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MD2 Neuro > Approach to Seizures and Epilepsy > Flashcards

Approach to Seizures and Epilepsy Flashcards

1
Q

Define seizure

A

Intermittent, stereotyped disturbance of consciousness, behaviour, emotion, motor or sensory function resulting from abnormal cortical neuronal discharges

Simply: abnormal hypersynchronous neural activity

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2
Q

List 2 non-epileptic causes of seizure

A

Alcohol withdrawal

Hypoglycaemia

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3
Q

List 2 seizure syndromes unrelated to epilepsy

A

Single seizures

Childhood febrile seizures

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4
Q

SUDEP

A

Sudden unexpected death in epilepsy

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5
Q

List 4 risk factors for epilepsy

A

FHx

Childhood febrile seizures (small increased risk, esp if convulsive status epilepticus)

Perinatal event or abnormal early development

Other previous brain insult (e.g. significant head trauma, stroke, meningitis, encephalitis)

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6
Q

Distinguish between focal and primary generalised seizures

A

Focal: unilateral networks at onset

Primary generalised: bilateral networks at onset

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7
Q

List 3 types of focal seizures

A

Simple focal

Focal dyscognitive (PKA complex partial; affects consciousness)

Secondary generalised tonic clonic

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8
Q

List 4 types of primary generalised seizures

A

Absence

Myoclonic/atonic

Tonic

Primary generalised tonic clonic (GTCS; often all seizures are called this; important to clarify this is actually the case)

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9
Q

Focal seizures

A

Seizure starts (symptoms due to ictal areas)

Seizure discharges may spread enough to impair awareness

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10
Q

Where do focal seizures most commonly start?

A

Temporal lobe

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11
Q

List 5 early temporal lobe seizure symptoms

A

Olfactory and gustatory hallucinations (typically noxious)

Changes in speech (esp if seizure starts on dominant hemisphere; impt to distinguish from TIA)

Deja vu

Autonomic phenomena (e.g. butterflies in stomach)

Auditory hallucinations (less common; esp hallucinations of reverberating machine-like noise)

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12
Q

Later symptoms of temporal lobe seizures

A

Automatisms; can look at predominant side involved to estimate the lateralisation of the seizure

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13
Q

What are 4 distinctive clinical features of frontal lobe seizures?

A

Bizarre stereotyped movements, often from sleep

More rapid recovery than temporal lobe seizures

Often fully aware throughout

Sudden onset and offset

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14
Q

What are the main symptoms of occipital lobe seizures?

A

Visual symptoms (commonly simple hallucinations, e.g. coloured circles and patterns)

Occasionally negative phenomena (i.e. blindness)

Headache after occipital lobe seizures (can be confused with migraine)

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15
Q

How can visual hallucinations caused by migraine be differentiated from those caused by occipital lobe seizure?

A

Migraine: black and white

Occipital: colour

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16
Q

What is the main symptom of parietal lobe seizures?

A

Somatosensory symptoms (often with neuropathic characteristics; tend to travel from periphery centrally)

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17
Q

What is one of the activating states for seizures?

A

Hyperventilation

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18
Q

How long do absence seizures last?

A

Often extremely frequent and extremely brief (several seconds)

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19
Q

When is the commonest age for onset of absence seizures?

A

Childhood (very unlikely after mid-20s)

Usually 4-8 years but can be up to age 12

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20
Q

List 3 features of absence seizures

A

Eye-flickering

Behavioural arrest

Can have minor automatisms but no loss of postural tone

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21
Q

How can absence seizures be distinguished from focal dyscognitive seizures?

A

Focal dyscognitive longer, pt feels tired afterward

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22
Q

Describe the typical progression of a primary generalised tonic clonic seizure

A

Sudden stiffening often in association with ictal cry

Stiffen usually in fully extended position, arms and/or legs may be flexed (can have fractures, dislocations in this phase)

No ventilation during this time, pt will be cyanosed

After 15-20 seconds, low amplitude high frequency vibration movements

As seizure progresses, movements become higher in amplitude and lower in frequency before seizure ceases

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23
Q

Differential diagnosis of blackout/collapse

A

Syncope

Functional attacks (pseudo-seizures)

Migrainous visual aura

TIA (usually negative symptoms)

Metabolic dysfunction (e.g. hypoglycaemia; distinguish from focal seizures

Tinnitus (distinguish from lateral temporal seizures with auditory aura)

Physiological deja vu (distinguish from mesial temporal seizures)

Parasomnias (distinguish from frontal seizures; quite complex but good literature about how to do it)

Movement disorders (e.g. hemiballismus, paroxysmal dyskinesias; distinguish from frontal seizures)

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24
Q

List 4 causes/types of syncope

A

Neurally mediated/vasovagal

Orthostatic hypotension

Cardiac arrhythmias

Structural cardiopulmonary (e.g. AS)

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25
Q

Is EEG a useful diagnostic tool for epilepsy?

