Epilepsy Flashcards
Ix for epilepsy
EEG
MRI brain
What is a generalised tonic-clonic seizure
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.
What is the post-ictal period in generalised tonic-clonic seizures
After the seizure there is a prolonged post-ictal period where the person is confused, drowsy and feels irritable or depressed.
Mx of generalised tonic-clonic seizures
First line: sodium valproate
Second line: lamotrigine or carbamazepine
What are focal seizures
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
Mx of focal seizures
First line: carbamazepine or lamotrigine
Second line: sodium valproate or levetiracetam
Reverse of GTCS
What are absence seizures
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.
Mx of absence seizures
First line: sodium valproate or ethosuximide
What are atonic seizures
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.
Syndrome associated with atonic seizures
Lennox-gastaut syndrome
Mx of atonic seizures
First line: sodium valproate
Second line: lamotrigine
What are myoclonic seizures
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
Mx of myoclonic seizures
First line: sodium valproate
Other options: lamotrigine, levetiracetam or topiramate
What are infantile spasms
This is also known as West syndrome
It is characterised by clusters of full body spasms. There is a poor prognosis
Mx of infantile spasms
Prednisolone
Vigabatrin
Maintenance option for epilepsy
Sodium valproate - all forms of epilepsy except focal
Side effects of sodium valproate
Teratogenic so patients need careful advice about contraception
Liver damage and hepatitis
Hair loss
Tremor
1st line maintenance therapy for focal seizures
Carbamazepine
Notable side effects of carbamazepine
Agranulocytosis
Aplastic anaemia
Induces the P450 system so there are many drug interactions
Notable side effects of phenytoin
Folate and vitamin D deficiency Megaloblastic anaemia (folate deficiency) Osteomalacia (vitamin D deficiency)
Notable side effects of ethosuximide
Night terrors
Rashes
Notable side effects of lamotrigine
Stevens-Johnson syndrome or DRESS syndrome. These are life threatening skin rashes.
Leukopenia
Definition of status epilepticus
Seizures lasting more than 5 minutes or more than 3 seizures in one hour
Mx of status epilepticus
A-E
IV lorazepam 4mg - repeat after 10 mins if seizure continues
If seizures persist - IV phenobarbital or phenytoin
Medical options for management of status epilepticus in the community
Buccal midazolam
Rectal diazepam
Factors which support pseudo seizures
pelvic thrusting family member with epilepsy much more common in females crying after seizure don't occur when alone gradual onset
Factors favouring true epileptic seizures
tongue biting
raised serum prolactin*
Video telemetry is useful for differentiating
DVLA advice - first unprovoked/isolated seizure
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
DVLA advice - established epilepsy or those with multiple unprovoked seizures
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
DVLA advice - withdrawal of epilepsy medication
should not drive whilst anti-epilepsy medication is being withdrawn and for 6 months after the last dose
When do NICE recommend initiating anti-epileptic treatment after a first seizure
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
Specific features of temporal lobe seizures
HEAD
Hallucinations (auditory/gustatory/olfactory), Epigastric rising/Emotional, Automatisms (lip smacking/grabbing/plucking), Deja vu/Dysphasia post-ictal)
Specific features of frontal lobe seizures
Motor
Head/leg movements, posturing, post-ictal weakness, Jacksonian march
Specific features of parietal lobe seizures
Sensory
Paraesthesia
Specific features of occipital lobe seizures
Floaters/flashes
