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Epilepsy > Classification of epilepsy > Flashcards

Classification of epilepsy Flashcards

1
Q

How is epilepsy is classified?

A

Epilepsy is defined by a logical framework, a bit like a flow diagram:
Epilepsy is initially categorised by seizure type
Further subdivided and categorised by epilepsy type
And then by epilepsy syndrome which is a cluster of conditions categorised together by specific signs and symptoms

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2
Q

How does co-morbidities and aetiology also contribute to the classification framework of epilepsy?

A

Both co-morbidities and aetiology also contributes to epilepsy classification and they run alongside seizure and epilepsy type and epilepsy syndrome.
Depending on the epilepsy type this determines the co-morbidity risk and also depending on the aetiology this can determine the classification.

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3
Q

Can neonates also be diagnosed using the same framework?

A

Seizures in neonates are usually provoked by an acute cause and therefore do not fit into the same classification system as adults and older children.

Electroencephalogram should be used as the gold standard for diagnosing epilepsy in neonates.

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4
Q

How can seizures be classified?

A

The international league against epilepsy (ILAE) updated seizure classification in 2017 and used multiple factors to help consider seizure classification, this includes:
Where the seizure started in the brain?
The patients’s level of awareness
Did the patient experience any other symptoms?

Depending on these factors seizures can be then classified into three main groups.:
Focal seizures
Generalised seizures
Unknown

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5
Q

What are focal seizures and how do they compare to generalised seizures?

A

Focal seizures is when there is increased neuronal activity that originates and remains in one hemisphere of the brain.
This contrasts to generalised seizures which the increased neuronal activity that is widespread across both hemispheres of the brain.

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6
Q

How are focal seizures categorised?

A

Firstly focal seizures are categorised into, following ILAE’s classification scheme, into the patient’s level of awareness during the seizure:
- Simple focal seizures (awareness)
- Complex or focal dyscognitive seizures (loss of awareness)

Both simple and complex seizures can then further be divided into, again following ILAE’s classification, whether the patient experienced motor or non-motor symptoms (movement or non-movement symptoms).

So finally the four classifications of focal seizures are:
Simple focal with motor symptoms
Simple focal with non-motor symptoms

Complex focal with motor symptoms
Complex focal with non-motor symptoms

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7
Q

What do the signs and symptoms of a focal seizure depend upon?

A

The area of the brain that is affected by the increase in neuronal activity, and the function it is responsible for/controls.

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8
Q

State the potential symptoms you would expect to see within focal seizures with a motor onset.

A

Automatisms
Atonic
Clonic
Epileptic spasms
Hyperkinetic
Myoclonic
Tonic

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9
Q

State the potential symptoms you would expect to see within focal seizures with a non-motor onset.

A

Autonomic
Behavioural arrest
Cognitive
Emotional
Sensory

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10
Q

How are generalised seizures classified in comparison?

A

As generalised seizures normally result with impaired awareness they are simply subdivided into:
-Presence of visible motor symptoms
- Non-motor symptoms (also known as absence seizures)

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11
Q

Describe the seizure classification for a patient with a generalised seizure onset presenting with motor symptoms?

A

Tonic
Atonic
Myoclonic
Tonic-Clonic
Clonic

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12
Q

Describe the seizure classification for a patient with a generalised seizure onset presenting with non-motor symptoms?

A

Absent seizures

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13
Q

When are epileptic seizures considered unclassified?

A

If there is insufficient information on the person’s seizure or because of the unusual nature of the seizure. This term can only be used by a healthcare professional if they are confident a seizure has occurred but are unable to classify it.

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14
Q

How are seizures with an unknown onset generally categorised?

A

Again the same as generalised seizures they are classified into; motor and non-motor symptoms.

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15
Q

What are automatisms and what symptoms does automatisms present with (motor onset)?

A

Automatisms are the moving or functioning of an organ, tissue or body part without conscious control that occurs either independently of external stimuli or under influence of external stimuli.
Symptoms you would expect with automatisms include lip smacking, chewing or finger rubbing.

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16
Q

Which symptoms would you expect with an epileptic spasm (motor onset)?

A

This usually involves arm, leg and head flexion which is the pulling in or extending out from the body.

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17
Q

What do hyperkinetic symptoms involve (motor onset)?

A

Hyperkinetic means unwanted or excessive movements.

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18
Q

Which symptoms would you expect to see with an atonic seizure/symptoms (both generalised and focal)?

A

Atonic means without tone, and muscle and body parts become limp (eyelids drooping, heads down)
These seizures are usually brief

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19
Q

Which symptoms would you expect to see with an clonic seizure/symptoms (both generalised and focal)?

A

Clonic seizures involves rhythmical twitching movements of the arms and legs, alternating between contraction and relaxation

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20
Q

Which symptoms would you expect to see with an myoclonic seizure/symptoms (both generalised and focal)?

A

Myoclonic seizures involve muscle twitching (single or multiple muscle groups) of the upper limbs

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21
Q

Which symptoms would you expect to see with an tonic seizure/symptoms (both generalised and focal)?

