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Epilepsy:
Central nervous system (neurological) disorder in which brain…
Epilepsy:
Central nervous system (neurological) disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations, and sometimes loss of awareness.
Pathophysiology:
Recurrent & unpredictable seizure
- Neuron are synchronously active when it not suppose to be.
- Neuron is firing & sending messages using electrical signals relayed from neuron to neuron.
Neuron activity during seizure:
- Clusters of neurons in the brain become temporarily impaired and start sending out a ton of excitatory signal over and over again, to be paroxysmal.
- Paroxysmal electrical discharge are thought to happen due to either too much excitation or too little inhibition.
Too much excitation:
- Main excitatory neurotransmitter in the brain: Glutamate.
- NMDA is primary receptor that responds to glutamate by opening ion channel that let calcium ion Ca+ positive ion tell the cell to send signals.
- Pt have fast or long lasting activation of the receptor
Too little inhibition:
- Main inhibitory neurotransmitter in the brain: GABA.
- GABA receptor: Primary receptor that responds to GABA by closing ion channel that let chloride ion Cl-, negative ion tell the cell to inhibit signal.
- Some pt have genetic mutation the GABA receptor dysfunctional,the receptor unable to help inhibit the signal.
Risk factors:
- Born with abnormal areas in the brain.
- Born small for the actual age.
- Hvg seizure for the 1st month of the life.
- Hvg seizures within days after a head injury (called “early posttraumatic seizures”).
- Fever-related (febrile) seizures that last longer than usual.
- Long episodes of seizures or repeated seizures (called “status epilepticus”).
- Fmly history of epilepsy or fever-related seizures.
- Using illegal drugs, like cocaine.
Clinical manifestations:
- Focal seizure
- Partial complex seizures originating from the temporal lobe (temporal lobe epilepsy/psychomotor epilepsy).
- Begin with a visceral sensation or other aura(breeze) and are followed by a state of impaired consciousness, automatic motor activities or convulsions.
- EEG localizes the epileptogenic focus in the medial portion of the temporal lobe.
- Because TLE is refractory to drugs, it is often treated by resection of the temporal lobe including the hippocampus and surrounding area and the amygdala.
- Examination of temporal lobectomy specimens reveals pathology in most cases.
Did not loss consciousness:
- Uncontrollable jerking movements of the arms and legs.
- Temporary confusion.
- Dizziness
- Alter emotions/change the way things look, smell, feel, taste or sound.
Impaired awareness:
- Staring spell
- Perform repetitive movement eg: walking in a circle, hand rubbing.
- Unresponsiveness.
- Generalized seizure (involve the whole part of the brain).
- Absence seizures: Absence seizures, previously known as petit mal seizures, often occur in children and are characterized by staring into space or subtle body movements such as eye blinking or lip smacking; may occur in clusters and cause a brief loss of awareness.
- Atonic seizures: Known as drop seizures cause a loss of muscle control where the muscle , suddenly relaxed and floppy , which may cause you to suddenly collapse or fall down, often forward.
- Tonic seizures: Cause stiffening of your muscles; usually affect muscles in your back, arms and legs and may cause you to fall to the ground, often backward.
- Clonic: cause violent muscle contraction also known as convulsion.
- Tonic-clonic seizures: Pt experienced tonic phase where the muscle suddenly tensed up followed by clonic phase where the muscle rapidly contract and relax.
- Myoclonic seizures: Cause short muscle twitches sometimes single twitches sometime many a short amount of time.
Complications:
- Injuries
- Some people may stare blankly for a few moments while others may experience twitching arms and legs. The loss of consciousness brought on by epileptic seizure makes it easy to fall over and cause injury.
- Permanent brain damage
- Epilepticus occurs when you experience a seizure for more than five minutes at a time, or if you have several seizures in a row without gaining complete consciousness in between each attack. Epilepsy patients with status epilepticus have an increased risk of permanent brain damage, which can be fatal.
