Seizure Disorders

• Epileptic Seizures: Singular events of abnormal brain activity, affecting 5-10% of people at some point.
• Epilepsy: A condition characterized by recurrent seizures, affecting about 1% of the population.

Causes

• Hyponatremia, hypoglycemia, stroke or transient ischemic attack (TIA).
• Dementia (e.g., Alzheimer’s disease), traumatic brain injury.
• Infections (brain abscess, meningitis, encephalitis, HIV/AIDS).
• Congenital brain defects, metabolic disorders (e.g., phenylketonuria).
• Brain tumors, abnormal brain vessels, and other illnesses damaging brain tissue.
• Genetic factors can also play a role in some types of epilepsy.

Risk Factors

• Family history of seizures or epilepsy.
• Age extremes (young children and older adults).
• Certain neurological conditions.
  • Neurological conditions like stroke, traumatic brain injury, and brain tumors.
  • Neurodegenerative diseases such as Alzheimer’s and other dementias.
  • Infectious diseases of the brain, including meningitis and encephalitis.
  • Chronic disorders like cerebral palsy and multiple sclerosis.
  • Brain abscess or infection leading to localized inflammation.

Types of Seizures

Generalized Seizure:

• Grand Mal Seizure: Unconsciousness, convulsions, muscle rigidity.
• Absence Seizure: Brief loss of consciousness.
• Clonic Seizure: Repetitive jerking movements.
• Myoclonic Seizure: Sporadic jerking movements.
• Tonic Seizure: Muscle stiffness, rigidity.
• Atonic Seizure: Loss of muscle tone.

Partial Seizure:

• Preservation of consciousness, potentially evolving into loss of consciousness and convulsions.
• Jacksonian March: Seizure spreads from distal limb to ipsilateral face.
• Simple Seizure: Jerking, muscle rigidity, spasms, head-turning; unusual sensations affecting vision, hearing, smell, taste, or touch.
• Complex Seizure: Lip smacking, chewing, fidgeting, walking, and other repetitive, involuntary but coordinated movements; an aura is often present; often involves the temporal lobe.

Labs, Studies, and Physical Exam Findings

• Electroencephalogram (EEG): Helps determine the type of seizure and may show generalized or focal abnormalities.
• MRI / CT Scan: Used to identify structural causes of seizures.
• Laboratory Tests: Including blood glucose, electrolytes, complete blood count, renal and liver function tests, toxicologic screening, arterial blood gas, blood culture, urinalysis, and CSF analysis.

Treatment

First Aid and Emergency Protocols:

• Ensure safety, place in recovery position, do not place anything in the mouth, and time the seizure.
• For prolonged seizures or status epilepticus, immediate medical intervention is required, often involving IV administration of benzodiazepines like lorazepam or diazepam.
• Treat underlying cause if identifiable.

Medications:

• Anticonvulsants include Midazolam, Phenytoin, Carbamazepine, Valproate, Phenobarbital, Levetiracetam, and Lamotrigine.

Surgery:

• Considered for refractory cases, especially focal seizures where the seizure focus can be safely resected.

Status Epilepticus

A life-threatening neurologic disorder defined as 5 minutes or more of continuous seizure activity or multiple seizures without a return to baseline between them. It can be convulsive (tonic-clonic movements) or non-convulsive (subtle or no motor activity).

Causes

• Medication-related: Insufficient dosage, sudden withdrawal, interaction with new medications, or resistance to current anticonvulsants.
• Metabolic disturbances: Imbalances in blood glucose, electrolytes, calcium, magnesium.
• Alcohol-related: Consumption with anticonvulsants, or withdrawal.
• Structural brain changes: Stroke, hemorrhage.
• Infections: Encephalitis, meningitis.
• Traumatic brain injury.

Labs, Studies, and Physical Exam Findings

• Physical and Neurologic Exam: Initial assessment to evaluate the severity and possible causes.
• Laboratory Tests: Blood glucose, electrolyte levels, complete blood count, renal and liver function tests, toxicologic screening, anticonvulsant drug levels, arterial blood gas, blood culture, urinalysis, CSF analysis.
• EEG: Essential for diagnosing non-convulsive SE.
• CT Scan or MRI: To identify reversible causes like tumors or stroke.

Treatment

Urgent Management

Immediate treatment is crucial. It includes airway protection and monitoring of vital signs.

Medications

• First Line: Benzodiazepines such as Diazepam, Lorazepam, Midazolam.
• Second Line: Anticonvulsant agents like Phenytoin, Fosphenytoin, Levetiracetam, Valproate, Lacosamide.
• In Refractory Cases: Barbiturates (Phenobarbital) and Anesthetics (Propofol).

Supportive Therapy

Involves managing the underlying cause and maintaining vital functions.

