Epilepsy 2

Question 1

What counselling is required when someone presents with seizure or epilepsy ?

Answer 1

Explain the diagnosis & if its first seizure explain that this doesn’t unnecessarily mean epilepsy as not everyone who has a seizure goes on to develop epilepsy

Explain there is a risk of seizure recurrence however and that the DVLA MUST be informed

Question 2

If someone present with there 1st isolated seizure then what are the guidelines on driving a car and a lorries or other large vehicles (HGV/ PCV) ?

Answer 2

1. For car you are allowed to drive again after 6 months if no further seizures occur
2. For lorries & other large vehicles (HGV/ PCV) you are allowed to drive them again after 5yrs if no further seizures occur

Question 3

If someone is diagnosed with epilepsy what are the guidelines on driving ?

Answer 3

1. For driving a car - if only ever had asleep seizures (happen as you are falling sleep, while you are asleep or as you are waking up) can drive if not had one in 1yr
2. For driving a car - if history of awake seizures then have to wait 3yrs since last awake seizure
3. For driving a lorry & other large vehicles e.g. bus - can only drive again after 10yrs without an epileptic attack & haven’t taken anti-epileptic medication for 10yrs

Question 4

What are the risk factors for developing epilepsy ?

Answer 4

• Brith - SGA, born with abnormal areas of the brain
• Development - conditions with intellectual & developmental disabilities, seizures in past - including febrile
• Head injury - including loss of consciousness
• Fam history - of seizures/ epilepsy
• Drug history - cocaine, opiates, analgesics e.g. tramadol, theophylline, anti-emetics e.g. prochlorperazine, antibiotics e.g. penicillins, cephalosporins, quinolones, Alcohol & benzo withdrawal

Question 5

What are the indications for a CT scan acutely ?

Answer 5

1. Clinical or radiological skull fracture
2. Deteriorating GCS
3. Focal neurological signs (i.e. certain areas affected)
4. Head injury with seizure
5. Failue to be GCS 15/15 4hrs after survival
6. Suggestion of other pathology e.g. SAH

Question 6

Who does epilepsy more commonly present in ?

Answer 6

Infants & old age

Question 7

Who is focal and generlaised epilepsy more in?

Answer 7

• Generalised epilepsy is more common in young people
• Focal epilepsy is more common in adults

Question 8

What are the 3 main classifications of epilepsy ?

Answer 8

1. Focal (partial)
2. Generalised
3. Unclassified

Question 9

Describe in general terms what focal (partial) seizures are and why MRI is important in the investigation of them

Answer 9

• Focal seizures have focal onset with features referrable to part of one hemisphere (i.e. can localise the features seen to an area of the brain being affected)
• It is usually due to an underlying structural abnormality (rather than being idiopathic) hence MRI imaging is key in the investigation of these type of seziures

Question 10

What is the link/ crossover between focal and generalised seizures ?

Answer 10

Focal seizures can develop into generalised seizures but note that they have a focal onset to begin with

Question 11

Describe in general terms what a generalised seizure is

Answer 11

This is a seizure which causes simultaneous onset of electrical activity throughout the cortex with no localising features referrable to only one hemisphere

Question 12

How can focal (partial) seizures be further classified ?

Answer 12

Can be classified as simple or complex

Question 13

In general terms what is the range of symptoms someone may experience with focal seizures ?

Answer 13

Some may experience movements (motor-symptoms) & some may experience unusual feelings or sensations (non-motor & psych symptoms)

Question 14

Specifically now what are the different motor symptoms someone experience with a focal seizure ?

Answer 14

• Lip-smacking or chewing movements
• Repeatedly picking up objects or putting on clothes
• Suddenly losing muscle tone & limbs going floppy, or limbs suddenly becoming stiff
• Repetitive jerking movements that affect one or both sides of the body
• Making a loud cry or scream
• Making strange postures or repetitive movements such as cycling or kicking

Question 15

Specifically what are the different non-motor symptoms someone having a focal seizure may experience ?

Answer 15

Sensory:

• Getting an unusual smell or taste
• Strange feeling like a ‘wave’ going through the head
• Stiffness or twitching in part of the body (such as arm or hand)
• Feeling of numbness or tingling
• Sensation that arm or leg feels bigger or smaller than it actually is
• Visual disturbances such as coloured or flashing lights

Psych:

• Hallucinations (visual)
• Deja vu
• Jamais vu - involves a sense of eeriness and the observer’s impression of seeing the situation for the first time, despite rationally knowing that he or she has been in the situation before
• Depersonalisation - ones thoughts or feelings seem unreal or not belonging to them
• Aphasia

Question 16

Define a simple focal seizure

Answer 16

This is a focal seizure where consciousness is unimpaired, with focal motor, sensory, autonomic or psychiatric symptoms. No post-ictal symptoms

Question 17

Define a complex focal seizure

Answer 17

• This is a focal seizure where consciousness is impaired. May have a simple focal onset (= aura) or impaired consciousness from the onset. Most commonly arise from the temporal lobe (so ans might be a temporal lobe seizure)
• Post-ictal confusion is common with temporal lobe seizures, whereas recovery is rapid after seizures in the frontal lobe

Question 18

Define secondary generalised seizures

Answer 18

• This occurs in 2/3rds of focal seizures, it is where electrical disturbance which starts focally spreads widely throughout cortex
• When this happens the person becomes unconscious & will usually have a tonic clonic (convulsive) seizure

Question 19

What features of a focal seizure would suggest it is occurring in the temporal lobe ?

Answer 19

Think ‘HEAD’

• Hallucinations - auditory, smell or taste
• Epigastric (rising) discomfort/ Emotional (sudden terror, panic, elation)
• Automatisms - lip smacking, grabbing, plucking, signing, kissing, driving etc
• Dysphagia/Deja vu(+ jamais vu)

Automatism = action performed unconsciously & no recollection afterwards

Question 20

What features of a focal seizure would suggest it is occurring in the frontal lobe ?

Answer 20

Think ‘motor’ features

• Head and leg movements
• Posturing movements
• Motor arrest (unable to move)
• Post-ictal weakness (todds palsy)
• Jacksonian march - spreading of focal motor seizure with retained awareness often starting with face or a thumb

Question 21

What features of a focal seizure would suggest it is occurring in the parietal lobe ?

Answer 21

• Sensory disturbances - paraesthesia (tingling & numbness), pain (rare)

Question 22

What features of a focal seizure would suggest it is occurring in the occipital lobe ?

Answer 22

Visual phenomena such as flashes or floaters