- Psychological problem
- People with epilepsy are more likely to experience emotional problems, including depression and anxiety. Although psychological issues may be present regardless of the condition, the difficulties of dealing with epilepsy are a common factor leading to depression.
- Sudden unexplained death
- A small risk of sudden unexplained death in epilepsy or SUDEP. Although no one is certain of the cause of SUDEP, it may be related to heart and respiratory complications. Talk to your doctor about controlling your epilepsy because there is a higher risk of SUDEP when epilepsy is poorly controlled.
Medical diagnostic/tx:
- Neurological exam: To test the behavior, motor abilities, mental function and other areas to diagnose patient's condition and determine the type of epilepsy he/she may have.
- Blood tests: To check for signs of infections, genetic conditions or other conditions that may be associated with seizures.
- Electroencephalogram (EEG): Electrodes are attached to the scalp with a paste-like substance or cap. The electrodes record the electrical activity of brain. If the patient has epilepsy, it is common to have changes in the normal pattern of brain waves, even when the patient not having a seizure.
- High density EEG: spaces electrodes more closely than conventional EEG which is about a half a centimeter apart. High-density EEG may help the doctor more precisely determine which areas of brain are affected by seizures.
- Computerized tomography (CT) scan: uses X-rays to obtain cross-sectional images of brain. CT scans can reveal abnormalities in the brain that might be causing patient's seizures, such as tumors, bleeding and cysts.
- Magnetic resonance imaging (MRI): Uses powerful magnets and radio waves to create a detailed view of brain. Doctor may be able to detect lesions or abnormalities in brain that could be causing patient's seizures.
- Functional MRI (fMRI): Measures the changes in blood flow that occur when specific parts of brain are working. Doctors may use an fMRI before surgery to identify the exact locations of critical functions, such as speech and movement, so that surgeons can avoid injuring those places while operating.
- Positron emission tomography (PET): Scans use a small amount of low-dose radioactive material that's injected into a vein to help visualize active areas of the brain and detect abnormalities.
- Single-proton emission computerized tomography (SPECT): Used primarily if patient had an MRI and EEG that did not pinpoint the location in brain where the seizures are originating. SPECT test uses a small amount of low-dose radioactive material that is injected into a vein to create a detailed, 3-D map of the blood flow activity in brain during seizures. Doctors also may conduct a form of a SPECT test called subtraction ictal SPECT coregistered to MRI (SISCOM), which may provide even more-detailed results.
- Neuropsychological tests:doctors assess patient's thinking, memory and speech skills. The test results help doctors determine which areas of brain are affected. Along with the test results, doctor may use a combination of analysis techniques to help pinpoint where in the brain seizures start.
- Statistical parametric mapping (SPM): Comparing areas of the brain that have increased metabolism during seizures to normal brains, which can give doctors an idea of where seizures begin.
- Curry analysis: Technique that takes EEG data and projects it onto an MRI of the brain to show doctors where seizures are occurring.
- Magnetoencephalography (MEG): measures the magnetic fields produced by brain activity to identify potential areas of seizure onset.
Tx:
- AEDs (Anti-epileptic drugs) are the most commonly used treatment for epilepsy.
- AEDs work by changing the levels of chemicals in the brain but they do not cure epilepsy, but can stop seizures happening.
Common types of AEDs:
- Sodium valproate
- Carbamazepine
- Lamotrigine
- Levetiracetam
- Oxcarbazepine
- Ethosuximide
- Topiramate
General SE of AEDs:
- Drowsiness
- A lack of energy
- Agitation
- Headaches
- Uncontrollable shaking (tremor)
- Hair loss/unwanted hair growth
- Swollen gums
- Rashes (serious reaction- to contact doctor)
-
Surgical interventions:
- Lobe resection: Temporal lobe epilepsy, in which the seizure focus is within the temporal lobe, is the most common type in teens and adults. In a temporal lobe resection, brain tissue in this area is cut away to remove the seizure focus. Extratemporal resection involves removing brain tissue from areas outside of the temporal lobe.
