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Folate should be prescribed for all women of childbearing age who are taking AEDs. AED therapy during the 1st trimester is associated with doubled risk for major fetal malformations (6% vs. 3%).
Phenytoin in pregnancy may result in fetal hydantoin syndrome.
Valproate is associated with neural tube defects.
Fetal insult from seizures following withdrawal of therapy also may be severe. Risk-to-benefit balance should be evaluated with high-risk pregnancy and neurology consultations. Most patients remain on anticonvulsants.
Consider vagal nerve stimulator during pregnancy (8)[B].
‚
ISSUES FOR REFERRAL
For refractory seizures, consider referral to an epilepsy specialist (9)[B]. ‚
ADDITIONAL THERAPIES
- Vagal nerve stimulator provides periodic stimulation to vagus nerve; may induce hoarseness, cough, and dysphagia. High-frequency stimulation in adults provides greater reduction in seizure frequency than low-frequency stimulation but also has greater rates of side effects (10)[B].
- Deep brain stimulation may decrease seizure frequency in medically refractive epilepsy but its efficacy varies by seizure source location (11)[B].
- Repetitive magnetic transcranial stimulation may reduce the frequency of seizures in individuals with refractory focal seizures (12)[B].
SURGERY/OTHER PROCEDURES
- For refractory partial complex seizures with identifiable focus
- Preoperative testing, such as Wada test, should be done to decrease likelihood of inducing aphasia and memory loss.
- 34 " “74% will be seizure-free after temporal lobe surgery. Prognosis varies for surgical resection of extratemporal foci (13)[B].
- Goal of surgical intervention is to reduce reliance on medications; most patients remain on anticonvulsants postoperatively.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
Admit for unremitting seizure (partial/secondary generalized status epilepticus). ‚
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
- Most states have restrictions on driving for those with seizure disorders.
- Depending on seizure manifestation, may also recommend against activities such as swimming, climbing to heights, or operating heavy machinery
Patient Monitoring
AED levels if concern over toxicity, noncompliance, or for breakthrough seizures ‚
DIET
Ketogenic or low-glycemic index diet may improve seizure control in some patients but is not well-tolerated (14)[B]. ‚
PATIENT EDUCATION
Avoid potential triggers such as alcohol or drug use and sleep deprivation. ‚
PROGNOSIS
- Risk of seizure recurrence: ~30% after first seizure; of these, 50% will occur in the first 6 months; 90% in the first 2 years.
- Depends on seizure type; rolandic epilepsy has a good prognosis; temporal lobe epilepsy is more likely to be persistent.
- ~25 " “30% of all seizures are refractory to current medications.
- AEDs initiated after an initial seizure have been shown to decrease the risk of seizure over the first 2 years but are not demonstrated to reduce long-term risk of recurrence.
- The potential for AEDs to confer neuroprotection is under investigation.
- The risk of developing seizure after mild TBI remains high for a long period (>10 years) (1)[B].
COMPLICATIONS
- Risk of accidental injury
- Up to 50 " “60% of individuals with epilepsy will also have a mood disorder, the most common being depression and anxiety.
- 20 " “30% of individuals with epilepsy will have memory impairment.
