Epilepsy

Question 1

Definition of epilepsy?

Answer 1

recurrent tendency to spontaneous, intermittent, abnormal electrical activity in the brain, manifested as seizures

Question 2

Classification of epilepsy?

Answer 2

Focal onset

• with or without awareness
• motor or non-motor
• focal to bilateral tonic-clonic

Generalised onset
- always impaired awareness
- Motor
Tonic-clonic seizures - LOC, stiff then jerk
Myoclonic seizures -sudden jerks
Atonic seizures -sudden loss of tone, no LOC
Non-motor
Absence seizures-brief pauses of <10sec
Unknown onset

Question 3

Causes of Epilepsy?

Answer 3

Idiopathic - 2/3, often familiar

Structural - Cortical scarring, SOL, stroke

Systemic - sarcoidosis, SLE, PAN

Non-epileptic causes of seizure

• Trauma, haemorrhage, increased ICP
• Alcohol or benzo withdrawal
• Liver disease
• Infection (meningitis, encephalitis)
• drugs (TCA, cocaine, tramadol)
• Pseudo seizures

Question 4

History/Presentation?

Answer 4

Details of seizures (ideally from eyewitness)
-length of time, what it looked like, LOC, tongue biting, incontinence

Prodrome - change of mood and aura
Post ictal period - headache, confusion, myalgia, lethargy

Triggers - eg flickering lights, alcohol, TV
Family History

Recent drugs or alcohol use, lack of sleep=triggers

Question 5

Examination findings?

Answer 5

Evidence of focal brain lesion?
Exclude non-neurological causes
Pay attention to signs of traumatic injury
Check tongue

Question 6

Diagnosis made by?

Answer 6

Clinical diagnosis
Positive findings of EEG can help but not refute
Make sure it’s truely a seizure
Highly likely if:
- No provocation
- Absence of syncopal prodrome
- Post -ictal drowsiness +/- confusion
- Tongue biting or urinary/fecal incontinence

Question 7

Differential diagnosis?

Answer 7

Syncope 
  Reflex - Vasovagal 
  Orthostatic - Postural BP drop 
  Arrhythmia - transient
  Cardiac 
Hypoglycaemia

Question 8

Investigations

Answer 8

FBC, glucose, electrolytes, Ca, Mg, Creatinine, LFTs
Urine Tox screen 
CXR 
Consider LP 
CT head esp if focal neurology 
ECG/MRI

Question 9

Management - NP

Answer 9

Avoid triggers
Avoid driving until seizure free for 1 year
counselling re swimming, heights, heavy machinery
Epilepsy nurse specialist
Refer to seizure clinic

Question 10

Pharmacological

Answer 10

Do not start treatment after 1st seizure unless structureal brain lesion, focal neurological deficit or unequivocal epileptiform EEG
Neurologist to commence drug therapy after 2nd seizure
If only 1-2 seizures a year and no need to drive they may wish not to take medication

Generalised seizures (TC, myoclonic, absence, atonic)_

• Sodium Valproate
• Lamotrigine (OK IN PREGNANCY)
• Levitiracetam, carbamazapine, topiramate, oxycarbazepine
• avoid carbamazepine and oxycarbazepine in tonic, atonic and myoclonic seizures

INVASIVE
- resection possible if clear epileptogenic focus