Wed- 8-9 Thurs- 11-12 10/13/20101Dr. Alka Stoelinga

Wed- 8-9Thurs- 11-12

10/13/2010 1Dr. Alka Stoelinga

Focal neurological deficit=Focal neurologic signs also known as focal signs or focal CNS signs are perceptual or behavioral impairments which are caused by lesions in a particular area of the central nervous system.

• Frontal lobe signs usually involve the motor system:– unsteadiness in walking– muscular rigidity, resistance to passive movements of the limbs (hypertonia)– paralysis of a limb (monoparesis) or a larger area on one side of the body

(Hemiparesis)– paralysis face and eye movements– inability to express oneself/ broken speech described as an expressive aphasia

(Broca's aphasia)– focal seizures which can spread to adjacent areas (Jacksonian seizure)– grand mal or tonic-clonic seizures– changes in personality such as disinhibition, rage without provocation; or loss

of initiative and concern, apathy, akinetic mutism, general retardation– "frontal release" signs, i.e. reappearance of primitive reflexes such as the

snout reflex, the grasp reflex, and the palmar-mental reflex– unilateral loss of smell (anosmia)


• Parietal lobe signs usually involve somatic sensation, and may include:– impairment of tactile sensation– impairment of proprioception, i.e. postural sensation and

sensation of passive movement– sensory and visual neglect syndromes, i.e. inability to pay

attention to things in certain parts of the person's sensory or spatial environment. This can be as extreme as denial of a limb.

– loss of ability to read, write or calculate (dyslexia, dysgraphia, dyscalculia)

– loss of ability to find a defined place (geographical agnosia)

– loss of ability to identify objects based on touch (astereognosia)


• Temporal lobe signs usually involve auditory sensation and memory, and may include:– deafness without damage to the structures of the ear,

described as cortical deafness– tinnitus, auditory hallucinations– loss of ability to comprehend music or language,

described as a sensory aphasia (Wernicke's aphasia)– amnesia, memory loss (affecting either long- or short-

term memory or both)– other memory disturbances such as déjà vu– complex, multimodal hallucinations– complex partial seizures (temporal lobe epilepsy)


• Occipital lobe signs– Occipital lobe signs usually involve visual sensation, and

may include:– total loss of vision (cortical blindness)– loss of vision with denial of the loss (Anton's syndrome)– loss of vision on one side of the visual field of both eyes

(homonymous hemianopsia)– visual agnosias, i.e. inability to recognize familiar objects,

colors, or faces– visual illusions such as micropsia (objects appear smaller)

and macropsia (objects appear larger)– visual hallucinations, displaying elementary forms, such as

zigzags and flashes, in one half of the visual field only for each eye. (In contrast, temporal lobe visual hallucinations display complex forms, and fill the entire visual field.)


• Damage to the Limbic System involves loss or damage to memory, and may include:– Loss or confusion of long-term memory prior to

focal neuropathy (Retrograde amnesia)– Inability to form new memories (Anterograde

amnesia)– Loss of, or reduced emotions (Apathy).– Loss of olfactory functions.– Loss of decision making ability.


• Cerebellar signs– Cerebellar signs usually involve balance and

coordination, and may include:– unsteady and clumsy motion of the limbs or torso

(ataxia)– inability to coordinate fine motor activities

(intention tremor), e.g. "past-pointing" (pointing beyond the finger in the finger-nose test)

– inability to perform rapid alternating movements (dysdiadochokinesis), e.g. inability to rapidly flip the hands

– involuntary left-right eye movements (nystagmus)


• Brainstem signs– Brainstem signs can involve a host of specific

sensory and motor abnormalities, depending on which fiber tracts and cranial nerve nuclei are affected.

• Spinal cord signs– Spinal cord signs generally involve unilateral

paralysis with contralateral loss of pain sensation


• TPA= Tissue plasminogen activator (catalyses conversion of plasminogen into plasminbreaks down clot)

• Afib= Atrial fibrillation• Hge= Hemorrhage• Aura= An aura is a distinct perception, either visual, motor, sensory,

or psychological felt around the time a seizure occurs • Post-ictal= altered state of consciousness that a person enters after

experiencing a seizure. – It usually lasts between 5 and 30 minutes, but sometimes longer in

the case of more severe seizures– Is characterized by drowsiness, confusion, nausea, hypertension,

headache or migraine and other disorienting symptoms.– Additionally, emergence from this period is often accompanied by

amnesia or other memory defects.– It is during this period that the brain recovers from the trauma of the

seizure


Seizures

• Seizure is a paroxysmal event due to abnormally discharging central nervous system neurons.

