Epilepsy Flashcards
What are the two main definitions for diagnosis of epilepsy?
▪️At least 2 unprovoked seizures >24 hours apart
OR
▪️One unprovoked seizure and probability of further seizures similar to recurrence after two
When is epilepsy considered resolved?
▪️Past the applicable age if age-dependent
OR
▪️Seizure-free for last 10 years and no medicines for last 5 years
What are the three main types of seizure?
▪️Focal onset
▪️Generalised onset
▪️Unknown onset
How can you further classify focal onset seizures?
▪️Aware vs impaired awareness
▪️Motor onset vs nonmotor onset
What is an absence seizure?
▪️Generalised onset
▪️Nonmotor
▪️Brief, sudden lapses of consciousness
▪️Impaired awareness/behavioural arrest
What is a tonic-clonic seizure?
▪️Typically generalised
▪️Body goes stiff (tonic)
▪️Followed by twitching (clonic)
How might a focal onset nonmotor seizure present?
▪️Autonomic
▪️Behaviour arrest
▪️Cognitive
▪️Emotional
▪️Sensory
Which is a clonic seizure?
Rhythmic jerking of arms and legs of one or both sides
What is a tonic seizure?
Sudden stiffness or tension in muscles
What is a myoclonic seizure?
Brief shock-like jerks of a muscle or group of muscles
What is a ‘grand mal’ seizure?
Old name for generalised tonic-clonic seizure
What are the 4 main stages of a tonic-clonic seizure (‘grand mal’)?
- Myoclonic
- Tonic
- Intermediate vibratory phase
- Clonic
Are tonic-clonic seizures symmetrical or asymmetrical?
Can be either
What can head deviation in a seizure tell us?
Can indicate the location of the seizure onset as the head turns to the side that it is on
(pushing motion from muscle)
What can asymmetric arm straightening tell us about the seizure?
Might indicate the location of the seizure - straightened arm is often contralateral to the side of the seizure onset
Lots of seizures start __________ then quickly ___________
▪️Focally
▪️Generalise
Can be hard then to differentiate!
Who is more likely to have focal epilepsy?
▪️Following injury to head
▪️Older (younger people more likely generalised)
What is JME?
▪️Juvenile myoclonic epilepsy
▪️Absence + myoclonic events in childhood
▪️May develop early morning tonic-clonic seizures as teenagers
▪️Generalised but short events
▪️Typically early morning
If someone talks throughout the seizure, what does this suggest?
Focal onset in the right temporal lobe
Might last longer and associate with an aura
What are the two main types of absence seizures?
▪️Limbic complex partial seizure (mesial temporal lobe epilepsy)
▪️Typical absences (idiopathic generalised epilepsy)
What might awareness during a seizure suggest?
Focal onset
What are the main signs of a typical generalised absence seizure?
▪️Often young children
▪️Short and uncomplicated
▪️No aura
▪️Most commonly in the morning
▪️Distinct focal spikes but normal between seizures
▪️~40% have a relative with them
What are the main signs of a TLE absence seizure?
▪️Prolonged and complicated
▪️Often begin with aura
▪️More frequent
▪️Focal onset
▪️Automatisms
▪️More often maintain awareness
What are the main differential diagnoses for epilepsy?
▪️Syncope (reflex, vasovagal, cardiac, orthostatic hypertension)
▪️Psychogenic/dissociative seizures
▪️Other (e.g. stroke, cataplexy, migraine, “drop attacks”)
What are the
What is a syncope?
▪️Transient loss of consciousness and postural tone
▪️Caused by cerebral hypoperfusion ▪️Spontaneous recovery
What is a vasovagal syncope?
▪️Reflex syncope
▪️Sudden drop in blood pressure
▪️Often associated with situational triggers (e.g. Long time standing up, warm environment, physiological stress, acute pain, venepuncture)
▪️Facilitated by dehydration or anxiety
▪️Very common!
How can you tell if someone had a syncope?
▪️Describe aura (lightheaded, neuasea, sweaty, blurry vision)
▪️Witness accounts (sweaty, sudden floppy, collapse, spontaneous recovery)
What might memory of the syncope event and aura suggest?
Pseudo-syncope - aura but doesn’t actually faint
How long do syncopes usually last and what might a prolonged event indicate?
▪️LoC < 20 seconds
▪️Prolonged = reflect anoxic seizure
What might post-ictal confusion indicate?
Seizure rather than syncope/faint
What are some of the issues with differentiating between seizure and syncope?
▪️First episode
▪️No clear trigger
▪️Rapid evolution
▪️No recall of typical symptoms
▪️Eyes open
▪️Post-ictal confusion?
▪️Incontinence
What are the main signs of non-organic syncope (PNES) ?
