Seizures as a Manifestation of Systemic Disease

Exercise, medication adherence, and the menstrual cycle: How much do these change seizure risk?

People with epilepsy can experience tremendous stress from the uncertainty of when a seizure will occur. Three factors deemed important because of their potential influence on seizure risk are exercise, medication adherence, and the menstrual cycle. A narrative review was conducted through PubMed searching for relevant articles on how seizure risk is modified by 1) exercise, 2) medication adherence, and 3) the menstrual cycle. There was no consensus about the impact of exercise on seizure risk. Studies about medication nonadherence suggested an increase in seizure risk, but there was not a sufficient amount of data for a definitive conclusion. Most studies about the menstrual cycle reported an increase in seizures connected to a specific aspect of the menstrual cycle. No definitive studies were available to quantify this impact precisely. All three triggers reviewed had gaps in the research available, making it not yet possible to definitively quantify a relationship to seizure risk. More quantitative prospective studies are needed to ascertain the extent to which these triggers modify seizure risk.

Seizures in patients with respiratory disease - a retrospective single center study

OBJECTIVE

Seizures are a neurological condition commonly experienced during the follow-up period after systemic or metabolic disorders. The aim of the present study was to determine the etiological factors of seizures in patients at a tertiary care chest clinic.

METHODS

We reviewed all neurology consultations that were requested due to seizures in inpatient clinics in a tertiary care hospital specializing in respiratory disorders between January 2011 and January 2018 were retrospectively reviewed.

RESULTS

The present study included 705 of 2793 (25.2%) patients who requested consultations for seizures during the study period. The mean age of the sample was 64.05±17.19 years. Of the 705 patients, 307 (43.5%) had a previous history of epilepsy (Group I) and 398 (56.5%) had a first-time seizure and were considered to have symptomatic seizures (Group II). Multiple factors played roles in the development of seizures in 54.8% of the patients. In most patients, metabolic causes, systemic infections, and drug use were identified and an intracranial metastatic mass lesion was the major cause in patients with lung cancer. Rates of hypoxemia and respiratory acidosis were significantly higher in patients with symptomatic seizures (Group II) than in patients with primary epilepsy (Group I).

CONCLUSIONS

Blood gas changes such as hypoxemia and respiratory acidosis were among the factors statistically associated with the development of symptomatic seizures in patients with respiratory diseases. Additionally, hypoxemia, hypercapnia, and respiratory acidosis were correlated with mortality in patients hospitalized for respiratory system diseases who requested consultations for seizures.

Treatment, Therapy and Management of Metabolic Epilepsy: A Systematic Review

Metabolic epilepsy is a metabolic abnormality which is associated with an increased risk of epilepsy development in affected individuals. Commonly used antiepileptic drugs are typically ineffective against metabolic epilepsy as they do not address its root cause. Presently, there is no review available which summarizes all the treatment options for metabolic epilepsy. Thus, we systematically reviewed literature which reported on the treatment, therapy and management of metabolic epilepsy from four databases, namely PubMed, Springer, Scopus and ScienceDirect. After applying our inclusion and exclusion criteria as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we reviewed a total of 43 articles. Based on the reviewed articles, we summarized the methods used for the treatment, therapy and management of metabolic epilepsy. These methods were tailored to address the root causes of the metabolic disturbances rather than targeting the epilepsy phenotype alone. Diet modification and dietary supplementation, alone or in combination with antiepileptic drugs, are used in tackling the different types of metabolic epilepsy. Identification, treatment, therapy and management of the underlying metabolic derangements can improve behavior, cognitive function and reduce seizure frequency and/or severity in patients.

