8: Epilepsy - seizures, syndromes and differentials Flashcards by Ross Wilson

What are the differences between a faint (syncope) and a seizure?

Syncope:

Startled look, falls to the ground, unresponsive but little/no movement, awakens and is quickly back to normal

Seizure:

Abnormal vocalisations / sensations / movements +/- loss of consciousness, slow to recover

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When taking a funny turn history, ask what happened ___, ___ and ___ the event.

before, during and after

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___ accounts are helpful for determining the cause of a collapse.

Eyewitness

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What should you ask about the onset of a funny turn?

What were you doing at the time?

How did you feel?

What did you look like?

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If a patient is having recurring events, what could you ask them to give you?

Video

Eyewitness account

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What are some risk factors for epilepsy?

Birth / developmental problems

Hx head injury, tumours

Hx seizure (including febrile!)

Fx epilepsy

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Can people with a diagnosis of epilepsy drive?

A person with active epilepsy needs to stop driving and inform the DVLA

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An epilepsy diagnosis has consequences for a patient’s ___.

occupation

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What should you examine in a patient presenting with syncope?

Full cardio exam

Blood pressure

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What are some notable drugs which may precipitate seizures?

Analgesics e.g tramadol

Antibiotics

Anti-emetics

Opioids

if a patient has worsening seizures, check these before adjusting anticonvulsants

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What investigation must you get for someone with new onset seizures?

ECG

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Why is obtaining an ECG important in anyone with new onset seizures?

Arrhythmias (e.g long QT syndrome) cause cerebral hypoperfusion, precipitating seizures

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In which case would a patient presenting with a seizure get an immediate CT scan?

Serious acute underlying pathology is suspected cause

e.g head trauma, haemorrhage, stroke, tumour

Persistently low GCS after admission

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What is an EEG?

Electroencephalography

like an ECG for your brain, “brain waves”

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Are EEGs used to diagnose epilepsy?

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What are EEGs used for?

Classification of epilepsy

Confirming non-epileptic attacks

Confirming non-convulsive status epilepticus

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What are some epilepsy mimics?

Syncope

Non-epileptic attacks

Panic attacks

TIAs

Hypoglycaemia

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What is epilepsy?

Tendency to have spontaneous, recurring epileptic seizures

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What is an epileptic seizure?

UNPROVOKED abnormal discharges of electricity in the brain

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Are the electrical discharges in an epileptic seizure excitatory or inhibitory?

Usually excitatory

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What does focal epileptic seizure mean?

Discharge affects one area of the brain only

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What does generalised epileptic seizure mean?

Discharge affects several areas of the brain

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At what ages do patients typically develop

a) focal
b) generalised

epilepsy?

a) focal - older patients
b) generalised - children and teens

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What is SUDEP?

Sudden death syndrome re: epilepsy

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Patients with epilepsy are **(more likely / less likely)** to die than normal patients. Why?

**more likely** aspiration; nocturnal seizures; drink and drug problems, depression and suicide; learning difficulties

What is a **focal** seizure?

Discharge remains in one part of the brain causing a focal epilepsy

What causes focal epilepsy?

Structural abnormality in one part of the brain

Focal epilepsy causes seizures with symptoms relating to the ___ of the brain the structural abnormally is in.

Area e.g motor sensory visual memory

What is a generalised seizure?

Discharge propagating via pathways to multiple areas of the brain

Can focal epilepsy cause generalised seizures?

Yes, if discharge propagates via pathways

What is generalised epilepsy?

Structural abnormality is found ON a pathway, causing immediate generalised seizures

Can generalised epilepsy cause focal seizures?

No, discharge propagates by default as abnormality is found on a cortical pathway

What is a seizure? what is epilepsy?

Seizure - abnormal discharge of electricity in the brain Epilepsy - tendency to have recurrent seizures

Focal and generalised epilepsy have different \_\_\_.

managements i.e different drugs

What types of focal seizure can you have?

Focal motor Focal sensory **these are SIMPLE focal seizures** Focal discognitive **which is a COMPLEX focal seizure involving temporal lobe**

**focal seizures** - affecting one brain area unilaterally - simple (awareness maintained) and complex (lost) - can cause a secondary generalised seizure if found ON propagating pathway **generalised seizures** - affecting multiple brain areas - tonic-clonic (grand mal), absence (petit mal), myoclonic (children), tonic, atonic look at Kumar and Clark!

What is the tonic phase of a grand mal seizure?

