Disease and Clinical Features of Epilepsy Flashcards by Adrian Yan

What is the definition of an epileptic seizure?

A transeint event experienced by a subject as a result of a synchronous and excessive discharge of cerebral neurones

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What do the following mean?

Prodrome

Aura

Post-ictal

Prodrome - hours/days - may rarely precede seizure: change in behaviour

Aura - part of the seizure, where the patient is aware - strange feeling in gut, dejavu, strange smells/flashing lights

Post-ictal - symptoms follow seizure -

headache, confusion, myalgia, sore tongue
temporary weakness after focal seizure in motor cortex (Todd’s Palsy)
Dysphasia - following focal seizure in temporal lobe

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What are strong clues when assessing whether someone has had an epileptic seizure?

Tongue biting and slow recovery

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What is a primary generalised seizure?

Simultaneous involvement of both hemispheres, associated with Loss of consciousness/awareness

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What are the different types of generalised seizures?

Absence

Tonic Clonic

Myoclonic

Tonic

Atonic

Infantile

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What is an absence seizure?

Begins in childhood

Loss of awareness and vacant expression <10s, return to normal as if nothing has happened

May go on to develop generalised convulsive seizures

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What is a tonic clonic seizure and what are the stages involved?

Prodrome - Often no warning, may be aura if 2^o generalised seizure

Tonic-clonic - Tonic stiffening ⇆ clonic synchonous jerking of the limbs → until convulsion stops

Eyes remain open, tongue bitten, incontinence

Post-ictal phase - flaccid unresponsiveness → gradual return of awareness with confusion and drowsiness +/- headache

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What is a myoclonic seizure?

Brief contractions of muscle or muscle groups → sudden involuntary twitch of finger/hand

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What is a tonic seizure?

Consistent stiffening of the body, without jerking

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What is an atonic (akinetic) seizure?

Sudden loss of muscle tone → fall, without LoC

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What are infantile spasms?

West syndrome - a triad of:

Infantile spasms

Severe myoclonic convulsions
Nodding attack (head drawn inward)
Salaam/Jackknife - bending neck and raising arms

EEG (hypsarrhythmia)

Developmental regression

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What is a partial seizure?

Electrical discharge restricted to a limited part of cortex of one cerebral hemisphere

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What are the different types of partial seizure?

Simple

Complex

Secondary generalisation - starts as partial seizure, spreads widely

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What is a simple partial seizure?

Without LoC

e.g. focal motor seizure (Jacksonian)

Originate in motor cortex
Jerking begins in one side of mouth/hand → spread (march of the seizure)
Local temporary paralysis sometimes follows (Todd’s)

With frontal seizures, can get forceful, sustained turning to one side by eyes, head or body = Adversive seizure

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What is a complex partial seizure?

Loss of consciousness

Arise from temporal lobe or frontal lobe

Awareness impaired

Temporal lobe → post-ictal confusion (takes time)

Frontal lobe → rapid (fast) recovery

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What are the characteristics of a Temporal Seizure?

Automatisms - complex motor phenomena, impaired awareness and no recollection afterwards

Abdominal rising sensation/pain

Dysphasia

Memory phenomena

Emotional disturbance - Hippocampus - sudden terror

Uncal involvement - hallucinations or taste or smell and dream like state

Delusional behaviour

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What characterises frontal lobe seizures?

Motor features - posturing, versive movements of head and eyes

Jacksonian march

Motor arrest - Dysphasia or speech arrest

Subtle behavioural disturbance

Post-ictal Todd’s palsy

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What characterises occipital lobe seizures?

Visual phenomena - spots, lines, flashes

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What characterises parietal lobe seizures?

Sensory disturbances - tingling, numbness, pain

Motor symptoms

What structural changes can causes epilepsy?

Cortical scarring (head injury)

Developmental (tumour)

Space-occupying lesion

Stroke

Hippocampal sclerosis

Valscular malformations

What are non-epileptic causes for seizures?

Trauma, Stroke, Haemorrhage, raised ICP,

alcohol/benzo withdrawal,

metabolic disturbance, liver diease,

infections: meningitis, encephalitis, syphilis, HIV,

raised temperature,

drugs: tricyclics, cocaine, tramadol, theophylline

What are the differentials for epilepsy?

Syncope - Reflex (vasovagal) or cardiogenic

Non-epileptic attacks (psychogenic)

Panic attacks

Sleep disorders, Migraines, TIAs, Hypoglycaemia

What investigations are conducted for epilepsy?

ECG - rule out cardiac cause

EEG - low sensitivity, high specificity. Useful for classification, localisation. Video EEG = Gold standard

Imaging - find cause, response to anti-epileptic drugs, prognosis

What causes of epilepsy are associated to onset at the following ages?

