Blackouts and Seizures Flashcards
What is the difference between blackouts and seizures?
Blackouts are loss of consciousness
Seizures are changes in physical activity or behaviour as a result of changes in the electrical activity in the brain
For a patient who has passed out what do you want to know about before the attack?
What were they doing before?
Were any symptoms described experienced before (aura, vasovagal)?2
For a patient who has passed out what do you want to know about during the attack?
Did they lose consciousness? Were they responsive? Did they make any movements? Floppy or rigid? Did they change colour?
For a patient who has passed out what do you want to know about after the attack?
How long did they take to recover?
How did they feel after recovering?
Any sleepiness, confusion or disorientation?
Any weakness or change in sensation?
For a patient who has passed out what do you want to know about the background to the episode?
Any triggers?
Has it happened before? When did they start?
How frequent are they?
Were the previous attacks the same as this one?
What are examples of drugs that lower the seizure threshold?
Anaesthetics IV antibiotics (penicillins, cephalosporins) Antipsychotics - clozapine Ciclosporin Antidepressants Anticholinesterases Antihistamines
What investigations should be done for a patient who has collapsed?
Cardio and resp examination Blood pressure (postural) ECG Urine dipstick Bloods CT/MRI Sometimes EEG
When should CT/MRI be done for a patient who has collapsed?
If suspected stroke, skull fracture, head injury, deteriorating GCS
When should an EEG be done for a patient who has collapsed?
To classify epilepsy or to confirm non-convulsive status
What are the differential diagnoses for a patient who has collapsed?
Head injury
Drug induced
Neurological: epilepsy, stroke, CNS infection, SOL
Psychiatric: anxiety, non epileptic attacks
Medical: hypoglycemia, orthostatic hypotension, syncope, drop attacks, stokes adams
What is syncope?
Reflex bradycardia with or without peripheral vasodilation
When can a stroke occur in syncope?
When the bradycardia and peripheral vasodilation is associated with cerebral hypoperfusion
What is the presentation of syncope?
Pre-syncope: light-headednesss, dizziness, sweating, nausea, pallor, tachycardia
The seizure: loss of consciousness, no movement or brief symmetrical colonic jerks with no tonic contraction, no incontinence or tongue biting, lasts about 2 mins
Post-ictal: rapid recovery (<1 min), no prolonged symptoms
What are the causes of syncope?
Vasovagal (fear, emotion, pain, standing for too long)
Situational: cough, exercise, micturition
Carotid body hypersensitivity - brought on by minimal exertion e.g. head turning, shaving
Reflex anoxic - when young children hold their breath and faint and fit
What is a Stoke Adams attack?
Transient arrhythmias causing reduced cardiac output and loss of consciousness
Attacks can happen multiple times per day and in any posture
What is the presentation of a Stoke Adams attack?
Pre-attack: palpitations
Attack: fall to the ground with loss of consciousness, pallor, slow or absent pulses
Recovery within seconds, with associated flushing
What are drop attacks?
Attacks of sudden weakness of the legs with no warning or any loss of consciousness
Most are benign and resolve after a few attacks
What are the causes of drop attacks?
Idiopathic
Hydrocephalus
Cataplexy
What is the presentation of a drop attack?
Attack: sudden weakness in the legs not associated with any warning symptoms, loss of consciousness
Recovery: no associated confusion
Who are drop attacks most often seen in?
Elderly women
What is epilepsy?
Recurrent tendency to spontaneous, intermittent, abnormal electrical activity in the brain that manifests as convulsions or abnormal behavior
What is needed for a diagnosis of epilepsy?
At least 2 events
What are the causes of epilepsy?
Idiopathic Structural abnormalities due to: SOL Stroke Developmental abnormalities Head injury Childhood febrile convulsions
What is an aura?
Individualized and stereotyped symptoms that precede the seizure by minutes
E.g. deja vu, flashing lights, tastes or smells, strange feelings
What are the general features of epileptic seizures?
Loss of conscious and unresponsive
Lasts <5 mins
Associated with tongue biting and urinary incontinence
Slow recovery associated with confusion, headache, muscle ache, temporary weakness
What is Todd’s palsy?
Temporary weakness following an seizure
What is a focal seizure?
Epileptic seizures that arise due to isolated, increased activity in one region in the brain, with there often being an associated underlying structural abnormality
What is a simple focal seizure?
A seizure associated with localised symptoms of any nature, no loss of awareness and no post-octal symptoms
What is a complex focal seizure?
Localised symptoms associated with an aura, loss of awareness and post-octal symptoms
What is a focal seizure with secondary generalisation?
Localised symptoms that proceed the generalised seizures that are usually convulsive due to spread of electrical activity across the brain
What are the symptoms caused by focal symptoms in the temporal lobe?
