mbchb md fracp neurologist, hamilton north/sun_room11_0830_timmings... · 2014-06-14 · epilepsy...
TRANSCRIPT
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Dr Paul TimmingsMBChB MD FRACP
Neurologist, Hamilton
Disclosures: Nil
Journey: Ongoing
Passion: Abundant
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Fits and Faints: Syncope vs SeizureA few Thoughts and Tips
Dr Paul Timmings, MBChB MD FRACP
Neurologist
Waikato
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Case 1
• Ms LC, age 17
• Fooling around on sofa w friends, Sunday am.
• Late night before (probably an early morning),
• Excess unaccustomed alcohol that night
• Sudden LOC, Back arched, Body briefly stiff.
• Quickly OK after ?transiently muddled
• To GP next day (Monday!)
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Case 1
• O/E NAD, fully well, no tongue bite
• No PHx
• ECG; NAD, Bloods NAD
• Hx reviewed with boy-friend (eye witness)
• Advised no driving, no at risk activities (eg bathing)
• Diagnosis not entirely clear
• No Rx meantime
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LOC - ?Cause
• A common presentation and question
– 6% of ED attendances & 3% of Medical admissions
– 15% under 18 have had “syncope”
– 25% of > 70 will have LOC ?cause in next 10yrs
• Huge capacity of Dr to influence QOL & DOL
• No substitute for a detailed and careful Hx
• Eye-witness accounts are vital
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LOC ?Cause: Differential Dx• Seizure:
– Focal
– Generalised
• Syncope:
– Cardiac (arrhythmia, cardiomyopathy)
– Non-Cardiac (vasovagal, orthostatic, medication induced)
• Migraine
• Movement disorder (with paroxysmal events)
• Toxic / Metabolic (Hypo/Hyper-glycaemia, Alcohol, Drugs)
• Sleep disorder (Narcolepsy, Parasomnia)
• Cerebrovascular (TIA (rarely), Stroke)
• Psychogenic (Anxiety/Panic, Conversion (NEAD))McKeon et al Lancet Neurology 2006
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LOC ?Cause: Differential Dx
• Differential is difficult & wide, - even huge
• 25-45% are undiagnosed at time of hosp Dx
• Investigative costs are large (e7756 in mid ‘90s review)
• Inappropriate investigations consume resources and choke waiting lists
• Incorrect or uncertain diagnoses add unnecessary social disability eg work/driving issues
McKeon et al Lancet Neurology 2006
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How can we do better?
• Some features may help discriminate
Eg: prodrome, pallor, posturing, confusion
• 2/3 of blackouts are syncope
& ½ those are vasovagal
– Many episodes of LOC-?Cause are benign.
Sarasin et al Am J Med 2001
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How can we do better?
• Some symptoms may help discriminate
Eg: prodrome, pallor, posturing, confusion
• 2/3 of blackouts are syncope & ½ those are vasovagal
• But – 9% of syncope cases are dead in 18 months &
30% with underlying cardiac disease are dead in 1 yr
• Correct triage and management of cardiac cases will save lives
Sarasin et al Am J Med 2001
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Examples of Malignant Syncope
• LV or RV disease– AS, HOCM, Pul emboli, Pul hypertension
– Pump failure
– Ischaemia
• Rhythm problems– AF, PAT, PAF, AV node abn pathways eg WPW
– Heart block, VT, VF, Long QT
• Volume problems– Vasoactive drugs, autonomic neuropathy, volume
depletion
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What about the Jerking?
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What about the Jerking?
• Myoclonus occurs in 90 % of syncope patients
• Focal movements & automatisms also occur.
• Eyes open, shut, rolling, or moving side to side are not discriminatory either.
• The commonly held belief that jerking means epileptic seizure is WRONG.
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Symptom Scoring is 94% Accurate
Sheldon et al J Am Col Cardiol 2002
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LOC ?Cause: Investigations
• BioChem, BGL, CBC
• ECG
• Prolactin usually unhelpful
– Can be elevated in both syncope or seizure
– Usually normal in psychogenic sz – so may be useful
– Psycho-active drugs also elevate prolactin
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Case 1
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Case 1
• What key additional test(s) will help
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EEG – 3 Hz spike&wave
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LOC ?Cause: 2nd Tier Cardiac Investigations
• Holter monitor correctly identifies 10% of arrhythmias in 24hrs, repeat
gets another 10%.
