GENERAL NEUROLOGY
Acute symptomatic seizures
Updated on 25/06/2024, published on 20/05/2024
- a seizure is defined as a transient occurrence of signs and/or symptoms resulting from abnormal synchronous (epileptic) neuronal activity in the brain
- seizures can affect behavior, movement, sensation, and levels of consciousness
- acute symptomatic seizures (ASS) occur in close temporal association with an acute cerebral insult or disturbance and account for about 40% of first seizure episodes
- the time frame for ASS is typically within 7-10 (14) days of the event (such as stroke, traumatic brain injury, metabolic disorder, or infection)
- unlike epilepsy, which involves recurrent seizures with no apparent immediate cause, ASSs are directly related to the transient disturbance caused by the acute condition
- the risk of ASS is influenced by the nature and location of the cerebral disorder, as well as other factors (genetics, age, comorbidities)
- continuous EEG (cEEG) can be used to predict the occurrence of symptomatic seizures (2HELPS2B)
- ASSs do not include:
- seizures triggered by specific stimuli (e.g., visual), which are common in patients with epilepsy
- seizures triggered by sleep deprivation (sleep deprivation is not an independent trigger for the development of ASSs)
Acute symptomatic seizures are directly related to an acute insult or condition, while epilepsy is a chronic disorder characterized by recurrent unprovoked seizures
Etiology
Structural brain lesions | |
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Toxic-metabolic disorders | |
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Inflammation | |
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Others | |
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- according to various sources, 25-60% of all ASSs
- 50-70% of ASSs occur in the first 48 hours after the onset of stroke
- more common in patients with bleeding and dural sinus thrombosis
- especially in hemorrhage, continuous EEG monitoring is recommended in the acute stage → significantly higher detection rate of clinically unrecognized seizures and NCSE
- ASS risk increases with more extensive lesions and cortical involvement; in SAH, a relationship with the amount of blood in the basal cisterns has been described
- prophylactic administration of anti-seizure medication (ASM) is not recommended (AHA/ASA 2019 III/C-LD)
- continuous EEG monitoring shows a higher incidence of ASS (mainly non-convulsive) in moderate to severe TBI
- most seizures occur within 24 hours after injury
- the risk of ASS or epilepsy depends on the severity of the injury and is higher in hemorrhage (SDH, EDH, or parenchymal – 7-10%), as well as in impressive calvary fractures and contusion injuries
- laboratory abnormalities occur in temporal relationship with seizures; both the absolute value and the speed at which the disorder develops play important roles
- uremia or electrolyte imbalance may play a role in renal failure; seizures occur in hemodialysis patients due to:
- uremic encephalopathy
- dysequilibration syndrome
- hypocalcemia
- hypoglycemia
- hyponatremia
- ASSs are uncommon in hepatic failure and are related to hyperammonemia
- ASSs occur in patients with hyponatremia, hypomagnesemia, and hypocalcemia
hypoglycemia | glucose < 2,0 mmol/l |
hyperglycemia with ketoacidosis | glucose > 25 mmol/l |
hypomagnesemia | Mg < 0,3 mmol/l |
hypocalcemia | Ca2+ < 1,2 mmol/l |
hyponatremia | Na < 115 mmol/l |
renal failure |
urea > 35.7 mmol/l
creatinine > 884 umol/l |
- high risk of ASS and epilepsy is associated with brain abscess and herpetic encephalitis
- alcohol
- ASSs are most commonly associated with withdrawal syndrome (in regular consumption > 5 g/day) (⇒ Alcohol Withdrawal Seizure – AWS)
- seizures occur between 7-48 hours, often in combination with delirium
- clustered seizures or even ASSE may occur
- in chronic alcoholics, it is necessary to rule out concurrent metabolic disorders (hypoglycemia, hyponatremia, etc.) and consider structural brain lesions (hemorrhage, trauma, etc.)
- medications
- dose-dependent effect, often due to intoxication (intentional or unintentional)
- higher risk associated with polypharmacy and more common in older patients
- ASS and SE can also occur during drug withdrawal (barbiturates, benzodiazepines, opioids, baclofen, vigabatrin)
- drugs (cocaine, amphetamines, cannabinoids)
Drugs with the risk of developing ASS when used in therapeutic dose | |
neuroleptics | phenothiazines (chlorpromazine), haloperidol, clozapine |
antidepressants | tricyclics, maprotiline, clomipramine, SNRIs (venlafaxine), SSRIs (fluoxetine, sertraline) |
antibiotics | beta-lactams (penicillins), fluoroquinolones, metronidazole |
analgesics | meperidine and normeperidine, tramadol, fentanyl and sufentanil, morphine intrathecally |
anesthetics | sevoflurane, propofol |
cytostatics | 5-fluorouracil, busulfan, chlorambucil, methotrexate |
antiasthmatics | theophylline |
immunosuppressants | cyclosporine |
antihistamines | diphenhydramine |
muscle relaxants | baclofen |
antiulcer drugs | cimetidine |
Clinical presentation
- semiology of seizure (see ILAE classification for more information)
- focal seizures with/without impaired consciousness (motor or non-motor onset)
- focal impaired awareness seizures – FIAS (previously complex partial seizures)
- focal aware seizures – FAS (previously called simplex partial seizures)
- focal to bilateral tonic-clonic seizures (FBTCS) (previously secondary generalized seizure)
- generalized seizures (motor x non-motor)
- unknown onset (motor x non-motor)
- focal seizures with/without impaired consciousness (motor or non-motor onset)
- number of seizures:
- isolated seizure
- cluster of seizures
- acute symptomatic status epilepticus (ASSE)
Management
Detection and elimination of provoking causes
- causal treatment of seizures – correction of metabolic disorders, management of intoxication, withdrawal of inappropriate medication, etc.