Commonly associated with Hx of febrile convulsions Dysphasia Déjà vu Flashbacks Emotional disturbance Odd tastes or smells Visual and auditory hallucinations Movements such as lip smacking, chewing, swallowing, grabbing, fumbling and singing
What are the symptoms caused by focal symptoms in the frontal lobe?
Dysphasia
Posturing movements
Subtle changes in behaviour
Jacksonian seizure (twitching movements of the upper limbs that spread to the face and lower limbs, commonly associated with Todd’s Palsy)
What are the symptoms caused by focal symptoms in the parietal lobe?
Sensory disturbance such as numbness and tingling
What are the symptoms caused by focal symptoms in the occipital lobe?
Visual phenomena such as spots, lines and flashes
What is a generalised seizure?
Epileptic seizures that occur due to simultaneous abnormal electrical activity in multiple parts of the brain
Who most often present with generalised seizures?
Younger patients - usually <30
What are generalised seizures often triggered by?
Flashing lights, sleep deprivation
What are the different patterns of generalised seizures?
Tonic clonic
Absence
Myoclonic
Atonic
What are the different phases in a tonic clonic seizure?
Tonic: patient falls, becomes rigid and cyanosed, stop breathing, tongue biting and incontinence can occur, lasts about 1 min
Clonic: after tonic phase, asymmetrical convulsive jerks, eyes roll back and breathing starts again, lasts a few minutes
Post-ictal: confusion, drowsiness, muscle ache and headache common
What are the features of an absence seizure?
Seizure manifests as a brief lapse of awareness in which the patient stops what they are doing and stares blankly
What happens to an EEG in an absence seizure?
Spike and wave at 3Hz
What are the features of an myoclonic seizure?
Seizures that manifest as clonic-like jerks without the tonic contraction
What is juvenile myoclonic epilepsy?
Usually seen around puberty
Associated with early morning myoclonic seizures and day-time absences
Most go on to develop tonic clonic
EEG: photosensitive poly spike and wave
What is an atonic seizure?
Seizures that manifests as sudden loss of all muscle tone with maintenance of consciousness, which differentiates it from narcolepsy
How is epilepsy diagnosed?
Mostly clinical
CT/MRI to identify structural abnormality
Sometimes EEG
When is an EEG done?
To classify epilepsy
Confirm non-epileptic attacks
Evaluate patients being considered for surgery
To confirm non convulsive status epilepticus
What is the management for generalised absence seizures?
1st line: valproate orr ethosuximide
2nd line: topiramate, levetiracetam
What is the management for generalised myoclonic seizures?
First line: valproate, levetiracetam, clonazepam
Second line: lamotrigine, topiramate
What is the management for generalised atonic or tonic clonic seizures?
Valproate, levetiracetam, topiramate, lamotrigine
What is the management for focal seizures?
First line: carbamazepine
Second line: lamotrigine, valproate, topiramate
What are side effects of sodium valproate?
Nausea Tremor Oedema Teratogenicity Ataxia Encephalopathy, liver failure Ect
What are the side effects of lamotrigine?
Maculo-papular rash Stephen Johnson syndrome Diplopia and photosensitivity Tremor Agitation
What are the side effects of topiramate?
Sedation
Dysphasia
Weight loss
What are the side effects of levetiracetam?
Mood swings
Depression
What are the side effects of carbamazepine?
Makes generalised seizures worse Lucopenia Drowsiness Double or blurred vision Impaired balance
What is SUDEP, and what causes increased risk?
Sudden unexplained death in epilepsy
Poorly controlled epilepsy, patient smokes, drinks and uses illicit drugs
What needs to be taken into account for women with epilepsy?
Avoid valproate
Contraception efficacy will be reduced
Most anticonvulsants have risk of congenital abnormalities (risk reduced by taking folate)
What is status epilepticus?
Seizure that has lasted more than 5 minutes
Multiple seizures within 30 minutes
Second seizure that occurs before full neurological recovery from the first
What are triggers for status epilepticus?
Infection Head injury Eclampsia Abrupt withdrawal of anti convulsants Metabolic upset: hypoglycemia, hyponatremia
What is the management for status epilepticus?
ABCDE
1st line: IV Lorazepam (2-4mg, max doses: 2)
2nd line: Phenytoin
3rd line: General anaesthesia
What is non-epileptic attack disorder?
Functional seizures that are largely mediated at the subconscious level
Have a strong association with past trauma, especially childhood sexual abuse.
What are the features of a seizure in non-epileptic attack disorder?
Excessively long seizures lasting 10-20 minutes
Coordinated, symmetrical, florid convulsions with large movements
Maintenance of normal breathing and awareness
No associated tongue biting or incontinence
Made worse by use of anti convulsants
How is diagnosis made for non-epileptic attack disorder?
Suggested by normal examination, negative investigations and seizures being uncontrollable with the use of a variety of anti convulsant drugs
Linguistic analysis
EEG
Admission to epilepsy unit for medium to long term monitoring
What is the management for non-epileptic attack disorder?
Counselling and psychological therapies