• External loop recorder correctly identifies 25%
• Implantable recorders identify arrhythmias in 25-46% and prove Sinus
Rhythm during Syx in 24-42%. Giving overall yield of 50-88%
• Echocardiogram helpful if cardiac Hx (otherwise low yield)
– If systolic dysfunction on echo, is highly predictive of arrhythmia
• Tilt table testing (35-70% yield)
• Cardiac EP studies (up to 80% yield in selected cases)
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Seizure
Spontaneous Seizure
Repeated Spontaneous
SeizuresEpilepsy
Focal
Symptomatic
Treat Cause
Single
Wait, no Rx Gen
EEG+/- Imaging
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LOC ?Cause: 2nd Tier Neuro Investigations
• EEG
– Routine EEG within 24hrs has 50% yield, after that only 25-30%
• Sleep during the EEG adds 25%
• Sleep deprivation adds 25%
– Sleep deprived EEG with sleep sensitivity = 85%
• Imaging: CTB or MRB
– 2% yield if primary generalised seizure (on Hx & EEG)
– 17% yield if focal onset seizures or focal Ep activity on EEG
• Video EEG may alter diagnosis in 24-58% especially in psychogenic / non-epileptic events
Roupakiotus et al Seizure 2000King et al Lancet 1998
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EEG: What Use is It?
• A normal EEG will not exclude Seizure/Epilepsy(due to technique dependent false negative rate)
• A normal EEG (in a patient who had a seizure)
implies 20-30% chance of second seizure by 2 yrs
• An abnormal EEG that shows interictal
epileptogenic activity means 60-75% chance of a
second seizure by 2 yrs
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Risk Factors for Seizure
• Febrile convulsion
• Perinatal insult / abnormal gestation / delivery
• CNS infection
• CNS mass lesion
• Family Hx of epilepsy
• TBI with LOC > 30min or penetrating brain injury
• Dev delay / “IHC”
• Stroke
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LOC ?Cause: Syncope vs Seizure: Distinguishing the Clinical Features
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Seizure: Investigative and Management Algorithm
McKeon et al Lancet Neurology 2006
GeneralisedFocal or
Focal then Gen? NEAD Provoked
EEG sleep deprived w
sleep
EEG routine and
MRB or CTB
Wait for 2nd Szbefore starting
Rx.EEG gives prognostic
information.
Focal EEG IED’s & focal brain
lesion = Epilepsy.
Video EEGMay need
monitoring
Treat cause.
Arrange psychiatry / psychology
help.
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Syncope: Investigative and Management Algorithm
McKeon et al Lancet Neurology 2006
Typical prodromeNormal examNormal ECG
Cardiac Red FlagsChest pain, No warning Abn Cardiac exam/ECG. FHx Sudden death
Cough, Pain, Micturition, Defaecation
Orthostatic
Neurallymediated.
Cardiogenic.?Carotid sinus
Cardiac work up:Telem/Holter/Echo/Angio
Situational
DrugsVolume lossAutonomic failure
Diabetes MSA
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Syncope: Investigative and Management Algorithm
McKeon et al Lancet Neurology 2006
Typical prodromeNormal examNormal ECG
Cardiac Red FlagsChest pain, No warning Abn Cardiac exam/ECG. FHx Sudden death
Cough, Pain, Micturition, Defaecation
Orthostatic
Neurallymediated.
Cardiogenic.?Carotid sinus
Cardioinhibitoryor Vasodepressor
Conservative Rx.HUTT if atypical
Midodrine/ Fludrocort/?Pacemaker
Cardiac work up:Telem/Holter/Echo/Angio
May need implantable recorder
Treat Cardiac Disease
Situational
Manage Situation or other disease.
May need Neurology review
DrugsVolume lossAutonomic failure
Diabetes MSA
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Case 2• 47 yr old tanker driver
• Sent by employer. Had put truck though fence off highway. No injuries. Just after taking a break & PU’ing @ Tirau.
• No recall of event, no witness.
• No PHx
• Single, non smoker, 24-48 stubbies per wkend.
• O/E NAD, wt 103kg, BMI 32,ECG NAD, Bloods NAD
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Case 2• 47 yr old tanker driver
• Sent by employer. Had put truck though fence off highway. No injuries. Just after taking a break & PU’ing @ Tirau.
