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MBBS 3: Internal Medicine > Epilepsy > Flashcards

Epilepsy Flashcards

1
Q

What is a seizure?

A
  • Hypersynchronous continuous discharge of cortical neurons without inhibition
  • It’s a symptom, not a disease
  • Only from cortex (not from brainstem, basal ganglia, etc.)
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2
Q

Symptoms of a seizure?

A
  1. Loss of consciousness
  2. Loss of awareness
  3. Uncontrollable movements
  4. Unusual behaviors or sensations
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3
Q

What is epilepsy?

A
  • Recurrent spontaneous seizures
  • At least two unprovoked seizures occurring more than 24 hours apart
    Note: a single unprovoked seizure has a high recurrence (i.e., >60% over the next 10 years)
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4
Q

Clinical manifestations of epilepsy?

A
  • range from a major motor convulsion to a brief period of lack of awareness.
  • The stereotyped and uncontrollable nature of the attacks is characteristic of epilepsy
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5
Q

When is epilepsy considered resolved?

A

for people who have been seizure-free for the past 10 years with no medication for the past 5 years

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6
Q

Prevalence of epilepsy in Malawi?

A

Malawi - 2.8% prevalence rate overall.

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7
Q

Epidemiology and course of epilepsy?

A

Epilepsy usually presents in childhood or adolescence but may occur for the first time at any age
1. newborns
2. early school age
3. adolescents
4. seniors

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8
Q

Pathogenesis of epilepsy?

A
  1. EXCESSIVE NEURONAL EXCITABILITY
    - (no balance) and a pattern of synaptic connections between neurons that permits hypersynchrony
  2. CELLULAR PROCESSES
    - altered activity of voltage gated ion channels which affects resting potential and electrical excitability
  3. EXCITATORY NEUROTRANSMITER glutamate (increased in epilepsy) and inhibitory gamma aminobutyric acid (GABA) (decreased)
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9
Q

Categories of epilepsy seizure syndromes?

A
  1. generalized seizures
  2. focal/partial seizures
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10
Q

Describe generalized epilepsy?

A

the predominant type of seizures begins simultaneously in both cerebral hemispheres
- subcortical in origin
Note: Many forms of generalized epilepsy have a strong genetic component; in most, neurologic function is normal

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11
Q

Describe focal epilepsy?

A

seizures originate in one or more localized foci, although they can spread to involve the entire brain
- cortical in origin
Note: believed to be the result of one or more central nervous system insults, but in many cases the nature of the insult is never identified

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12
Q

Epilepsy classification?

A
  1. focal seizures
  2. generalized seizures
  3. unclassified seizures
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13
Q

Triad of focal/partial seizures?

A
  1. Preceding aura
  2. Always stereotype - complex series of automatism
  3. Confusion post ictally
    - With secondary generalization
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14
Q

What are Automatisms?

A

arenon-purposeful, stereotyped, and repetitive behaviors that commonly accompany focal impaired awareness seizures

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15
Q

Focal seizures evolve to what kind of convulsions?

A

tonic/clonic convulsions
- muscle stiffening and jerking sudden LOC and loss of bladder control

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16
Q

Seizures evolving from the frontal lobe result in what kind physical actions?

A
  1. thrashing of the arms
  2. losing control of the bladder or bowels
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17
Q

Seizures evolving from the parietal lobe result in what kind of physical actions?

A

tingling/warm feeling down one side

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18
Q

Seizures evolving from the occipital lobe results in?

A

flashes of light, brief loss of vision

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19
Q

Seizures evolving from the temporal lobe results in?

A
  1. plucking at clothes
  2. smacking lips
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20
Q

What are the types of generalized seizures?

A
  1. Absence
  2. Myoclonic seizures
  3. Tonic-Clonic seizures
  4. Tonic seizures
  5. Clonic seizures
  6. Atonic seizures
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21
Q

Abscence seizure?

A

a type of seizure that involves brief, sudden lapses in attention

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22
Q

Myoclonic seizures?

A

sudden brief jerks or twitches of muscles, as if shocked by electricity with no change in your level of awareness or consciousness

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23
Q

Tonic-clonic seizures?

A

muscle stiffening and jerking sudden LOC and loss of bladder control

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24
Q

Tonic seizures?