Delirium

• An acute state of confusion characterized by sudden onset, fluctuating course, and often a change in alertness.

• Causes:

  • Electrolyte imbalances, advancing age.
  • Fever, acute infections (especially in children).
  • Visual/hearing impairment, poor nutrition or dehydration.
  • Severe, chronic, or terminal illness; multiple medical problems or procedures.
  • Medication-related: anticholinergics, opioids, alcohol or drug abuse/withdrawal.
  • Psychological stress, severe pain, lack of sleep.

• Clinical Presentation:

  • Rapid onset with symptom fluctuation throughout the day.
  • Changes in alertness, varying levels of consciousness.
  • Disorientation to time or place, short-term memory impairment.
  • Altered perception, including hallucinations or delusions.
  • Emotional or personality changes (e.g., agitation, depression, euphoria).
  • Sleep disturbances, movement changes, incontinence.

• Labs, Studies, and Physical Exam Findings:

  • Comprehensive neurologic and mental status examination.
  • Blood tests: Glucose, electrolytes, liver/renal function, toxicology screen.
  • Imaging (CT/MRI) and EEG to rule out other causes like stroke or seizures.
  • Additional tests: ABG, creatine kinase, urinalysis, CSF analysis, Vitamin B1 and B12 levels.
  • Geriatric assessment in older patients.

• Treatment:

  • Address underlying causes: infections, anemia, heart/kidney/liver failure, etc.
  • Environmental modifications: Adequate lighting, noise reduction, sleep hygiene.
  • Medication review and adjustment:
  • Medications: Haloperidol, Olanzapine, Benzodiazepines (for specific withdrawal syndromes), Trazodone.
  • Non-pharmacologic: Supportive care, familiar environment, orientation aids.

Mild Neurocognitive Disorder (MCI)

Mild Neurocognitive Disorder (MCI) is characterized by a slight but noticeable decline in cognitive abilities, including memory and thinking skills, which does not significantly impair daily activities and independence.

Clinical Presentation:

• Cognitive Changes: Most commonly involves memory difficulties, especially in recalling recent events or information.
• Other Cognitive Impairments: May include problems with language (word-finding), attention, problem-solving, and visuospatial abilities.
• Maintained Independence: Individuals can generally manage daily activities and responsibilities despite these cognitive changes.

Labs, Studies, and Physical Exam Findings:

• Clinical Assessment: A detailed history and physical examination to identify cognitive deficits and their impact on daily functioning.
• Cognitive Testing: Neuropsychological tests to assess memory, language, and other cognitive functions. Common tests include the MMSE and MoCA.
• Laboratory Tests: To rule out reversible causes of cognitive impairment, such as thyroid dysfunction or vitamin deficiencies.
• Imaging: Brain imaging (MRI or CT) may be used to rule out other causes of cognitive symptoms.

Treatment:

• Managing Underlying Conditions: Treatment of any underlying medical or psychiatric conditions that may be contributing to cognitive impairment.
• Cognitive Interventions: Memory training and cognitive rehabilitation strategies.
• Lifestyle Modifications: Regular physical exercise, cognitive engagement, social activities, and a heart-healthy diet can help slow cognitive decline.
• Monitoring: Regular follow-up to monitor cognitive changes and assess for progression to major neurocognitive disorder.

Major Neurocognitive Disorder

Major Neurocognitive Disorder, often synonymous with dementia, significantly impacts cognitive function and daily living independence.

Clinical Presentation:

• Cognitive Impairment: Marked deficits in memory, attention, language, visuospatial skills, and executive function.
• Behavioral Symptoms: Includes agitation, restlessness, wandering, aggression, and changes in eating habits.
• Psychiatric Manifestations: More prevalent and severe in major disorder, including depression, anxiety, hallucinations, and delusions.
• Physical Decline: Progressive loss of motor skills, coordination difficulties, and in later stages, problems with walking, eating, and self-care.

Labs, Studies, and Physical Exam Findings:

• Comprehensive Clinical Assessment: Detailed patient and caregiver interviews, physical and neurological examinations.
• Standardized Cognitive Testing: MMSE, Montreal Cognitive Assessment (MoCA), and other neuropsychological tests.
• Laboratory and Imaging Workup: Blood tests for metabolic, endocrine, and vitamin deficiencies; neuroimaging (MRI or CT) for strokes, tumors, or structural abnormalities.

Treatment:

• Symptomatic Management: Cholinesterase inhibitors (e.g., Donepezil), memantine for cognitive symptoms; antipsychotics, antidepressants, and anxiolytics for behavioral and psychiatric symptoms.
• Non-Pharmacological Interventions: Cognitive and behavioral therapies, lifestyle modifications, environmental adjustments.
• Caregiver Support and Education: Managing daily care needs, understanding disease progression, and handling behavioral changes.