Epilepsy

Question 1

What is epilepsy?

Answer 1

Epilepsy is an umbrella term for a condition where there is a tendency to have seizures. Seizures are transient episodes of abnormal electrical activity in the brain. There are many different types of seizure.

A diagnosis of epilepsy is made by a specialist based on the characteristics of the seizure episodes.

Question 2

Types of seizures?

Answer 2

Generalised Tonic-Clonic Seizures

Focal Seizures

Absence seizures

Atonic seizures

Myoclonic Seizures

Infantile Spasms

Question 3

Generalised Tonic-Clonic seizures features?

Answer 3

These are what most people think of with an epileptic seizure. There is loss of consciousness and tonic (muscle tensing) and clonic (muscle jerking) movements. Typically the tonic phase comes before the clonic phase. There may be associated tongue biting, incontinence, groaning and irregular breathing.

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

Question 4

Management of tonic-clonic seizures is with:

Answer 4

First line: sodium valproate
Second line: lamotrigine or carbamazepine

Question 5

Focal seizures features?

Answer 5

Focal seizures start in the 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

Treatment for focal seizures?

Answer 6

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

One way to remember the treatment is that the choice of medication is the reverse of tonic-clonic seizures

Question 7

Absence seizures features?

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 to 20 seconds. Most patients (more than 90%) stop having absence seizures as they get older.

Question 8

Treatment for absence seizures?

Answer 8

First line: sodium valproate or ethosuximide

Question 9

Atonic seizures features?

Answer 9

Atonic seizures are 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. They may be indicative of Lennox-Gastaut syndrome.

Question 10

Treatment of atonic seizures?

Answer 10

First line: sodium valproate
Second line: lamotrigine

Question 11

Myoclonic seizures features?

Answer 11

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 12

Treatment of myoclonic seizures?

Answer 12

First line: sodium valproate
Other options: lamotrigine, levetiracetam or topiramate

Question 13

Infantile spasms features?

Answer 13

This is also known as West syndrome. It is a rare (1 in 4000) disorder starting in infancy at around 6 months of age. It is characterised by clusters of full body spasms. There is a poor prognosis: 1/3 die by age 25, however 1/3 are seizure free.

Question 14

Treatment of infantile spasms?

Answer 14

Prednisolone
Vigabatrin

Question 15

What are febrile convulsions?

Answer 15

Febrile convulsions are seizures that occur in children whilst they have a fever. They are not caused by epilepsy or other underlying neurological pathology (such as meningitis or tumours).

By definition, febrile convulsions occur only in children between the ages of 6 months and 5 years. Febrile convulsions do not usually cause any lasting damage. One in three will have another febrile convulsion. Having febrile convulsions slightly increases the risk of developing epilepsy in the future.

Question 16

Investigations for epilepsy?

Answer 16

An electroencephalogram (EEG) can show typical patterns in different forms of epilepsy and support the diagnosis. Perform an EEG after the second simple tonic-clonic seizure. Children are allowed one simple seizure before being investigated for epilepsy.

An MRI brain can be used to visualise the structure of the brain. It is used to diagnose structural problems that may be associated with seizures and other pathology such as tumours. It should be considered when:

The first seizure is in children under 2 years
Focal seizures
There is no response to first line anti-epileptic medications
Additional investigations can be considered to exclude other pathology that may cause seizures:

ECG to exclude problems in the heart.
Blood electrolytes including sodium, potassium, calcium and magnesium
Blood glucose for hypoglycaemia and diabetes
Blood cultures, urine cultures and lumbar puncture where sepsis, encephalitis or meningitis is suspected

Question 17

General advice for epileptic patients?

Answer 17

Patients and families presenting with seizures need to be given advice about safety precautions, recognising, managing and reporting further seizures. It is important to avoid situations where a seizure may put the child in danger, with advise to:

Take showers rather than baths
Be very cautious with swimming unless seizures are well controlled and they are closely supervised
Be cautious with heights
Be cautious with traffic
Be cautious with any heavy, hot or electrical equipment

Older teenagers with epilepsy will need to avoid driving unless they meet specific criteria regarding control of their epilepsy. These rules change frequently so it is always worth looking them up if advising patients.

Question 18

Sodium valporate: MoA, side effects

Answer 18

This is a first line option for most forms of epilepsy (except focal seizures). It works by increasing the activity of GABA, which has a relaxing effect on the brain. Notable side effects of sodium valproate include:

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

There are a lot of warning about the teratogenic effects of sodium valproate and NICE updated their guidelines in 2018 to reflect this. It must be avoided in girls unless there are no suitable alternatives and strict criteria are met to ensure they do not get pregnant.

Question 19

Carbamazepine

Answer 19

This is first line for focal seizures. Notable side effects are:

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

Question 20

Phenytoin

Answer 20

Notable side effects:

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

Question 21

Ethosuximide

Answer 21

Notable side effects:

Night terrors
Rashes

Question 22

Lamotrigine

Answer 22

Notable side effects:

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

Question 23

Management of Seizures

Answer 23

Put the patient in a safe position (e.g. on a carpeted floor)
Place in the recovery position if possible
Put something soft under their head to protect against head injury
Remove obstacles that could lead to injury
Make a note of the time at the start and end of the seizure
Call an ambulance if lasting more than 5 minutes or this is their first seizure.

Question 24

What is the definition of status epilepticus?

Answer 24

Status epilepticus is an important condition you need to be aware of and how to treat. It is a medical emergency.

It is defined as a seizure lasting more than 5 minutes or 2 or more seizures without regaining consciousness in the interim.

Question 25

Management of status epileptics in the hospital (take an ABCDE approach):

Answer 25

Secure the airway

Give high-concentration oxygen

Assess cardiac and respiratory function

Check blood glucose levels

Gain intravenous access (insert a cannula)

IV lorazepam, repeated after 10 minutes if the seizure continues

If the seizures persist the final step is an infusion of IV phenobarbital or phenytoin. At this point intubation and ventilation to secure the airway needs to be considered, along with transfer to the intensive care unit if appropriate.

Question 26

Medical options in the community:

Answer 26

Buccal midazolam
Rectal diazepam

Question 27

Plucking of clothes is typically seen in which type of seizure?

Answer 27

Temporal lobe seizures

Question 28

loss of consciousness, stiffening and jerking of the body is associated with which type of seizure?

Answer 28

Generalised tonic-clonic seizures

Question 29

sensory abnormalities are associated with which type of seizure?

Answer 29

Parietal seizures

Question 30

When starting a phenytoin infusion what is required

Answer 30

cardiac monitoring is required due to the pro-arrhythmogenic effects it elicits.