Blackouts, First seizures and Epilepsy Flashcards
What is the 9 different causes of a black out
Syncope
First seizure
Hypoxic seizure
Concussive seizure (after blow to head)
Cardiac arrhythmia
Non-epileptic attack
Narcolepsy,
Movement disorder,
Migraine
What is the commonest cause of fainting/syncope
Vasovagal syncope:
When you faint because your body overreacts to certain triggers, such as the sight of blood or extreme emotional distress causing your heart rate and blood pressure to drop suddenly
What is the features of syncope
Happens in the upright position
Pallor common
Gradual onset
Rapid recovery
Incontinence rare
Precipitants common
Injury rare
Early symptoms: Light-headed, Nausea Hot, sweating Tinnitus Tunnel vision
Why is injury rare in syncope and common in seizure
Due to gradual onset, patients can get themselves into a safe position avoiding injury, where in a seizure there is no warning do injury is more common
What is the features of seizures
Occur in any posture Pallor uncommon Sudden onset Injury quite common Incontinence common Slow recovery Precipitants rare
What occurs in hypoxic seizures
Continued oxygen deprivation, e.g. when individual kept upright in a faint
Patient has succession of collapses
What is an example of a cardiac arrhythmia that can cause seizure
Long QT syndrome
When would long QT syndrome result in a seizure
Collapse occurs with exercise
When should you consider cardiac arrhythmias as the cause of seizures
When there is a family history of sudden death,
When there is a cardiac history
When collapse occurs with exercise
What can seizures cause over time
Cardiac arrhythmias
What is common features of non-epileptic attacks
Commoner in women than men
Can be frequent
May look bizarre
Can be prolonged
May have a history of other medically unexplained symptoms
May have history of abuse
What does a non-epileptic attack look like
May superficially resemble a generalised tonic-clonic seizure (rigid with jerking)
May resemble a “swoon”- flat on the ground and pale
May involve bizarre movements (thrusting of hips - sexual abuse)
What investigations must take place at a possible first seizure
Blood sugar - rule out as cause of blackout
ECG - what kind of seizure
Consideration of alcohol and drugs
CT head - see structural problems
After diagnosing a first seizure what needs to be discussed with the patient
Enquire about employment and dangerous leisure actuates
Explain driving regulations
What is the driving regulations put in place after a patient has their first seizure
Patient may drive a car after 6 months if their investigations are normal and they have had no further events
They may drive an Heavy good vehicle or Public Service Vehicle after 5 years if their investigations are normal, they have no further events and they are not on anti-epileptic medication
After first seizure, when would an epilepsy diagnosis be made
After a second unprovoked attack
Sometimes on taking the history after a first seizure, it is clear that they have undiagnosed epilepsy
What features in your history suggest undiagnosed primary generalised epilepsy
History of myoclonic jerks, especially first thing in the morning
Absences or feeling strange with flickering lights
What is features in your history suggesting a focal onset epilepsy
History of “deja vu”, rising sensation from abdomen,
Episodes where look blank with lip-smacking,
Fiddling with clothes
Define an epileptic seizure
Epileptic seizure is an intermittent stereotyped disturbance of consciousness, behaviour, emotion, motor function or sensation which, on clinical grounds, is believed to result from abnormal neuronal discharges
Define epilepsy
condition in which seizures recur, usually spontaneously
Where does damage occur in an epileptic seizure
Grey matter
What is the two ILAE Classifications of epilepsy
Generalsed seizures
Focal seizures
What are the 6 different types of generalise seizures
Tonic-clonic seizures
Myoclonic seizures
Clonic seizures
Tonic seizures
Atonic seizures
Absence seizures
What occurs in a tonic-clonic seizure
Usually begins on both sides of the brain, but can start in one side and spread to the whole brain.
A person loses consciousness, body become rigid (tonic) , and jerking movements (clonic) are seen
What occurs in a myotonic seizure
Brief shock - like jerks of a muscles and the person is usually awake and able to think clearly
What is seen in a tonic seizure
Produce constant contractions of the muscles. The person may turn blue if breathing is impaired
What is seen in a clonic seizure
involve shaking of the limbs in unison
What is seen in an absence seizure
Non convulsive seizure
Can be subtle, with only a slight turn of the head or eye blinking.