Antiseizure medication (ASM)
- there are no clear recommendations based on trials for choosing ASMs for short-term treatment of ASSs
- the most commonly used drugs are diazepam or clonazepam, levetiracetam, valproate, phenytoin, lacosamide
- clonazepam is preferred for focal seizures
- for treatment of status epilepticus, follow local protocols
- short-term preventive treatment may be considered in selected patients
Management of seizure clusters
- administer intravenous anticonvulsants
- Establish intravenous (IV) access via cubital or jugular vein
- rectal or intramuscular diazepam can be used as initial therapy
- 1st line therapy: diazepam, midazolam
- 2nd line therapy:
- focal seizures: clonazepam, lacosamide
- generalized seizures: levetiracetam, valproate, lacosamide, phenytoin
Parameter | Details |
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Initial dosing (PO) | start with 500 mg twice daily can be rapidly titrated up; typical increments are 500 mg every 1-2 days, depending on seizure control and tolerability |
Initial dosing (IV) |
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Maintenance dose |
500-1500 mg twice daily, adjusted based on response, tolerance, and renal function |
Notes |
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Main contraindications | hypersensitivity to levetiracetam or any component of the formulation |
Parameter | Details |
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Initial dosing (PO) | slow titration of 100 mg per week |
Initial dosing (IV) |
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Maintenance dose |
typically 300 mg/day (max dose 500mg/d) in adults divided into 2-3 doses |
Notes | monitor for hypotension and arrhythmias during IV administration |
Contraindications |
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Parameter | Details |
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Initial dosing (PO) | start with 400-600 mg, divided into 2 doses |
Initial dosing (IV) |
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Maintenance dose |
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Notes |
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Contraindications |
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Parameter | Details |
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Initial Dosing (PO) | start with 50 mg twice daily |
Initial Dosing (IV) |
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Maintenance dose |
100-200 mg twice daily, adjusted based on response and tolerance |
Notes |
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Contraindications |
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Parameter | Details |
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Initial Dosing (PO) | start with 100-200 mg twice daily |
Maintenance dose |
800-1200 mg/day divided into 2 doses; adjust dose based on response and tolerance |
Notes |
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Contraindications |
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Parameter | Details |
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Initial Dosing (PO) | start with 0.5 mg twice daily |
Dosing (IV) |
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Maintenance dose |
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Notes | titrate dose slowly to minimize sedation and dizziness; monitor for signs of dependency and withdrawal |
Contraindications | significant liver disease, acute narrow-angle glaucoma, and hypersensitivity to clonazepam or benzodiazepines |
ASMs therapeutic levels (values may differ in various labs) | |
carbamazepine (CBZ) | 17-51 µmol/L (4-12 µg/mL) toxic level: >85 µmol/L (>20 µg/mL) |
valproate (VPA) | 350-700 µmol/L (50-100 µg/mL) toxic level: >1040 µmol/L (>150 µg/mL) |
phenytoin (PHE) | 40-80 µmol/L (10-20 µg/mL) toxic levels: >120 µmol/L (>30 µg/mL) |
lamotrigine (LTG) | 10-60 µmol/L (3-14 µg/mL) toxic levels: >70 µmol/L (>18 µg/mL) |
levetiracetam (LEV) |
35-217 µmol/L (5-25 µg/mL)
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topiramate (TPM) | 10-50 µmol/L (2-10 µg/mL) |
lacosamide (LCM) | 10-60 µmol/L (2.5-15 µg/mL) |
Indications for a long-term prophylactic anticonvulsant therapy
An isolated seizures, the cause has resolved (e.g., hyper/hypoglycemia, hyponatremia)
An isolated seizure or multiple seizures, the cause persists (severe stroke, TBI)
An initial cluster of ASS or ASSE
Two or more seizures with at least one seizure occurring > 14 days post-insult ⇒ epilepsy
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Prognosis
- the risk of transition from symptomatic seizures to unprovoked seizures (epilepsy) depends on the following:
- the cause, extent, and location of lesions
- increased risk is associated with, e.g., parenchymal hemorrhage, presence of malformations, cortical, larger ischaemic lesions, etc.
- comorbidities (e.g., previous insults, chronic metabolic conditions)
- premorbid and postmorbid conditions may play a role in the pathogenesis of stroke-related epilepsy (STRE)
- the term primary STRE can be used only if no such significant condition is detected
- the cause, extent, and location of lesions
- prognostic tools to detect an increased risk of STRE:
- SeLECT score – its usefulness is debated [Finsterer, 2018]
- focal seizures (especially with Todd’s hemiparesis) may pose a diagnostic challenge (Is it a new stroke or seizure? Should we initiate thrombolysis?)
- in the case of recurrent, uniform attacks that occur despite effective secondary prevention, a therapeutic trial with ASMs is appropriate