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Finals: Medicine > Epilepsy > Flashcards

Epilepsy Flashcards

1
Q

Define epilepsy

A

Epilepsy is a chronic neurological disorder characterised by recurrent seizures

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2
Q

Define a seizure

A

Symptom not a condition

Seizures are transient episodes of abnormal synchronous, hyperexcited neuronal activity in the brain

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3
Q

Epilepsy most commonly occurs in isolation although certain conditions have an association with epilepsy.

Name a condition that is associated with epilepsy?

A

Cerebral palsy

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4
Q

Define a primary seizure

A

Unprovoked seizure

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5
Q

Define a secondary seizure

A

Clear precipitate leading to the seizures e.g. stroke, head injury, alcohol, severe infection, medication

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6
Q

GABAergic characteristically:

a) Inhibitory
b) Excitatory

A

a) Inhibitory

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7
Q

GABAergic signals are characterised by which type of receptors

A

Gamma-aminobutyric acid (GABA)

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8
Q

Glutamatergic characteristically:

a) Inhibitory
b) Excitatory

A

b) Excitatory

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9
Q

Glutamatergic signals are characterised by which type of receptors

A

Glutamate receptors

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10
Q

GABA is the main ____ neurotransmitter

a) Inhibitory
b) Excitatory

A

GABA is the main Inhibitory neurotransmitter

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11
Q

What type of receptors are GABA receptors and what ion does it influence?

A

Ligand-gated ion channel that allows flow of chloride ions.

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12
Q

Glutamate is the main ____ neurotransmitter

a) Inhibitory
b) Excitatory

A

b) Excitatory

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13
Q

What type of receptors are glutamate receptors?

A

Multiple types e.g. G coupled receptors, ion channels etc

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14
Q

What happens during the tonic phase of seizure

A

Prolonged depolarisation with action potential

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15
Q

What happens during the clonic phase of seizure

A

Period of depolarisation followed by hyperpolarisation

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16
Q

There are four stages of a seizure.

Name these stages

A
  1. Prodromal
  2. Early-ictal
  3. Ictal
  4. Post-ictal
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17
Q

Describe the prodromal phase of a seizure

A

Describes a period of subjective feeling or sensation a set of non-specific symptoms that occurs before the onset of a seizure

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18
Q

Describe the early ictal phase of a seizure

A

This phase is characterised by aura

An aura is a sensory disturbance e.g. visual, olfactory etc, that precede an attack, usually just by a few minutes.

Not all patients will experience an aura – it is more suggestive of focal seizures

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19
Q

Describe the ictal phase of a seizure

A

Refers to the seizure

Highly variable depending on seizure type.

It may be associated with urinary incontinence and tongue biting, and normally lasts 1-2 minutes

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20
Q

Describe the post-ictal phase of a seizure

A
  • This is the recovery period, when the seizure has abated
  • During the period of recovery there may be altered consciousness, confusion, memory loss, drowsiness, general malaise, feeling irritable and/or depressed
  • This period may last hours
  • It typically does not occur if they retained consciousness during the ictal phase
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21
Q

What are the two key clinical features of a seizure which is able to distinguish it from other differential diagnosis?

A
  • Tongue biting
  • Experience incontinence of urine during the seizure
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22
Q

Seizure can be classified based on 3 key features.

Name these three features

A
  1. The area where the seizures begin in the brain
  2. Level of awareness they have during a seizure
  3. Features e.g., motor features, non-motor features
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23
Q

What are the characteristics of a focal seizure

A
  • Seizures which arise from a specific area, on one hemisphere – typically the temporal lobe
  • Level of awareness varies
  • They may experience either motor or non-motor features
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24
Q

In focal seizures the level of awareness varies depending on what type of focal seizure it is.

What is the name given to the two types of level of awareness

A

Primary focal aware

Primary focal impaired awareness

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25
Q

Define the term “primary focal aware”

A

Primary focal aware refers to when they are aware that the seizure is happening

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26
Q

Define the term “primary focal impaired awareness”

A

Primary focal impaired awareness refers to when they are not aware the seizure is occurring. These types of seizures are most commonly originating at the temporal lobe

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27
Q

Name some of the motor features associated with a focal seizure

A

Jacksonian march, lip-smacking, blinking

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28
Q

Name some of the non-motor features associated with a focal seizure

A

déjà vu

Hallucination

Doing things on autopilot

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29
Q

What is a focal to bilateral convulsive seizure

A

A focal seizure that has spread to affect a wider network of neurons involving both hemispheres and thus eveolves to a generalised seizure, which is typically tonic-clonic