Infants

Children/Adolescent

Young adults

30-50

50+

Infants - Developmental malformation, perinatal injury, infection

Children/Adolescent - Idiopathic Generalised Epilepsy

Young adults - IGEs, Various: head injury, alcohol, vascular malformations, hippocampal sclerosis

30-50 - brain tumours

50+ - Cerebrovascular disease, mass lesions - neoplasms

What is idiopathic generalised epilepsy?

Mixture of generalised seizures Start in childhood, teen or young adulthood Imaging **normal (structurally)** **EEG abnormal** - abnormal firing Seizures triggered by **alcohol excess** and **sleep deprivation** [Juvenile Myoclonic Epilepsy, Childhood Absence Epilepsy]

What is Juvenile Myoclonic Epilepsy? And how is it treated?

Upper limb jerks, GTCS, Absences Seizures on waking, precipitation by alcohol excess and sleep deprivation EEG - spike and wave, **photosensitivity** common **MRI normal** Treatment: Sodium Valporate; (2nd) Lamotrigine; (3rd) Levetiracetam

What is hippocampal sclerosis?

Scarring and atrophy to the hippocampus and surrounding cortex Main cause of temporal lobe epilepsy **Childhood febrile convulsions** are the main RF visible on MRI Refractory epilepsy - resection of damaged temporal lobe may be an option

What is a hamartoma?

Benign local malformation which resembles a neoplasm

How may traumatic brain injury be linked to epilepsy?

May cause epilepsy, sometimes years after event Risk does not increase after mild injury Depressed skull, penetrating injury, intracranial haemorrhage increase risk significantly

How is cerebral palsy related to epilepsy?

1/3 of children with cerebral palsy have epilepsy

How does prematurity and foetal hypoxia relate to epilepsy?

They may cause periventricular leukomalacia which can cause early-onset epilepsy

In which part of the brain are mass lesions likely to cause epilepsy?

The grey matter

After age 60, what is the commonest cause of epilepsy?

Stroke and small vessel cerebrovascular disease

what is a cavernoma?

Cavernomas (cluster of abnormal dilated vessels) usually present with epilepsy

How are inflammatory conditions related to epilepsy?

Often seizures are presenting feature of encephalitis, cerebral abscesses or tuberculomas Also in chronic meningitis

What does pork tapeworm cause?

Neurocyticercosis - major cause of seizures in countries where pork tapeworm is endemic

How are alcohol and drugs related to epilepsy?

Chronic alcohol use - whilst drinking heavily/during period of withdrawal Alcohol-induced hypoglycaemia/head injury can also → seizures Drugs: Antipsychotics, SSRIs, Lithium, Lidocaine, Ciclosporin, Cocaine Withdrawal of anti-epileptics or benzodiazepines may cause seizures

What metabolic abnormalities can cause seizures?

Hypoglycaemia, hypocalcaemia, hyponatraemia Acute hypoxia Uraemia, hepatic encephalopathy Pophyria (abnormal metabolism of Hb)

What are the treatments for Generalised TC seizures?

1 - Sodium Valporate/Lamotrigine 2. Carbamazepine (Na⁺ channels)/Topiramate Others: Levetiracetam, oxycarbazepine, clobazam

What are the treatments for Absence Seizures?

Sodium Valporate Lamotrigine Ethosuximide

What is the treatment for tonic, atonic or myoclonic seizures?

1. Sodium valporate/Lamotrigine 2. Topiramate Other: Levetiracetam, Clobazam (same as GTCS, but avoid carbamazepine/oxcarbazepine)

What is the treatment for partial seizures?

1. Carbamazepine 2. Sodium Valporate/Lamotrigine/Oxcarbazine/Topiramate Others: Levetiracetam, GABApentin, Tigabine, Phenytoin, Clobazam

What is status epilepticus?

Seizure or series of seizures lasting for 30mins without regaining consciousness **MEDICAL EMERGENCY** Seizures lasting \>5min need treating Mortality 20%

What is the immediate management for status epilepticus?

Secure airway, monitor vital signs IV access Oxygen U+Es, Ca, Mg, ABGs, ECG +/- anti-epileptic drug levels IV glucose and thiamine (if alcohol suspected)

What are the treatments for early, established and refractory status epilepticus?

Early - IV **Lorazepam** 4mg, repeated once after 10 mins * alternatives: Diazepam, Buccal Midazolam Established - IV **Phenytoin** - Monitor BP and Cardiac * alternatives: valporate, levetiracetam, phenobarbitone Refractory - ITU, GA. IV **Propofol, Thiopental, Midazolam** EEG, continue treatment + existing AEDs

What is non-convulsive status epilepticus?

Electrographic status (diagnose with EEG), but no convulsions Confusion, reduced GCS, psychiatric symptoms Responds well to **benzodiazepines**

What is SUDEP?

Sudden Unexpected Death in Epilepsy * non-traumatic unwitnessed death * post-mortem normal * Cardiac arrhythmias, perictal hypoxia, postictal cerebral depression → hypoventilation and bradycardia