Epilepsy

Question 1

Ix for epilepsy

Answer 1

EEG

MRI brain

Question 2

What is a generalised tonic-clonic seizure

Answer 2

There is loss of consciousness and tonic (muscle tensing) and clonic (muscle jerking) episodes.

Typically the tonic phase comes before the clonic phase.

There may be associated tongue biting, incontinence, groaning and irregular breathing.

Question 3

What is the post-ictal period in generalised tonic-clonic seizures

Answer 3

After the seizure there is a prolonged post-ictal period where the person is confused, drowsy and feels irritable or depressed.

Question 4

Mx of generalised tonic-clonic seizures

Answer 4

First line: sodium valproate

Second line: lamotrigine or carbamazepine

Question 5

What are focal seizures

Answer 5

Focal seizures start in temporal lobes. They affect hearing, speech, memory and emotions. There are various ways that focal seizures can present:

Hallucinations
Memory flashbacks
Déjà vu
Doing strange things on autopilot

Question 6

Mx of focal seizures

Answer 6

First line: carbamazepine or lamotrigine
Second line: sodium valproate or levetiracetam

Reverse of GTCS

Question 7

What are absence seizures

Answer 7

Absence seizures typically happen in children. The patient becomes blank, stares into space and then abruptly returns to normal.

During the episode they are unaware of their surroundings and won’t respond. These typically only lasts 10-20 seconds.

Question 8

Mx of absence seizures

Answer 8

First line: sodium valproate or ethosuximide

Question 9

What are atonic seizures

Answer 9

also known as “drop attacks”. They are characterised by brief lapses in muscle tone. These don’t usually last more than 3 minutes. They typically begin in childhood.

Question 10

Syndrome associated with atonic seizures

Answer 10

Lennox-gastaut syndrome

Question 11

Mx of atonic seizures

Answer 11

First line: sodium valproate

Second line: lamotrigine

Question 12

What are myoclonic seizures

Answer 12

Myoclonic seizures present as sudden brief muscle contractions, like a sudden “jump”.

The patient usually remains awake during the episode. They occur in various forms of epilepsy but typically happen in children as part of juvenile myoclonic epilepsy

Question 13

Mx of myoclonic seizures

Answer 13

First line: sodium valproate

Other options: lamotrigine, levetiracetam or topiramate

Question 14

What are infantile spasms

Answer 14

This is also known as West syndrome

It is characterised by clusters of full body spasms. There is a poor prognosis

Question 15

Mx of infantile spasms

Answer 15

Prednisolone

Vigabatrin

Question 16

Maintenance option for epilepsy

Answer 16

Sodium valproate - all forms of epilepsy except focal

Question 17

Side effects of sodium valproate

Answer 17

Teratogenic so patients need careful advice about contraception
Liver damage and hepatitis
Hair loss
Tremor

Question 18

1st line maintenance therapy for focal seizures

Answer 18

Carbamazepine

Question 19

Notable side effects of carbamazepine

Answer 19

Agranulocytosis
Aplastic anaemia
Induces the P450 system so there are many drug interactions

Question 20

Notable side effects of phenytoin

Answer 20

Folate and vitamin D deficiency
Megaloblastic anaemia (folate deficiency)
Osteomalacia (vitamin D deficiency)

Question 21

Notable side effects of ethosuximide

Answer 21

Night terrors

Rashes

Question 22

Notable side effects of lamotrigine

Answer 22

Stevens-Johnson syndrome or DRESS syndrome. These are life threatening skin rashes.
Leukopenia

Question 23

Definition of status epilepticus

Answer 23

Seizures lasting more than 5 minutes or more than 3 seizures in one hour

Question 24

Mx of status epilepticus

Answer 24

A-E
IV lorazepam 4mg - repeat after 10 mins if seizure continues
If seizures persist - IV phenobarbital or phenytoin

Question 25

Medical options for management of status epilepticus in the community

Answer 25

Buccal midazolam

Rectal diazepam

Question 26

Factors which support pseudo seizures

Answer 26

pelvic thrusting
family member with epilepsy
much more common in females
crying after seizure
don't occur when alone
gradual onset

Question 27

Factors favouring true epileptic seizures

Answer 27

tongue biting
raised serum prolactin*

Video telemetry is useful for differentiating

Question 28

DVLA advice - first unprovoked/isolated seizure

Answer 28

6 months off if there are no relevant structural abnormalities on brain imaging and no definite epileptiform activity on EEG. If these conditions are not met then this is increased to 12 months

Question 29

DVLA advice - established epilepsy or those with multiple unprovoked seizures

Answer 29

may qualify for a driving licence if they have been free from any seizure for 12 months
if there have been no seizures for 5 years (with medication if necessary) a ’til 70 licence is usually restored

Question 30

DVLA advice - withdrawal of epilepsy medication

Answer 30

should not drive whilst anti-epilepsy medication is being withdrawn and for 6 months after the last dose

Question 31

When do NICE recommend initiating anti-epileptic treatment after a first seizure

Answer 31

the patient has a neurological deficit
brain imaging shows a structural abnormality
the EEG shows unequivocal epileptic activity
the patient or their family or carers consider the risk of having a further seizure unacceptable

Question 32

Specific features of temporal lobe seizures

Answer 32

HEAD

Hallucinations (auditory/gustatory/olfactory), Epigastric rising/Emotional, Automatisms (lip smacking/grabbing/plucking), Deja vu/Dysphasia post-ictal)

Question 33

Specific features of frontal lobe seizures

Answer 33

Motor

Head/leg movements, posturing, post-ictal weakness, Jacksonian march

Question 34

Specific features of parietal lobe seizures

Answer 34

Sensory

Paraesthesia

Question 35

Specific features of occipital lobe seizures

Answer 35

Floaters/flashes