An overview of the relevant aspects of the epidemiology, clinical presentation, basic disease mechanisms, diagnostic approaches and treatment options of the most common neurological diseases.
Module 3 Part 4: Patient Evaluation
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Из курса от партнера University of California, San Francisco
Introduction to Clinical Neurology
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Epilepsy & Neurodegenerative Diseases
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Daniel Lowenstein, MDProfessor and Vice Chair, Department of Neurology
School of Medicine
S. Andrew Josephson, MDAssociate Professor
School of Medicine
Wade Smith, MDProfessor
School of Medicine
Okay everybody. We've covered the EEG.
We've talked about what's going on in a seizure focus.
We've defined epilepsy and epileptic genesis.
And we've talked about the classification of seizures.
So, now we're, now we're ready to start talking about the care of the patient.
So, in this module, we are going to talk about the evaluation
of a patient who comes to you with a first time seizure.
Now I think it's worthwhile taking
a moment to just consider what the first
date is for someone who is having a seizure.
So whether you are health professional or not
you may, you may have already experienced being in
a situation where you'd like to be able to
provide help to someone who's clearly having a seizure.
So let's just go over that briefly. The first thing is stay calm and
make sure that there's someone who is, who is helping to take care of the patient.
You know, that actually might be you.
The second thing is regardless of the, of the, of the nature of
the seizure, it's important that the person be put into a safe location.
Certainly, if they're having the big convulsive movements, you, you don't
want them to be banging their arm, arm or legs against something.
You could place something soft under their head.
Quickly access airway breathing circulation.
jus, for those of you who haven't exper,
have not experienced this, I should tell you that.
During the a full convulsion it looks as
though the person is not breathing very well.
But that's almost always not a problem.
Of course if you detect that there's clearly a major
problem with ventilation, you need to be able to administer CPR.
The patient should be rolled over to his or her side
far enough so that their saliva and any
other secretions can be cleared to try to prevent aspiration.
And really importantly please do not try to place anything in the person's mouth.
There it's been said that a, a patient with
a seizure is at risk of quote swallowing their tongue.
I can tell you that that is phy,
physiologically totally impossible.
And if the person is going to have injured their tongue or mouth
for any reason it occurred the first few seconds of the seizure.
So it's almost certain that any attempt to try to put in a tongue blade or a
spoon or anything else to prevent further damage
is probably going to be causing more damage in itself.
You should look to see whether the patient has any
MedAlert tags on their wrist or on a necklace to
see whether they have a known history of epilepsy or
whether they're taking any medications and they have other medical problems.
And then the question is, you know, if this
happens outside of the hospital do you call emergency services?
And generally the default should be definitely should.
If it looks as though it's the person's first time they've had a seizure.
If the seizure's lasting more
than four to five minutes and if there's any
indication whatsoever of any other kind of medical problems.
I think the only reason to, the only reason to
not call would be if the patient immediately wakes up.
Is totally back to normal.
And says very clearly, you know, there's no
need for you to send me to the hospital.
You know, I can take care of this.
Or, more typically, that there's a family member or friend who's able to indicate
that in, in fact, there's no need for calling an ambulance.
Okay.
So we have a person who presents with a first time seizure.
Well, the first thing actually is to step
back and say, well, was this really a seizure?
And in terms of the differential diagnosis of a seizure, the main issue as you
can see here is, was it a seizure, or was it syncope, or a faint?
There are other
things to consider when someone has kind of a spell.
Some kind of abnormal, brief abnormal behavior or impairment of consciousness.
For example, there are people who have events that look
all the world like a seizure but they're psychogenic in nature.
Equally important in terms of understanding what
it is and approaching it properly with treatment.
But very different in terms of both the
diagnostic and the therapeutic components. They are various sleep disorders that can
have associated with them brief events or spells that may be seizure like.
Certain forms of migraine can actually have
very unusual behavioral disturbances including impairment of consciousness.
And finally, transient ischemic attacks or other stroke like
events can mimic aspects of, of of a seizure.
But again, the main differential diagnosis is whether the
person had a true seizure or a syncopal event.
And this table gives gives some of the characteristics that
can be extremely helpful into trying to discriminate between the two.
I won't go into this and exhaust the detail.