A

muscle stiffening or increased muscle tone, fall backwards

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25
Q

Clonic seizures?

A

rhythmic jerking muscle movements, muscles of neck face, arm, legs

26
Q

Atonic seizures?

A

drop attacks, sudden loss of muscle tone, drop down

27
Q

Describe features of grand mal/tonic clonic generalized seizures?

A
  1. Abrupt loss of consciousness or bladder control
  2. All muscles go into spasm (tonic)
  3. Tonically contracting muscles (tonic)
    - Extensors stronger than flexors (tonic)
  4. Periodic release of contraction causes ‘jerks’ /clonus (clonic)
  5. Continuous for 1-2min with post ictal confusion following
28
Q

Describe features of generalized absence petit mal seizures?

A
  1. Interruption of stream of consciousness and Very brief Loss of awareness
  2. No loss of tone
  3. Few seconds at a time
  4. Children most affected
  5. Blank stare with or without sudden bodily movement (lip smacking or eye blinking)
  6. Not aware they have it for years
29
Q

Febrile seizures?

A

seizure in children between 6 months and 5 years when they have a temperature of >38 degrees

30
Q

2 types of febrile seizures?

A
  1. simple generalized
    - <15 minutes
    - 1 seizure in 24 hours
  2. complex focal
    - >15 minutes
    - > 1 seizure in 24 hours
31
Q

Vascular causes of seizures?

A
  1. hemorrhagic - more epileptogenic
  2. ischemic - most common
  3. venous system
    - cerebral venous sinus thrombosis, venous infarction
  4. malformations
    - arteriovenous malformation, cavernoma
  5. hypoxic-ischemic
    - perinatal asphyxia, anoxic encephalopathy e.g. cardiac arrest
  6. dysregulation
    - eclampsia, HTN encephalopathy, cerebral vasospasm
  7. stroke syndromes
    - moyamoya, lupus vasculopathy, sickle cell, vasculitis
32
Q

CNS Infectious that cause seizures?

A
  1. viral encephalitis
    - HSV-1, HIV (opportunistic infections), measles
  2. bacterial meningitis
    - granulomatous: TB, syphilis
    - pyogenic meningoccoccus, pneumococcus, H. influenzae B
  3. parasitic meningitis
    - neurocysticercosis, malaria, toxoplasmosis, toxocariasis, schistosomiasis
  4. fungal meningitis
33
Q

Systemic infections that cause seizures?

A

1.urinary tract infections
2. pneumonia

34
Q

Traumatic causes of seizures?

A

Encephalomalacia
- isthe softening or loss of brain tissue after cerebral infarction, cerebral ischemia, infection, craniocerebral trauma, or other injury.

35
Q

Autoimmune causes of seizures?

A
  1. Rasmussen encephalitis
  2. anti-NMDA R encephalitis
36
Q

Metabolic causes of seizures?

A
  1. hyper/hypoglycemia
  2. hyponatremia <120
37
Q

Iatrogenic/illicit + alcohol causes of seizures?

A
  1. antidepressants - buproprion, venlafaxine
  2. analgesics - tramadol, meperidine
  3. antibiotics - carbapenems, isoniazid, fluoroquinolones
  4. miscellaneous - amphetamines, cyclosporine, theophylline
  5. withdrawal - benzodiazepines, baclofen, alcohol
38
Q

Neoplasms that cause seizures?

A
  1. gliomas - more epilptogenic
  2. brain METs
  3. meningiomas
    - most common
39
Q

Social causes of seizures?

A
  1. medication non-compliance
  2. alcohol withdrawal
  3. sleep deprivation
  4. emotional/physical stress
40
Q

Congenital causes of seuzures?

A
  1. vascular and traumatic - hypoxic ischemic encephalopathy
  2. infections - TORCH infections
  3. metabolic - inborn errors of metabolism
  4. malformations - CNS malformations
41
Q

Degenerative causes of seizures?

A

Alzheimers disease

42
Q

Epilepsy differential diagnosis?