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30
Q

What is the first line antiepileptic pharmaceutical therapy in managing focal seizures

A

Carbamazepine or lamotrigine

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31
Q

What is the second line antiepileptic pharmaceutical therapy in managing focal seizures

A

Sodium valproate or levetiracetam

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32
Q

What are the characteristics of a generalised seizure

A
  • Involve networks on both hemispheres
  • Generalised seizures will always occur with no awareness as all loss consciousness
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33
Q

What is the first line antiepileptic pharmaceutical therapy in managing generalised seizures

A

Sodium valproate

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34
Q

What is the second line antiepileptic pharmaceutical therapy in managing generalised seizures

A

Lamotrigine or Carbamazepine

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35
Q

Name some of the types of generalised seizures

A
  • Tonic-Clonic: Stiffening and shaking
  • Tonic: Generalised muscle stiffening
  • Clonic: Rhythmic muscle jerking
  • Atonic: drop seizure
  • Myotonic: brief, shock-like jerking
  • Absence: staring blankly into space and returns back to normal after 10-20 secs
36
Q

What are the key characteristics of a generalised tonic clonic seizure

A
  • Characterised by a loss of consciousness and tonic (muscle tensing/stiffening) and clonic (muscle jerking) – typically in that order
  • May be associated with tongue biting, incontinence, groaning and irregular breathing
  • Prolonged post-ictal phase
37
Q

What is the first line antiepileptic pharmaceutical therapy in managing generalised tonic clonic seizures

A

Sodium Valproate

38
Q

What is the second line antiepileptic pharmaceutical therapy in managing generalised tonic clonic seizures

A

Lamotrigine or Carbamazepine

39
Q

What are the key characteristics of a generalised atonic seizure

A
  • Characterised by brief lapses in muscle tone
  • Lasting < 3 mins
  • Typically begin in childhood
40
Q

Atonic seizures may be indicative of what syndrome

A

Lennox-Gastaut syndrome

41
Q

Name the three types of generalised seizures that typically occur in childhood

A

Atonic seizure

Myoclonic seizure

Absence seizure

42
Q

What is the first line antiepileptic pharmaceutical therapy in managing generalised atonic seizures

A

Sodium Valproate

43
Q

What is the second line antiepileptic pharmaceutical therapy in managing generalised atonic seizures

A

Lamotrigine

44
Q

What are the key characteristics of a generalised myoclonic seizure

A
  • Characterised by sudden brief muscle contractions – almost like a sudden “jump”
  • These contractions can be of a limb, trunk or face
  • Patient usually remains conscious during these seizures
45
Q

Myoclonic seizures typically happen in children as part of what syndrome

A

Juvenile myoclonic epilepsy

46
Q

What is the first line antiepileptic pharmaceutical therapy in managing generalised myoclonic seizures

A

Sodium valproate

47
Q

What is the second line antiepileptic pharmaceutical therapy in managing generalised myoclonic seizures

A

Lamotrigine, levetiracetam or topiramate

48
Q

What drug should not be used in the managing of myoclonic seizures as it can worsen the seizures

A

Carbamazepine

49
Q

What are the key characteristics of a generalised absence seizure

A
  • Patients, often children, becomes blank, stares into space briefly, < 10 seconds, and then abruptly returns to normal
  • During the episode they are unaware of their surroundings and won’t respond
50
Q

What is the first line antiepileptic pharmaceutical therapy in managing generalised absence seizures

A

Sodium valproate or ethosuximide

51
Q

What drug should not be used in the managing of absence seizures as it can worsen the seizures

A

Carbamazepine

52
Q

What are the two key investigations that help support a diagnosis of epilepsy (as it is a clinical diagnosis)

A

Neuroimaging (usually MRI)

Electroencephalogram (EEG)

53
Q

What does an electroencephalogram (EEG) assess?

A

A non-invasive method of assessing and recording the electrical activity of the brain

It is not used as a sole diagnostic tool and cannot be used to exclude epilepsy, particularly if the clinical presentation supports a diagnosis of epilepsy.

54
Q

If MRI is not available or suitable what is the second line neuroimaging technique for assessing epilepsy

A

CT

55
Q

Following a single seizure, patients are typically referred to a “first fit” clinic for further assessment.

What are the assessments involved in this visit

A

The clinic involves formal assessment (history and examination) and organisation of relevant investigations (e.g. MRI, EEG) to determine whether the seizure is likely to represent epilepsy.

56
Q

What is the aim of anti-epileptic drug treatment?

