Approach to Seizures

Question 1

What is epilepsy?

Answer 1

Recurrent unprvoked seizures

Question 2

Are all seizures epilepsy?

Answer 2

No - Acute symptomatic seizures.
e.g. associated with alcohol withdrawal, hypoglycaemia
Not epilespy

Question 3

What are the RFx for epilepsy?

Answer 3

FHx (50% genetic, 50% environmentally acquired)
Childhood febrile seizures (small risk)
Perinatal event or abnormal early development
Other previous brain insult: significant head trauma, stroke, meningitis, encephalitis.

Question 4

What are the main different types of seizure?

Answer 4

Focal (unilateral networks at onset) OR primary generalised (bilateral networks at onset).

Question 5

What are the types of focal seizure?

Answer 5

Simple focal, focal dyscognitive (pka complex partial), secondary generalised tonic clonic.

Question 6

What are the types of primary generalised seizure?

Answer 6

Absence, myoclonic/atonic, tonic, primary generalised tonic clonic.

Question 7

What is the progression of focal seizures?

Answer 7

1. Seizure onset.
   2.
   3.

Question 8

What is the most common onset location of focal seizures?

Answer 8

Temporal lobe

Question 9

What are the symptoms of temporal focal seizure?

Answer 9

Olfactory/gustatory/auditory hallucination
May have speech changes
Deja vu
Autonomic phenomena

Question 10

What are the symptoms of frontal lobe seizures?

Answer 10

Bizarre stereotyped movements; often from sleep.

Characteristically have rapid onset/offset and recovery.

Question 11

What are the symptoms of occipital lobe seizures?

Answer 11

• Visual symptoms (simple visual hallucinations): coloured circles/patterns (but highly variable). Often begins in one hemi-field but frequently bilateral.
• Can be negative phenomena: e.g. paroxysms of blindness.

Question 12

What is the biggest Dx symptom of migraine aura vs occipital seizure?

Answer 12

Migraine generally black and white.

Occipital seizure almost always coloured.

Question 13

What are the symptoms of parietal lobe seizures?

Answer 13

Somato sensory seizures: rapid spread of abnormal sensory symptoms (often neuropathic e.g burning) often moving from periphery -> central.
Very uncommon (often missed).

Question 14

What are the EEG changes on frontal lobe seizure? How would you determine whether seizure or not?

Answer 14

Often minimal/absent.

To determine if seizure, monitor for several days and all seizures will look very very similar.

Question 15

When is the commonest onset of absence seizures? How can they be distinguished?

Answer 15

Childhoood.
After adolescence mostly focal dyscognitive (distinguish using automatisms - often more complex if FDS, with prolonged recovery time; longer duration).

Question 16

What is the progression of generalised tonic clonic seizure?

Answer 16

Prodrome: unease or irritability hours to days before the event.
Tonal ictal phase: tonic muscle contractions, trunk/neck hyperextension, arm flexion and adduction, leg extension, cry (resp muscle spasm), 10 - 30s.
Clonic ictal phase: clonus involving violent jerking of face and limbs, tongue biting, cyanosis, frothing, incontinence.
Post ictal: deep uncosciousness, flaccid limbs, extensor plantar reflexes, headache, confusion, aching muscles, sore tongue, amnesia.

Question 17

What is the DDx of blackout/collapse?

Answer 17

Syncope (vasovagal, orthostatic hTN, arrhythmias, structural cardiopulmonary).

Question 18

What favours syncope as cause of collapse?

Answer 18

Previous syncope
Rising to upright posture
prolonged standing
pain/fright/needles
cough/microturition/hairbrushing etc
after exercise (vasovagal syncope)
during exercise (favours cardiogenic syncope)

Question 19

What favours seizure as cause of collapse?

Answer 19

Stress, sleep deprivation, photic triggers, drug withdrawal.(e.g. recreational benzos, regular anti-convulsants)

Question 20

What are the differences in recovery of seizure v syncope?

Answer 20

Syncope: nausea, rapid recovery to orientation.
Seizure: headache, confusion, post-ictal amnesia, slow recovery to orientation.

Question 21

What features favour pseudo seizures?

Answer 21

Often b/g abuse; other medicaly unexplained symptoms
Multiple attacks / day
Longer duration (10 - 20 mins)
Attacks variable
Flurries of attacks

Question 22

What is the aetiology of seizures?

Answer 22

• Idiopathic (no structural lesion)
• Provoked:
  i) Structural e.g. scar, congenital, neoplasm, vascular, trauma, infection
  ii) Metabolic e.g. hypoglycemia, electrolyte abnormalities, renal or liver failure
  iii) Toxic
• Cryptogenic: presumed provoked origin but not yet demonstrated

Question 23

What are the symptoms of absence seizure?

Answer 23

Usually only in children, unresponsive for 5 - 10s with arrest of activity, staring, blinking or eye-rolling.
No post-ictal confusion.
3Hz spike and slow wave activity of EEG.

Question 24

What are the signs and symptoms of tonic seizure?

Answer 24

Decreased LOC with muscle contraction in flexion or extension +/- drop attack, arrest of ventilation causing cyanosis.

Question 25

Clonic seizure signs and symptoms.

Answer 25

Decreased LOC with repeated clonic jerks.

Question 26

Myoclonic seizure signs and symptoms

Answer 26

Brief contractions localised to muscle group of one or more extremities (or more generalised); can be single or multiple.

Question 27

Atonic seizure signs and symptoms

Answer 27

Loss of postural tone leading to drop attack.