A

No; can be normal

Best diagnostic tool is a good history (including witness history)

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26
Q

What 5 aspects are important when assessing a paroxysmal episode of collapse?

A

Background to pt

Setting

Prodrome

Event

Recovery

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27
Q

Syncope vs seizure: background

A

Syncope: previous syncope

Seizure: PMHx or FHx of epilepsy

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28
Q

Syncope vs seizure: setting

A

Syncope: rising, prolonged standing, pain/fright/needles, cough, micturition, hairbrushing, after exercise (favours vasovagal), during exercise (favours cardiogenic syncope)

Seizure: stress, sleep deprivation, photic triggers, drug withdrawal

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29
Q

Syncope vs seizure: prodrome

A

Syncope: nausea, palpitations, dyspnoea, pallor, warm sensation, sweating, light-headedness, greying of vision, hearing becomes distant

Seizure: aura may reflect ictal focus

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30
Q

Syncope vs seizure: attack

A

Syncope: pallor, motionless collapse

Seizure: tongue biting, head turning, unusual posturing, cyanosis, urinary incontinence in bed

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31
Q

Syncope vs seizure: recovery

A

Syncope: nausea, rapid recovery to orientation

Seizure: headache, confusion, post-ictal amnesia, slow recovery to orientation (ask what was the first thing the pt remembers after their episode)

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32
Q

Pseudoseizure

A

Arching of the trunk common

Attacks tend to be prolonged (20-30 mins), wax and wane, multiple attacks common, very variable in semiology

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33
Q

Seizures vs pseudoseizures

A

Pseudoseizures: often background abuse, may be other medically unexplained symptoms (e.g. pain), attacks variable, often wax and wane, flurries of attacks common, attacks often prolonged (e.g. 20 mins)

Seizures: may be background brain injury or FHx epilepsy, attacks stereotyped, attacks evolve then stop, attacks usually 1-2/day (except absences, NFLE), attacks >4 mins uncommon

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34
Q

Migraine vs seizure?

A

Migraine: flickering, uncoloured zigzags, central zigzags, may leave scotoma

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35
Q

How does a myoclonic seizure present?

A

Sudden shock-like jerk

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36
Q

How does an atonic seizure present?

A

Sudden relaxation which may impair posture

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37
Q

How does a tonic seizure present?

A

Usually whole body stiffening, pt can fall over

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38
Q

Why are episodes of syncope often mistaken for seizure?

A

Because jerks, stiffness and sometimes automatism-like gestures can occur in syncope

39
Q

What might focal occipital lobe seizures mimic?

A

Migrainous visual aura

40
Q

What type of seizure might mimic a TIA?

A

Focal seizure, esp focal occipital seizure with negative symptoms

41
Q

What type of seizure might mimic metabolic dysfunction (e.g. hypoglycaemia)?

A

Focal seizures

Physiological deja vu (distinguish from mesial temporal seizures)

Parasomnias (distinguish from frontal seizures; quite complex but good literature about how to do it)

Movement disorders (e.g. hemiballismus, paroxysmal dyskinesias; distinguish from frontal seizures)

42
Q

What type of seizure might mimic tinnitus?

A

Lateral temporal seizures with auditory aura

43
Q

Define ictus

A

Sudden neurological event

44
Q

Define epilepsy

A

Tendency to repeated, spontaneous seizures

45
Q

Describe the typical progression of a tonic clonic seizure

A

Tonic phase: arms down, eyes open, cry

Clonic phase: low amplitude high frequency vibratory movements (amplitude increases and frequency decreases until this ceases)

Apnoea: cyanosis or plethora

Aftergoing confusion

Usually lasts 1-5 mins, minor injury is common

46
Q

What are the main features of an absence seizure?

A

Alteration of consciousness but with no loss of postural tone: pt stays upright, no warning, difficult to detect

Facial twitch: 3Hz blink with oral myoclonias, eyes often drift open

47
Q

Compare the duration of a generalised tonic clonic seizure to that of an absence seizure

A

Tonic clonic: 1-5 mins

Absence: 2-10 secs

48
Q

What is myoclonus?

