Assessment and Management of Subtle Seizure Manifestations Flashcards
When might a condition be labelled as “epileptic encephalopathy”?
When frequent epileptic/epileptiform activity leads to deterioration in cognition and behaviour
What two types of cognitive impairment must you distinguish between when considering subtle manifestations of epilepsy?
▪️Permanent impairment
▪️State-dependent impairment
What is state-dependent cognitive impairment?
Potentially reversible and treatable cognitive impairment
What are the two types of state-dependent cognitive impairment seen in epilepsy?
▪️Drug induced
▪️Caused by epilepsy itself
What is a subtle manifestation in epilepsy?
A change resulting from:
▪️An effect that’s not an obvious manifestation of a seizure although seizure itself may be obvious
▪️An effect of a subtle seizure or epileptiform activity not manifesting as an obvious seizure
What is the most important factor to consider in the management of subtle manifestations of epilepsy?
Diagnosis!
Important to take a good history and examine the patient
What features of the ictal phase of a seizure may contribute to state-dependent cognitive impairment?
▪️Frequent absence seizures (non-convulsive status epilepticus)
▪️Complex partial status epilepticus
▪️Focal discharges - frequent localised and hemispheric discharge
What is TCI and what might cause it in epilepsy?
Transitory Cognitive Impairment
Frequent focal discharges
What is nonconvulsive status epilepticus (NCSE) ?
State of continuous seizure activity for at least 30 minutes with cognitive or behavioural change
Often altered mental status/consciousness
What EEG pattern is most frequently seen during seizure?
Spike-and-wave
What is the problem with subtle absence seizures with no clinical manifestation?
Sometimes able to carry on normally so may go undiagnosed
Frequent absence seizures mag be affecting cognition
What subtle manifestations might be seen with frequent absence seizures?
▪️Poorer cognitive performance
▪️Withdrawn behaviour
▪️Fragmented thought processes
▪️Attention deficit and motor overactivity
▪️Attention seeking behaviour
Why is knowing the pattern of manifestation important?
Can develop management strategies around it
E.g. if worse in mornings, such as in JME, causing functioning difficulties, then learn to get up an hour earlier
How might frequent left temporal discharges present?
Increased aggressive behaviour
What post-ictal factors might impact cognition?
▪️Frequent daytime seizures
▪️Frequent nighttime seizures
▪️Electrical status epilepticus during slow-wave sleep (ESES)
Why might frequent daytime seizures lead to cognitive impairment?
Unable to fully recover between them
Why might frequent nighttime seizures and ESES lead to cognitive impairment?
Disrupted sleep
Why might someone with epilepsy be misdiagnosed as having permanent cognitive impairment?
If in a constant post-ictal state from frequent seizures
How might frontal lobe seizures present?
▪️Frequent brief nocturnal attacks
▪️Bizarre non-rhythmical limb movements
▪️Vocalisations
▪️Awareness
What medications can be used for nocturnal frontal lobe seizures?
▪️Carbamazepine
▪️Levetiracetam
How might nocturnal seizures affect daytime cognition?
▪️Lack of sleep
▪️Direct post-ictal effects
What is Landau Kleffner syndrome?
A rare epilepsy, usually in young children, characterised by loss of language skills (aphasia) and silent electrical seizures during sleep (ESES)
How might you treat Landau Kleffner syndrome and other epilepsies with CSWS and ESES?
▪️Valproate
▪️Combination therapy with lamotrigine, benzodiazepines, and steroids
▪️Multiple subpial transection
What is ESES?
Electrical status epilepticus during slow wave sleep
(Age-dependent, self-limiting epilepsy syndrome in children characterised by cognitive and behavioural disturbances)
What is CSWS?
Continuous spike and wave during slow wave sleep
(same as ESES)
Can antiepileptic treatment help cognition?
Yes
What is the main problem with treating CSWS/ESES epilepsies and subtle cognitive/behavioural manifestations?
Early, prompt treatment is recommended as may prevent permanent loss of skills/cognitive behavioural problems
What could you consider if medication is ineffective?
Multiple subpial transection
What should be used to investigate children with loss of skills?
Nocturnal EEG monitoring