▪️Frequent episodes
▪️Emotional triggers
▪️Memory of losing consciousness
▪️Partly aware, may move to space place to fall
▪️Long events, on and off
▪️Subtle eyelid flutter
What might cause cardiac syncope?
▪️Bradycardia
▪️Arrest
▪️Bradycardia-tachycardia syndrome
▪️Atrial fibrillation (irregular)
▪️Structural obstruction (e.g. narrowing of valves, swelling o muscle)
IMPORTANT TO DO ECG!
What is cataplexy?
Sudden muscle weakness (atonic) in response to strong emotions such as anger or laughter
What might cataplexy be confused with?
▪️Atonic seizure
▪️Narcolepsy
▪️Syncope
▪️PNES
What signs might indicate cataplexy?
▪️Partial atonia spreading gradually
▪️No LoC
▪️No “postictal” clouding
▪️Depressed reflexes during
▪️Emotional trigger
What is the main demographic of PNES?
▪️Women
▪️Late adolescencr/early adulthood
▪️10% also have epilepsy (~20% PwE also have PNES)
What can you use to differentially diagnose epilepsy from PNES?
▪️History
▪️Video EEG
What signs outside of seizure presentation are suggestive of PNES instead of epilepsy?
▪️Inconsistent response to AED
▪️More likely in presence of witness
▪️6x more likely to have witnessed a seizure
▪️History of sexual abuse
What ictal presentations may be suggestive of PNES instead of epilepsy?
▪️Lack of event stereotypes - changing ictal symptoms and types
▪️Longer, fluctuating events
▪️Eyes closed, resistent to opening (but open on command)
▪️Pelvic thrusting/rocking
▪️Emotional response
▪️Stay seated
If someone has a seizure whilst asleep, what might this suggest?
Epileptic event as oppose to PNES
What signs are not very indicative of the nature of a seizure?
▪️Tongue biting
▪️Urinary incontinence
▪️Flailing and trashing movements
What is photic stimulation?
A technique whereby lights are flashed at the patient to try and evoke a seizure
How can you differentiate a panic attack from a focal seizure?
▪️Could be gradual
▪️Triggers?
▪️Longer duration
▪️Other symptoms (e.g. chest pain, nausea, sweating)
▪️No “postictal” confusion
Sleep ____________ epilepsy
promotes
increases risk of
When conducting an EEG, patients are often asked to be ________________
Sleep deprived
What sleep disorders may present with movements similar to epilepsy?
▪️Hypnic jerks (benign hypnagogic myoclonus)
▪️Excessive daytime sleepiness
▪️Arousal parasomnias
▪️REM parasomnias
What seizures might most commonly be mistaken for abnormal parasomnias?
Nocturnal frontal lobe seizures
How might sleep influence seizures?
▪️Increase in transitional phases
▪️More prevalent when tired
▪️Decrease during REM
What focal seizures are seen most commonly in sleep?
Frontal (as oppose to temporal)
What stage of sleep are you most likely to see seizures such as generalised tonic or focal frontal?
NREM
How might seizures influence sleep?
▪️Increased REM latency
▪️Interictal generalised spike wave discharge may lead to epileptic arousals and sleep disruption
▪️Viscious cycle (sleep disrupted = more tired = more likely to have seizure)
What is the relationship between OSA and epilepsy?
▪️More common in PwE
▪️Can make epilepsy worse - disordered sleep architecture?
What is the most common site of focal onset epilepsy?
Temporal lobes
How might frontal lobe seizure present?
▪️Hyperkinetic
▪️Early motor manifestations
▪️Bizarre automatisms
▪️Strange, ballistic movements, can be asynchronous
▪️Pelvic thrusting and turning
▪️Partial awareness
▪️Brief and often in sleep
▪️Vocal and have little confusion afterwards
How might orbitofrontal seizures present?
▪️Hyperkinetic
▪️Emotional
How might medial temporal lobe epilepsy present?
▪️Auras (epigastric?)
▪️Automatisms (e.g. hand movements)
▪️Orofacial automatisms (e.g. lip smacking, chewing)
▪️Contralateral dystonia posturing
How might lateral temporal lobe epilepsy present?
▪️Auras (dysphasia, auditory hallucinations)
▪️Motionless staring
▪️Contralateral clonic jerking
▪️Slower ictal activity than mTLE and wider field
How might occipital seizures present?
▪️Visual phenomena
▪️Mixed degree of recall depending on onset location (calcarine vs occipitotemporal)
▪️Can spread to involve motor symptoms
How does OLE aura differ from migraine auras?
▪️Multicoloured
▪️Rounded patterns
▪️Rapid onset and disappearance
▪️Association with other seizure symptoms
How might EEG look after and inbetween seizures?
Often abnormal activity, can take a while to normalise if at all
What is the difference between a tonic movement and a spasm?
Tonic = shorter, more brief contractions
