Epilepsy

Question 0

After what time do seizures become self sustaining

What can occur after this time

Answer 0

15-30 minutes

Neuronal injury

Question 1

What is status epilepticus

Answer 1

A generalised seizure that last more than 30 minutes or multiple seizures without recovery

Question 2

What is the incidence of status epilepticus

Answer 2

10-41/100,000

Lifetime risk 10% (pts with epilepsy)

Question 3

What is the mortality rate of status epilepticus?

Answer 3

9-60%
Status >30 minutes 20% mortality

Severe neurological/cognitive morbidity 11-16

Question 4

How does convulsive status epilepticus present

Answer 4

Convulsions associated with rhythmic jerking
Generalised tonic clonic movements
Mental status impaired

Question 5

What happens neurophysiologically when a seizure converts to status

Answer 5

Receptors move from synaptic membranes and endosomes
Inhibitory GABA receptors destroyed

Become less responsive to GABAergic drugs (ie benzos)

Excitatory NMDA and AMPA receptors move to synaptic membrane causing further excitation

Question 6

How much less effective are benzos after 30 minutes

Answer 6

20
Phenytoin less so

NMDA blockers less likely to lose efficacy

Question 7

How does status lead to increased excitability

Answer 7

Increased proconvulsive neuropeptides

Depletion of inhibitory neuropeptides

Question 8

What occurs after extreme length status

Answer 8

Long term gene expression changes as a result of neuronal death &reorganisation

Seizures inhibit brain synthesis

Question 9

List the aetiologies of status

Answer 9

Low AED levels in blood (34%)
Remote symptomatic causes (24%)
CVA (22%)
Anoxia/hypoxia (10%)
drug/ alcohol withdrawal (10%)

Question 10

How do you initially manage status

Answer 10

First aid
Recovery position , oxygen
ABCDEFG

Question 11

After a seizure of longer than ten minutes or longer than expected what should you consider the possibility of

Answer 11

NEAD/pregnancy

Question 12

What treatments should you consider for prolonged seizure just before conversion to status

Answer 12

Emergency AED therapy
Glucose +/- high dose IV pabrinex if Low nutrition
Treat severe acidosis

Question 13

What are the pros and cons of anesthesia in status

Answer 13

Pro:
Powerful AEDS
Can protect the airway
Can get scans and treat easily

Con:
Pnumonia
Hypotension and cardiac arythmias
Infection and consequences of not moving

Question 14

What are the consequences of a status coma

Answer 14

Pressure sores 
DVT
pnumonia 
Muscle weakness 
Organ dysfunction (GI tract , immune system) 
Psychological impacts (PTSD)

Question 15

What are the benefits of EEG during status

Answer 15

Can see ongoing seizure activity

Can suggest other causes ie encephalitis NEAD

Question 16

Define refractory status epilepticus

Answer 16

Seizures that continue despite two appropriate AEDS at appropriate doses
Mortality 23-60
Can go on for months

Question 17

What are the predictors of refractory status

Answer 17

Encephalitis
Hyponatraemia
Longer duration
More seizure activity

Question 18

Five causes of acquired epilepsy

Answer 18

Severe head injury 
Cerebral hemorrhage 
Brain tumour 
CNS infection
Early life fibrile seizures?

Question 19

define a seizure

Answer 19

the clinical manifestation of an abnormal excessive excitation and synchronization of a population of cortical neurons

Question 20

define epilepsy

Answer 20

recurrent seizures (two or more) which are not provoked by systemic or acute neurological insults

Question 21

what is the incidence of seizures?

Answer 21

incidence 80/100,000,
lifetime incidence 9%
(1/3 febrile convulsions)

Question 22

what is the incidence of epilepsy?

Answer 22

45/100,000 per year.
Point prevalence 0.5-1%,
cumulative lifetime incidence 3%

Question 23

seizures can either be

Answer 23

partial or generalised

Question 24

what are the three types of partial seizures?

