Epilepsy Flashcards
What is epilepsy?
Epilepsy is a common neurological condition characterised by recurrent seizures.
How many people in the UK have epilepsy?
There are around 500,000 people in the UK with epilepsy.
What percentage of people with epilepsy achieve satisfactory seizure control with medication?
Around two-thirds achieve satisfactory seizure control with antiepileptic medication.
What are some conditions associated with epilepsy?
Conditions associated with epilepsy include cerebral palsy (around 30% have epilepsy), tuberous sclerosis, and mitochondrial diseases.
What are some common causes of recurrent seizures?
Common causes include febrile convulsions, alcohol withdrawal seizures, and psychogenic non-epileptic seizures.
What characterizes febrile convulsions?
Typically occur in children between 6 months and 5 years, affecting around 3% of children, and usually occur early in a viral infection as temperature rises rapidly.
What is the peak incidence of alcohol withdrawal seizures?
The peak incidence of seizures is around 36 hours following cessation of drinking.
What is the classification of seizures based on?
The classification is based on where seizures begin in the brain, level of awareness during a seizure, and other features of seizures.
What are focal seizures?
Focal seizures start in a specific area on one side of the brain, with varying levels of awareness.
What are generalised seizures?
Generalised seizures involve networks on both sides of the brain at onset, with immediate loss of consciousness.
What is a focal to bilateral seizure?
A focal to bilateral seizure starts on one side of the brain before spreading to both lobes.
What are infantile spasms?
Brief spasms beginning in the first few months of life, characterized by flexion and extension movements, often with poor prognosis.
What is Lennox-Gastaut syndrome?
A syndrome that may extend from infantile spasms, characterized by atypical absences and falls, with a high rate of mental handicap.
What are the symptoms following a generalized seizure?
Patients may bite their tongue and experience incontinence of urine.
What investigations are done after a first seizure?
Patients generally have both an electroencephalogram (EEG) and neuroimaging (usually an MRI).
When do neurologists typically start antiepileptics?
Most neurologists start antiepileptics following a second epileptic seizure.
What is the recommendation regarding prescribing antiepileptics?
It is recommended to prescribe antiepileptics by brand rather than generically due to the risk of different bioavailability.
What is the mechanism of action of sodium valproate?
Sodium valproate increases GABA activity and is used for generalized seizures.
What are the adverse effects of carbamazepine?
Adverse effects include dizziness, ataxia, drowsiness, and visual disturbances.
What is the acute management for seizures that do not terminate?
If seizures do not terminate after 5-10 minutes, benzodiazepines such as diazepam may be administered.
What is status epilepticus?
Status epilepticus is a medical emergency where a patient continues to fit despite treatment.
What are the three key features of the new basic seizure classification?
- Where seizures begin in the brain
- Level of awareness during a seizure
- Other features of seizures
What are focal seizures?
Focal seizures start in a specific area, on one side of the brain. The level of awareness can vary.
What terms are used to describe the level of awareness in focal seizures?
Focal aware, focal impaired awareness, and awareness unknown.
What types of focal seizures are there?
Focal seizures can be classified as motor, non-motor, or having other features such as aura.
What are generalised seizures?
Generalised seizures engage networks on both sides of the brain at the onset, with immediate loss of consciousness.
How are generalised seizures subdivided?
Generalised seizures can be subdivided into motor and non-motor.
What are specific types of generalised seizures?
Tonic-clonic, tonic, clonic, typical absence, and atonic.
What does ‘unknown onset’ refer to in seizure classification?
‘Unknown onset’ is reserved for when the origin of the seizure is unknown.
What are focal to bilateral seizures?
Focal to bilateral seizures start on one side of the brain in a specific area before spreading to both lobes.
What factors should women with epilepsy consider regarding contraception?
- The effect of the contraceptive on the effectiveness of the anti-epileptic medication.
- The effect of the anti-epileptic on the effectiveness of the contraceptive.
- The potential teratogenic effects of the anti-epileptic if the woman becomes pregnant.
What does the Faculty of Sexual & Reproductive Healthcare (FSRH) recommend for women with epilepsy?
Consistent use of condoms, in addition to other forms of contraception.
What is the UKMEC classification for women taking phenytoin, carbamazepine, barbiturates, primidone, topiramate, or oxcarbazepine regarding the COCP and POP?
UKMEC 3: the COCP and POP.
What is the UKMEC classification for women taking phenytoin, carbamazepine, barbiturates, primidone, topiramate, or oxcarbazepine regarding the implant?
UKMEC 2: implant.
What is the UKMEC classification for women taking phenytoin, carbamazepine, barbiturates, primidone, topiramate, or oxcarbazepine regarding Depo-Provera, IUD, and IUS?
UKMEC 1: Depo-Provera, IUD, IUS.
What is the UKMEC classification for women taking lamotrigine regarding the COCP?
UKMEC 3: the COCP.
