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Seizure Disorders

  1. Background/Cultural Points:

    Section titled “Background/Cultural Points:”
    Seizure disorders are common in Cambodia, including epilepsy and neurocysticercosis (Tinea solium). It is important to clarify what patient means by “prakach” – seizure vs syncope. Most cases of epilepsy can be managed at MMC with no head imaging and minimal labs.

  2. Diagnosis & Lab:

    Section titled “Diagnosis & Lab:”
    1. Confirm DIAGNOSIS of seizure with history & physical exam

    2. History suggestive of Seizure: Aura, postictal confusion, tongue biting, incontinence (Note: Syncope may have: pre-episode cardiac symptoms, myoclonic movements, and post-episode fatigue)
    3. Evaluate for other causes of mental status change as indicated: Trauma, Cardiac/Syncope, Drug/Toxin Exposure, infection, metabolic disease, etc.
    4. Perform thorough neurologic exam to R/O focal findings
    5. If patient is higher risk for intracranial pathology, consider Head CT w/ Contrast (Calmette Hospital; pre-order Creatinine; Non-Contrast if risk of IC Bleed):
    6. RISKS for intracranial pathology: HIV/AIDS, concerning headache, persistent altered mental status, partial seizure, history of malignancy, fever, age >40, trauma, recent history of anticoagulation
    7. Order limited labs based on risk only: HIV, Glucose, Na/K, Ca, Creatinine, CBC, ALT, U/A, Urine Tox (rarely), bHCG
    8. Consider EEG only if absolutely necessary (Calmette Hospital)

  3. Management/Education/Treatment:

    Section titled “Management/Education/Treatment:”
    1. Management may vary based on Seizure Classification:
      GeneralizedPartial (Focal)

      Generalized Tonic Clonic

      (Grand Mal)

      Absence (Petit Mal)

      Other

      Simple

      Complex

      Complex with secondary

      leneralization

    2. Treat underlying cause/s.
    3. Neurocysticercosis: most patients should be treated with pre-treatment Prednisolone (1mg/kg/d with taper off), which is continued during infectious treatment (high dose Albendazole, prolonged course), while patient also taking anti-convulsant or Diazepam. Caution based on number and location of cysts.
    4. Favor empiric treatment if low risk for IC pathology (see above).
    5. Recommended medical management:
      1. 1st line (Gen or Partial) = Carbemazepine (Tegretol) 200mg (SE: GI irritant, hepatic inflammation, aplastic anemia), increase to max of 600-1800mg/d; Consider baseline CBC, AST/ALT; Caution patient of warning symptoms—unexplained fever, jaundice,RUQ pain
      2. 2nd line = Phenytoin (Dilantin) 100mg (max 300-400 QD)(more expensive than Carbamazepine); SE: gingival hyperplasia, Cat X; Rx contraception for women child- bearing age
      3. 3rd line = Phenobarbitol 30mg (max 150mg/d; Inexpensive, but addiction issues)
      4. Consider Diazepam as adjunct/rescue.
    6. Patient Counseling
      1. Do NOT stop taking medicine suddenly
      2. Do not drive unless >12-18 months seizure free
      3. Wear helmet on motorcycle
      4. Do NOT get pregnant (Offer contraceptive options as indicated).

  4. Follow-Up:

    Section titled “Follow-Up:”
    1. Initial follow-up at 1 month, then q3-6 mos, then annually
    2. Monitor labs appropriately, based on medication chosen (EG, CBC/AST/ALT if taking Carbamazepine).