But I would like you to study this because it's
just so important in terms of the evaluation of a patient.
But basically,
with regard to the onset of symptoms, patients who have Syncope or have a faint
usually have stereotypic or very similar descriptions.
In other words, any, any you who have ever had a faint
or almost fainted if we, if we shared what that experience is like.
We'd probably use similar, similar terms or we'd be trying
to convey a common experience.
And that is, the person, you feel kind
of light-headed, you might feel kind of stars seeing
stars, you might kind of feel the sense of,
of just sort of things closing down around you.
There might be some palpitations, you might feel your
heart racing, you might get, be sweaty and clammy.
Those are features of syncope.
For seizure, and in this case, I'm comparing syncope with
a full loss of consciousness to a generalized seizure, not a focal seizure.
But either a generalized seizure or a focal seizure with
secondary generalization in which again, there's full loss of consciousness.
The actual experience can be really, really different from patient to patient.
But it's usually consistent in the individual patient.
Many folks will say that they have no warning whatsoever.
They were perfectly fine, and the next thing they knew, they were
being looked at by a paramedic because they had
apparently fallen to the ground and had these shaking movements.
however, for patients who have a focal seizure that secondarily generalizes, they
may have what's called an aura, which is the beginning of a seizure.
And for some people it might be the experience of having deja vu.
Other folks talk about having the sense of a weird feeling
kind of coming up from their abdomen, or a gastric rising,
or changes in their cognition. Again, highly variable.
You can hear many different stories from different
patients, but for the individual patient they'll tend to
say that, you know, I noticed that when
my seizures occur they usually have these initial symptoms.
and, which again are usually quite distinctive
from what I've just described about Syncope.
During the event in a sync-able event most
patients don't have a long term movements. Actually, they may have
small myoclonic jerks or some type of behavioral or, or motor movements.
But these are usually very, very brief, almost never
la last long than ten, longer than ten seconds.
Whereas in a generalized seizure that the movements are more characteristic,
they may be clonic or tonic clonic and usually last much
longer than ten seconds.
Skin color may be different palor associated
with the hyper profusion that is a
typical cause of syncope versus sinosis in the patient who is having a convulsion.
And finally, and important the recovery time.
Most people who have a syncopal event come to relatively quickly.
Certainly they're awake and beginning
to respond within a matter of a minute or so.
And by three to four to five minutes they're
fully awake fully cognitive able to have a conversation.
They may not feel well, they may have a headache or feel nauseated.
But cognitively they're essentially back to normal.
And that's opposed to a, a full generalized seizure or convulsion.
Those patients
after completing the seizure itself, because of all the inhibition
that follows seizure activity usually don't wake up for many minutes.
At 15 or 20 minutes, they may begin to interact more
normally, but they're still not at their 100% at their typical baseline.
At least, in the most common forms of generalized seizures.
Okay, so that's the differential diagnosis.
Let's assume
that we've decided that the patient who has come to see
us, say in the emergency room, has truly had a convulsive seizure.
The next step is to think about what the potential causes are.
And in this slide I have broken this
down into various age categories, just to give you
a taste, if you will, of the many
different causes of, of both focal and generalized seizures.
So, for neonates for
newborns less than a month old.
As you can see here, a whole host of causes.
Hypoxia and ischemia around the time of birth.
Intracranial hemorrhage.
Metabolic changes associated with birth, or
some sort of underlying genetic disorder.
Infection infectious processes, developmental disorders, withdraw in
a, in a neonate that's been exposed to
drugs during during the pregnancy.
Infants and children, those greater than a month old
or less than 12 years, the most common causes are
central nervous system infection, a variety of genetic disorders, Febrile
seizures which by the way is a topic in itself.
You'll, you should read up on that on your own.
But a, but a very, very common form of
seizures that is generally, fortunately benign but extremely common.
And then head trauma.
For adolescents the list again CNS infections, genetic disorders, trauma.
Now brain tumor's become more of a concern and illicit drug use.
For adults, trauma, brain tumor, drug use, and alcohol withdrawal.
And for older adults: metabolic disturbances, brain tumor, alcohol
withdrawal, cerebrovascular disease, and
Alzheimer's and other degenerative diseases.