Acute Symptomatic Seizures Caused by Electrolyte Disturbances

In this narrative review we focus on acute symptomatic seizures occurring in subjects with electrolyte disturbances. Quite surprisingly, despite its clinical relevance, this issue has received very little attention in the scientific literature. Electrolyte abnormalities are commonly encountered in clinical daily practice, and their diagnosis relies on routine laboratory findings. Acute and severe electrolyte imbalances can manifest with seizures, which may be the sole presenting symptom. Seizures are more frequently observed in patients with sodium disorders (especially hyponatremia), hypocalcemia, and hypomagnesemia. They do not entail a diagnosis of epilepsy, but are classified as acute symptomatic seizures. EEG has little specificity in differentiating between various electrolyte disturbances. The prominent EEG feature is slowing of the normal background activity, although other EEG findings, including various epileptiform abnormalities may occur. An accurate and prompt diagnosis should be established for a successful management of seizures, as rapid identification and correction of the underlying electrolyte disturbance (rather than an antiepileptic treatment) are of crucial importance in the control of seizures and prevention of permanent brain damage.

Electroencephalography of encephalopathy in patients with endocrine and metabolic disorders

Patients with acute alteration in mental status from encephalopathy because of underlying metabolic-toxic or endocrine abnormalities are frequently seen in the acute hospital setting. A rapid diagnosis and correction of the underlying cause is essential as a prolonged state of encephalopathy portends a poor outcome. Correct diagnosis and management remain challenging because several encephalopathies may present similarly, and further laboratory, imaging, or other testing may not always reveal the underlying cause. EEG provides rapid additional information on the encephalopathic patient. It may help establish the diagnosis and is indispensable for identifying nonconvulsive status epilepticus, an important possible complication in this context. The EEG may assist the clinician in gauging the severity of brain dysfunction and may aid in predicting outcome. This review summarizes the current knowledge on EEG findings in selected metabolic and endocrine causes of encephalopathy and highlights distinct EEG features associated with particular etiologies.

A Prospective Evaluation of the Impact of Initial Glasgow Coma Score on Prehospital Treatment and Transport of Seizure Patients

Hypothesis:

The initial Glasgow Coma Score (GCS) obtained by prehospital personnel on seizure victims is associated with the likelihood of treatment and transport.

Methods:

Prehospital data were collected prospectively for all patients presenting with seizures to a mid-sized emergency medical services system during a five-month period. A total of 419 cases occurred (62.8% male, 37.2% female). Seizure frequency was highest in infants under the age of three years and in adults in their late 20s. A GCS was recorded in 378 cases (90.2%, study group). The GCS was >10 in 304 patients (80.4%) and ≤10 in 74 (19.6%). Patients with GCS≤10 were more likely to receive: oxygen (50.0% vs. 20.1%, p<.0001); IV (35.1% vs. 8.9%, p<.0001); intravenous (IV) medications (16.2% vs. 1.0%, p<.0001); and transport (97.3% vs. 76.3%, p<.0001).

Conclusion:

Seizure patients with a GCS of ≤10 were more likely to receive a variety of prehospital treatments and to be transported than were patients with GCS >10. However, the clinical indicators that were used to make the decision that it was “safe” not to transport nearly one-third of the patients are unclear. Essentially no data exist regarding the parameters impacting treatment and transport of seizure patients. Future investigations with outcome data, are needed to determine whether low risk criteria can be developed to identify those patients (if any) that do not require treatment or transport. A GCS may provide an objective, reproducible parameter upon which to begin formulating such criteria.

Progressive alterations in the hypothalamic-pituitary-adrenal axis in the R6/2 transgenic mouse model of Huntington's disease

