Epilepsy Flashcards
What are the main causes for transient loss of consciousness?
Vasovagal, reflex syncope, cardiogenic syncope, epilepsy, metabolic and unknown
What can cause loss of consciousnness?
Prolonged standing, postural change, pain, vomiting, passing urine, coughing, exercising, sleep deprived, excess alcohol and illicit drug
What are some warning symptoms for syncope?
Light headed, nausea, hot, cold sweat, loss of hearing, tinnitus, loss of vision
Deja vu, sudden feeling anxiety or panic
Palpitations/ cardiac symptoms
What are the 3 categories of syncope?
Reflex (neuro-cardiogenic)
Orthostatic
Cardiogenic
What could cause reflex syncope?
Taking blood or medical situations
Cough, medication
What could cause orthostatic syncope?
Dehydration, medication related, endocrine and autonomic nervous system
What could cause cardiogenic syncope?
Arrhythmia and aortic stenosis
What is included in patient history of syncope?
Need stimulus and context - blood taken, in bathroom, standing
Did they have a warning
Is clammy or sweaty, fully oriented quickly and if any urinary incontinence
What is the witness account of syncope?
Looked a bit pale, suddenly went floppy, few brief jerks and brief LOC
Rapid recovery or prolonged if propped up
Describe the assessment of syncope
Exam - heart sounds, pulse, BP
Must have ECG - heart block and QT ratio
May need 24 hour ECG
What is the patients account of cardiogenic syncope?
Can have exertion before
Chest pain, palpitations and SOB
Can have these same symptoms after, can come around quickly but recovery longer
Usually clammy/ sweaty
What is the witness account for cardiac syncope?
Suddenly went floppy, looked grey, seemed to stop breathing, and unable to feel pulse
Variable duration of LOC
How is cardiogenic syncope assessed?
FH important
Exam - heart sounds and pulse
ECG
Refer to cardiology
May need 24hr ECG/ ECHO or prolonged monitoring
What is a pseudo-seizure?
Non epileptic attack
What is the patient account for pseudo-seizures?
Events may occur at stress or while at rest, may describe dissociation, can maybe recall what people said during and can be prolonged episode
What is the witness account of pseudoseizures?
May recognise stress as trigger, signs of patient retaining awareness, movements which are not typical of seizers, try catch episode on EEG
What can cause provoked seizures?
Alcohol withdrawal, drug withdrawal, days after head injury, within 24hrs of stroke or neurosurgery, electrolyte disturbance and eclampsia
What is epilepsy?
Tendency of recurrent seizures
If electrical activity in neurons is disrupted then can lead to seizure
Used if more than one unprovoked seizure but can be only after one if investigations show
Describe the pathophysiology of epilepsies
Synchronous discharge in cortical neurons - too much excitement, damaged neurons or too little excitement
What causes too little excitement in neurons?
GABA receptors
What can cause damaged neurons?
Stroke, tumour, trauma or developmental causes
What can cause too much excitement of neurons?
Glutamate receptors, Ion channels and excitatory amino acids
How does Valproate help epilepsy?
Increases GABA turnover, decreases Na+ channels and decreases NMDA receptors
What factors can increase the risk of seizure?
Missed medications, sleep disturbance, hormonal changes, drug/ alcohol use, drug interactions, stress/ anxiety, photosensitivity
What is the basic classification of seizures?
Generalised and focal seizures
What is included in generalised seizures?
Absence, generalised tonic-clonic, myoclonic, juvenile myoclonic and atonic seizures
What is included in focal seizures?
Simple partial, complex partial, secondary generalised, or by localisation of onset (temporal, frontal)
Describe primary generalised seizures
No warning, under 35, generalised abnormality on EEG and may have FH
Can have history of absences and myoclonic jerks as well as GTCS
Describe focal/ partial seizures
May get an aura (warning)
Any age cause can be any focal brain abnormality, focal abnormality on EEG and MRI can show cause
Simple and complex partial can become secondary generalised
What is the patient account of generalised tonic clonic seizure?
Unpredictable, tend to cluster, PMH - complication of birth, trauma, meningitis and brain injuries
May have vague warning or irritability before
Lateral tongue biting, incontinence, muscle pain
What is the witness account of generalised tonic clonic seizure?
Groaning sound, tonic (rigid phase) then generalised jerking in all 4 limbs, foaming of mouth, staring/ roll upwards, jerking then groggy
May be agitated after and can be clustered
Describe absence seizures
Often in children and they are unaware
May be provoked by hyperventilation/ photic stimulation
Brief staring then eye lid fluttering
Restarts what they were doing
What is the patient account of complex partial seizures - temporal?
Rising feeling in stomach funny smell/taste, deja vu, no recollection and is disorientated for a spell
What is the witness account for complex partial seizure?
Sudden arrest in activity, staring blank into space, automatisms - lip smacking and repetitive picking of clothes
May be disorientated after
Describe frontal lobe seizures
Can be mistaken for non-epileptic attack as strange
Brief, bizarre and motor
Can be frequent with rapid recovery
Pattern of movement is stereotyped
How is seizures clinically assessed?
Refer to seizure clinic, do ECG, routine bloods (GIc), A+E usually arrange CT
Neurology - may need MRI, EEG, antiepileptic drugs, epilepsy nurse and discuss driving
What investigations are used for epilepsy?
EEG from primary generalised epilepsies
MRI for patients under 50 as possible focal onset seizure
Video telemetry if uncertainty
What is the first line treatment for epilepsy?
Sodium Valproate, Lamotrigine, Levetiracetam for primary generalised epilepsy
Lamotrigine, Carbamazepine, Levetiracetam for partial and secondary generalised
Ethosuximide for absence
What is the second line treatment for generalised epilepsy?
Topiramate and Zonisamide
Generally avoid Carbamazepine
What is used for second line treatment for partial seizures?
Sodium valproate, topiramate, brivaracetam, gabapentin
What are the side effects of sodium valproate?
Tremor, weight gain, ataxia, nausea, drowsiness, transient hair loss, pancreatitis and hepatitis
Avoid in women of child bearing age
What are the side effects carbamazepine?
Ataxia, drowsiness, nystagmus, blurred vision, low sodium serum levels, skin rash
What are the side effects of Lamotrigine?
Skin rash and difficulty sleeping
What are the side effects of Levetiracetam?
Irritability and depression
Describe status epilepticus
Generalised convulsive or non convulsive seizures going on for 5 mins or more either continuously or repetitively with no intervening recovery
What are some risk factors of status epilepticus?
Non adherence to treatment, chronic alcoholism, refractory epilepsy, toxic or metabolic causes and acute brain injury
What is the first line treatment of status epilepticus?
Midazolam - 10mg buccal or nasal route
Lorazepam
What is the second and third line treatment for status epilepticus?
Valproate, Levetiracetam, Phenytoin
Third line - Anaesthesia with propofol or thiopentone
