Epilepsy Flashcards
What is epilepsy?
It is defined as a condition in which individuals have a tendency to experience recurrent seizures
What are seizures?
They are transient episodes of abnormal electrical discharges
What are the three pathophysiological causes of seizures?
Neuronal Overexcitation
Neuronal Damage
Neuronal Under Inhibition
What are the four abnormalities that can cause neuronal overexcitation?
Glutamate receptor pathologies
Sodium ion channel pathologies
Calcium ion channel pathologies
Excitatory amino acid pathologies
What abnormality can cause neuronal under inhibition?
GABA receptor pathologies
What are the nine causes of epilepsy?
VINDICATE
Vascular
Infection
Neoplasms
Drugs
Iatrogenic
Congenital
Autoimmune
Trauma
Electrolyte Imbalances
What is the vascular condition associated with epilepsy?
Stroke
What three infections are associated with epilepsy?
Meningitis
Encephalitis
HIV
Which neoplasms are associated with epilepsy?
Brain
Which two drugs are associated with epilepsy?
Alcohol
Illicit Drugs
Which antibiotic is known to lower the seizure threshold?
Ciprofloxacin
What is an iatrogenic cause of epilepsy?
Drug withdrawal
What three congenital conditions are associated with epilepsy?
Tuberous Sclerosis
Cerebral Palsy
Mitochondrial Disease
What are the three clinical features of tuberous sclerosis?
Epilepsy
Depigmented skin
Roughened patches of skin over the lumbar spine
What autoimmune condition is associated with epilepsy?
Vasculitis
What three electrolyte imbalances are associated with epilepsy?
↓Na+
↓Ca2+
↑Glucose
What are the two general classifications of seizures?
Focal
Generalised
What is another term for focal seizures?
Partial seizures
What are focal seizures?
They are defined as seizures that involve networks within a specific region of the brain, in one cerebral hemisphere
Which cerebral lobe is most commonly affected by focal seizures?
Temporal
What are the two subclassifications of focal seizures?
Simple focal seizures
Complex focal seizures
How do we sub classify focal seizures into simple and complex seizures?
It is based upon the level of awareness individuals experience during the seizure
What are simple focal seizures?
They are defined as focal seizures that don’t impair consciousness or cause postictal clinical features
What is the posticital phase?
It refers to the period of time immediately following a seizure
How long can the posticital phase last for?
It can last from seconds to days
What is a common posticital clinical feature?
Todd’s palsy
What is Todd’s palsy?
It is transient post-ictal paralysis
What clinical features do simple focal seizures result in - motor or non-motor?
Motor
What are the four clinical features associated with simple focal seizures?
Uncontrollable Fit
Jacksonian March
Hallucinations
Paraesthesia
What is Jacksonian March?
It is is defined as a phenomenon in which a seizure spreads from the distal part of the limb toward the ipsilateral face
What are complex focal seizures?
They are defined as focal seizures that impair consciousness or cause postictal clinical features
Describe the timeline of complex focal seizures
Individuals tend to experience aura features prior to the seizure onset, have no memory of the seizure itself and then experience postictal confusion
What clinical features do complex focal seizures result in - motor or non-motor?
Non-motor
What are the four clinical features associated with complex focal seizures?
Automatism
Staring Into Space
Déjà Vu
Jamais Vu
What is automatism?
It is defined as the performance of non-purposeful repetitive movements without being aware of what is happening, such as lip smacking, blinking, grunting, etc
In what two ways do we localise focal seizures?
We can look at the patient’s clinical features
We can conduct an EEG scan
What are the four clinical features that indicate focal seizures are localised to the frontal lobe?
JPJP
Jerky movements
Posturing
Jacksonian march
Posticital weakness
What clinical feature indicates focal seizures are localised to the parietal lobe?
Paraesthesia
What four clinical features indicates focal seizures are localised to the temporal lobe?
HEAD
Hallucinations
Epigastric Rising Aura/Emotional
Automatisms
Deja Vu/Dysphasia
What two clinical features indicates focal seizures are localised to the occipital lobe?
Floaters
Flashing lights
What are the two first line management options for focal seizures?
Lamotrigine
Levetiracetam
What are the three second line management options for focal seizures?
Carbamazepine
Oxcarbazepine
Zonisamide
What is another term for generalised seizures?
Complete seizures
What are generalised seizures?