A

Tonic seizures are categorised by a sudden sustained stiffness or tension in the muscles of the arms, legs or trunk, consciousness may be impaired, seizures brief, extension from the body

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22
Q

Which symptoms would you expect to see with a generalised tonic-clonic seizure?

A

In a tonic-clonic seizure it begins by presenting tonically (with muscle rigidity, loss of consciousness, respiration stops, involuntary crying) into clonic phase (muscle twitching, relaxing and contracting with loss of bladder or bowel control)/

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23
Q

What happens in a focal to bilateral tonic clonic seizure?

A

These seizures are called focal to bilateral tonic-clonic, because they start in a limited area on one side of the brain and spread to involve both sides. This is different from a generalized onset tonic-clonic seizure, which starts on both sides of the brain.

24
Q

Which symptoms would you expect with autonomic symptoms (non-motor onset)?

A

Patient may present with changes in heart rate, breathing and colour

25
Q

Which symptoms would you expect with behavioural arrest (non-motor onset)?

A

Patient stops talking, blank stares and stops moving

26
Q

Which symptoms would you expect with cognitive symptoms (non-motor onset)?

A

Problems talking, understanding, confusion and slowed thinking

27
Q

Which symptoms would you expect with emotional symptoms (non-motor onset)?

A

Sudden fear, anxiety, dread or pleasure

28
Q

Which symptoms would you expect with sensory symptoms (non-motor onset)?

A

Changes in taste, hearing, vision, tingling, pain

29
Q

What can the epilepsy type be categorised into?

A

Focal (focal epilepsy with focal seizure types)
Generalised (generalised epilepsy with generalised seizure types)
Combined generalised and focal (patient experiences both focal and generalised seizure types)
Unknown (patient has been diagnosed with epilepsy but seizure type is unclassified)

30
Q

What is epilepsy syndromes?

A

These are epilepsy syndromes with specific signs and symptoms which means they can be clustered together.
So an epilepsy syndrome is classed as a type of epilepsy identified by a specific seizure type or types.

31
Q

Which factors can be used to identify epilepsy syndromes?

A

Age of onset of seizures
Types of seizures
Specific EEG patterns and imaging
Associated co-morbidities (such as learning difficulties)
Etiology

32
Q

Define status epilepticus.

A

Any seizure lasting more than 5 minutes or when seizures are very close together and the patient does not regain consciousness in between them.

33
Q

Does status epilepticus only occur in patients who have had seizures before or with a certain type?

A

Status epilepticus can occur in any seizure type in patient who have epilepsy and experienced seizures before or in patients experiencing a seizure for the first time.
Status epilepticus is not common, and is worth noting that most patients seizures are of the same duration each time they occur.

34
Q

What are the triggers for status epilepticus?

A

Head injury
Metabolic disturbances such as hypoglycaemia
Cerebrovascular accidents
Alcohol withdrawal

35
Q

Which type of status epilepticus is considered a medical emergency?

A

Convulsive epilepticus which is defined as a tonic-clonic seizure lasting for five or more minutes or when the patient does not regain consciousness in between them.

If left untreated, prolonged seizures can result in long-term brain injuries or possibly death.

36
Q

What is the first line advice for the community management for convulsive status epilepticus?

A

First line management (also generic advice for any seizures):
First note the time of the seizure, or put a stopwatch on
Provide first aid by:
Moving any object out of the patient’s way
Ensuring you do not restrain them in any way
Check airways and place in the recovery position once the seizure has finished (patient has stopped convulsing).

37
Q

If the convulsive seizure has lasted more than 5 minutes or they have experienced 3 within the last hour, what is the community advice?

A

ABC management - check the patient’s airways, are they clear (saliva or blood)
Check the patient’s breathing
Check the patient’s cardiac function

First line treatment in the community is:
Buccal Midazolam or Rectal Diazepam

38
Q

When should an ambulance be called for status convulsive epilepticus?

A
  • If the seizure continues 5 minutes after emergency medication has been given
  • If the patient has a history of frequent serial seizures, who has convulsive status epilepticus or this is the first episode requiring emergency treatment
  • If there are concerns/difficulties monitoring the patient’s airways, breathing or cardiac function
39
Q

What are the key diagnostic considerations for dealing with a convulsive status epilepticus patient in a hospital setting initially?

A

From 0-5 minutes:
Time seizure from the onset
Establish IV route
Check observations including:
- Blood glucose
- Arterial blood gas
- Urea
- Creatine
- Liver function
- Na, Ca, Mg
- FBC
- CRP
- Clotting
- Anti-convulsant drug levels
- Toxicology

Assess for possibility of non-epileptic status (psychosis, dissociative seizures)

40
Q

What are the key management considerations for dealing with a convulsive status epilepticus patient in a hospital setting initially?

A

Secure airways (semi-prone position, nasopharyngeal airway)
Start regular observations monitoring (Blood pressure, Pulse, ECG etc.)
Give high concentration oxygen
Give high-potency thiamine if there is suspicion of alcohol abuse or impaired nutrition
Give glucose if hypoglycaemic
Prepare benzodiazepine

41
Q

What are the key diagnostic considerations for dealing with early convulsive status epilepticus patient in a hospital setting between 5-20 minutes?