Lasting only a few seconds
The person often does not fall over and may return to normal right after the seizure ends
What is focal seizures characterised by
According to aura:
Motor features, Autonomic features
Degree of awareness or responsiveness
What can focal seizures progress to
Generalised convulsive seizures
What can focal seizures be divided into
Simple e.g. hand jerk and conscious
Complex e.g. any disturbance to your conscious level
(appear confused or dazed and can not respond to questions or direction)
What is the common presentation of primary generalised epilepsy
No warning
Diagnosed <25 years
History of absences and myoclonic jerks as generalised tonic-clonic seizure
May have a family history
Abnormal EEG
What is the common presentation of a focal epilepsy
May get an “aura”
Any age – cause can be any focal brain abnormality
Simple partial and complex partial seizures can become secondarily generalised
Focal abnormality on EEG
MRI may show cause
What investigation can show the cause of a focal epilespy
MRI
What occurs in primary generalised epilepsy
Occurs in both hemispheres
due to disorder of brain function causing a group of neurones to fire in an abnormal, excessive, and synchronized manner
What is a common pathological cause of generalised epilepsy
Channelopathies
Inhibitory neurons not functioning properly
so there is a constant firing of excretory neurone resulting in a wave of depolarisation across the brain
What occurs in focal onset epilepsy
Disorder of brain structure usually occurring in one hemisphere of the brain
Focal epilepsy is often preceded by certain experience known as auras, these include
Sensory, visual, psychic, autonomic, olfactory or motor phenomena with a degree of awareness or responsiveness
What are the investigation used for epilepsy
EEG
MRI
CT (exclude other causes)
Video- telemetry
What further processes take place with an EEG to help diagnose epilepsy
Hyperventilation
Photic stimulation
Sleep deprivation
- used to help trigger an primary generalised epileptic seizure
When is an MRI investigation used in epilepsy
For patients under age 50 with possible focal onset seizures
How and when would video-telemetry occur in epileptic investigations
If the diagnosis is uncertain
Using EEG and ECG monitoring to see how long someone is have a seizure so can differentiate between no epileptic and epileptic
What is the first line treatment for primary generalised epilepsy
Sodium Valproate
Lamotrigine
Levetriacetam
What is the first line treatment for partial and secondary generalised seizures
Lamotrigine
Carbamazepine
What is the first line treatment for absence seizures
Ethosuximide
What is the second line treatment for generalised epilepsy
Topiramate
Zonisamide
(carbamazepine)
What is the second line treatment for partial seizures
- Sodium valproate
- Topiramate
- Leviteracetam
- Gabapentin
- Pregabilin
- Zonisamide
- Lacosamide
- Perampanel
- Benzodiazepines
What is the side effects of sodium valproate
tremor,
weight gain,
ataxia,
nausea, drowsiness, transient hair loss, pancreatitis, hepatitis
Why is sodium valproate avoided during pregnancy
As can cause birth defects:
Delayed language development
Autism
What is the side effects of carbamazepine
Ataxia, drowsiness, nystagmus, blurred vision, low serum sodium levels, skin rash
What is the side effects of levetiracetam
Irritability
Depression
What is the side effects of topiramate
weight loss,
word-finding difficulties,
tingling hands and feet
What is the side effects of zonisamide
bowel upset, cognitive problems
What is the contradiction in carmazepine treatment
Makes myoclonic jerks worse
When can epileptic patients hold a group 1 licence
Once they have been seizure free for a year or have only had seizures arising from sleep for a year.
If they have ever had a day time seizure but then the pattern becomes noctural, this must be established for three years before they can drive
When can epileptic patients hold a HGV and PSV licence
Have been seizure free for 10 years and are not on anti-epileptic medication
Define status epilepticus
Prolonged or recurrent tonic-clonic seizures persisting for more than 30 minutes with no recovery period between seizures
Status epilepticus usually occurs in patients with no previous history of epilepsy, so what is the potentially causes
Stroke
Tumour
Haemorrhage
Intoxicants (alcohol, drugs)
Status epilepticus can be life threatening with out treatment so what is the first line treatment available
Midazolam: 10mg by buccal or intra-nasal route, repeated after 10mins if necessary
Lorazepam: 0.07mg/kg, usually 4mg bolus repeated once after 10 mins
Diazepam: 10 - 20mg iv or rectally, repeated after 15 mins if necessary
What is the second line treatment of Status epilepticus if first line treatment doesn’t work
Phenytoin - slow infusion of 15 – 18mg/kg at 50mg/min
Valproate – 20 -30mg/kg iv at 40mg/min
Levetiracetam - IV
(near status)
What is the third line treatment of status epilepticcus if it still isn’t under control
Anaesthesia usually with propofol or thiopentone
What occurs in third line treatment of status epilepticcus
Shuts of brain activity, and leave for 24 hours, and administrate anticonvulsants
What is SUDEP
Sudden unexpected death in epilepsy (SUDEP) is a fatal complication of epilepsy, where brain activity just flat lines
What mechanisms are potential involved in SUDEP
Autonomic malfunction
- Cardiac arrhythmias
- Respiratory failure
- Pulmonary dysfunction
- Brain stem - apnea