- Lesionectomy: Removes brain lesions (areas of injury or defect like a tumor or malformed blood vessel that cause seizures). Seizures usually stop once the lesion is removed.
3. Corpus callostomy: Corpus callosum a band of nerve fibers connecting the two halves (called hemispheres) of brain. In this operation, which is sometimes called split-brain surgery, surgeon cuts the corpus callosum. This stops communication between the hemispheres and prevents the spread of seizures from one side of brain to the other. It works best for people with extreme forms of uncontrollable epilepsy who have intense seizures that can lead to violent falls and serious injury.
- Functional hemispeherectomy: Removes an entire hemisphere or half of the brain. In a functional hemispherectomy, the surgeon leaves the hemisphere in place but disconnects it from the rest of the brain, then only removes a limited area of brain tissue. This surgery is mostly for children younger than 13 who have one hemisphere that does not work the way it should.
- Multiple subpial transection (MST):Help control seizures that begin in areas of brain that cannot be safely removed. The surgeon makes a series of shallow cuts (transections) in the brain tissue. These cuts interrupt the flow of seizure impulses but do not disturb normal brain activity. That leaves the patient's abilities intact.
- Vagus nerve stimulation (VNS): Device put under the skin sends an electronic jolt to the vagus nerve, which controls activity between the brain and major internal organs. It lowers seizure activity in some people with partial seizures.
- Responsive neurostimulation device (RNS): Surgeons put a small neurostimulator in the skull, just under the scalp. Then, link it to one or two wires (called electrodes) that they place either in the part of the brain where the seizures start or on the brain’s surface. The device detects abnormal electrical activity in the area and sends an electric current. It can stop the process that leads to a seizure.
- Deep brain stimulation: Surgeons put electrodes into a specific area of the brain. They directly stimulate the brain to help stop the spread of seizures in adults who have not responded to medication and aren't candidates for other surgeries.
Risks:
- Infection/bleeding, the chance of allergic reaction to the anesthesia.
- Making existing problem worse/create new trouble with the way brain works (lose vision, speech, memory, movement).
- Return of seizures.
Pharmacotherapeutics:
(Anti-epileptic medications)
- Older AEDs:
-Phenobarbital, Phenytoin, Primidone
- Ethosuximide, Carbamazepine, Valporate
- Newer AEDs:
- Lamotrigine,Topiramate, Tiagabine
- Oxcarbazepine, Zonisamide, Levetiracetem
- Vigabatrin, Felbamate, Pregabalin
- Rufinamide, Lacosamide, Stiripentol, Clobazam
- Eslicarbazepine, Ezogabine, Perampanel
Priority nsg care:
Nsg diagnosis: Risk for trauma related to loss of muscle, hand or eye coordination.
Goal: After 4 hours, patient will demonstrate behaviours and lifestyle changes to reduce risk factors and protect self from injury during hospitalization.
Interventions:
- Explore with patient various stimulus that may precipitate seizure activity as lack of sleep, flashing lights and prolonged television viewing may increase brain activity that may cause potential seizure activity.
- Discuss with patient the seizure warning signs and usual seizure pattern as early detection can minimize patient from self injury.
- Keep padded side rails up with bed at lowest position to minimize injury when seizures happen.
- Evaluate the need to wear protective gear as it can give extra protection for patient who suffer recurrent or severe seizure.
- Do not leave patient during and after seizure to monitor patient safety.
- Maintain strict bed rest if prodromal signs or aura experienced as patient may feel restless to ambulate or even defecate during aural phase, thereby inadvertently removing self from a safe environment and easy observation.
Evaluation: After 4 hours, patient demonstrated behaviours and lifestyle changes to reduce risk factors and protect self from injury during hospitalization.
Health education:
- Encourage patient to compliance with medications to reduce risk of seizure.
- Avoid alcohol as this helps to decrease the seizure threshold.
- Have a well-balanced diet.
- Promote adequate rest.
- Avoid from driving, operating machines, swimming until seizures are well controlled.
- Encourage active lifestyle.