• Epilepsy is defined as a group of disorders in which there are recurrent episodes of altered cerebral function associated with paroxysmal excessive and hypersynchronous discharge of cerebral neurons.– It is a condition of recurrent seizures due to a chronic

underlying process.


SEIZURE LOSS OF CONSCIOUSNESS

AURA + -

CYANOSIS + -

TONGUE BITE + -

POST-ICTAL CONFUSION + -

POST-ICTAL HEADACHE + -

POST-ICTAL AMNESIA + -


Etiology/ Causes of seizures• Vascular (Stroke, bleed, arteriovenous malformations)• Infection (Meningitis, abscess, encephalitis)• Trauma (Especially penetrating injuries)• Autoimmune (CNS vasculitis)• Metabolic (Hyponatraemia, hypocalcaemia,

hypomagnesaemia, hypoglycemia, hypoxia, drug overdose or withdrawal)

• Idiopathic• Neoplasm• pSychiatric[Pneumonic (Seizures are caused by “VITAMINS”)]


Causes of seizure according to age group

• 0-2 years– Birth asphyxia– Birth injury– Neonatal sepsis

• 2-12 years– Idiopathic– Head injury– Fever– Infections (Meningitis,

encephalitis)

• 12-35 years– Idiopathic– Head injury– Drugs and toxin- alcohol,

antidepressants, amphetamines– Vascular malformations,

aneurysm, tumors• Above 35 years

– Cerebral tumors– Vascular malformations,

aneurysms, CVA, Vasculitis like SLE– Metabolic: Uremia, hepatic failure,

hypoglycemia– Multiple sclerosis

10/13/2010 Dr. Alka Stoelinga 13

Diagnosing a case of epilepsy

1. Detailed history from the patient himself or from an eye witness regarding

2. Any injury- Tongue bite, bruises3. Symptoms of aura and its duration4. Defecation/ micturation/ salivation during the

episode5. Any abnormal movements- limb stiffening, jerky

movements, automatism6. Post ictal symptoms: Limb/ muscular pains,

headache, drowsiness, disorientation,Sleepiness


Physical examination

Pt may be absolutely normalHowever, examine for1. Head, neck, eyes, tongue for any bruises2. Vitals3. Head- for any trauma4. Skin lesions: Neurofibromas, Epiloia (Tuberous

sclerosis)5. Visual and optic field6. Limbs: Hemiparesis, hyperreflexia


Clinical presentation

• Sudden onset of paroxysmal, involuntary abnormal movement

• With or without loss of consciousness• With or without aura• Postictal phase- Disorientation, sleepiness muscle

aches• Incontinence• Tongue bite• Headache


Types of seizuresAccording to the source of the seizure within the brain• Partial or focal onset seizures- Localized

– According to the level of consciousness affected• Simple Partial seizures (Consciousness unaffected)• Complex partial seizures (Consciousness affected)

• Generalized seizures- Distributed– According to the effect on the body

• Absence• Myoclonic• Clonic• Tonic• Tonic-clonic• Atonic

• Mixed– Both partial and generalized seizure in same patient


Factors precipitating seizure

• Sleep deprivation• Alcohol (Withdrawal)• Recreational drug misuse• Physical and mental exhaustion• Flickering lights, including TV and computer

screens• Intercurrent infections and metabolic disorders• Sometimes: Loud noises


Management• After diagnosis, explanation regarding its curability should be given to the

patient or their relatives• Immediate care of seizure (Outside hospital)

– Move the patient away from danger (Fire/ water/ machinery)– After the convulsions cease, turn the patient into recovery/ semiprone

position to ensure proper airway– If convulsion continues for more than 5 mins or recurs without person

regaining consciousness, seek immediate medical attention– Padded gag/ rolled handkerchief should NOT be kept in mouth between teeth

to avoid tongue bite– DO NOT leave the patient alone for next 30-60 mins until he regains full

consciousness (Drowsy/ confused) – Oxygen at high concentration, if available, to prevent cerebral hypoxia