Huntington's disease (HD) is characterized by a triad of motor, psychiatric and cognitive symptoms. Although many of these symptoms are likely to be related to central nervous system pathology, others may be due to changes in peripheral tissues. The R6/2 mouse, a transgenic model of HD expressing exon 1 of the human HD gene, develops progressive alterations in the hypothalamic-pituitary-adrenal axis, reminiscent of a Cushing-like syndrome. We observed muscular atrophy, reduced bone mineral density, abdominal fat accumulation and insulin resistance in the mice. All these changes could be consequences of increased glucocorticoid levels. Indeed, hypertrophy of the adrenal cortex and a progressive increase in serum and urine corticosterone levels were found in R6/2 mice. In addition, the intermediate pituitary lobe was markedly enlarged and circulating adreno-corticotrophic hormone (ACTH) increased. Under normal conditions dopamine represses the ACTH expression. In the R6/2 mice, however, the expression of pituitary dopamine D2 receptors was reduced by half, possibly explaining the increase in ACTH. Urinary samples from 82 HD patients and 68 control subjects were analysed for cortisol: in accord with the observations in the R6/2 mice, urinary cortisol increased in parallel with disease progression. This progressive increase in cortisol may contribute to the clinical symptoms, such as muscular wasting, mood changes and some of the cognitive deficits that occur in HD.

Structural lesions in periodic lateralized epileptiform discharges (PLEDs)

In this study we investigated the structural lesions of patients with periodic lateralized epileptiform discharges (PLEDs) to determine the possible relationship of lesions to PLEDs' localization on EEG and to metabolic abnormality. Clinical findings and electroencephalography (EEG), computerized tomography (CT) and magnetic resonance imaging (MRI) of the 71 adult patients with PLEDs were evaluated. Stroke, herpes encephalitis and intracranial tumor or abscess were the most common etiological factors. Cortical gray matter and adjacent subcortical white matter lesions were detected in 64.7%, cortical gray matter lesions in 11.3% and subcortical white matter lesions in 4.2% of the patients. Although it is thought that PLEDs occur mostly with acute lesions, chronic lesions causing PLEDs were found in 35.2% of the patients. Bilateral lesions were detected in 19.7% and 33.8% of the patients had metabolic abnormality. PLEDs localized the region of the lesion in 63.4% of the patients. PLEDs are usually self-limited features, but chronic PLEDs were detected in 5 patients in this study. Acute structural lesions involving cortical gray matter with adjacent subcortical white matter were found in most of the patients with PLEDs, but the lesion localization and age, acute or chronic, varied.

Evaluation of the patient with seizures: an evidence based approach

Statistics tell us that as many as 1 in 20 members of the population will suffer a seizure at some point in their lifetime, a figure which becomes even more likely if one lives to the age of 80. Thus, a careful evidence based approach to the patient with seizure is immensely useful to the emergency physician. The authors evaluate current studies on the subject, discuss seizures as they relate to specific patient groups, and, ultimately, make recommendations on this important subject.

Treatment of complex partial status epilepticus unmasking acute intermittent porphyria in a patient with resected anaplastic glioma

We report a 42-year-old woman with an established complex partial seizure disorder, who presented in refractory complex partial status epilepticus, the treatment of which with lorazepam, phenytoin, carbamazepine, and pentobarbital precipitated an attack of acute intermittent porphyria (AIP). The subsequent clinical course and management with gabapentin is discussed.

Alcohol-related seizures, Part I: Pathophysiology, differential diagnosis, and evaluation

Alcoholism may be society's most devastating problem short of war and malnutrition. Perhaps the most complex and perplexing medical complication of alcoholism is alcohol-related seizures. This article is a collective review designed to provide emergency physicians with an overview of the topic that is pertinent to their clinical practice. Part 1 addresses the pathophysiology, differential diagnosis, and evaluation of alcohol-related seizures. Part 2 will concentrate on the clinical presentation, management, and disposition. In addition, a classification of alcohol-related seizures will be proposed.