**Sudden muscle contraction (causing fall), flexion of arms, extension of legs** **Dilation of pupils** **Epileptic cry caused by contraction of inspiratory muscles** lasts 10s

What causes the tonic phase of a generalised seizure?

Uncoordinated discharge in both motor strips

What is the clonic phase of a seizure?

**1-3 min period, following tonic phase, of muscle jerking in a grand mal seizure**

Why does the clonic phase of a seizure occur?

Motor strip discharges become less frequent Gradually, relaxation overcomes contraction

What are the symptoms of a sensory seizure?

Abnormal sensations somatic, olfactory, visual, taste, auditory

What are the symptoms of a seizure affecting the **temporal lobe?**

Abnormal memories (familiar but not familiar) Deja vu Hallucinations

Which population are more likely to have focal seizures? Why?

Over 50s More likely to have focal brain abnormalities

Which population are more likely to have generalised seizures?

Young people (under 30)

What is drug of choice for generalised epilepsy?

Sodium valproate

Sodium valproate patients must be warned that it is \_\_\_.

teratogenic

What is the alternative to sodium valproate for generalised epilepsy?

Lamotrigine

Which type of **generalised epilepsy** affects young people and causes **involuntary muscle jerks**, typically brought on by **alcohol excess, bright lights and sleep deprivation?**

**Juvenile myoclonic epilepsy**

What is the drug of choice for focal epilepsy?

Carbamazepine

What drug can be used instead of carbamazepine for **focal epilepsy**?

Lamotrigine

35% of patients have ___ \_\_\_ epilepsy.

drug resistant

Which two antiepileptic drugs interact with one another?

**Sodium valproate** **Lamotrigine** risk of toxicity and SJS

Which drugs are given first line for a) focal b) generalised seizures?

a) carbamazepine, lamo b) sodium valproate, lamo

Which drug **musn't** you give in **generalised, myoclonic epilepsy**?

**Carbamazepine**

What is an **anti-convulsant** which can be used **second line** in **generalised epilepsy?**

Phenytoin

Sodium valproate is cautioned against in ___ because of its side effects.

**women** teratogenic, interacts with the pill

When are anticonvulsant drugs given?

Only if: patient has diagnosed epilepsy patient has had one seizure and is at high risk of more e.g head injury, brain tumour, high genetic likelihood the patient who has one/both of the above actually wants it

Women who are using ___ should be warned about the side effects of anticonvulsants. What are they?

contraception sodium valproate is teratogenic reduces efficacy of OCP (increase dose) and implants, nullifies progesterone pill also need a higher dose morning after pill

Which supplement should all pregnant women be on?

Folic acid

Women who plan to be pregnant need to know that some medication for epilepsy is \_\_\_.

teratogenic

What is a neurological emergency related to epilepsy?

**Status epilepticus**

What is status epilepticus?

Continuous epileptic seizures without ROC for at least 30 mins

What is non-convulsive status epilepticus? Which investigation would you use to confirm it?

**Continuous motor seizures but consciousness intact** **EEG**

What can precipitate status epilepticus?

Metabolic disorders Infection Head injury big list

Why does convulsive status epilepticus cause death?

Tonic phase requires huge amount of energy Aspiration Respiratory INSUFFICIENCY Hyperthermia Hypotension (vasodilation in response to hyperthermia) Rhabdomyolysis (massive muscle damage causing AKI)

Which lobes are most active in status epilepticus? Why?

Frontal lobes Tonic, frontal lobe is where motor strips are found

How is a patient in status epilepticus managed initially?

ABCDE

Which investigations must you do for someone in status epilepticus?

Bloods CT scan LP if still unsure

Ten minutes into status epilepticus, what is a patient given?

**Phenytoin**

Which drugs need to be used with care in status epilepticus?

Benzos

Which class of drug are given alongside benzodiazepine in convulsive status epilepticus?

Anticonvulsants

What should patients in status epilepticus be given if they have histories of a) diabetes b) alcohol abuse?

a) glucose (on the off chance this is a hypo) b) IV thiamine (on the off chance this is B1 deficiency encephalopathy)

Who should be called thirty minutes into status epilepticus if below and anticonvulsants have failed to resolve a seizure?

ICU

Should people in non-convulsive status be given benzos?

Yes problem is abnormal brain discharges, it should wake them up

What is the only situation in which seizures are treated acutely?

Status epilepticus I.e after 10+ minutes of fitting

8: Epilepsy - seizures, syndromes and differentials Flashcards

(75 cards)