Answer 24

simple partial
complex partial
secondary generalised

Question 25

what are the four types of simple patial seizure?

Answer 25

SPAM with special or somatosensory symptoms (ie butterflies),

with motor signs,

with autonomic symptoms or signs (ie flushing)

with psychic or experiential symptoms (ie déjà vu, jaime vu)

Question 26

describe the manifestations of complex partial seizures

Answer 26

impaired consciousness,
clinical manifestations vary with site of origin and degree of spread.
Can include: aura, automatisms, other motor activity. Duration is usually less than 2 minutes

Question 27

describe the manifestations of secondary generalised seizures.

Answer 27

begins focally,
with or without focal neurological symptoms ,
variable symmetry intensity and duration of TONIC and CLONIC phase,
typical duration 1-3 mins,
post ictal confusion somnolence,
with or without transient focal deficit.

Question 28

describe typical absence seizures

Answer 28

brief staring spells with impairment of awareness, 
generally 3-20 seconds, 
sudden onset and resolution, 
often provoked by hyperventilation, 
more common in childhood

Question 29

what ages does typical absence seizures usually affect?

Answer 29

typical onset 4-14 yrs, often resolved by 18

Question 30

describe ATYPICAL absence seizures

Answer 30

variable responsiveness, 
5-30 seconds, 
gradual onset and resolution, 
generally not provoked by hyperventilation. 
Typical onset  6yrs

Question 31

ATYPICAL absence seizures are often associated with

Answer 31

global cognitive impairment, and atonic and tonic seizures

Question 32

describe myoclonic seizures

Answer 32

epileptic myoclonus,

brief shock like jerks of a muscle or group of muscles. EEG generalised 4-6hz polyspike

Question 33

describe tonic seizures

Answer 33

symmetric tonic muscle contraction of extremities with tonic flexion of waist and neck,
duration 2-20 seconds

Question 34

describe atonic seizures

Answer 34

sudden loss of postural tone, (when severe, often results in falls, milder produces head nods or jaw drops)

consciousness usually impaired, duration usually seconds,
rarely more than 1 min

Question 35

describe tonic clonic seizures

Answer 35

loss of consciousness and post ictal confusion/drowsiness, 30-120 seconds,

TONIC phase,
stiffening and falling,

CLONIC phase,
rythmic extremity jerking.

Question 36

epilepsy syndromes can be either

Answer 36

idiopathic or symptomatic

Question 37

cryptogenic refers to

Answer 37

epilepsies that are thought to be symptomatic but the cause in a patient is unknown

Question 38

define idiopathic

Answer 38

the disorder is not associated with other neurological or neuropsychological abnormalities

Question 39

name the focal epilepsy syndromes

Answer 39

IDIOPATHIC:
benign childhood epilepsy with centrotemporal spikes (rolandic) ,
childhood epilepsy with occipital paroxysms.

SYMPTOMATIC: 
chronic progressive epilepsia partialis continua of childhood (e.g rasmussen's), 
Frontal lobe epilepsies, 
occipital lobe epilepsies, 
parietal lobe epilepsies, 
temporal epilepsies, 

CRYPTOGENIC…

Question 40

name the generalised epilepsy syndromes

Answer 40

IDIOPATHIC (with age related onset) 
Benign neonatal familial, 
benign neonatal convulsion, 
benign myoclonic epilepsy in childhood. 
Childhood absence epilepsy. 
Juvenile absence epilepsy, 
juvenile myoclonic epilepsy 

CRYPTOGENIC or SYMPTOMATIC:
West syndrome,
Lennox-Gastaut syndrome

Question 41

wet syndrome

Answer 41

infantile onset,
hypsarrythmic EEG,
infantile spasms.
Cryptogenic V symptomatic

Question 42

Lennox gastaut syndrome

Answer 42

childhood onset,
tonic,
atypical absense,
atonic and other seizure types and mental retardation, myoclonic epilepsies of infancy or early childhood