A
  1. Syncope attacks
    - when pt. is standing; results from global reduction of cerebral blood flow; prodromal pallor, nausea, sweating; jerks
  2. Cardiac arrythmias (e.g. Adams-Stokes attacks)
    - Prolonged arrest of cardiac rate will progressively lead to loss of consciousness – jerks!
  3. Migraine
    - Basilar migraine may lead to loss of consciousness!
  4. Hypoglycemia
    – seizures or intermittent behavioral disturbances may occur.
  5. Narcolepsy
    – inappropriate sudden sleep episodes
  6. Panic attacks
  7. PSEUDOSEIZURES
    – psychosomatic and personality disorders
43
Q

Routine and neuroimaging investigations?

A
  1. Haematology
  2. biochemistry (electrolytes, urea ,LFTs, glucose and calcium, magnesium)
  3. CSF if indicated, level of anticonvulsant drugs
44
Q

Neuroimaging investigation?

A

CT/MRI
- should be performed in all persons aged 25 or more presenting with first seizure and in those pts with focal epilepsy irrespective of age

45
Q

Specialized neurophysiological investigations?

A

electroencephalogram (EEG), EEG video monitoring

46
Q

Advanced investigations?

A

in pts. with intractable focal epilepsy where surgery is considered
1. Neuropsychology
2. Semiinvasive or invasive EEG recordings
3. MR Spectroscopy
4. Positron emission tomography (PET)
5. ictal Single-photon emission computed tomography (SPECT)

47
Q

When is surgery necessary?

A

in intractable cases
- the treatment target is seizure freedom and improvement of quality of life

48
Q

What are the basic rules of drug treatment?

A
  • Drug treatment should be simple, preferably using one anticonvulsant (monotherapy)
  • “Start low, increase slow“. - Add-on therapy is necessary in some patients
49
Q

What anticonvulsant treatment is used in epilepsy?

A
  1. Carbamazepine
  2. Sodium valproate
  3. Lamotrigine (first line drugs)
  4. Levetiracetam
  5. Topiramate
  6. Pregabaline (second line drugs)
  7. Zonisamide
  8. Eslicarbazepine
  9. Retigabine (new AEDs)
50
Q

Treatment for generalized absence seizures?

A
  1. etosuximide
  2. valproate
51
Q

Treatment for partial tonic-clonic/simple/complex seizures?

A
  1. phenobarb
  2. phenytoin
  3. valporate
  4. carbamazepine
52
Q

When to withdraw pharmacotherapy?

A
  • If patient is seizure-free for three years
  • Withdrawal should be carried out only if patient is satisfied that a further attack would not ruin employment etc. (e.g. driving license)
  • It should be performed very carefully and slowly! 20% of pts will suffer a further seizure within 2 yrs
53
Q

What drug has a risk of teratogenicity?

A

valproates

54
Q

Describe the problems with pharmacotherapy in epileptic females?

A
  1. teratogenicity with valproates
  2. withdrawing drug therapy in pregnancy is riskier than continuation
  3. Epileptic females must be aware of this problem and thorough family planning should be recommended
    NB: Over 90% of pregnant women with epilepsy will deliver a normal child.
55
Q

What is drug intractable epilepsy?

A

Failed AED’s x 2
- affects 30% of patients

56
Q

What could cause drug intractable epilepsy?

A
  1. Pseudo epilepsy.
  2. Compliance - Blood levels
  3. Temporal lobe epilepsy
57
Q

Describe the surgical treatment for epilepsy?

A
  • A proportion of the pts with intractable epilepsy will benefit from surgery
  • Epilepsy surgery procedures:removal of epileptic focus) 50-80% success rate
58
Q

What is neurostimulation?

A
  • palliative treatment for patients with drug-resistant epilepsy who are not candidates for respective surgery
  • Vagus nerve, deep brain stimulation showing a seizure reduction of 50% or more in more than a half of treated patients
59
Q

What is status epilepticus?

A

A condition when consciousness does not return between seizures for more than 30 min
- This state may be life-threatening with the development of pyrexia, deepening coma and circullatory collapse
- Death occurs in 5-10%.

60
Q

Causes of status epilepticus?

A
  1. frontal lobe lesions (incl. strokes)
  2. following head injury
  3. on reducing drug therapy
  4. with alcohol withdrawal
  5. drug intoxication
  6. metabolic disturbances
  7. pregnancy
61
Q

Treatment of status epilepticus?

A
  1. AEDs intravenously ASAP
  2. general anesthesia with propofol or thipentone should be commenced immediately

MBBS 3: Internal Medicine (72 decks)

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