A

Aim to establish past medical history, medications, recreational drug use, pre-existing illness, history of epilepsy etc
Request chest x-ray to assess for possibility of aspiration
Consider urgent CT of the head if no previous epilepsy history or if there is new focal neurology

42
Q

What are the key management considerations for dealing with early convulsive status epilepticus patient in a hospital setting between 5-20 minutes?

A

Check if any pre-hospital benzodiazepines have been given
Give IV Lorazepam or IV Diazepam if it is unavailable
No IV route give buccal Midazolam
Only a maximum of two doses should be given including pre-hospital
If no response after 10-20 minutes

43
Q

What dose of Lorazepam should be given?

A

For children between one month to 11 years:
100 micrograms/kg (max. per dose 4 mg) for one dose, then 100 micrograms/kg after 5–10 minutes (max. per dose 4 mg) if required for 1 dose, to be administered into a large vein

For children and adults over 12:
4mg for 1 dose, then 4mg after 5-10 minutes if required for 1 dose, to be administered into a large vein

However screencast says:
0.1mg/kg per dose; maximum 4mg

44
Q

What are the key diagnostic considerations for dealing with established convulsive status epilepticus patient in a hospital setting between 20-40 minutes?

A

Consider further investigations if a clear precipitant has not been identified (e.g. lumbar puncture if you suspect CNS infection or inflammation).

45
Q

What are the key management considerations for dealing with established convulsive status epilepticus patient in a hospital setting between 20-40 minutes?

A

Alert anaesthetist and ICU
Give a second line IV anti-convulsant, following local protocol.
Options include:
Levetiracetam
Sodium Valproate
Phenytoin or Fosphenytoin

NICE however recommends Phenytoin, Fosphenytoin and Phenobarbital

46
Q

What are the key diagnostic considerations for dealing with refractory convulsive status epilepticus patient in a hospital setting between 40-60 minutes?

A

Consider an urgent CT-head for any patient with refractory status epilepticus

47
Q

What are the key management considerations for dealing with refractory convulsive status epilepticus patient in a hospital setting between 40-60 minutes?

A

Call the anesthetist and the neurologist and arrange immediate transfer to ICU
These patients require general anaesthesia and EEG monitoring.
This could be:
Propofol
Midalozam
Thiopental sodium

Anaesthetic should continue for 12-24 hours after last clinical/electrographic seizure, tapering the dose

48
Q

What is SUDEP?

A

SUDEP stands for Sudden unexpected death in epilepsy. It refers to death in a patient with epilepsy that is not caused by drowning or injury.

49
Q

What are the believed possible causes of SUDEP?

A

Breathing: seizures can cause changes in breathing rate, if patient doesn’t breathe for a substantial period of time, this can cause oxygen levels to fall. Furthermore in a convulsive seizures, airways may become obstructed.

Cardiac arrhythmias: seizures can cause changes in heart rhythm, can lead to cardiac arrest

It may also be a combination of these factors

50
Q

What are the risk factors for SUDEP?

A

Main risk factors:
Uncontrolled or frequent seizures
Tonic clonic seizures

Other risk factors include:
Seizures that begin at a young age
Many years of living with epilepsy
Missed doses of medicine
Drinking alcohol

51
Q

What are the main strategies to reduce the risk of SUDEP?

A

Taking seizure medication as prescribed, if seizures continue contacting the Doctor
Avoiding seizure triggers
Avoiding drinking too much alcohol
Getting sufficient sleep
Training other household members in first aid

52
Q

State the seizure phases.

A

Beginning phase (including prodrome and aura)
Middle (ictal) phase
Ending (post-ictal) phase

53
Q

What happens in the pro-dromal phase of a seizure, what symptoms may you expect?

A

The pro-dromal phase is when only some patients can tell a seizure is on its way. This can be hours or days before it occurs.
Symptoms:
Mood changes
Light headed
Behavioural changes
Difficulty sleeping and staying focused

54
Q

What happens in the aura phase of a seizure, what symptoms may you expect?

A

Not all patients experience this, but for some this can indicate the start of a seizure.
Symptoms:
Dizziness
Visual disturbances
Numbness or ‘pins or needles’ in part of the body
Nausea
Headache
Panic

55
Q

What happens in the middle phase of a seizure, what symptoms may you expect?

A

The middle phase of seizure is known as the ictal phase, this is the time of increased neuronal activity in the brain. This is from when the seizure begins with the first symptom to when it ends.
Symptoms include that associated with the seizure type.

56
Q

What happens in the ending phase of a seizure, what symptoms may you expect?

A

The ending phase of a seizure also known as the post-ictal phase occurs after the seizure has ended. This is the recovery stage and during this phase any physical after effects of the seizure are felt, the duration of this phase is dependent upon seizure type and part of the brain affected.
Symptoms include:
Confusion
Lack of consciousness
Tiredness
Exhaustion
Headache
Thirst
Nausea
Loss of bladder or bowel control

Epilepsy (6 decks)

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