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1 Supplementary Online Content Gavvala JR, Schuele SU. New-onset seizure in adults and adolescents: a review. JAMA. doi: /jama eappendix 1. Seizure Evaluation Checklist eappendix 2. Antiepileptic Medications Checklist This supplementary material has been provided by the authors to give readers additional information about their work.
2 eappendix 1. Seizure Evaluation Checklist TRANSIENT ISCHEMIC ATTACK Speed of onset... Rapid Loss of consciousness... Usually not Motor findings... Loss of Motor Function Neurologic findings... Loss of Neurologic Function IF Loss of consciousness=yes... Consider brainstem TIA Prodrome...No Self-awareness of symptoms... Yes IF Inattention/Decreased LOC 1... Brainstem TIA Postictal state...no Same as patient reports... Yes IF not the same as the patient... Consider Brainstem TIA Brain MRI... Yes MR Angiogram (head/neck-evaluate carotids)... Yes Carotid Duplex... Alternative to MR angiogram MIGRANE Speed of onset... Hours/Days Loss of consciousness... No Motor Findings... None Neurologic Symptoms (No Aura)... Occasional IF Loss of consciousness=yes... Migraine with Brainstem Aura Prodrome... Visual Aura-Sometimes Prodrome... Nausea, Emesis-Sometimes Prodrome... Unilateral/Pulsating Headache-Sometimes Self-awareness of symptoms... Yes Inattention/Decreased LOC 1... Confusional Migraine Inattention/Decreased LOC 1... Basilar Migraine Postictal state...no
3 Same as patient reports... Yes Same as patient reports... No (Confusional/Basilar Migraine) Prior migraine history... Yes Family history... Yes SYNCOPE Speed of Onset... Rapid Loss of consciousness... Yes Prodrome... Lightheadedness-Sometimes Trigger (Vasovagal)... Fear, Pain Trigger (Vasovagal)... Medical Procedures Trigger (Vasovagal)... Coughing, Valsalva Trigger (Vasovagal)... Micturition, Defecation Trigger (Vasovagal)... Orthostasis Self-awareness of symptoms... Yes (if no LOC) Sensations... Lightheadedness, ear fullness, nausea, blurred vision Skin... Pale, cold and clammy Muscle... Flaccid Postictal state... Possibly (usually brief) Myoclonic jerks... Sometimes at the end of the event Tonic Posturing... Sometimes at the end of the event Tilt Table... Rule out orthostasis Echocardiography... Rule out cardiac etiology Cardiac telemetry... Rule out cardiac etiology EEG... Rule out seizures PSYCHOGENIC NONEPILEPTIC SEIZURES Speed of Onset... Variable/May be Intermittent Loss of consciousness... Variable Motor... Eye closure, stuttering course Motor... pelvic thrusting, whole body shaking Prodrome... May have nonspecific symptoms Trigger... Emotional events/stressors
4 Duration... Variable, typically minutes Duration... Frequently waxing and waning course Symptom self-awareness... Sometimes (including motor symptoms) Duration... Waxing and waning course Motor... Eye closure, pelvic thrusting, local stuttering Continuous EEG... Rule out epilepsy FOCAL SEIZURE Speed of Onset... Abrupt onset with aura Motor movements... Typically unilateral IF bilateral motor movements... Frontal lobe seizure Progress to generalized convulsions... Sometimes Sensations... Typically unilateral IF bilateral sensations... Parietal lobe seizures Prodrome... May have aura Prodrome... May have loss of awareness Symptoms self-awareness... sometimes initial sx awareness IF no symptom self-awareness... Occurs with LOC Self-awareness of symptoms... Sometimes Temporal lobe epilepsy... Déjà vu aura Temporal lobe epilepsy... Epigastric aura Parietal lobe epilepsy... Contralateral paresthesias Occipital lobe... visual distortions Symptoms... May be aware of progression to generalized seizure Symptoms... Post seizure tongue bites Symptoms... post seizure urinary incontinence Motor... Semi purposeful movements of the hands and feet Motor... Tonic clonic seizure activity Motor... Focal or whole body stiffening Eyes... Patient staring, frequent eye blinking, open eyes
5 Bowel/Bladder... Urinary incontinence Mental status... Post event lethargy or confusion EEG... focal epileptiform discharge brain MRI... evaluate for structural lesions GENERALIZED SEIZURE Speed of Onset... Sudden Motor... generalized tonic-clonic activity Motor... myoclonic jerks Prodrome... Not typically Self-awareness of symptoms...no Eyes... brief staring spells Self-awareness of symptoms...no Self-awareness of symptoms... sometimes recall myoclonic jerks Self-awareness of symptoms... Post seizure tongue bites Self-awareness of symptoms... post seizure urinary incontinence Motor... Report generalized tonic-clonic seizures EEG... confirm epileptiform discharges Footnotes 1- level of consciousness
6 eappendix 2. Antiepileptic Medications Checklist Generalized Epilepsy (or unknown type of epilepsy) Type of Seizure Myoclonic Seizures... Consider LEV, VPA Generalized tonic clonic seizures Consider VPA, LEV, LTG > TPM, ZON Absence Seizures... Consider ETX, VPA > LTG Combination of above... Consider VPA, LEV, LTG Female of child bearing age?... Avoid VPA, TPM Age > 65 years old?... Consider LEV, LTG On concurrent medications?... Consider LEV, LTG Comorbidities Depression/Anxiety?... Avoid LEV Headaches?... Consider TPM, VPA Cognitive Impairments?... Consider LTG, LEV Kidney Stones... Avoid TPM, ZON Renal dysfunction?... Avoid LEV, caution with TPM, LTG, ZON Liver dysfunction?... Avoid VPA, LTG Side Effect concerns Weight gain... Avoid VPA Weight loss... Avoid TPM, ZON Excessive sleepiness... Avoid TPM, ZON, VPA Osteoporosis... Avoid VPA Focal Epilepsy Female of childbearing age?... Avoid VPA, TPM Age > 65 years old?... Consider LTG, LEV, GBP On concurrent medications?... Avoid CBZ, PHT, VPA Comorbidities Depression/Anxiety?... Avoid LEV Headaches?... Consider VPA, TPM > GBP Cognitive impairments?... Consider LTG, LEV, GBP, LCM Cardiac rhythm abnormalities?... Avoid CBZ, LCM, PHT, ESL Kidney stones?... Avoid TPM, ZON Hyponatremia?... Avoid OXC, CBZ, ESL Liver dysfunction?... Avoid VPA, LTG, CBZ, PHT
7 Renal dysfunction?... Avoid LEV, caution w/ GBP, TPM, LTG, ZON Side Effect concerns Weight gain... Avoid VPA, GBP Weight loss... Avoid TPM, ZON Excessive sleepiness... Avoid TPM, PHT, ZON, CBZ, VPA Osteoporosis... Avoid PHT, CBZ, VPA Antiepileptic medications abbreviations LEV: levetiracetam VPA: valproate LTG: lamotrigine TPM: topiramate ZON: zonisamide ETX: ethosuximide PHT: phenytoin GBP: gabapentin LCM: lacosamide CBZ: carbamazepine ESL: eslicarbazepine OXC: oxcarbazepine
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