They are defined as seizures that involve networks within both cerebral hemispheres – with no localising features referable to a single hemisphere
What are the five subclassifications of generalised seizures?
Generalised Tonic Clonic Seizures
Absence Seizures
Atonic Seizures
Myoclonic Seizures
Infantile Seizures
How do we sub classify generalised seizures?
In all subclassifications, generalised seizures result in a loss of consciousness
They are instead classified based upon whether they result in motor or non-motor clinical features
What is another term for generalised tonic clonic seizures?
Grand mal seizures
What are generalised tonic clonic seizures?
They are defined as those that result in motor clinical features, specifically tonic (muscle tensing) and clonic (muscle jerking) episodes
What usually occurs first in generalised tonic clonic seizures - the tonic or clonic phase?
Tonic
THEN
Clonic
Are generalised tonic clonic seizures motor or non-motor?
Motor
What are the five additional clinical features observed in generalised tonic clonic seizures?
Groaning
Eye Rolling/Deviation
Urinary Incontinence
Mouth Foaming
Tongue Biting
What four postictal features occur following generalised tonic clonic seizures?
Confusion
Drowsiness
Irritability
Depression
What is the first line management option for generalised tonic clonic seizures?
Sodium valproate
What are the two second line management options for generalised tonic clonic seizures?
Lamotrigine
Levetiracetam
What is another term for absence seizures?
Petit mal seizures
Are absence seizures motor or non-motor?
Non-motor
Which patient group tends to be affected by absence seizures?
Children
What are the two triggers for absence seizures?
Hyperventilation
Photosensitivity
Describe the clinical features observed during absence seizures
Individuals become blank, stare into space and then abruptly return to normal
During the episode they are unaware of their surroundings and become unresponsive
How long do absence seizures tend to last? How many times can they occur a day?
5-10 seconds
100 times per day
What is the feature of abscence seizures on EEG scans?
3Hz spike and wave
What is the first line management option for absence seizures?
Ethosuximide
What is the second line management option for absence seizures - in males?
Sodium valproate
What are the two second line management options for absence seizures - in females?
Lamotrigine
Levetiracetam
What happens to absence seizures as individuals get older?
They spontaneously stop
What is another term for atonic seizures?
Drop seizures
Are atonic seizures motor or non-motor?
Motor
Which patient group tends to be affected by atonic seizures?
Children
1-5 years old
What do atonic seizures usually indicate?
Lennox-Gastaut syndrome
How does Lennox Gastaut syndrome present on an EEG?
Slow spike
How do we manage Lennox Gastaut syndrome?
Ketogenic diet
Describe the clinical features observed during atonic seizures
Individuals experience a brief lapse in muscle tone within the legs – causing the individual to suddenly collapse or fall down
How long do atonic seizures last?
They usually last less than 3 minutes
What is the first line management option used for atonic seizures?
Sodium valproate
What is the second line management option used for atonic seizures?
Lamotrigine
Are myoclonic seizures motor or non-motor?
Motor
Which patient group tend to be affected by myoclonic seizures?
Children
What do myoclonic seizures indicate?
Juvenile myoclonic epilepsy
What is another term for juvenile myoclonic epilepsy?
Janz syndrome
Which patient group tends to be affected by juvenile myoclonic epilepsy?
Female
Teens
When does juvenile myoclonic epilepsy tend to present?
Morning
There are no daytime seizures
Describe the clinical features observed during myoclonic seizures
Individuals experience sudden brief muscle contractions, like a sudden jump
What is the first line management option for myoclonic seizures?
Sodium valproate
What is the second line management option for myoclonic seizures?
Levetiracetam
What is another term for infantile spams?
West syndrome
Are infantile spasms motor or non motor?
Motor
Which gender tend to be affected by infantile spasms?
Males
Which age group tend to be affected by infantile spasms?
Those between 4 -8 months old
What do infantile spasms indicate?
A secondary neurological abnormality, such as tuberous sclerosis, encephalitis or birth asphyxia
What is a feature on clinical examination of infantile seizures?
Salaam attack
What is a Salaam attack?
This is when individuals experience clusters of full body spasms, resulting in flexion of the head, trunk and limbs and extension of the arms
How long do infantile seizures last? How many times can they occur a day?
1-2 seconds
50 times per day
What EEG feature indicates infantile seizures?
Hypsarrhythmia in 2/3rd of infant
What are the two first line management options for infantile seizures?