What is the UKMEC classification for women taking lamotrigine regarding POP, implant, Depo-Provera, IUD, and IUS?
UKMEC 1: POP, implant, Depo-Provera, IUD, IUS.
What is the minimum amount of ethinylestradiol recommended in a COCP for women with epilepsy?
A minimum of 30 µg of ethinylestradiol.
What is a typical feature of seizures in the temporal lobe?
May occur with or without impairment of consciousness or awareness.
An aura occurs in most patients, typically a rising epigastric sensation, and can include psychic or experiential phenomena such as déjà vu, jamais vu, and less commonly, hallucinations (auditory/gustatory/olfactory).
How long do seizures in the temporal lobe typically last?
Seizures typically last around one minute.
Automatisms (e.g. lip smacking/grabbing/plucking) are common.
What are the typical features of frontal lobe seizures?
Head/leg movements, posturing, post-ictal weakness, Jacksonian march.
What is a typical feature of parietal lobe seizures?
Paraesthesia.
What are the typical visual features of occipital lobe seizures?
Floaters/flashes.
What are the risks of uncontrolled epilepsy during pregnancy?
The risks of uncontrolled epilepsy generally outweigh the risks of medication to the fetus.
What should women considering pregnancy take to minimize the risk of neural tube defects?
Women should be advised to take folic acid 5mg per day well before pregnancy.
What is the percentage of congenital defects in newborns born to non-epileptic mothers?
Around 1-2% of newborns born to non-epileptic mothers have congenital defects.
What is the percentage of congenital defects in newborns if the mother takes antiepileptic medication?
This rises to 3-4% if the mother takes antiepileptic medication.
What is the recommendation regarding antiepileptic drug levels during pregnancy?
There is no indication to monitor antiepileptic drug levels.
What is sodium valproate associated with?
Sodium valproate is associated with neural tube defects.
Which older antiepileptic is often considered the least teratogenic?
Carbamazepine is often considered the least teratogenic of the older antiepileptics.
What congenital defect is phenytoin associated with?
Phenytoin is associated with cleft palate.
What do studies suggest about lamotrigine and congenital malformations?
Studies suggest the rate of congenital malformations may be low; however, the dose of lamotrigine may need to be increased in pregnancy.
Is breastfeeding safe for mothers taking antiepileptics?
Breastfeeding is generally considered safe for mothers taking antiepileptics, with possible exception of barbiturates.
What should pregnant women taking phenytoin be given in the last month of pregnancy?
Pregnant women taking phenytoin should be given vitamin K to prevent clotting disorders in the newborn.
What warning was issued regarding sodium valproate in the November 2013 Drug Safety Update?
There was a warning about a significant risk of neurodevelopmental delay in children following maternal use of sodium valproate.
What is the conclusion regarding the use of sodium valproate during pregnancy?
Sodium valproate should not be used during pregnancy and in women of childbearing age unless clearly necessary.
What should women of childbearing age do before starting treatment with sodium valproate?
Women of childbearing age should not start treatment without specialist neurological or psychiatric advice.
When do most neurologists start antiepileptics for epilepsy treatment?
Following a second epileptic seizure.
What do NICE guidelines suggest regarding starting antiepileptics?
Start after the first seizure if any of the following are present:
1. The patient has a neurological deficit.
2. Brain imaging shows a structural abnormality.
3. The EEG shows unequivocal epileptic activity.
4. The patient or their family or carers consider the risk of having a further seizure unacceptable.
What is the risk associated with maternal use of sodium valproate?
It is associated with a significant risk of neurodevelopmental delay in children.
What is the current guidance regarding sodium valproate use in pregnancy?
Sodium valproate should not be used during pregnancy and in women of childbearing age unless clearly necessary.
What is the first-line treatment for males with generalised tonic-clonic seizures?
Sodium valproate.
What is the first-line treatment for females with generalised tonic-clonic seizures?
Lamotrigine or levetiracetam.
What is the first-line treatment for girls under 10 years with generalised tonic-clonic seizures?
Sodium valproate may be offered first-line if they are unlikely to need treatment when they are old enough to have children or if they are unable to have children.
What is the first-line treatment for focal seizures?
Lamotrigine or levetiracetam.
What are the second-line treatments for focal seizures?
Carbamazepine, oxcarbazepine, or zonisamide.
What is the first-line treatment for absence seizures (Petit mal)?
Ethosuximide.
What are the second-line treatments for absence seizures in males?
Sodium valproate.
What are the second-line treatments for absence seizures in females?
Lamotrigine or levetiracetam.
What should be noted about carbamazepine in relation to absence seizures?
Carbamazepine may exacerbate absence seizures.
What is the first-line treatment for myoclonic seizures in males?
Sodium valproate.
What is the first-line treatment for myoclonic seizures in females?
Levetiracetam.
What is the first-line treatment for tonic or atonic seizures in males?
Sodium valproate.
What is the first-line treatment for tonic or atonic seizures in females?
Lamotrigine.
