Seizures in Critical Care - A Guide to Diagnosis and Therapeutics

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Chapter 1

Presentation and Pathophysiology of Seizures in the Critical Care Environment: An Overview

1.1. Introduction

1.2. Cellular Pathphysiology of ICU Seizures

1.3. Clinical Manifestations and Diagnosis

1.4. Overview of Status Epilepticus

1.5. Paroxysmal Lateralizing Epileptiform Discharges (PLEDS)

1.6. Conclusion

References

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Chapter 2

Diagnosing and Monitoring Seizures in the ICU: The Role of Continuous EEG for Detection and Management of Seizures in Critica

2.1. Introduction

2.2. How To Monitor

2.3. Data Analysis

2.4. Who To Monitor

2.5. What To Look For

2.6. Why Monitor

2.7. How Long To Monitor

2.8. Future Directions

2.9. Summary

References

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Chapter 3

Stroke and Critical Care Seizures

3.1. Introduction

3.2. Seizures After Ischemic Stroke

3.2.1. Clinical Studies

3.2.2. Status Epilepticus

3.2.3. Pathophysiology

3.2.4. EEG Findings

3.2.5. Neuroimaging

3.2.6. Seizures Post Stroke in the Young and the Elderly

3.2.7. Treatment of Post-Ischemic Stroke Seizures

3.3. Intracerebral Hemorrhage (ICH)

3.3.1. Clinical Studies

3.3.2. SE Following ICH

3.3.3. Pathophysiology of Seizures Post ICH

3.3.4. Treatment of Seizures Post ICH

3.4. Subarachnoid Hemorrhage

3.4.1. Clinical Studies

3.4.2. Treatment of Seizures after SAH

3.5. Arteriovenous Malformations

3.5.1. Clinical Studies

3.5.2. Treatment of AVM-Related Seizures

3.6. Reperfusion–Hyperperfusion Syndrome

3.7. Cerebral Vein and Dural Sinus Thrombosis

3.7.1. Clinical Studies

3.7.2. Treatment of Seizures Related to CVT

References

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Chapter 4

Traumatic Brain Injury and Seizures in the ICU

4.1. Introduction

4.2. Incidence of Seizures in Traumatic Brain Injury

4.3. Experimental Approaches to Posttraumatic Seizures

4.4. Pathophysiology of Posttraumatic Seizures

4.5. Diagnosis of Seizures

4.6. Treatment of Posttraumatic Seizures

4.7. Outcome of Seizures Complicating TBI

4.8. Conclusions

References

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Chapter 5

Brain Tumors and ICU Seizures

5.1. Introduction

5.2. Incidence

5.3. Clinical Presentation

5.4. Pathophysiology

5.5. Evaluation of Patients with ICU Seizures

5.6. Treatment

5.6.1. Prophylactic Administration of Antiepileptics

5.6.2. Treatment of Seizures in the ICU

5.7. Outcome

References

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Chapter 6

Global Hypoxia–Ischemia and Critical Care Seizures

6.1. Introduction

6.2. Epidemiology

6.3. Pathophysiology

6.3.1. Pathological and Chemical Changes in Hypoxic–Ischemic Injury and Seizures

6.3.2. Myoclonus in Hypoxic–Ischemic Coma

6.3.3. Lance–Adams Syndrome

6.4. Clinical Presentation

6.4.1. Generalized Tonic-Clonic Seizures

6.4.2. Focal and Complex Partial Seizures

6.4.3. Myoclonus

6.4.4. Lance–Adams Syndrome

6.5. Laboratory Investigation

6.5.1. Electroencephalography

6.5.2. Electromyography

6.5.3. Somatosensory-Evoked Potentials

6.5.4. Brain Imaging

6.5.5. Cerebrospinal Fluid Analysis

6.6. Differential Diagnosis

6.7. Treatment

6.7.1. General Considerations

6.7.2. Simple and Complex Partial Seizures

6.7.3. Generalized Tonic-Clonic Seizures

6.7.4. Myoclonus

6.7.5. Prophylactic Anticonvulsant Use

6.7.6. Lance–Adams Syndrome

6.7.7. Supportive Management

6.8. Prognosis and Outcomes

6.9. Hypothermia and Seizures after Resuscitation from Cardiac Arrest

References

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Chapter 7

Seizures in Fulminant Hepatic Failure, Multiorgan Failure, and Endocrine Crisis

7.1. Introduction

7.2. Organ Failure

7.2.1. Hepatic Failure

7.2.1.1. Treatment of Seizures in Hepatic Failure

7.2.2. Renal Failure

7.2.2.1. Introduction

7.2.2.2. Uremic Encephalopathy

7.2.2.3. Dialysis Dysequilibrium Syndrome

