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Neurology > Epilepsy > Flashcards

Epilepsy Flashcards

1
Q

What are the most common diagnosis in patients referred to first seizure clinics?

A
  • Epilepsy (25%)
  • Syncope (23%)
  • Single seizure (including provoked, 16%)
  • Psychiatric/psychological (6%)
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2
Q

Describe how episodes of collapse are assessed?

A
  • Patients account
    • History and preceding events
      • Context/timing
    • History of event itself
      • Warning symptoms
      • Level of awareness/recollection
    • Afterwards
      • First recollection
      • Seizure markers (prolonged disorientation, tongue biting, incontinence, muscle pains)
  • Witness account (always try and get this)
    • How they were before
      • Context
    • Description of episode
      • Eyes open or closed
      • Description of abnormal movements
      • Pallor, alteration in breathing pattern, pulses
      • Duration of LOC
      • Time to recovery
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3
Q

What are important things to ask witnesses of someone collapsing to assess the episode?

A
  • How they were before
    • Context
  • Description of episode
    • Eyes open or closed
    • Description of abnormal movements
    • Pallor, alteration in breathing pattern, pulses
    • Duration of LOC
    • Time to recovery
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4
Q

What are the 3 categories of syncope?

A
  • Reflex (neuro-cardiogenic)
    • Taking blood/medical situations
    • Cough, micturition
  • Orthostatic
    • Dehydration, medication related (anti-hypertensive)
    • Endocrine, autonomic nervous system
  • Cardiogenic
    • Arrhythmia, aortic stenosis
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5
Q

What can cause reflex syncope?

A
  • Taking blood/medical situations
  • Cough, micturition
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6
Q

What can cause orthostatic syncope?

A
  • Dehydration, medication related (anti-hypertensive)
  • Endocrine, autonomic nervous system
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7
Q

What can cause cardiogenic syncope?

A
  • Arrhythmia, aortic stenosis
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8
Q

Generally, what is syncope due to?

A

It is due to either a low BP or global cerebral hypoperfusion

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9
Q

What is the medical term for temporary loss of consciousness?

A

Syncope

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10
Q

Describe important parts of a history for syncope?

A
  • Patient account
    • History of preceding events
      • Stimulus (blood being taken, defecation)
      • Context (only in bathroom, only when standing)
    • History of event itself
      • Warning sign (felt lightheaded, clammy, vision blacking out)
    • Afterwards
      • Very brief LOC
      • Urinary incontinence
  • Witness account
    • Description of episode
      • Looked a bit pale
      • Suddenly went floppy
      • May have been a few brief jerks
      • Brief LOC
        • Rapid recovery
        • If more prolonged was the patient propped up
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11
Q

When assessming syncope what investigations should be done?

A
  • Examination
    • Heart sounds, pulse
    • Postural BPs
  • Must have ECG
    • Look for heart block
    • QT ratio
  • May need 24 hour ECG
    • May need to see cardiology if recurrent (5 day recordings, reveal devices)

Consider tilt table

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12
Q

Describe a typical history for cardiogenic syncope?

A
  • History of preceding events
    • On exertion
  • History of event itself
    • Chest pain, palpitations, SOB
  • Afterwards
    • Chest pain, palpitations, SOB
    • Came around fairly quickly
      • Recovery may be longer
    • Clammy/sweaty

Witness account:

  • Description of episode
    • Suddenly went floppy
    • Looked grey/ashen white
    • Seemed to stop breathing
    • Unable to feel a pulse
      • There may have been a few brief jerks
      • Variable duration of LOC
        • Rapid recovery
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13
Q

Do patients who have cardiogenic syncope recover quickly or slowly?

A

Quick recovery

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14
Q

What assessments are important for cardiogenic syncope?

A
  • Family history important
  • Examination
    • Heart sounds, pulse
  • Must have ECG
    • Look for heart block
    • QT ratio
  • Refer to cardiology urgently/admission for telemetry
  • May need 24 hour ECG/ECHO/prolonged monitoring
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15
Q

What is epilepsy?

A

Tendency to recurrent seizures

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16
Q

Neurons have background electrical activity, what happens if this is disrupted?

A

Seizures

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17
Q

How many unprovoked seizures are required for the term epilepsy to be used?