A

Sudden, involuntary muscle twitch not specific to seizure (hypnagogic myoclonus occurs normally)

49
Q

In what condition is myoclonus common?

A

Metabolic encephalopathy

50
Q

Distinguish between simple focal seizures and focal discognitive seizures

A

Simple: no alteration of consciousness, features depend on location (e.g. temporal may cause deja-vu), usually brief

Focal discognitive: alteration of consciousness due to bilateral involvement of the temporal lobe (effects are localised)

51
Q

How do focal dyscognitive seizures differ from absence seizures?

A

Longer (>30 secs)

Less distinct offset

Automatisms (more florid than in absence)

Less frequent

Preceding simple focal seizure

52
Q

What features are important for defining an epilepsy syndrome?

A

Seizure type (determined by clinical characteristics of seizure and patient, and EEG features)

Age

Clinical course

Interictal EEG

MRI

+/- genetics

53
Q

What subsyndromes are seen in genetic generalised epilepsies?

A

Childhood absence epilepsy

Juvenile myoclonic epilepsy

Juvenile absence epilepsy

Epilepsy with tonic-clonic seizures alone

54
Q

What proportion people who have had a single seizure as an adult will not develop epilepsy?

A

50%

55
Q

Distinguish between disease vs. syndrome in the context of epilepsy

A

Disease: illness with shared aetiology, pathology, progression and presentation, and with a known cause

Syndrome: collection of clinical features that present together, clinical first step to defining a disease

There are a variety of causes which may produce the same seizure syndrome

56
Q

What kinds of seizures can appear as a prodrome to GTCS?

A

Myoclonic seizures

57
Q

What seizure subsyndrome presents with myoclonus that is more prominent in the morning?

A

Juvenile myoclonic epilepsy

58
Q

DDx for seizure syndrome in a generalised convulsion

A

Primary GTCS

Late stage focal seizure

Because recognisable partial phase is variable so the two syndromes may be indistinguishable

59
Q

What seizure types are seen in genetic generalised epilepsies?

A

GTCS

Absence

Myoclonic

60
Q

What are the clinical features of genetic generalised epilepsies?

A

No clinical, radiological or EEG evidence of brain damage

Epileptiform discharges 3 Hz or faster

Response to therapy is usually good

61
Q

What are the clinical features of childhood absence epilepsy?

A

40-50 seizures/day

No fatigue or weakness after each episode

Can induce by hyperventilating

62
Q

Childhood absence epilepsy PKA?

A

Petit mal

63
Q

What seizure types are seen in childhood absence epilepsy?

A

Absence seizures (many/day)

40% also experience GTCS

64
Q

Describe the natural Hx of childhood absence epilepsy

A

20% continue having absences and develop juvenile absence epilepsy

20% develop juvenile myoclonic epilepsy

60% resolve

65
Q

What is the onset of juvenile absence epilepsy and what seizure types are seen?

A

Onset in adolescence

GTCS and (infrequent) absence seizures

66
Q

What is absence status?

A

Absence status epilepticus, is marked by a generalised seizure affecting the whole brain resulting in episodes characterized by a long-lasting stupor, staring, and unresponsiveness

67
Q

What is the typical age of onset for juvenile myoclonic epilepsy (Janz syndrome) and what seizure types are seen in juvenile myoclonic epilepsy?

A

Onset: 12-18 years

Seizure types: myoclonus, GTCS, absences in 30%

68
Q

What are the clinical features of juvenile myoclonic epilepsy?

A

Photosensitive

Related to sleep-wake cycle (more common after wakening)

69
Q

What is the prognosis of juvenile myoclonic epilepsy?

A

Not often refractory

Spontaneous remission rare

70
Q

What are the clinical characteristcs and EEG features of an absence seizure?

A

Clinical characteristics: brief lapse of attention (~5 secs), otherwise normal patient

EEG features: run of 4Hz spike-wave

71
Q

Describe the age of onset, typical clinical course and appearance on MRI of childhood absence epilepsy

A

Onset: 5 years

Clinical course: response to valproate, often remission at 14 years

MRI: normal

72
Q

List 5 predisposing factors and 4 triggers for syncope

A

Dehydration

Anti-HTNs

Prolonged standing

Stressful situation

Recent awakening

Triggers: emotional, valsalva, pain, postural change

73
Q

3 features of pre-syncope

A

“Dizziness”

Feeling of distance

Visual disturbance: silver flickers, greying of vision

74
Q

Describe features seen during syncope

A

Pale

Eye elevation

Collapse (may be described as stiff)