7.2.2.4. Subdural Hematoma

7.2.2.5. Dialysis Dementia

7.2.2.6. Drug Induced Seizures

7.2.2.7. Treatment of Seizures Related to Renal Failure

7.3. Endocrine Disease

7.3.1. Thyroid Disease

7.3.2. Diabetes Mellitus and Glycemic Homeostasis

7.3.3. Pituitary Hormones

7.3.4. Sex Hormones

7.3.5. Parathyroid Hormones

7.3.6. Adrenal Glands

References

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Chapter 8

Seizures in Organ Transplant Recipients

8.1. Incidence of Seizures in Transplant Patients

8.1.1. Liver Transplant

8.1.2. Bone Marrow Transplant

8.1.3. Heart Transplantation

8.1.4. Kidney Transplantation

8.1.5. Lung Transplantation

8.1.6. Pancreas Transplantation

8.2. Clinical Evaluation of Patients

8.3. Etiology of Seizures in Transplant Patients

8.3.1. Immunosuppression Drugs

8.3.2. Cyclosporin

8.3.3. Tacrolimus (FK-506)

8.3.4. Muromonab-CD3 (OKT3)

8.3.5. Carmustine and Busulfan

8.4. Diagnostic Evaluation

8.5. Management of Seizures

8.5.1. Antiepileptic Drugs

8.5.2. AED Interaction with Immunosuppression

8.5.2.1. Management Considerations in Kidney Failure Patients

8.5.2.2. Management Considerations in Liver Failure Patients

8.6. Case Studies

8.6.1. Case Study: #1

8.6.2. Case Study: #2

References

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Chapter 9

Extreme Hypertension, Eclampsia and Critical Care Seizures

9.1. Introduction

9.2. Hypertension and Pregnancy

9.2.1. Pre-eclampsia and Eclampsia

9.2.1.1. Epidemiology

9.2.1.2. Pathophysiology

9.2.1.3. Clinical Presentation

9.2.1.4. Electrographic and Radiographic Features

9.2.1.5. Management

9.2.2. HELLP Syndrome

9.3. Hypertensive Encephalopathy

9.3.1. Epidemiology

9.3.2. Clinical Features

9.3.3. Pathophysiology

9.3.4. Electrographic and Radiographic Features

9.3.5. Management of Hypertensive Encephalopathy

9.4. Posterior Leukoencephalopathy Syndrome

9.4.1. Clinical Features

9.4.2. Pathophysiology

9.4.3. Radiological Features

9.4.4. Management

References

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Chapter 10

Infection or Inflammation and ICU Seizures

10.1. Introduction

10.2. CNS Infectious Disorders

10.2.1. Meningitis

10.2.2. Encephalitis

10.2.2.1. Japanese Encephalitis

10.2.2.2. Herpes Simplex Encephalitis

10.2.2.3. West Nile Virus Encephalitis

10.2.3. Brain Abscess

10.2.4. Intracranial Extra-Axial Pyogenic Infections

10.2.5. Ventriculitis

10.2.6. HIV Infection and Seizures

10.3. Vasculitides

10.3.1. Necrotizing Vasculitides

10.3.1.1. Wegner’s Granulomatosis

10.3.1.2. Polyarteritis Nodosa

10.3.1.3. Churg–Strauss Syndrome

10.3.2. Vasculitides Associated with Connective Tissue Disease

10.3.2.1. SLE

10.3.2.2. Rheumatoid Arthritis

10.3.2.3. Scleroderma

10.3.2.4. Sjogren’s Syndrome (SS)

10.3.2.5. Mixed Connective Tissue Disease (MCTD)

10.3.3. Vasculitis Associated with Other Systemic Diseases

10.3.3.1. Behçet Disease

10.3.3.2. Sarcoidosis

References

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Chapter 11

Electrolyte Disturbances and Critical Care Seizures

11.1. Introduction

11.2. Mechanisms for Ion Regulation and Effects of Concentration Changes

11.2.1. Potassium

11.2.2. Acid–Base Status

11.2.3. Osmotic Effects

11.3. Sodium Imbalance

11.3.1. Hyponatremia

11.3.1.1. Acute Hyponatremia in the ICU

11.3.2. Hypernatremia

11.4. Hypomagnesemia

11.5. Disorders of Calcium Homeostasis

11.5.1. Hypocalcemia

11.5.2. Hypercalcemia

11.6. Hypophosphatemia

11.7. Summary

References

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Chapter 12

Alcohol-Related Seizures in the Intensive Care Unit

12.1. Introduction

12.2. Alcohol Withdrawal Syndrome

12.2.1. Minor Alcohol Withdrawal

12.2.2. Alcohol Hallucinosis

12.2.3. Delirium Tremens

12.3. Alcohol-Related Seizures

12.3.1. Differential Diagnosis

12.3.1.1. Sample Case

12.3.2. Alcohol-Related Status Epilepticus

12.4. Pathophysiology of Alcohol-Related Seizures

12.5. Comorbid Medical Conditions

12.6. Evaluation

12.7. Treatment

12.7.1. Supportive Care