Prednisolone
Vigabatrin
What is benign rolandic epilepsy?
It is a form of childhood epilepsy charactersised by partial seizures, which tend to occur during sleep
What is a risk factor of benign rolandic epilepsy?
Family History
What are the three clinical features assoacited with benign rolandic epilepsy?
Hemifacial Paraesthesias
Oropharyngeal Manifestations
Hypersalivation
What are the three other common causes of seizures other than epilepsy?
Febrile convulsions
Alcohol withdrawal
Psychogenic non-epileptic seizures
What are febrile convulsions?
They are defined as brief generalised tonic-clonic seizures that occur early in a viral infection as the temperature rises rapidly
Which age group tend to be affected by febrile convulsions?
6 months - 5 years old
When should parents be advised to call an ambulance during a febrile convulsaion?
When febrile convulsions last longer than 5 minutes
What is a red flag of febrile convulsions, which should prompt referral to paediatrics?
Droswy > 2 hrs of seizure
What can be administered by specialists in those with recurrent febrile convulsions?
Rectal Diazepam
Buccal Midazolam
What are alcohol withdrawal seizures?
These are seizures that occur in patients with a history of alcohol excess who suddenly withdraw alcohol
How soon after alcohol withdrawal does seizures onset occur?
36 hrs
What drug class is administered to prevent the development of alcohol withdrawal seizures?
Benzodiazepines
What is another term for psychogenic non-epileptic seizures?
Pseudo seizures
What are psychogenic non-epileptic seizures?
They describe patients who present with epileptic like seizures that do not have characteristic electrical discharges
Which patient group tend to be affected by psychogenic non-epileptic seizures?
Those with mental health problems
What is a feature indicative of psychogenic seizure?
Widespread convulsions without conscious impairment
What investigation can be used to differentiate between psychogenic non-epileptic seizures and true seizures?
Prolactin levels
True seizures = increased
When do we usually initiate pharmacological management of epilepsy?
After the second epileptic seizure
In which three circumstances do we initiate pharmacological management of epilepsy after the first epileptic seizure?
If the patient has a neurological deficit, brain imaging shows a structural abnormality
If the EEG shows unequivocal epileptic activity
If the patient/family/carers consider the risk of having a further seizure unacceptable
In general, what anti-epileptic is used as a first line management option for generalised seizures?
Sodium valproate
In general, what anti-epileptic is used as a first line management option for focal seizures?
Carbamazepine
What are the two investigations used to diagnose epilepsy?
Electroencephalogram (EEG)
MRI Scan
What is an EEG?
It involves the attachment of electrodes to the scalp in order to record electrical activity of the brain
What EEG feature indicates epilepsy?
Abnormal electrical activity
How are MRI scans used to diagnose epilepsy?
It is used to diagnose structural problems that may be associated with seizures and other pathologies, such as tumours
When do we acutely manage epilepsy?
When seizures don’t self-terminate within 5-10 minutes
How do we acutely manage epilepsy?
We administer benzodiazepines, such as diazepam
What two routes are used to administer benzodiazepines for acute treatment of epilepsy?
Rectally
Intranasally
What is the first line acute pharmacological management option of epilepsy? What dose?
Rectal diazepam 10mg
What is status epilepticus?
This is when seizures continues for more than 5 minutes or there are more than 3 seizures in one hour despite intervention
This is a medical emergency requiring hospital treatment
What two causes of status epilepticus must be ruled out before other causes are considered?
Hypoxia
Hypoglycaemia
What are the seven management steps used to treat status epilepticus in hospital?
Secure Airway
Administer High Concentration O2
Assessment of Cardiac/Respiratory Function
Check Blood Glucose Levels
Insert IV Cannula
Administer IV Lorazepam 4mg (Repeat After 10 Minutes If Seizure Continues)
Administer IV Phenytoin (If Seizures Persist With Lorazepam)
What investigation is required when starting IV phenytoin? Why?
Cardiac monitoring
This is due to the pro-arrythmogenic effects
What are the two management steps used to treat status epilepticus in the community?
Administer Buccal Midazolam 10mg (Repeat After 10 Minutes If Seizure Continues)
Administer Rectal Diazepam (If Seizures Persist With Midazolam)
What is sodium valporate’s mechanism of action?
It is involved in increasing the activity of GABA, which produces a relaxing effect on the brain
When is sodium valproate used to manage epilepsy?
