8: Epilepsy - seizures, syndromes and differentials Flashcards
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
When taking a funny turn history, ask what happened ___, ___ and ___ the event.
before, during and after
___ accounts are helpful for determining the cause of a collapse.
Eyewitness
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?
If a patient is having recurring events, what could you ask them to give you?
Video
Eyewitness account
What are some risk factors for epilepsy?
Birth / developmental problems
Hx head injury, tumours
Hx seizure (including febrile!)
Fx epilepsy
Can people with a diagnosis of epilepsy drive?
No
A person with active epilepsy needs to stop driving and inform the DVLA
An epilepsy diagnosis has consequences for a patient’s ___.
occupation
What should you examine in a patient presenting with syncope?
Full cardio exam
Blood pressure
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
What investigation must you get for someone with new onset seizures?
ECG
Why is obtaining an ECG important in anyone with new onset seizures?
Arrhythmias (e.g long QT syndrome) cause cerebral hypoperfusion, precipitating seizures
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
What is an EEG?
Electroencephalography
like an ECG for your brain, “brain waves”
Are EEGs used to diagnose epilepsy?
No
What are EEGs used for?
Classification of epilepsy
Confirming non-epileptic attacks
Confirming non-convulsive status epilepticus
What are some epilepsy mimics?
Syncope
Non-epileptic attacks
Panic attacks
TIAs
Hypoglycaemia
What is epilepsy?
Tendency to have spontaneous, recurring epileptic seizures
What is an epileptic seizure?
UNPROVOKED abnormal discharges of electricity in the brain
Are the electrical discharges in an epileptic seizure excitatory or inhibitory?
Usually excitatory
What does focal epileptic seizure mean?
Discharge affects one area of the brain only
What does generalised epileptic seizure mean?
Discharge affects several areas of the brain
At what ages do patients typically develop
a) focal
b) generalised
epilepsy?
a) focal - older patients
b) generalised - children and teens
What is SUDEP?
Sudden death syndrome re: epilepsy
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
