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YR6: NEURO > Epilepsy > Flashcards

Epilepsy Flashcards

1
Q

What is epilepsy?

A

a tendency to recurrent seizures, defined by:
>,2 unprovoked seizures occurring >24h apart.
OR
1 unprovoked seizure + high risk of subsequent seizure (>, 60% over the next 10y)
OR
Dx of an epilepsy syndrome.

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2
Q

What is reflex epilepsy?

A

Epilepsy in which seizures are consistently provoked by a certain trigger (e.g., lights, music, hormonal changes during menstrual cycle).

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3
Q

What is a seizure?

A

excessive +/or hypersynchronous activity of cortical neurons that results in transient neurological Sx

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4
Q

What is convulsive status epilepticus?

A

a prolonged convulsive seizure lasting >,5 mins
OR
recurrent seizures one after the other without recovery in between

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5
Q

What are the 2 broad types of seizure?

A

Focal: originate in 1 hemisphere. Retained or impaired awareness.
Generalised: originate bilaterally. Motor or Non-motor.

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6
Q

Give 3 causes of insult to the brain that can provoke one-off seizures

A

Infection e.g. meningitis, encephalitis
Trauma
Metabolic disturbance

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7
Q

List 3 conditions associated with epilepsy

A

Cerebral palsy
Tuberous sclerosis
Mitochondrial diseases

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8
Q

Give 3 causes of recurrent non-epileptic seizures

A

Febrile convulsions
Alcohol withdrawal seizures
Psychogenic non-epileptic seizures

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9
Q

Describe epidemiology of febrile convulsions

A

6 months- 5y
~3% of children will have at least 1 febrile convulsion

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10
Q

Describe febrile convulsions

A

usually early in a viral infection as temp rises rapidly
Seizures typically brief + generalised tonic/ tonic-clonic in nature

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11
Q

In which patients do alcohol withdrawal seizures occur?

A

Those with hx of alcohol excess who suddenly stop drinking
e.g. on admission to hospital

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12
Q

Describe pathophysiology of alcohol withdrawal seizures

A

Chronic alcohol consumption enhances GABA mediated inhibition in the CNS + inhibits NMDA-type glutamate receptors.
Withdrawal is thought to be lead to the opposite (decreased inhibitory GABA + increased NMDA glutamate transmission)

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13
Q

When is peak incidence of alcohol withdrawal seizures?

A

~36h

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14
Q

What are psychogenic seizures?

A

aka. pseudoseizures
Epileptic-like seizures but no characteristic electrical discharges
May have a hx of MH problems or personality disorder

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15
Q

What is the most common form of epilepsy?

A

Temporal lobe epilepsy

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16
Q

Give 4 features of temporal lobe seizures

A

+/- impaired awareness
Aura in most
Typically last 1 minute
Automatisms common

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17
Q

Describe the aura in temporal lobe seizures

A

Typically a rising epigastric sensation
also psychic or experiential phenomena, e.g. déjà vu, jamais vu
less commonly hallucinations (auditory/gustatory/olfactory)

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18
Q

What automatisms may be seen in temporal lobe epilepsy?

A

Lip smacking
Grabbing
Plucking

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19
Q

Give 4 features of frontal lobe seizures

A

Motor: Head/ leg movement
Posturing
Jacksonian march
Post-ictal weakness

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20
Q

What is Jacksonian march?

A

Spreading of paresthesia/ uncontrolled motor activity from one part of the body to adjacent areas, usually distally to proximally

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21
Q

Describe parietal lobe seizures

A

Sensory: paraesthesia

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22
Q

Describe occipital lobe seizures

A

Visual: floaters/ flashes

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23
Q

Which type of focal seizure is most likely to cause impaired awareness?

A

Temporal lobe seizure

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24
Q

How can focal aware seizures progress?

A

May spread from one hemisphere to both
= focal to bilateral tonic-clonic seizure

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25
Q

What occurs in focal to bilateral tonic-clonic seizures?

A

Starts as unilateral, localised focal Sx
Progresses to loss of consciousness + motor Sx (tonic-clonic seizure)

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26
Q

What are the 2 subtypes of generalised seizure?

A

Motor: visible physical movement
Non-motor: ‘absence’, no physical movement

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27
Q

Give 3 features common to generalised seizures

A

Involve both hemispheres
Start with loss of consciousness
Amnesia of the event

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28
Q

List 5 types of generalised motor seizure

A

Tonic-clonic
Tonic
Clonic
Myoclonic
Atonic

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29
Q

What occurs in a typical absence seizure?