It is used as a first line agent in generalised seizures
What are the five side effects of sodium valproate?
Weight Gain
Alopecia
Liver Damage (P450 Enzyme Inhibitor)
Tremor
Teratogenic
What is carbamazepine’s mechanism of action?
It binds to sodium ion channels, which increases their refractory period
When is carbamazepine used to manage epilepsy?
It is used as a first line agent in focal seizures
What are the six side effects of carbamazepine?
Agranulocytosis
Leucopoenia
Aplastic Anaemia
Ataxia
Liver Damage (P450 Enzyme Inducer)
Visual Disturbances (Diplopia)
Due to being a P450 enzyme inductor, what effect does carbamazepine have on warfarin?
It decreases INR
What two seizure classifications can carbamazepine exacerbate?
Absence seizures
Myoclonic seizures
What is lamotrigine’s mechanism of action?
It binds to and inhibits sodium ion channels
When is lamotrigine used to manage epilepsy?
It is used as a second line agent for a variety of generalised and focal seizures
What are the three side effects of lamotrigine?
Stevens Johnson Syndrome
DRESS Syndrome
Leukopenia
What is ethosuximide’s mechanism of action?
It binds to calcium ion channels of the thalamic neurons, which decreases the electrical activity of these neurones
When is ethosuximide used to manage epilepsy?
It is used as a second line agent for a variety of generalised seizures
What are the two side effects of ethosuximide?
Night Terrors
Rash
Which two anti-epileptics do we need to carefully review the patient’s other prescribed medications? Why?
Sodium valproate
Carbamazepine
Due to the fact that they induce/inhibit the P450 system, which can result in varied metabolism of other medications - such as warfarin and COCP
What anti-epileptic is prescribed in females of childbearing age? Why?
Lamotrigine
Due to the typical teratogenic effect of antileptics, particularly sodium valproate
What are the teratogenic effects of sodium valproate?
Neural tube defects
In comparison to normal pregnancies, what should patients on anti-epileptics be aware of when trying to conceive?
They should receive folic acid 5mg instead of 400mcg
In cases where pregnant patients are being administered phenytoin, what should be administered in the last month of pregnancy? Why?
Vitamin K
To prevent clotting disorders in the newborn
Is breastfeeding safe in mothers taking anti-epileptics?
Yes
The only exception is if they are taking barbiturates
Why is it important to discuss contraception options with epileptic patients of childbearing age?
This is due to the fact that the effect of anti-epileptics can reduce the effectiveness of contraceptive pills, vice versa
What general contraceptive advice is given to those taking anti-epileptics?
They should use condoms in addition to other forms of contraception
What are the three first line contraception methods advised in those administered phenytoin, carbamazepine, barbiturates, primidone, topiramate or oxcarbazepine?
Depo-Provera
IUD
IUS
What are the five first line contraception methods advised in those administered lamotrigine?
POP
Implant
Depo-Provera
IUD
IUS
In cases where epilepsy patients select the COCP, what dose should be administered?
It should contain a minimum of 30 µg of ethinylestradiol
How long is driving suspended for group one vehicles in individuals who experience a single seizure, without an epilepsy diagnosis? What other criteria must these individuals meet? How long is driving suspended for when these criteria are not met?
6 months
No relevant structural abnormalities on brain imaging or EEG
12 months
How long is driving suspended for group two vehicles in individuals who experience a seizure, without an epilepsy diagnosis?
5 years
How long is driving suspended for group one vehicles in individuals who experience a seizure, with an epilepsy diagnosis?
12 months
How long is driving suspended for group two vehicles in individuals who experience a seizure, with an epilepsy diagnosis?
10 years with no medication administration
What criteria must be obtained before anti-epileptic drugs can be stopped?
In cases where individuals are seizure free for > 2 years, with AEDs being stopped over 2 - 3 years
Can individuals drive whilst anti-epileptic drugs are being withdrawn?
No
This includes 6 months until after last dose
What are the five complications associated with epilepsy?
Sudden Unexplained Death in Epilepsy (SUDEP)
Depression
Anxiety
Injuries
Brain Damage
What drug is contraindicated in individuals with epilepsy?
Bupropion
What condition can present similarly to epilepsy? How do we differentiate between the two?
Syncope
The posticital period in epilepsy is prolonged, however does not exist in syncopal episodes
In addition, syncopal episodes are usually associated with stress and reduced nutritional intake