Convulse: brief (<30 secs), asymmetric, no tonic, often delayed

Often incontinent

Injury not uncommon

May be prolonged if held upright (e.g. if LOC in toilet cubicle)

75
Q

Describe features seen during recovery from syncope

A

Awaken rapidly: on the ground rather than in the ambulance (beware head injury)

Often tired

Not confused

76
Q

Distinguish between the prodrome and post-ictal state of GTCS vs syncope

A

Prodrome: presence/absence of syncopal triggers, posture (syncope while supine is more concerning), pre-syncope vs aura

Ictal state: tongue-biting more common in GTCS (may be incontinence in either syncope or GTCS)

Post-ictal state: speed of recovery

77
Q

List 3 predisposing factors/triggers for seizure

A

Sleep deprivation

Hangover or abrupt abstinence from EtOH

Flicker (photosensitivity)

78
Q

What medications may trigger seizure?

A

Clozapine

Tramadol

79
Q

What is TIA?

A

Sudden, focal neurological deficit

LOC exceptional (posterior circulation TIA almost always focal)

80
Q

List 6 common features of psychogenic pseudoseizure

A

Fluctuating intensity

Very long

Eyes closed (pseudo-sleep)

Non-anatomical tremor

Reactive

Consciousness retained (usually denied)

81
Q

Distinguish between seizure and pseudo-seizure in terms of EEG findings

A

Seizure: almost always abnormal

Pseudo-seizure: perfect

82
Q

What are interictal EEG findings useful for? What are the limitations?

A

Dx of epilepsy syndrome (not seizure) and prognosis

Limitations: not very sensitive (most abnormal patterns also seen in normals; most helpful for distinguishing between focal and generalised patterns)

83
Q

What is the role of CTB in epilepsy Dx?

A

Good for detecting certain conditions which may trigger seizure, including tumour, haemorrhage, neurocysticercosis (can visualise calcified cysts; this is one of the commonest causes of epilepsy in the world but not necessarily Aus)

Bad for almost everything else

84
Q

What does this MRI show? Describe the cliinical features and pathophysiology of this disorder

A

Double cortex or band heterotopia

Form of diffuse grey matter heterotopia affecting almost only women; refractory epilepsy is present in nearly all affected patients, with partial complex and atypical absence epilepsy being the most common syndromes

Precursor cells which make the cortex must migrate up a scaffold of glial cells; in some genetic disorders they stall because of a lack of appropriate machinery

85
Q

Can early treatment of seizure change prognosis? (In terms of longterm epilepsy rates)

A

Large randomised trial which provided treatment after either the first or second seizure found that there was better early seizure freedom if treated early but by five years the outcome was identical

86
Q

How is epilepsy diagnosed?

A

Hx of minor seizures (focal or myoclonus)

Await recurrence

Epileptiform EEG

Epileptogenic MRI lesion

87
Q

What activities should patients with epilepsy be counselled on in the interests of safety?

A

Swimming: should have showers not baths, have a swimming partner

Heights (including ladders)

Work

Driving

Avoiding triggers: alcohol, inadequate sleep, stress

88
Q

What criterion must be fulfilled in order for a patient with epilepsy to be able to drive?

A

6-12 months seizure free

89
Q

Mx of acute seizures

A

In the acute setting: benzodiazepenes for seizure termination, benzodiazepines or phenytoin (levetiracetam, valproate) for acute prophylaxis

In the long term setting: don’t treat - almost always self-limiting, only need to treat if prolonged or recurrent

90
Q

What drug options are there for treatment of genetic generalised epilepsy?

A

Ethosuxamide

91
Q

5 broad-spectrum treatments for epilepsy

A

Valproate (but teratogenic)

Levetiracetam

Lamotrigine

Zonisamide

Topiramate

92
Q

8 treatments for focal epilepsy (lesional and non-lesional)

A

Carbamazepine

Phenytoin

Oxcarbazepine

Lacosamide

Gabapentin

Pregabalin

Vigabatrin

Tiagabine

93
Q

What is SUDEP?

A

Sudden Unexpected Death in Epilepsy: high rate of sudden death in epilepsy (1-2 per 1000 patient years, 20-fold increase in 18-35 years), likely due to cardio-respiratory arrest (often in sleep)

Related to seizure frequency (risk is much reduced by seizure freedom; 6-9 per 1000 patients years in refractory focal epilepsy)

MD2 Neuro (9 decks)

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