A

Interrupted motion/ activity, blank stare, unresponsiveness
Usually <10s
Subtle automatisms common
Sudden onset + stop

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30
Q

What are absence seizures also known as?

A

Petit mal

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31
Q

Describe the post-ictal phase of absence seizures

A

Consciousness returns rapidly without any impairment
Amnesia is common

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32
Q

What occurs in a tonic-clonic seizure?

A

aka ‘grand mal’
Loss of consciousness
1. Tonic stage- generalised muscle contraction + increased sympathetic tone
2. Clonic stage- rhythmic muscle twitching
Bladder/ bowel incontinence
Usually lasts 1-3 mins

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33
Q

List 3 manifestations of increased sympathetic tone in the tonic phase of a TC seizure

A

Dilated, unresponsive pupils
Increased HR
Increased BP

34
Q

List 6 manifestations of generalised muscle contraction in the tonic phase of a tonic-clonic seizure

A

Rotated eyes
Apnoea
Tongue biting
Pooled oral secretions
Cyanosis
Loud moan

35
Q

List 6 post-ictal S/S of TC seizures

A

Unresponsiveness
Confusion
Aphasia
Fatigue
Muscle flaccidity + pain
Headache

36
Q

What occurs in a clonic seizure?

A

Loss of consciousness
Bilateral rhythmical jerking movements

37
Q

What occurs in a tonic seizure?

A

Loss of consciousness
Muscle stiffening (extension or flexion of head, trunk, extremities)

38
Q

What occurs in a myoclonic seizure?

A

+ve myoclonus: sudden jerk like muscle twitching
-ve myoclonus: brief loss of muscle activity during tonic contraction
Nonrhythmic (jerks occur at different intervals) + irregular (asymmetric + may change laterality)

39
Q

What occurs in an atonic seizure?

A

aka “drop seizure/ attack”
Sudden loss of muscle tone: sudden head drop/ collapse
Lasts <15s

40
Q

What investigations are used for epilepsy?

A

EEG
MRI

41
Q

Describe acute management of epileptic seizures

A

Most terminate spontaneously
<5 mins: start timer, protect from injury, monitor
>5 mins: Administer Benzodiazepines

42
Q

What benzodiazepines are used in the acute management of seizure?

A

In community: Buccal midazolam (or Rectal Diazepam)
If IV access: IV Lorazepam or Diazepam

43
Q

Describe management of status epilepticus

A
  1. A-E
  2. PR Diazepam or Buccal Midazolam (if pre-hospital) or IV Lorazepam
  3. Repeat benzo after 5-10 mins
  4. IV Phenytoin/ Levetiracetam/ Sodium Valproate
  5. Expert advice: Phenobarbital or GA
44
Q

What should be taken into account when considering second line agent in status epilepticus?

A

Levetiracetam may be quicker to administer + have less adverse effects

45
Q

When is treatment started for epilepsy?

A

Most: following 2 seizures
Start after 1 if certain criteria met

46
Q

In which circumstances should anti epileptics be started following first seizure?

A

Neurological deficit
Structural abnormality on brain imaging
Unequivocal epileptic activity on EEG
Pt/ family consider risk of having a further seizure unacceptable

47
Q

Describe drug choice for generalised tonic clonic seizures

A

M: Sodium Valproate
F: Lamotrigine or Levetiracetam

48
Q

When may sodium valproate be prescribed first line in females?

A

<10s who are unlikely to need Tx when old enough to have children
Women unable to have children

49
Q

Describe drug choice for focal seizures

A

1st: Lamotrigine or Levetiracetam
2nd: Carbamazepine, Oxcarbazepine or Zonisamide

50
Q

Describe drug choice for absence seizures

A

1st: Ethosuximide
2nd:
M: Sodium Valproate
F: Lamotrigine or Levetiracetam

51
Q

Which drug may exacerbate absence seizures?

A

Carbamezapine

52
Q

Describe drug choice for myoclonic seizures

A

M: Sodium valproate
F: Levetiracetam

53
Q

Describe drug choice for tonic or atonic seizures

A

M: Sodium valproate
F: Lamotrigine

54
Q

What is the MOA of Sodium Valproate?

A

Inhibits GABA activity

55
Q

List 9 side effects of sodium valproate

A

Vomiting
Alopecia + Ataxia
Liver toxicity
Pancreatitis + decreased platelets
Rash
Obesity
Appetite increase
Teratogenic + Tremor
Enzyme inhibitor (p450)

56
Q

What is the MOA of Carbamezapine?