REFERENCES
11 Christensen ‚ J, Pedersen ‚ MG, Pedersen ‚ CB, et al. Long-term risk of epilepsy after traumatic brain injury in children and young adults: a population-based cohort study. Lancet. 2009;373(9669):1105 " “1110.22 Fattal-Valevski ‚ A, Bloch-Mimouni ‚ A, Kivity ‚ S, et al. Epilepsy in children with infantile thiamine deficiency. Neurology. 2009;73(11):828 " “833.33 Brigo ‚ F, Igwe ‚ SC, Erro ‚ R, et al. Postictal serum creatine kinase for the differential diagnosis of epileptic seizures and psychogenic non-epileptic seizures: a systematic review. J Neurol. 2015;262(2):251 " “257.44 Gaillard ‚ WD, Cross ‚ JH, Duncan ‚ JS, et al. Epilepsy imaging study guideline criteria: commentary on diagnostic testing study guidelines and practice parameters. Epilepsia. 2011;52(9):1750 " “1756.55 Krumholz ‚ A, Wiebe ‚ S, Gronseth ‚ GS, et al. Evidence-based guideline: management of an unprovoked first seizure in adults: report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology. 2015;84(16):1705 " “1713.66 Bonnett ‚ LJ, Smith ‚ CT, Donegan ‚ S, et al. Treatment outcome after failure of a first antiepileptic drug. Neurology. 2014;83(6):552 " “560.77 Thompson ‚ K, Pohlmann-Eden ‚ B, Campbell ‚ LA, et al. Pharmacological treatments for preventing epilepsy following traumatic head injury. Cochrane Database Syst Rev. 2015;(8):CD009900.88 Houser ‚ MV, Hennessy ‚ MD, Howard ‚ BC. Vagal nerve stimulator use during pregnancy for treatment of refractory seizure disorder. Obstet Gynecol. 2010;115(2, Pt 2):417 " “419.99 Hemb ‚ M, Velasco ‚ TR, Parnes ‚ MS, et al. Improved outcomes in pediatric epilepsy surgery: the UCLA experience, 1986 " “2008. Neurology. 2010;74(22):1768 " “1775.1010 Panebianco ‚ M, Rigby ‚ A, Weston ‚ J, et al. Vagus nerve stimulation for partial seizures. Cochrane Database Syst Rev. 2015;(4):CD002896.1111 Sprengers ‚ M, Vonck ‚ K, Carrette ‚ E, et al. Deep brain and cortical stimulation for epilepsy. Cochrane Database Syst Rev. 2014;(6):CD008497.1212 Sun ‚ W, Mao ‚ W, Meng ‚ X, et al. Low-frequency repetitive transcranial magnetic stimulation for the treatment of refractory partial epilepsy: a controlled clinical study. Epilepsia. 2012;53(10):1782 " “1789.1313 Jobst ‚ BC, Cascino ‚ GD. Resective epilepsy surgery for drug-resistant focal epilepsy: a review. JAMA. 2015;313(3):285 " “293.1414 Levy ‚ RG, Cooper ‚ PN, Giri ‚ P. Ketogenic diet and other dietary treatments for epilepsy. Cochrane Database Syst Rev. 2012;(3):CD001903.
ADDITIONAL READING
- Walker ‚ LE, Mirza ‚ N, Yip ‚ VL, et al. Personalized medicine approaches in epilepsy. J Intern Med. 2015;277(2):218 " “234.
- Wilden ‚ JA, Cohen-Gadol ‚ AA. Evaluation of first nonfebrile seizures. Am Fam Physician. 2012;86(4):334 " “340.
CODES
ICD10
- G40.109 Local-rel symptc epi w simp prt seiz,not ntrct, w/o stat epi
- G40.209 Local-rel symptc epi w cmplx prt seiz,not ntrct,w/o stat epi
- G40.119 Local-rel symptc epi w simple part seiz, ntrct, w/o stat epi
- G40.219 Local-rel symptc epi w cmplx part seiz, ntrct, w/o stat epi
- G40.201 Local-rel symptc epi w cmplx prt seiz, not ntrct, w stat epi
- G40.111 Local-rel symptc epi w simple part seiz, ntrct, w stat epi
- G40.019 Local-rel idio epi w seiz of loc onset, ntrct, w/o stat epi
- G40.211 Local-rel symptc epi w cmplx partial seiz, ntrct, w stat epi
- G40.011 Local-rel idio epi w seiz of loc onset, ntrct, w stat epi
- G40.009 Local-rel idio epi w seiz of loc onst,not ntrct,w/o stat epi
- G40.001 Local-rel idio epi w seiz of loc onst, not ntrct, w stat epi
- G40.101 Local-rel symptc epi w simp part seiz, not ntrct, w stat epi
ICD9
- 345.50 Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, without mention of intractable epilepsy
- 345.40 Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, without mention of intractable epilepsy
- 345.51 Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, with intractable epilepsy
- 345.41 Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, with intractable epilepsy
SNOMED
- 29753000 Partial seizure (disorder)
- 117891000119100 simple partial seizure (disorder)
- 4103001 complex partial seizure with impairment of consciousness (disorder)
- 79348005 Simple partial seizure consciousness not impaired (disorder)
CLINICAL PEARLS
- It is controversial whether AED treatment is indicated after a first seizure. Treatment should be strongly considered when a clear structural cause is identified/risk of injury from seizure is high (e.g., osteoporosis, anticoagulation).
- Consider vagus nerve stimulation in pregnancy and in patients with medically refractory seizures.
- Postictal elevation in prolactin and CPK levels can help distinguish physiologic from psychogenic seizures.