A

The aim of treatment is to be seizure free on the minimum anti-epileptic medications

Ideally they should be on monotherapy with a single anti-epileptic drug

57
Q

As a general rule sodium valproate is used first-line for patients with what kind of seizures

A) Generalised

B) Focal

A

A) Generalised

58
Q

As a general rule carbamazepine is used first-line for patients with what kind of seizures

A) Generalised

B) Focal

A

B) Focal

59
Q

Ethosuximide is the 1st line therapy drug of choice for what kind of seizures

A

Absence seizures

60
Q

Carbamazepine may worsen what kind of seizures.

A

Myoclonic and absence

61
Q

In what patient group should sodium valproate use be avoided (or use should be carefully monitored)

A

Women of wearing bearing age as it is highly teratogenic

62
Q

What is the mechanism of action of sodium valproate

A

Increases GABA activity

63
Q

Name some of the adverse effects associated with sodium valproate

A

Highly teratogenic

Increase in appetite and weight gain

Alopecia: causes hair loss and when regrown it is curly

Drug induced hepatitis

Pancreatitis

Thrombocytopenia i.e. low platelet count

64
Q

What is the mechanism of action of carbamazepine

A

Sodium channel antagonist – binds to sodium channels, preventing sodium influx. Leading to an increase in their refractory period

65
Q

Name some of the adverse effects of carbamazepine

A

Agranulocytosis - increased risk of infections

Syndrome of inappropriate ADH secretion (SIADH)

p450 enzyme inducer – commonly causes drug interactions

66
Q

What is the mechanism of action of lamotrigine

A

Sodium channel blocker – preventing sodium influx in the presynaptic terminal

67
Q

Name some of the adverse effects of lamotrigine

A

Stevens-Johnson syndrome

Leukopenia - low WCC

68
Q

What is the mechanism of action of levetiracetam

A

Acts by binding to SV2A, interfering with synaptic vesicles and inhibiting neurotransmitter release

69
Q

What is levetiracetam used (in regards to epilepsy control)

A

Used second-line drug choice in myotonic seizures

70
Q

Name some of the adverse effects of levetiracetam

A

? teratogenic

CNS disturbance

Neuropsychiatric disturbance

71
Q

What is the mechanism of action of phenytoin

A

Sodium channel antagonist – binds to sodium channels increasing their refractory period

72
Q

When is phenytoin used (in the control of epilepsy)

A

No longer used first-line due to side-effect profile

However does give excellent seizure control in difficult cases (only used under the guidance of specialists)

73
Q

Name some of the adverse effects of phenytoin

A

P450 enzyme inducer

Folate and vit D deficiency

Megaloblastic anaemia (folate deficiency)

Osteomalacia (vitamin D deficiency)

Gum hypertrophy

Cerebellar atrophy

74
Q

What is the mechanism of action of ethosuximide

A

Calcium channel blocker – inhibits the T-type calcium channels in the presynaptic terminal. Calcium influx drives neurotransmitter release

75
Q

When is ethosuximide used (in epilepsy control)

A

Used first line in absence seizures

76
Q

Name some of the adverse effects of ethosuximide

A

Night terrors

Rashes

77
Q

Generally patients cannot drive for how long following a seizure

A

6 months

78
Q

For patients with established epilepsy they must be fit free for how long before being able to drive

A

12 months

79
Q

Name some of the complications of epilepsy

A
  • Status epilepticus
  • Depression
  • Suicide
  • Sudden unexpected death in epilepsy (SUDEP) - thought to be due to excessive electrical activity causing a cardiac arrhythmia and death.
80
Q

Define Status epilepticus

A
  • Defined as continuous seizure activity, which has failed to self-terminate.
  • Medical emergency
81
Q

Name the two criteria which can be used to diagnosis status epilepticus

A
  • A single epileptic seizures lasting > 30 minutes
  • A run of epileptic seizures (≥2) without regaining consciousness between episodes
82
Q

What is the 1st line therapy for status epilepticus

A

Benzodiazepine

83
Q

In what form is the Benzodiazepine given in status epilepticus

A
  • IV lorazepam 4mg
  • Rectal diazepam 10mg*
  • Buccal midazolam 10mg*

* if you do not have access

84
Q

If the seizures are still ongoing (in status epilepticus) despite the initial dose of Benzodiazepine.

What is the 2nd line treatment

A

2nd dose of Benzodiazepine

85
Q

If the seizures are still ongoing (in status epilepticus) despite the 1st and 2nd dose of Benzodiazepine.

What is the 3rd line treatment

A

IV loading of anti-epileptic medication e.g. phenytoin (alternatives are sodium valproate or levetiracetam)

NOTE: When giving phenytoin ensure ECG monitoring as it can lead to significant arrhythmias

Finals: Medicine (91 decks)

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