Case 7: Epilepsy, Hyperkinetic, GBS Flashcards
Syncope features
- Aura: Feeling light headed
- Flops to floor
- Appears: Pallor or ashen faced
- Eyes closed
- Couple of brief jerks possible
- Floppy position
- May have rapid breathing
- Rapid recovery, orientated
- Amnesic for a brief period, possibly seconds
Seizure features
- Aura: deja vu, focal SM symptoms possible
- Stiffens ‘tonic phase’
- Appears: red/blue
- Often eyes open
- Sustained convulsion
- Classically UL flexed, LL extended
- Tonic cry, grunting then snore post ictal
- Prolonged recovery, amnesic phase
- May have no recollection for hours after events
Non-epileptic attack
- May be emotionally upset, environment may trigger
- Normal colour unless breath holding
- May resist eye opening
- Waxing and waning arrhythmic movement
- May have thrashing or irregular movement
- Variable, may be tearful or breath holding
- Variable recollection
- Often full awareness including during event but disassociated from surroundings so cant respond
Types of generalised seizures and Todd’s paresis
Generalised seizures: tonic clonic, absence, myoclonic, atonic
Todd’s paresis: post ictal weakness especially after focal seizure
What happens in a tonic-clonic seizure
- Limb stiffens then rhythmically jerks
- May be accompanied by loss of consciousness, biting of side of tongue, incontinence, post ictal confusion
What happens in different types of seizures
- Absence: behavioural pause, usually less than 10s
- Atonic: sudden loss of tone (limpness) and loss of consciousness
- Myoclonic: sudden jerk of bilateral limbs, face or trunk
- Simple focal seizure: jerkiness in distal limb which spreads
- Complex focal: odd behaviour (wandering), hallucinations, delusions
The different childhood epileptic syndromes
- benign rolandic
- infantile spams/ West syndrome
- juvenile myoclonic epilepsy
- Lennox gastaut
Benign rolandic epilepsy: childhood seizure
- focal motor seizures involving one side of face or muscles involved in speech and swallowing
- presents at night
West syndrome: childhood epilepsy
- repeated flexion followed by extension of arms
- presents age 4-8 months
- usually affects those who have suffered brain damage or have genetic abnormalities
- poor prognosis
Juvenile myoclonic epilepsy presents: childhood epilepsy
- upper body mycoclonic seizure or tonic clonic seizure
- Presents when child wakes up
Investigations for epilepsy
- rule out non-epileptic causes of seizures: glucose, U+Es, ECG
- EEG
- consider MRI
Side effects of anti-epileptics
- General: sedation, dizziness, suicidal thoughts, psychosis, weight changes, osteoporosis
- may cause elevated LFTs
- carbamazepine may cause mild leukopenia
- sodium valproate may cause thrombocytopenia
- Carbamzepine reduces effectiveness of contraception except UID/IUS
- Lamotrigine- use progesterone only contraception
How long after first seizure can patients not drive for
- 6 months if investigations normal
- 12 months if structural abnormality or abnormal EEG
Vasovagal syncope: causes and management
- Causes- pain, unpleasant sensation, orthostatic, prolonged recumbency
- Mangement- Lie flat, reassurance
Epilepsy investigations
- EEG- doesnt exclude epilepsy, helps assess risk of reoccurence
- ECG- in case its an arrhyhtmia (check QTc)
- Observation
- Basic bloods including glucose
- Neurological and cardiovascular exam
- Consider brain imaging i.e. head injury, neurological abnormality, Todds paresis
After 2 or more seizures you scan and treat
Risk factors for recurrent seizures
- Remote symptomatic seizure
- Neurological defecit
- Seizure whilst asleep
- Abnormal EEG
- Abnormal MRI
Management of status epilepticus
- Early onset 5-10 mins- Lorazepam (Benzo diazepam)
- Established status 10-30mins- Valproate/ Phenytoin/ Levetiracetam
- Refractory status >30 mins- Propofol/ Midazolam/ Thiopentone
- Lots of epipilepsy medication is teratogenic (valproate) and shouldnt be given to anyone of child bearing age
SUDEP
- Sudden unexplained death in epilepsy with no clear cause
- Risk factors- male, poor compliance, generalised seizures, nocturnal seizures, LD, pregnancy
Management mainly around managing epilepsy and education/awareness
Causes of seizures
- Generalised seizures are due to global problems with the brain i.e. probably genetic
- Focal seizures are due to local problems i.e. stroke, tumour, encephalomalacia secondary to trauma
- Provoked seizures i.e. metabolic (glucose, sodium), head injuries, drugs, alcohol withdrawal
Causes of recurrent seizures in epilepsy
- Drug resistant epilepsy (1/3 all patients)
- Non compliance
- Alcohol/drugs
- Sleep deprivation
- Changes in AED levels e.g. pregnancy, enzyme inducing meds
- Infection
- Wrong diagnosis
- Development of another diagnosis e.g. syncope