A

If patients have more than 1 unprovoked seizures:

  • Also used after single seizure if investigations suggest a tendency to recurrence (over 60% risk of recurrence over 10 years)
  • This could be thought due to abnormality on imagining or EEG
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18
Q

What is the pathophysiology of epilepsies?

A
  • Synchronous discharges in cortical neurones
    • too much excitation
      • glutamate receptors
        • ion channels = Na/Ca
        • excitatory amino acids
    • damaged neurones
      • stroke/tumour/trauma
      • developmental causes
    • too little inhibition
      • GABA receptors
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19
Q

When can the term epilepsy be used after a single unprovoked seizure?

A
  • After single seizure if investigations suggest a tendency to recurrence (over 60% risk of recurrence over 10 years)
  • This could be thought due to abnormality on imagining or EEG
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20
Q

What are examples of provoked seizures?

A
  • Alcohol withdrawal
  • Drug withdrawal
  • Within a few days after a head injury
  • Within 24 hours of stroke
  • Within 24 hours of neurosurgery
  • With severe electrolyte disturbance
  • Eclampsia
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21
Q

What is used to classify seizures?

A

The international league against epilepsy (ILAE)

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22
Q

What does ILAE stand for?

A

International league against epilepsy

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23
Q

What are the different classes of seizures from ILAE?

A
  • Generalised seizures
    • Absence seizures
    • Generalised tonic-clonic seizures
    • Myoclonic seizures
    • Juvenile myoclonic epilepsy
    • Atonic seizures
  • Focal seizures
    • Simple partial seizures
    • Complex partial seizures
    • Secondary generalised
    • Or by localisation of onset (temporal lobe, frontal etc)
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24
Q

What are examples of generalised seizures?

A
  • Absence seizures
  • Generalised tonic-clonic seizures
  • Myoclonic seizures
  • Juvenile myoclonic epilepsy
  • Atonic seizures
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25
Q

What are examples of focal seizures?

A
  • Simple partial seizures
  • Complex partial seizures
  • Secondary generalised
  • Or by localisation of onset (temporal lobe, frontal etc)
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26
Q

Compare and contrast primary and focal seizures?

A
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27
Q

What are focal seizures also known as?

A

Partial seizures

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28
Q

What is the difference in typical age between primary and focal seizures?

A

Primary - < 25 years

Focal - any age

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29
Q

What is a generalised tonic clonic seizure?

A

Disturbance in the functioning of both sides of your brain. This disturbance is caused by electrical signals spreading through the brain inappropriately

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30
Q

Describe the patients account of a generalised tonic clonic seizure?

A
  • History preceding events
    • Unpredictable, tend to cluster
    • Past medical history (complications at birth, feb conv, trauma, meningitis, brain injuries)
  • History of event itself
    • May have vague warning
    • Irritability before them
  • Associted with
    • tongue biting, incontinence, irregular breathing, foaming, eyes rolling backwards
  • Afterwards
    • After seizure, there is a prolonged phase = post-ictal phase where the patient is
      • confused, drowsy, irritable, depressed
    • First recollection in ambulance or hospital
    • Muscle pain
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31
Q

Describe the witness account of generalised tonic clonic seizure?

A
  • Groaning sound
  • Tonic (rigid phase)
    • Then generalised jerking in all 4 limbs
  • Eyes open
    • Staring/roll upwards
  • Foaming at the mouth
  • Jerking for a few minutes then groggy for 15-30 mins
  • May be agitated afterwards, may have a cluster of episodes stopping and starting
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32
Q

What is the management for generalised tonic clonic seizures?

A

First line = sodium valproate

Second line = iamotrigine or carbamazepine

33
Q

What is an absence seizure?

A
  • Typically happens in children - unaware of them
  • Patient becomes
    • blank
    • stares into space
    • abruptly returns to normal
  • brief staring, eye-fluttering and then restart what they’re doing
34
Q

What happens in an absence seizure?

A
  • Sudden arrest of activity for a few seconds
    • Brief staring
    • May have eye-lid fluttering
  • Re-start what they were doing
  • During an episode, they are unaware of their surroundings and won’t respond
    • only lasts 10-20 seconds
35
Q

What is an abscense seizure provoked by?

A
  • hyperventilation
  • photic stimulation = light through trees whilst in the car
36
Q

What is the management of an abcense seizure?

