Epilepsy

Definitions

According to the American Academy of Neurology, epilepsy is defined as two or more seizures without acute provocation.*

*Neurology, 2000 Sept;55(5):616-23. DOI: 10.1212/wnl.55.5.616.

Intractable Epilepsy Definition

“Intractable Epilepsy” is defined as persistent seizures in an epileptic child, despite adequate trials with ≥ 2 anti-seizure medications (ASMs).

When intractable epilepsy requires escalation of therapy beyond anti-seizure medications, there are three main treatments used: ketogenic diet, epilepsy surgery, and vagus nerve stimulator.

Please note the following terms are considered equivalent to Intractable Epilepsy – Pharmacoresistant; Treatment resistant; Refractory; Drug resistant epilepsy. Intractable epilepsy, or an equivalent term, should be documented when present to accurately reflect severity of illness. 

According to the International League Against Epilepsy (ILAE), epilepsy is considered “resolved” if a person has been seizure-free for the past 10 years and has been off all seizure medications for at least the last 5 years. 

Status Epilepticus Definition

  • Status epilepticus is defined as a seizure lasting >5 minutes or recurrent seizures without return to baseline consciousness between (this is the current definition and updated from the historical definition of seizure >30 min or mult seizures across 30 min without return to baseline)**

    • Can include both convulsive and non-convulsive forms

**Pediatr Rev, 2023; 44(7):383-392. DOI: 10.1542/pir.2022-005632.

Seizure Classifications

  • Generalized seizures: both hemispheres are involved at seizure onset. Nearly always involved impaired awareness.

  • Focal seizures: initial clinical or EEG changes originate within networks limited to a specific region or hemisphere of the brain. May or may not have impaired awareness during the seizure

Seizure Classifications

Seizure Classifications

Type Characteristics
Motor

● Tonic-clonic seizures

● Myoclonic seizures

● Clonic seizures

● Tonic seizures

● Myoclonic atonic seizures

● Atonic seizures

● Hypermotor (hyperkinetic) seizures

● Automatisms
Non-Motor

● Absence (typical, atypical, or absence w/ special features [e.g. myoclonic absence, eyelid myoclonia])

● Focal (e.g. sensory, emotional, autonomic, cognitive, behavior arrest)
Epileptic Spasms

● May be focal or generalized

● May outlast infancy or begin after infancy

● Example: infantile spasms
* Seizure type classifications based on clinical presentation and onset characteristics

Tips for Documentation

  • Always specify the type of Epilepsy if known.

    • Mention if intractable (aka refractory, treatment-resistant, pharmacoresistant)

    • Provide further specificity when possible (i.e. partial, focal, localized vs. generalized epilepsy, focal with altered consciousness, focal without altered consciousness, absence, tonic, clonic, myoclonic, atonic, etc.)

  • Underlying cause, when known:  

    • Structural, Metabolic, Genetic, Acquired, or Unknown problems.

  • Include clinical indicators: 

    • Home anti-seizure medications (can include previous med trials if known)

    • Patient admitted for initiation of the Ketogenic Diet or Surgical Evaluation

    • Presence of Vagal Nerve Stimulator (VNS) 

    • Administration of rescue anti-seizure medications for prolonged seizure episode

    • Patient admitted for “breakthrough seizures” (Consider “status epilepticus, if applicable”)