• Restrict patient to:– Work near fire/ water and machineries– Driving, cycling, swimming, mountaineering


Investigations• Electroencephalogram (EEG)• CBC, ESR, Electrolytes, blood urea, calcium• Glucose• Arterial blood gases• Liver function tests (LFT)• Toxicology scanning• Serological tests for syphilis• HIV- for high risk groups• ECG/CT/ MRI


Management• Immediate Medical Attention

– Ensure airway is patent– Give oxygen to offset cerebral hypoxia– Give intravenous anticonvulsants (Like Diazepam 10 mg) ONLY IF seizures are

continuous or repeated– Consider taking blood for anticonvulsants if patient is a known epileptic

• Anticonvulsant therapy– Begin with single drug of choice at low dosage, ↑ dosage over 4-6 weeks– If seizures are not controlled, ↑ dose to attain plasma level in upper part of

therapeutic range, until side effects are seen– If poorly controlled, change the drug into 2nd line of drug of choice, by

gradually decreasing the first drug in 3-4 weeks– Usually, 3 single drugs are tried before using combined therapy– NOTE: First seizure episode should not be followed by antiepileptic drug

therapy. Consider drugs after second or if repeated h/o seizures.


Drugs of choice


Types First line Second line Third line

Partial and/or secondary GTCS

Carbamazepine LamotrigineSodium valproateTopiramateTiagabineGabapentine

ClobazamPhenytoinPrimidonePhenobarbitalOxcarbazepineLevetiracetamVigabatrinAcetazolamide

Primary GTCS Sodium valproate LamotrigineTopiramateCarbamazepine

PhenytoinGabapentinePrimidonePhenobarbital

Absence Ethosuximide Sodium valproate LamotrigineClonazepamAcetazolamide

Myoclonic Sodium valproate Clonazepam PiracetamLamotriginePhenobarbital

Prognosis

• Generalized seizures are more readily controlled than partial seizures

• With 20 years of diagnosed epilepsy• 50% are free of seizures without continuing

medications since last 5 years• 20% are free of seizures with continuation of

medication• 30% Still continue seizing despite medical

therapy


Status epilepticus

• LIFE THREATENING MEDICAL EMERGENCY• Series of seizures occur without the patient

regaining awareness between attacks• Recurrent tonic clonic seizures (Major status)


Management of status epilepticus

• General measures• Immediate care (as discussed earlier)– IV access– Draw blood for glucose, electrolytes etc, save

some for other analysis– Inj Diazepam 10mg iv stat, repeat once after 15

mins– Transfer the patient to ICU for intensive Mn

• Pharmacological treatment


Pharmacological treatment• If seizures continue after 30 mins

– IV infusion with one of the following drugs:• Phenytoin: iv 15mg/kg @ 50mg/min• Fosphenytoin: iv 15mg/kg @ 100mg/min• Phenobarbital: iv 10mg/kg at 100mg/min

• If seizures continue after 30-60 mins– Start Rx for refractory status with intubation and ventilation,

and general anesthesia with propofol or thiopental• Once status is controlled

– Commence longterm anticonvulsant therapy with one of:• Sodum Valproate 10mg/kg iv over 3-5 mins, then 800-2000mg/day• Phenytoin: give a loading dose of 15mg/kg, infuse at <50mg/min, then

300mg/day• Carbamazepine 400mg by NG tube, then 400-1200mg/day


Antiepileptics in pregnancy

• Associated with congenital defects• Spina bifida, cleft lip, cardiac defects• Lamotrigine and gabapentine is supposed to

be comparatively safer • Pts are advised to use Folic acid 5mg daily 2

months prior to conception, which might reduce the risk of congenital deformity


Partial

• Occurs within discreet portion of brain• Involuntary jerking of finger or hand


Tonic clonic


Complex partial


Absence seizure

•


Partial motor


Partial sensory


versive


Partial visual


Classification of Epilepsy



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Wed- 8-9 Thurs- 11-12 10/13/20101Dr. Alka Stoelinga