A

First line = sodium valproate or ethosoximide

Second line = Iamotrigine

37
Q

What are myoclonic seizures?

A
  • Sudden brief muscle contraction e.g. sudden jump
  • Patient remains awake
  • Typically seen in children
    • as part of the juvenile myoclonic epilepsy
  • Early morning clonus
    • dropping things in the morning
    • brief limb jerks
  • Provoked by alcohol, sleep deprivation
38
Q

What is the management of myoclinic seizures/juvenile myoclonic epilepsy?

A

First line = sodium valproate

others = iamotrigine, levetiracetam

39
Q

What are complex partial seizures also known as?

A

Temporal lobe seizures or Focal seizures

40
Q

Describe the patient account in complex partial seizures?

A

Presents with:

  • hallucinations
  • memory flashbacks
  • deja vu
  • doing strange things on autopilot
  • rising feeling in stomach
  • no recollection
  • disorientated for a spell
41
Q

What is the management of focal seizures?

A

First line = carbamazepine or iamotrigine

second line = sodium valproate or levetiracetam

42
Q

What is done for the clinical assessment of seizures?

A
  • Refer to first seizure clinic
  • Do an ECG, routine bloods (glucose)
  • A and E will often arrange a CT
    • exclude serious causes
  • From neurology clinic:
    • May arrange an MRI for focal lesion
      • shows structure of the brain
    • May arrange EEG (usually <40 years)
      • shows epilepsy patterns
    • Discuss anti-epileptic drugs
    • Refer to epilepsy nurse
    • Discuss driving (inform DVLA)
43
Q

What are atonic seizures?

A
  • drop attacks
  • brief lapses in muscle tone
  • lasts no more than 3 minutes
  • being in childhood
44
Q

What is the treatement of atonic seizures?

A

first line = sodium valproate

second line = iamotrigine

45
Q

What is the incidence of epilepsy?

A

Incidence is 5-120/100000 per year

46
Q

What is the prevalence of epilepsy?

A

Prevalence is 5-8/1000

47
Q

What investigations are done for epilepsy?

A

EEG for primary generalised epilepsies including hyperventilation and photic stimulation

MRI for patients under 50 with possible focal onset seizure, CT usually adequate to exclude serious cause over this age

Video-telemetry if uncertain about diagnosis

48
Q

What are risk factors influencing seizure risk?

A
  • Missed medication (most common)
  • Sleep disturbance, fatigue
  • Hormonal changes
  • Drug/alcohol use, drug interaction
  • Stress/anxiety
  • Photosensitivity in a small group of patients (and other rarer reflexes such as patterns or noises)
49
Q

What is the most common cause of a seizure?

A

Missed medication

50
Q

What is the first line treatment for seizures?

A
  • Sodium valproate, lamotrigine, levetiracetam for primary generalised epilepsies
  • Lamotrigine, carbamazepine, levetiracetam for focal and secondary generalised seizures
  • Ethosuximide for absence seizures
51
Q

What is the first line treatment for primary generalised seizures?

A
  • Sodium valproate, lamotrigine, levetiracetam for primary generalised epilepsies
52
Q

What is the first line treatment for secondary generalised seizures?

A
  • Lamotrigine, carbamazepine, levetiracetam for focal and secondary generalised seizures
53
Q

What is the first line treatment for absence seizures?

A
  • Ethosuximide for absence seizures
54
Q

What is the treatment for acute seizures?

A
  • Lorazepam, midazolam (diazepam) first line
  • Valproate or phenytoin second line for status epilepticus
55
Q

What is the first line treatment for acute seizures?

A
  • Lorazepam, midazolam (diazepam) first line
56
Q

What is the second line treatment for acute seizures?

A
  • Valproate or phenytoin second line for status epilepticus
57
Q

What is the second line treatment for generalised epilepsy?

A

iamotrigine or carbamazepine

58
Q

What is second line treatment for partial seizures?

A

sodium valproate or levertiracetam

59
Q

What are side effects of epilepsy therapy?

A
  • Phenytoin
    • Arrhythmia, hepatitis, medication interactions
  • Sodium valproate
    • Tremor, weight gain, ataxia, nausea, drowsiness, hepatitis
    • Try and avoid in woman of childbearing age
  • Carbamazepine
    • Ataxia, drowsiness, nystagmus, blurred vision, low serum sodium levels, skin rash
  • Lamotrigine
    • Skin rash, difficulty sleeping
  • Levetiracetam
    • Irritability, depression
60
Q

What are side effects of phenytoin?