• No recall of event, no witness.
• No PHx
• Single, non smoker, 24-48 stubbies per wkend.
• O/E NAD, wt 103kg, BMI 32,ECG NAD, Bloods NAD
• EEG no abnormal activity
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Case 2
• EEG: Prominent snoring noted, & occasional gasping
• Epworth score =8
• OPSG: Prominent snoring, several respiratory pauses with O2 desaturation & arousals.
• Likely diagnosis
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Case 2
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Case 2• OSA & Sleep attack leading to MVA
• Sleep episodes may be abrupt & intrusive!?Due to fragmented night sleep & fatigue.
• Should not drive until managed CPAP
• Untreated OSA:
– Increased risk of: Accidents, BP, AF, cardiac events, stroke, sudden death.
• High Epworth score not always noted(Usually a marker of excessive daytime sleepiness)
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Case 3
• Mr L. J. Age 65
• BIBA
• Found sitting bemused by letter box
• Had grazed hand and knee
• Disoriented to time & place
• Pulse 80, reg. BP 136/82, BGL@ scene 6.2
• Admitted w confusion ? cause
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Case 3
• ECG: NSR. Urine non-infected. Bloods normal
• Other Hx:
– Lives with mildly demented wife
– 2 yrs ago in hosp with “minor stroke”, - good recovery but slight L limb weakness persists
• CTB: small old R cortex infarct, widespread white matter ischaemic changes
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Case 3
• Remained confused for 24hrs (in hospital)– Then “came right” & anxious to get home to wife.
So, was D/C’d but no Rx Δ. Dx ?TIA
• 2 similar spells over next 3 months1. Found by daughter sitting muddled on sofa.
2. Slumped briefly @ church, then confused.
• Neurology review: EEG R temporal sharp & slow waves
• Dx: Likely, post stroke epilepsy
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Case 4
• Ms P.S. age 72
• C/O repeated episodes of vaudeville music
– Definite onset, not related to any conscious thought
– All were songs that she knew as a young woman
– Like torture, - very intrusive. Even wake her from sleep
• Normal exam & Normal imaging
• EEG posterior temporal theta
– Dx: simple partial seizures
– All episodes ceased with VPA 400mg/day
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Epilepsy in th Elderly
• The young “fit fitters” come to clinic,
but
• The older “funny turners” are trapped in the corners at their (rest) homes.
• Epilepsy in older people is now their 3rd
commonest condition
– exceeded only by stroke & dementia
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Incidence & Prevalence Vs. Age
• Incidence & Prevalence of epilepsy in elderly is now the highest of any age group
Brodie 2005Hauser 2007
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Epilepsy Incidence in Infants & Children is Decreasing & Increasing in Elderly
Hauser 2007
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Epilepsy in Elderly:Cerebrovascular Disease is Main Cause
• Stroke risk rises with age
• 50% of new epilepsies are 20 to vascular events
Kramer 1999
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Type of “Stroke” Affects Seizure Risk
• By 5 yrs post event
– 10% of ischaemic infarcts will have seizures
– 25-30% of haemorrhages will have seizures
Burn 1997
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Diagnosis
• In the elderly “New Onset Epilepsy” is often manifest with vague complaints:
• confusion
• altered mental status
• memory difficulty
• Eye witness descriptions of onset, or the instant of “state change” are often unavailable
• Symptom scoring strategies don’t work!
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Diagnostic Difficulties• Many seizures are brief & may be un-noticed
• Almost all epileptic events in elderly are focal onset (i.e. Partial epilepsy)
– Caused by focal brain disease
• Seizures often leave elderly confused or disoriented for a day or longer
• Elderly are more prone to post ictal confusion & Todd’s paresis
• Post ictal confusion typically lasts longer
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Differential Diagnosis is Challenging
• Need to consider
– Syncope
– Cardiac arrhythmia
• e.g. transient cardiac stand still, unsustained VT, or PAT/F
– TIA
– TGA
– Episodic vertigo
– Metabolic disturbances eg
• Low sodium
• Low glucose
– Drug interactions and adverse effects
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Causes of Seizures in Elderly:The Top 4
• Previous vascular event(s) 50-70%
• Metabolic / toxic 10%
• Tumour (primary or met) 10-20%
• Dementia(s) & degenerations 10-18%
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Management
• Diagnose correctly – Think of it!