A

Binds to Na+ channels increasing refractory period

57
Q

List 6 side effects of carbamazepine

A

SIADH: hyponatraemia + water retention
Leukopenia + Agranulocytosis
Enzyme inducer (p450)
Ataxia
Teratogenic
VIsual disutrbance, esp. diplopia

58
Q

What is the MOA of Lamotrigine?

A

Na+ channel blocker

59
Q

Name a side effect of lamotrigine

A

Stevens-Johnson Syndrome

60
Q

What is the MOA of Phenytoin?

A

Binds to Na+ channels increasing their refractory period

61
Q

List 9 side effects of phenytoin

A

P450 inducer
Hirsuitism
Enlarged gums (gingival hyperplasia)
Nystagmus
Yellow-brown skin (melasma)
Teratogenic
Osteopenia
Inhibited folate absorption (megaloblastic anaemia)
Neuropathy

62
Q

Describe driving regulations for epileptic patients

A

Can’t drive for 6 months following a seizure.
If established epilepsy, must be fit free for 12 months

63
Q

List 4 forms of epilepsy seen in children

A

Infantile spasms (West’s syndrome)
Lennox Gastaut syndrome
Benign rolandic epilepsy
Juvenile myoclonic epilepsy (Janz syndrome)

64
Q

What occurs in West’s syndrome? Describe the nature of these

A

Brief spasms beginning in first few months of life
Flexion of head, trunk, limbs → extension of arms (Salaam attack); last 1-2s, repeat up to 50x

65
Q

Give 3 features of prognosis West’s syndrome

A

Progressive mental handicap

Usually 2nd to serious neurological abnormality (e.g. TS, encephalitis, birth asphyxia) or may be cryptogenic

Poor prognosis

66
Q

What is seen on EEG in West’s syndrome?

A

EEG: hypsarrhythmia

67
Q

What is Lennox Gastaut syndrome thought to be? When does it present? How?

A

May be extension of infantile spasms (50% have hx)
onset 1-5y
atypical absences, falls, jerks

68
Q

What is seen on EEG in Lennox-Gastaut syndrome?

A

EEG: slow spike

69
Q

Give 2 features of prognosis in Lennox Gastaut syndrome

A

90% moderate-severe mental handicap
ketogenic diet may help

70
Q

What occurs in Benign rolandic epilepsy?

A

paraesthesia (e.g. unilateral face)
Seizures characteristically occur at night

71
Q

In which group is juvenile myoclonic epilepsy more common?

A

Teens, esp. girls

72
Q

Describe the nature of juvenile myoclonic epilepsy

A
  1. Infrequent generalized seizures, often in morning
  2. Daytime absences
  3. Sudden, shock-like myoclonic seizure
73
Q

Juvenile myoclonic epilepsy usually has a good response to what?

A

Sodium valproate

74
Q

What are primary epilepsy syndromes?

A

idiopathic generalised epilepsy
Temporal lobe epilepsy
Juvenile myoclonic epilepsy

75
Q

What should you establish from the history prior to the seizure?

A

Rapidity of onset?
Duration of episode
Alteration of consciousness?
Tongue-biting/ incontinence?
Rhythmic synchronous limb jerking?
Post-ictal period?
Drug hx (alcohol, recreational drugs)

76
Q

What bloods should be taken in epilepsy?

A 
FBC 
U+E 
LFTs 
Glucose  
Calcium 
Magnesium 
ABG  
Toxicology screen  
Prolactin: transient increase shortly after seizures
77
Q

What investigation can help confirm the diagnosis of epilepsy?

A

EEG: to confirm dx + classify the epilepsy
Ictal EEGs are particularly useful

78
Q

What other investigations are performed when diagnosing epilepsy?

A

CT/ MRI: to exclude structural, space-occupying + vascular lesions.
LP to identify infectious aetiology
HIV serology

79
Q

What is included in the conservative approach of Patient Education for preventing seizures?

A

Avoid triggers
Use seizure diaries
Supervised swimming/ climbing
Anti-epileptic drugs can have teratogenic effects (consider pregnancy)
Drug interactions (e.g. AEDs can reduce effectiveness of OCP)

80
Q

List 3 complications of epilepsy

A

Fractures (Tonic-clonic seizures)
Behavioural problems
Sudden Death in Epilepsy

81
Q

What is the prognosis in epilepsy?

A

50% remission at 1 year

82
Q

What surgical approaches can be used in epilepsy?

A

Removal of definable epileptogenic focus
Vagus nerve stimulator

YR6: NEURO (47 decks)

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