Seizures, Generalized Tonic-Clonic : Causes Diagnosis Treatment by Nurses Note

 Seizures, Generalized Tonic-Clonic

 

DEFINITION OF SEIZURES, GENERALIZED TONIC CLONIC

Tonic-clonic seizures are characterized by the sudden loss of consciousness, muscle contraction (tonic phase), followed by rhythmic jerking activity (clonic phase).

SYNONYMS

Bilateral tonic-clonic seizures

Convulsive seizures

Grand mal seizures

Generalized tonic-clonic seizures

EPIDEMIOLOGY & DEMOGRAPHICS

INCIDENCE: 30 to 50 cases per 100,000 person/yr (epilepsy incidence).

PEAK INCIDENCE: Not applicable.

PREVALENCE: 5 to 8 cases per 1000 persons (epilepsy incidence).

PREDOMINANT SEX AND AGE: No gender preference.

PHYSICAL FINDINGS & CLINICAL PRESENTATION

•  Patients with tonic-clonic seizures usually have normal physical and neurologic examinations.

• During the seizures, the patients are unresponsive and can have violent postures with severe repetitive muscle contractions.

• After the seizure, the patients are usually lethargic and confused.

• Tonic-clonic seizures are associated with injuries, bladder incontinence, and tongue biting.

• Focal postictal weakness may point toward a focal neurologic lesion (Todd’s paralysis).

ETIOLOGY OF SEIZURES, GENERALIZED TONIC CLONIC

• Seizures are a cardinal sign of cortical neurologic injury. Generalized seizures include both hemispheres of the brain at the onset.

• The aetiology of seizures can be genetic or due to an acquired injury to the brain.

DIAGNOSIS OF SEIZURES, GENERALIZED TONIC CLONIC

DIFFERENTIAL DIAGNOSIS

• Convulsive syncope.

• Psychogenic nonepileptic spells.

• EPI

• TIA

• Vertigo

WORKUP

• EEG. An EEG can help confirm the presence of epilepsy but cannot be used to exclude the diagnosis.

• Ambulatory EEG and/or video EEG recommended for patients with diagnostic uncertainty.

• MRI of the brain.

LABORATORY TESTS

• Routine blood workup (CBC, CMP, glucose, electrolytes).

• Urine drug screen.

• Lumbar puncture is recommended in patients with suspicion of meningitis.

IMAGING STUDIES

• Neurodiagnostic imaging studies such as CT of the head or, preferably, MRI of the brain should be performed in all patients with first unprovoked seizure.

• CT scans of the head should be avoided in children due to unnecessary exposure to radiation and the low yield of the test. CT scans of the head are reserved for neurologic emergencies and are adjusted for weight in children.

 TREATMENT OF SEIZURES, GENERALIZED TONIC CLONIC

• The immediate management of a seizure focuses on stabilization of the patient with focus on the airway and vital signs and rapid identification and correction of reversible causes.

• Treatment is based on the type and etiology of seizures (i.e., metabolic disturbance, infectious, etc.).

• Levetiracetam is an effective and well-tolerated antiepileptic drug for treating generalized tonic-clonic seizures.

• Valproic acid is better tolerated than topiramate and more efficacious than lamotrigine in patients with generalized and unclassified epilepsy types.

• Valproic acid should be avoided in girls and women with childbearing potential due to the risk of teratogenicity.

NONPHARMACOLOGIC THERAPY

Not applicable.

GENERAL Rx

• First unprovoked seizure with normal imaging, EEG, and laboratory workup requires no treatment.

• Recurrent seizures and seizures with abnormal studies require treatment depending on the aetiology.

• Levetiracetam (Keppra): Initial dose 250 to 500 bid, maximum dose 1500 mg bid.

• Perampanel (Fycompa): Initial dose of 2 my once daily at bedtime, increments of 2 my once daily at weekly intervals to a recommended maintenance dose of 8 to 12 mg.(adjunctive treatment in patients with epilepsy 12 years of age and older).

• Valproic acid (Depakote): Initial dose: 10 to15 mg/kg/day (divided bid), maximum dose60 mg/kg/day.

CHRONIC Rx

According to a recent joint American Academy of Neurology and American Epilepsy Society evidence-based guideline on the management of a first unprovoked seizure in adults, there is strong evidence that the risk of a second seizure is highest in the first 2 yr and ranges from 21% to 45%. This risk is higher for patients with prior brain insults such as traumatic brain injury or stroke or those with epileptiform abnormalities on EEG. Significant brain imaging abnormalities and nocturnal seizures also indicate a more elevated risk of recurrent seizures. Chronic treatment with antiepileptic drugs is indicated for ≥2 unprovoked seizures or in patients with one seizure with abnormal workup. However, moderate evidence supports advising the patient that immediate antiepileptic therapy, compared with delaying treatment until a second unprovoked seizure, is likely to reduce the risk of a seizure recurrence in the next 2 yr. Furthermore, the risk of adverse events with antiepileptics ranges from 7% to 31%, with most of these adverse events being mild and reversible. Thus, the practice guideline suggests that under certain circumstances adults with one provoked seizure, even without high-risk EEG or MRI findings, can be treated with antiepileptic drugs because at least in the next 

2 yr the risk of a recurrent seizure is reduced. However, there is no strong evidence that such treatment improves the quality of life. However, even one seizure can have negative consequences on a patient’s ability to drive, thereby impacting social and occupational functioning, making treatment an attractive option for many. Furthermore, although immediate treatment reduces the risk of seizures in the next 2 yr, it does not impact the risk at 3 yr or beyond.

COMPLEMENTARY & ALTERNATIVE MEDICINE

Not applicable.

DISPOSITION

• Patients should avoid situations that may cause injuries or accidents in the event of a seizure, such as climbing ladders, swimming unsupervised, or taking baths (rather than showers).

• No driving until seizure-free in accordance with local laws and regulations.

REFERRAL

Patients with epilepsy and seizures should be referred for a consultation by a neurologist, preferably one with epilepsy training.

 PEARLS & CONSIDERATIONS

COMMENTS

• It is crucial to understand that tonic clinic seizures can occur in a variety of acute neurologic diseases.

• Successful treatment depends on the correct choice of antiepileptic drugs based on the type (partial-onset versus generalized onset) and aetiology of the seizures.

• Valproic acid should be avoided in girls and women with childbearing potential due to the risk of teratogenicity.

• All women of childbearing age taking antiepileptic drugs should take folic acid supplementation (1-4 mg/day) for the prevention of neural tube defects.

• Many antiepileptic drugs also affect vitamin D absorption or metabolism, prompting attention to patients’ bone health.

PREVENTION OF SEIZURES, GENERALIZED TONIC CLONIC

Sleep deprivation and alcohol consumption should be avoided.