding for neuro-

nal nicotinic acetylcholine receptor subunits, including

CHRNA2, CHRNA4, and CHRNB2. Seizures are usually focal

aware with hyperkinetic or tonic movements and occur dur-

ing non–rapid eye movement sleep. Patients frequently have

sensory or psychic auras. The interictal EEG is usually nor-

mal; the ictal EEG may show frontal discharges (or they may

be obscured by artifact), but it can also be normal.

Answer b.

Limited sleep deprivation can lower the seizure thresh-

old, but it would not be expected to provoke a seizure in

a person who did not have a tendency toward seizures.

All the other choices would be expected to cause acute

symptomatic seizures.

Answer a.

Children and older persons are the most likely to receive

a new diagnosis of epilepsy. The stroke in the 68-year-old

man increased his risk. Concussion is not a risk factor for

seizures. Hypoglycemia or febrile illnesses can cause sei-

zures that are provoked rather than unprovoked. A family

history of epilepsy is a risk factor for epilepsy, but the risk

is not as high as the risk with stroke.

Answer b.

Drug-resistant epilepsy, high seizure burden, multifocal or

evolving seizures, and a history of autoimmune disease are

clinical factors associated with autoimmune epilepsy. The

origins of generalized epilepsies are idiopathic and genetic.

Patients with infrequent seizures are less likely to have auto-

immune epilepsy. Multifocal epilepsy may occur with auto-

immune epilepsy, but a preexisting congenital brain anomaly

(polymicrogyria) would be a more likely cause. Patients with

autoimmune epilepsy may have cognitive impairment, but

an elderly patient with long-standing, well-controlled epi-

lepsy would be more likely to have dementia.

Answer e.

Syncope is sometimes mistaken for seizure and is 60 times

more common. Clinical features more suggestive of syn-

cope include history of cardiac disease or arrhythmia, pal-

pitations, short duration (typically seconds rather than

minutes), and associated autonomic symptoms (see Box

83.4). Convulsive syncope is a particularly perplexing con-

founder when the associated brief myoclonic motor activ-

ity is confused with a seizure. Vasovagal syncope may have

a typical provoking factor, such as pain or needles.

Answer b.

Psychogenic nonepileptic seizures can resemble epileptic

seizures, but Box 83.7 lists some features more common in

nonepileptic seizures. Lack of stereotypy would be atypi-

cal for epileptic seizures. Incontinence favors a diagnosis

of seizure, although it can occur with nonepileptic sei-

zures. Bicycling motion of the legs can be seen if patients

have a frontal seizure focus, whereas pelvic thrusting

would be unusual. Grunting, screaming, or moaning occurs

more commonly with frontal rather than temporal localiza-

tion, and laughter is sometimes a feature when patients

have hypothalamic lesions (eg, gelastic seizure). Head

turning and gaze deviation are also common with seizures.

VIII.9. Answer b.

Psychic symptoms such as déjà vu, a rising epigastric sen-

sation, powerful emotions (fear or fright), or a noxious

smell can indicate an aura emanating from the temporal

lobe. See Table 83.1.

VIII.10. Answer c.

Contraception should be discussed with all women of

childbearing age when antiseizure medication is pre-

scribed. Oral contraceptives are hepatically metabolized

by the same enzymes as many of the enzyme-inducing

antiseizure medications, so those medications can reduce

the effectiveness of contraception. Folic acid is recom-

mended as a supplement for women with childbearing

potential because supplementation can decrease the rate

of neural tube defects in the growing fetus. A common

dose is 0.4 to 1 mg daily. Although nearly all antiseizure

medications present some risk of teratogenic adverse

effects, valproic acid carries the highest potential harm.

During pregnancy, the dosing of medications may need to

be modified as the patient’s metabolism and volume of

distribution of the medication change. Monitoring drug

levels may be helpful. After delivery, the medications

should be adjusted again to avoid potential adverse effects.

VIII.11. Answer d.

Surgery is generally reserved for patients with refractory

seizures who have a focal lesion. Up to 70% of patients

with mesial temporal sclerosis can achieve seizure freedom

up to 2 years after surgical resection. Patients with cavern-

ous malformation may undergo surgery if the goal is to

reduce the rate of future hemorrhage. However, if the lesion

has not recently hemorrhaged and the patient responds to a

single medication, resection is not always pursued. Juvenile

myoclonic epilepsy is a generalized seizure disorder. Sulcal

subarachnoid blood is often due to underlying amyloid or

trauma (or both) and is not typically resected.

VIII.12. Answer e.

Box 84.1 reviews antiseizure medications and the route of

metabolism. Cannabidiol, carbamazepine, phenytoin, and

topiramate are predominantly metabolized through the

liver. Lacosamide is the only medication listed that is pre-

dominantly renally excreted.

VIII.13. Answer b.

Levetiracetam is indicated for complex partial seizures or

generalized seizures. It has minimal drug-drug interac-

tions. Felbamate is not commonly used because of its

potential for severe adverse effects. Divalproex and phe-

nytoin interact with warfarin. Ethosuximide is usually

used for generalized seizures such as absence seizures.