12.7.2. Benzodiazepines

12.7.3. Antiepileptic Medications

12.7.4. Antihypertensive Agents

12.7.5. Haloperidol

12.7.6. Propofol

12.7.7. Barbiturates

12.7.8. Intravenous Alcohol

12.7.9. Alcohol-Related Status Epilepticus

12.7.10. Outpatient Treatment

References

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Chapter 13

Drug-Induced Seizures in Critically Ill Patients

13.1. Introduction

13.1.1. Epidemiology

13.1.2. Risk Factors

13.1.3. Prevention

13.2. Causative Agents

13.2.1. Analgesics

13.2.1.1. Opioids

13.2.1.2. Salicylates

13.2.2. Anesthetics

13.2.2.1. General Anesthetics

13.2.2.2. Local Anesthetics

13.2.3. Antiepileptic Agents

13.2.4. Antimicrobial Agents

13.2.4.1. Beta-Lactams

13.2.4.2. Carbapenems

13.2.4.3. Fluoroquinolones

13.2.4.4. Isoniazid

13.2.4.5. Metronidazole

13.2.5. Antiviral Agents

13.2.6. Bronchodilators

13.2.7. Immunosuppressive Agents

13.2.8. Chemotherapeutic Agents

13.2.9. Psychotropic Agents

13.2.9.1. Antipsychotic Agents

13.2.9.2. Antidepressants

Tricyclic Antidepressants

Selective Serotonin Reuptake Inhibitors

Monoamine Oxidase Inhibitors

Bupropion

Miscellaneous Antidepressants

13.2.9.3. Lithium

13.2.10. Stimulants

13.2.11. Drug Withdrawal

13.2.12. Miscellaneous Agents

13.3. Treatment

13.3.1. Summary

References

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Chapter 14

Critical Care Seizures Related to Illicit Drugs and Toxins

14.1. Introduction

14.2. Illicit Drugs

14.2.1. Opiates

14.2.2. Sedatives and Hypnotics

14.2.3. Stimulants

14.2.4. Solvents

14.2.5. Hallucinogens

14.3. Epileptogenic Environmental Toxins

14.3.1. Marine Toxins

14.3.2. Mushroom and Plant Toxins

14.3.3. Carbon Monoxide

14.3.4. Heavy Metals

14.3.4.1. Introduction

14.3.4.2. Lead

14.3.4.3. Mercury

14.3.4.4. Tin

References

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Chapter 15

Management of Status Epilepticus and Critical Care Seizures

15.1. Introduction

15.2. Definition

15.3. Classification

15.4. Incidence and Clinical Presentation

15.5. Etiology

15.6. Pathophysiology

15.7. Differential Diagnosis

15.8. EEG

15.8.1. Indications and Timing

15.8.2. EEG Findings in SE

15.8.2.1. Generalized Convulsive SE

15.8.2.2. Generalized NCSE or Absence Status

15.8.2.3. Complex Partial Status

15.8.2.4. Focal Motor Status

15.8.2.5. Tonic Status

15.8.2.6. Myoclonic Status

15.8.2.7. NCSE vs. Metabolic Encephalopathy

15.9. Outcome

15.10. Goals of ICU Management of Seizures and SE

15.10.1. Emergent Medical Management

15.10.2. Termination of Seizures and Prevention of Recurrence of Seizures

15.10.3. Rationale for Using Specific Anti-Epileptic Medications

15.10.4. Medications Used to Control ICU Seizures and SE (Table 15-9)

15.10.4.1. Benzodiazepines

Introduction

Diazepam

Lorazepam

Midazolam

15.10.4.2. Phenytoin and Fosphenytoin

15.10.4.3. Valproic Acid (VPA)

15.10.4.4. Barbiturates

Issues with High Barbiturate Dose Use in the ICU

Depth and Duration of Barbiturate Coma

Phenobarbital

Thiopental

Pentobarbital

15.10.4.5. Propofol

15.10.4.6. Ketamine

15.10.4.7. Isoflurane

15.10.4.8. Other Less Commonly Used Medications for SE

15.10.5. Newer Antiepileptics in the Treatment of Prolonged Seizures or SE (Table 15-11)

15.10.5.1. Introduction

15.10.5.2. Felbamate

15.10.5.3. Gabapentin

15.10.5.4. Lamotrigine

15.10.5.5. Levetiracetam

15.10.5.6. Zonisamide

15.10.5.7. Topiramate

15.10.5.8. Tiagabine

15.10.5.9. Carbamazepine (CBZ) and Oxcarbazepine (OXC)

15.10.5.10. Pregabalin

15.10.5.11. Lacosamide

15.10.6. Hypothermia

15.10.7. Resective Surgery

15.10.8. Brain Stimulation

15.10.9. Prevention and Treatment of Complications

15.11. Management of Focal SE

15.12. Management of NCSE

15.13. Management of Seizures and SE with Antiepileptics in ICU Patients with Organ Dysfunction

15.13.1. Hepatic Failure

15.13.2. Renal Failure

15.13.3. HematoPoetic Dysfunction

15.14. Drug Interaction in the ICU

References

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