Defining the role of structural lesions and metabolic abnormalities in periodic lateralized epileptiform discharges

We reviewed the EEG, clinical manifestations, computed tomography (CT) and magnetic resonance imaging (MRI) scans of 39 patients with periodic lateralized epileptiform discharges (PLEDs) or bilateral periodic lateralized epileptiform discharges (BIPLEDs) to determine the role of structural lesions (SL) and metabolic abnormalities (MA) in their pathogenesis. Thirty-eight patients had CT and 7 had MRI scans. Thirty-eight had lesions on CT or MRI. All those with PLEDs consistently had lesions on the side of the discharges, and 5 of 6 with BIPLEDs had lesions on both hemispheres. A subgroup of 23 patients with metabolic determination within 24 h of EEG all showed mild to moderate MA. They all also had SL. These findings support a primary role for SL but cannot exclude an additional role for MA.

Magnesium: clinical considerations

Magnesium is gaining recognition as a clinically important electrolyte. Hypomagnesemia has been associated with a variety of disorders including seizures, malignant ventricular dysrhythmias, and sudden death. The emergency department patients who are most likely to be magnesium deficient include alcoholics, patients who take diuretics, and those in diabetic ketoacidosis. Hypokalemia and hypocalcemia may represent unrecognized hypomagnesemia. Clinical trials and case reports also document increasing interest in magnesium as an effective therapeutic agent for potentially life-threatening problems such as torsade de pointes, digitalis toxicity, bronchospasm, and alcohol withdrawal. We present an overview of hypomagnesemia, review the current literature, and focus on the role of magnesium in the acute care setting and the implications for the emergency physician.

Factors predictive of seizures among intensive care unit patients with gram-negative infections

From the medical records of 238 intensive care unit (ICU) patients who had infections with gram-negative pathogens commonly associated with serious illness, we developed a predictive score of clinical risk factors for seizures. To evaluate the predictive ability of this score, we applied it to a separate population of 645 seriously ill hospitalized patients with similar gram-negative infections who were in antibiotic clinical trials. The patients at highest risk were classified into one of the following three categories: (a) patients with major central nervous system (CNS) insults (CNS surgery, hemorrhage, infection, or other lesion within 1 month before hospital admission or any history of CNS neoplasia), (b) patients with a predisposing factor (renal impairment or a history of seizures) plus a precipitating factor (anoxic encephalopathy/coma or an acute hypotensive episode), and (c) patients with both renal impairment and a history of seizures. Receiver operating characteristic (ROC) curves were calculated in each of the two populations. The area under the ROC curve (AUC) represents the probability that the score would rank a randomly chosen patient who subsequently had a seizure as having had a greater prior level of seizure risk than a randomly chosen patient who did not experience a seizure. The AUC was 0.87 (SE = 0.05) for the original population used to develop the score and 0.81 (SE = 0.04) for the population used for the validation study. The clinical risk score, based on readily available information, provides a useful means to identify among seriously ill infectious disease service patients, those who are at highest risk for seizures. It also serves as a baseline for evaluating the non-drug-related risk factors for seizures in patients treated with antibiotics.

Compliance with a standard for the emergency department management of epileptics who present after an uncomplicated convulsion

We conducted a retrospective chart review to determine whether the treatment of uncomplicated convulsions in emergency department patients with a history of epilepsy complied with a clinical standard and whether the degree of compliance with the standard was related to the treating physician's specialty or postgraduate year of training. The standard specified items to be included in the medical record and appropriate diagnostic tests. A medical record score was defined by the presence of seven essential and seven desirable items obtained from the history and the physical examination. Only anticonvulsant levels and a serum glucose, when not ordered as part of a chemistry profile, were considered appropriate for all patients when drawn. A computed tomography head scan was deemed appropriate for patients whose neurologic status deteriorated or failed to return to baseline within one hour or who had a recent history of significant head trauma. The appropriateness of all other tests was evaluated by review of the medical record. One hundred consecutive ED visits by adult epileptics for an uncomplicated convulsion were considered. Patients ranged in age from 18 to 88 years (median, 28 years). Medical record scores ranged from 7 to 82 (median, 43). ED time ranged from eight to 539 minutes (median, 174.5 minutes). Ancillary services charges ranged from +0 to +1,774 (median, +181.50). Only 27.4% of these charges were for tests deemed appropriate. There was a significant relationship between the ED time and ancillary services charges (Spearman correlation = .5152, P less than .0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Utility of laboratory studies in the emergency department patient with a new-onset seizure