So in the evaluation of this patient who comes in with a first time seizure,
one needs to think about all of these
various causes associated with the particular age category.
Because your diagnostic workup on potential treatment should of
course be focused on any identifiable underlying disorder.
So having considered these potential causes, now let's talk
about what the actual laboratory workup would be.
Well, it's, it's focused on trying to see whether we can identify
any of the things that we just saw on the previous slide.
So typically we'll get a panel of blood studies, which
will include a CBC, electrolytes, glucose, liver and renal function tests.
You can consider an sed rate a tox screen, certainly for, for
the age, any of the age ranges that you think it's appropriate.
And pregnancy test. And again, this is simply.
A survey to try and identify any evidence for
specific systemic diseases, endogenous, exogenous toxins and so forth.
Most patients who have had a seizure should have an imaging study.
There are some exceptions in the pediatric population but
in most cases we do get some form of imaging.
CT is of course
most common.
If given the opportunity an MRI scan is often times more helpful.
But an imaging study is usually in order.
And then finally an EEG.
Now, given that workup the question is what, what do we do
in terms of treating a patient whose had, whose experienced a single seizure?
again, if a person had a single seizure it doesn't mean that they have epilepsy.
The definition of epilepsy is a tendency for recurrent seizures, but we still need
to decide what to do for someone who has had this first time event.
Well, the, the for sure the first thing is to treat
any underlying abnormalities that are disclosed through your diagnostic work up.
For example, the patient may have had a seizure
in the setting of a really low serum sodium, hyponatremia.
So the treatment strategy for sure
is going to be to correct the hyponatremia and also try
to reverse whatever the underlying cause is of that low sodium.
Another example would be someone who has taken an, an
illicit drug and has had a seizure in that setting.
Well, obviously the, the focus of treatment
needs to be on having the patient understand
the danger of that drug associated with
the seizure, and all the other adverse effects
that come with that sort of behavior.
Another consideration is to try to determine
whether there are any obvious precipitating factors.
It turns out that all of our brains are capable of
having a seizure in the, if you will, the wrong setting.
So, the network is capable of having a seizure, but most of
us who have gone through life without having one of these events.
Apparently we have a sufficient
threshold, if you will, that protects us from
getting to the point of having a seizure.
And there are a number of different types
of precipitating factors that could lead to either
a single seizure or to worsen someone who
worsen the condition of someone who has epilepsy.
One of the most notable factors is sleep deprivation.
So I've often times seen patients who come in with a single
seizure in the setting of, say they're a college student and they've
been you know, studying real hard during exam week.
And maybe they've taken some kind of medication that's that, that
lowers their seizure threshold and throw on top of that, sleep deprivation.
And boom, you know, they have, they have this single event.
Of course then the the treatment approach is going to be to counsel them on
the importance of being really, really careful about
the various medications or drugs that they use.
To be really, really careful about
sleep hygiene and so forth.
Another precipitating factor that we certainly see in people
with epilepsy, who have problems with recurring seizures is stress.
Stress can be associated with again, sort of hyper excitability of the brain.
And trying to focus attention on being able to better manage
the stress in someone's life and sometimes be very, very helpful.
And would, would apply to this situation as well.
Now, with regard to whether or not you take the step to specifically treat
someone who's had a single seizure, here
are some of the factors that one considers.
In terms of not needing to go forward and treat, would
be if the person has a precipitating factor that's immediately reversible.
The second would be that the work-up reveals
nothing to suggest that the person
has an underlying central nervous system disorder.
And, and, and third is, if the patient is a child, we're particularly cautious
about the decision to expose that that
young, young individual to an anti-epileptic drug.
Factors that favor treatment is if there's no obvious parti, reversible
precipitating factor, if the person has an abnormal neuro exam which
may or may not be associated with an abnormal EEG or an MRI.
And then, risk of serious consequences if the person
was to go on and have a second seizure.
One of the really important consideration in managing a person who
presents with a single seizure, has to do with driving privileges.
So, depending on where, where you come from which country you come from.
Government agencies may require you to report an individual
has had a loss of consciousness related to a seizure or any other cause.
And this can have an enormous impact on the sense of well-being of, of the patient
and it's, it's an aspect of the management
that needs to be done with particular care.
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