Epilepsy 3: Focal, Generalised seizures and Status epilepticus

Question 1

what are focal seizures?

Answer 1

when seizure activity is limited to a part of one brain hemisphere

Question 2

What is first-line treatment for newly diagnosed focal seizures?

Answer 2

1) Carbamazepine or Lamotrigine

2) if not tolerated Offer levetiracetam, oxcarbazepine or sodium valproate

Question 3

1) What are generalized seizures?

2) What are the different types of generalized seizure?

Answer 3

1) When there is widespread seizure activity in the left and right hemispheres of the brain
2) Absence, tonic-clonic, myoclonic, atonic and tonic

Question 4

what is first-line treatment for newly diagnosed generalized tonic-clonic seizures (GTC) ?

Answer 4

1) Sodium valproate (except in premenopausal women)

2) Lamotrigine is the alternative if sodium valporate is unsuitable but may exacerbate myoclonic seizures

Question 5

what is first-line treatment for newly diagnosed absence seizures?

Answer 5

1) Ethosuximide, or sodium valproate (except in premenopausal)
↳Sodium valproate used as the first choice if there is also a high risk of GTC seizures
2) lamotrigine is an alternative if above options are C/I. licensed for absence seizures in children but unlicensed in adults

Question 6

what is first-line treatment for newly diagnosed myoclonic seizures?

Answer 6

1) Sodium valproate as first-line (except premenopausal)

2) Topiramate and levetiracetam are alternatives

Question 7

1) Atonic and tonic seizures are usually seen in childhood, in specific epilepsy syndromes associated with what?
2) what are the problems associated with treating these patients?

Answer 7

1) Cerebral damage or mental retardation

2) They may respond poorly to the traditional drugs

Question 8

what is first-line treatment for atonic and tonic seizures?

Answer 8

1) Sodium valproate first-line (except in premenopausal)

2) Lamotrigine can be added as adjunctive treatment

Question 9

What are epilepsy syndromes?

Answer 9

1) Specific types of epilepsy that are characterised according to a number of features including seizure type, age of onset, and EEG characteristics
2) Some drugs are licensed for use in particular epilepsy syndromes

Question 10

Who should initiate treatment for Dravet’s syndrome?

What is the first-line treatment for Dravet syndrome?

Answer 10

1) A tertiary specialist should be involved in decisions regarding treatment
2) Sodium valproate (except females of childbearing potential) or topiramate are first-line
3) Adjunctive treatment: Clobazam or stiripentol

Question 11

what is first-line treatment in children for treating Lennox-Gastaut syndrome?

Answer 11

1) Sodium valproate is the first-line drug (except females of childbearing potential)
2) Lamotrigine adjunctive treatment in children and adults if sodium valproate is unsuitable

Question 12

Outline the immediate measures that should be undertaken in the management of convulsive status epilepticus

Answer 12

1) Positioning the patient to avoid injury
2) Supporting respiration including providing oxygen
3) Maintaining blood pressure, and the correction of any hypoglycaemia
4) Parenteral thiamine should if alcohol abuse suspected
5) Pyridoxine hydrochloride should be given if the status epilepticus is caused by pyridoxine deficiency

Question 13

1) How should convulsive status epilepticus seizures lasting longer than 5 minutes be treated?
2) What should be monitored in patients?

Answer 13

1) IV lorazepam (repeated once after 10 minutes if seizures recur or fail to respond)
2) IV diazepam if lorazepam unavailable but it carries a high risk of thrombophlebitis (reduced by using an emulsion formulation).
3) Patients should be monitored for respiratory depression and hypotension.

Question 14

Why is diazepam given IV instead of IM or by using a suppository in the management of status epilepticus?

Answer 14

Absorption of diazepam from intramuscular injection or from suppositories is too slow for treatment of status epilepticus.

Question 15

Where facilities for resuscitation are not immediately available in the management of convulsive status epilepticus, what can be given?

Answer 15

Diazepam can be administered as a rectal solution or midazolam oromucosal solution can be given into the buccal cavity.

Question 16

If, after initial treatment with benzodiazepines, convulsive seizures recur or fail to respond 25 minutes after onset, what should be done?

Answer 16

1) Phenytoin, fosphenytoin or phenobarbital is given
2) Contact intensive care unit if seizures continues
3) anaesthesia with thiopental , midazolam, or propofol, should be instituted with full intensive care support.

Question 17

outline the management of non-convulsive status epilepticus

Answer 17

1) If there is incomplete loss of awareness, usual oral antiepileptic therapy should be continued or restarted
2) if fail to respond to oral therapy or have complete lack of awareness treat in the same way as for convulsive status epilepticus

Question 18

How should brief febrile convulsions be managed in patients?

Answer 18

1) Brief febrile convulsions need no treatment

2) Antipyretic e.g. paracetamol ,used to reduce fever and prevent further convulsions (no evidence)

Question 19

How should prolonged (those lasting ≥ 5 minutes) or recurrent febrile convulsions be managed in patients?

Answer 19

1) Prolonged or recurrent febrile convulsions without recovery must be treated actively (as for convulsive status epilepticus).
2) Long-term anticonvulsant prophylaxis for febrile convulsions is rarely indicated

Question 20

Phenytoin or fosphenytoin can be given in convulsive status epilepticus if benzodiazepines fail and seizures recur or fail to respond 25 minutes after onset. how should these drugs be administered?

Answer 20

1) Phenytoin by slow IV injection, followed by the maintenance dosage
2) fosphenytoin can be given more rapidly and when given intravenously causes fewer injection-site reactions than phenytoin sodium. (IM absorption too slow, doses should be expressed in terms of phenytoin)