Extensive laboratory testing is often performed in the emergency department evaluation of the new-onset seizure patient. To determine the utility of such testing, a prospective study of patients with a new-onset seizure presenting to the ED of an inner-city, university-affiliated teaching hospital was done. One hundred thirty-six patients were entered into the study between October 1984 and January 1988. All patients had uniform data collection performed. Pertinent historical information and physical examination findings were recorded on a standardized form before laboratory abnormality was a sole or contributory cause of the seizure disorder. These included four patients with hypoglycemia, four with hyperglycemia, two with hypocalcemia, and one with hypomagnesemia. Only two cases (hypoglycemia) were not suspected on the basis of findings on the history or physical examination. In ED patients, the incidence of a new-onset seizure due to a correctable metabolic disturbance is low. We conclude that, with the exception of the serum glucose, the extensive ED laboratory workup often done for the evaluation of a new-onset seizure is unnecessary. Further test ordering should be directed by the medical history and physical examination.

Movement disorders as a manifestation of nonketotic hyperglycemia

Movement disorders are well-known presenting signs of metabolic disorders. Focal motor abnormalities may be the chief initial presentation of diabetes mellitus in the nonketotic hyperglycemic state in 6% of patients. Nonketotic hyperglycemia (NKH), in particular, may manifest any of a wide variety of movement disorders. These have been described as focal seizures, epilepsia partialis continua, myoclonus, and opsoclonia. There are descriptions of movement disorders in hyperglycemia that are similar to the coarse flapping tremor of asterixis, the posturing of paroxysmal kinetogenic choreoathetosis, and of "fencing (stance) seizures." Disorders of facial motor function including aphasia, facial muscle twitching and jerking, and disorders of muscular tone have been described. These may include hemiparesis and hemiplegias as well as increased tone, in some cases mimicking the nuchal rigidity of meningitis. The movement disorders in NKH may mimic cerebral vascular accidents, meningitis, or psychiatric disorders, as well as various types of seizures. Clinicians may be able to avoid expensive and time-consuming diagnostic evaluations to rule out NKH in patients with movement disorders. We present two patients with focal motor abnormalities associated with nonketonic hyperglycemia and review the pertinent literature.

Factors predisposing to seizures in seriously ill infected patients receiving antibiotics: experience with imipenem/cilastatin

Observations on 1,754 patients treated with imipenem/cilastatin in phase III dose-ranging studies in the United States were reviewed to determine risk factors for seizures. The patients were moderately to severely ill with numerous background disorders known to be associated with an increased risk of seizures. Fifty-two patients (3 percent) had seizures and in 16 (0.9 percent) of them the seizures were judged by the investigators to be possibly, probably, or definitely related to imipenem/cilastatin. An incidence of seizure of 2 to 3 percent was noted among patients treated with other antibiotics (usually including a beta-lactam in the regimen) at times when imipenem/cilastatin was not being given. The average time of onset of seizures for patients receiving imipenem/cilastatin was seven days after start of therapy. As with other beta-lactam antibiotics, central nervous system lesions and disorders including seizures and renal insufficiency were found to be strong risk factors for seizures. Imipenem/cilastatin dosages in excess of those currently recommended by the manufacturer, particularly in patients with renal insufficiency, were also associated with an increased risk of seizures. There was an association with Pseudomonas aeruginosa infection that remained statistically significant even after controlling for imipenem/cilastatin dosage as well as for the other factors indicated. A high background incidence of seizures in general in a group of severely ill patients makes it both difficult to assess the etiology of a seizure and important to consider the risk factors when choosing the appropriate dose of an antibiotic. Guidelines are presented for appropriate dosing of imipenem/cilastatin in relation to renal function, body weight, and infecting pathogen.