• Cardiac disease is also more common.
• Address co-morbidities & poly-pharmacy
• AED’s (Anti-Epileptic-Drugs) are effective
• Review safety issues (re seizures/falls/confusion)
– Living arrangements
– Supervision / support
• Educate
– Spouse / family / carers
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Pk-Pd issues in Elderly• Absorption
• Distribution
• Metabolism and excretion
• Decreased absorption
• Delayed oesophageal emptying
• Altered gastric pH
• Delayed gastric emptying
• Increased intestinal transit time
• Decreased albumin and degree of protein binding
(Albumin reduces by 2.5%/decade)
• Decreased body fat
• Decreased hepatic metabolism
• Decreased renal clearance
(Renal clearance reduces by 1%/yr)
Net metabolic capacity might be 50% of a younger adult
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Effect of Doubling Half-Life
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Choosing an AED: Special Considerations in Elderly
• Choose a Rx that works best in focal onset epilepsies
• Carbamazepine CR or Lamotrigine
– Equally effective
– Equally well tolerated
• Levetiracetam may be a good alternative
– (few interactions, inert metabolites)
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Choosing an AED: Special Considerations in Elderly
• Carbamazepine– Hyponataremia - if co-administered with diuretics– Enzyme inducer so many interactions
• Lamotrigine– Needs slow titration– Anti-depressant, alerting (slight)
• Levetiracetam– No important interactions– Depression– GI upset
• Valproate– Metabolic inhibitor, so possible interactions– Tremor, Parkinsonian symptoms, Encephalopathy (rare)
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Epilepsy in Elderly: Summary• Epilepsy in elderly is a growing but under-
recognised problem
– Seizures are now their 3rd commonest condition
• 50-70% are post stroke
– 10% of stroke patients have epilepsy by 5yrs
• Most seizures are atypical & have focal onset
– Many leave prolonged confusion in their wake
– Correct diagnosis can be tricky
• AED therapy is effective. But be mindful of interactions, odd adverse effects & reduced metabolic capacity (Go Low & Slow)
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Discussion?
Paul Timmings
Neurologist
Hamilton
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Extras
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EPILEPSY in OLDER PEOPLE: KEY POINTS
•Elderly have the highest incidence of seizures of any age group.
•Nearly half of acute symptomatic seizures in the elderly and 30% to 50% of all epilepsy cases in this age group are associated with stroke.
•In elderly, new onset of epilepsy is often associated with vague complaints such as confusion, altered mental status, or memory problems.
•The differential diagnosis of seizures in the elderly should rule out spells due to other causes, such as syncope (cardiac disease), transient ischemic attack, transient global amnesia, or episodic vertigo.
•In treating epilepsy, the choice of antiepileptic drug (AED) is usually dictated by seizure type and tolerability but will be complicated by co-morbidities or age-associated differences in AED pharmacokinetics.
•Older and newer AEDs are both effective.
•Newer AEDs generally have better overall tolerability, fewer drug interactions, more predictable kinetics, and a broader spectrum of activity; but they also have slower titration schedules and cost considerably more than older AEDs.
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EEG
• So, what use for EEG?
• A test of function vs a view of structure
• Useful in assessment of altered mental status– syncope /LOC ?cause
– Epilepsy management
– Non-convulsive status epilepticus (NCSE)
– Metabolic & encephalopathic disease
– Drug effects also often reflected in EEG
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EEG – Who needs it?
• Patients with poor or worsening Ep control,
- re ? new changes in EEG
• Investigation of toxic / metabolic
encephalopathies
• Some coma patients
• Some cerebral infections (eg Herpes, CJD, SSPE)
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EEG – Who needs it?
• LOC ? Cause with suspicion of seizure
• Altered mental status ?cause ?NCSE, – must include atyp. dementias and some psychoses (re ?NCSE)
• Single Sz patients (prognostic data)
• Can help define the Epilepsy Syndrome
• Well controlled Ep. Pts. re ? to stop Rx
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EEG
• Get more from an EEG test, after you
– Define your question
– Use the test appropriately
– Understand the result and its limitations
Dr Paul TimmingsNeurologist Hamilton
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Syncope: Investigative and Management Algorithm
McKeon et al Lancet Neurology 2006