A
  • Arrhythmia, hepatitis, medication interactions
61
Q

What are side effects of sodium valproate?

A
  • Tremor, weight gain, ataxia, nausea, drowsiness, hepatitis
  • Try and avoid in woman of childbearing age
62
Q

What are side effects of carbamazepine?

A
  • Ataxia, drowsiness, nystagmus, blurred vision, low serum sodium levels, skin rash
63
Q

What are side effects of lamotrigine?

A
  • Skin rash, difficulty sleeping
64
Q

What are side effects of levetiracetam?

A
  • Irritability, depression
65
Q

What are the driving regulations for people with epilepsy?

A

After a single seizure, a patient may drive a car after 6 months if their investigations are normal and they had no further events:

  • HGV after 5 years if their investigations are normal, had no further events and are not on anti-epileptic medication
66
Q

When can patients with epilepsy drive a car

A

Patients with epilepsy can drive a car once they have been seizure free for a year and have only had seizures arising from sleep for a year:

  • Ever had a daytime seizure but then the pattern becomes nocturnal this must be established for 3 years before they can drive
  • They can only hold a HGV licence if they have been seizure free for 10 years and are not on anti-epileptic medication
67
Q

What is status epilepticus?

A

Is prolonged or recurrent tonic-clonic seizures persisting for more than 30 minutes with no recovery periods between seizures

68
Q

What is the mortality of status epilepticus?

A

Mortality is 5-10%

69
Q

What is the treatment for status epilepticus?

A
  • First line
    • Midazolam
      • 10mg by buccal or intra-nasal route, repeated after 10 minutes if required
    • Lorazepam
      • 0.07mg/kg, usually 4mg bolus repeated once after 10 minutes
    • Diazepam
      • 10-20mg IV or rectally, repeated after 15 minutes if necessary
  • Second line
    • Phenytoin
      • Slow infusion of 15-18mg/kg at 50mg/min
    • Valproate
      • 20-30mg/kg IV at 40mg/min
  • Third line
    • Anaesthesia usually with propofol or thiopentone
70
Q

What is the first line treatmet for status epilepticus?

A
  • Midazolam
    • 10mg by buccal or intra-nasal route, repeated after 10 minutes if required
  • Lorazepam
    • 0.07mg/kg, usually 4mg bolus repeated once after 10 minutes
  • Diazepam
    • 10-20mg IV or rectally, repeated after 15 minutes if necessary
71
Q

What is the second line treatment for status epilepticus?

A
  • Phenytoin
    • Slow infusion of 15-18mg/kg at 50mg/min
  • Valproate
    • 20-30mg/kg IV at 40mg/min
72
Q

What is the third line treatment for status epilepticus?

A
  • Anaesthesia usually with propofol or thiopentone
73
Q

How does mortality of status epilepticus compare to other neurological conditions?

A
  • Mortality is highest secondary to strokes, encephalitis, mass lesions and trauma
    • 90% of deaths are a result of the underlying cause
74
Q

What is an example of a non-epileptic attack?

A

Pseudoseizure

75
Q

What are pseudoseizures?

A

Seizures that occur as a result of psychological causes, such as severe mental stress

76
Q

Describe the patient account of a pseudoseizure?

A
  • History of preceding events
    • Events may occur at times of stress or while at rest
    • Will often gives lots of detail of others reaction and little of events themselves
  • History of event itself
    • May recall what people said during episode
    • May be prolonged episode, waving and waining
    • May describe dissociation
  • Afterwards
    • Others reactions
77
Q

Describe the witness account of a pseudoseizure?

A
  • Description
    • May recognise stress as a trigger
    • May report signs of patient retaining awareness
      • Tracking eye movements, still some verbalisation during episodes
      • Movements not typical of seizures
        • Pelvic thrusting
        • Asynchronous movements, tremor
        • Episodes waxing and waining
      • Ideally try to capture a typical episode on EEG
78
Q

How can the number of pseudoseizures possibly be reduced in a patient?

A

Treat the underlying cause

Neurology (5 decks)

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