Epilepsy

Question 1

Prevalence in children

Answer 1

4 in 1000

Question 2

Defintion

Answer 2

chronic brain disorder characterized by recurrent (≥ 2), unprovoked seizures
A single seizure is not considered an epileptic seizure. Epilepsy is often idiopathic, but various brain disorders, such as malformations, strokes, and tumors, can cause symptomatic epilepsy.

Question 3

Types of generalised seizures

Answer 3

absence (typical or atypical), myoclonic, clonic, tonic, tonic-clonic, and atonic (astatic) types

Question 4

Types of partial seizures

Answer 4

Motor
Sensory
Autonomic
Psychiatric

Question 5

What is a seizure

Answer 5

transient neurological dysfunction caused by excessive activity of cortical neurons,
resulting in paroxysmal alteration of behaviour and/or EEG changes

Question 6

Describe an absent seizure

Answer 6

usually only seen in children, unresponsive for 5-10 s with arrest of activity, staring, blinking or eye-rolling, no post-ictal confusion; 3 Hz spike and slow wave
activity on EEG

Question 7

Most common cause of late onset >50 yo seizures

Answer 7

dementia

Question 8

Describe the presentations of simple->motor, sensory, psychiatric

Answer 8

simple (preserved LOC)
ŠŠmotor: postural, phonotory, forceful turning of eyes and/or head, focal muscle rigidity/jerking ± Jacksonian march (spreading to adjacent muscle groups)
ŠŠsensory: unusual sensations affecting vision, hearing, smell, taste or touch
ŠŠautonomic: epigastric discomfort, pallor, sweating, flushing, piloerection, pupillary dilatation
ŠŠpsychiatric: symptoms rarely occur without impairment of consciousness and are more
commonly complex partial

Question 9

Presentation of complex seizures

Answer 9

ƒƒcomplex (altered LOC)
ŠŠpatient may appear to be awake but with impairment of awareness
ŠŠclassic complex seizure is characterized by automatisms such as chewing, swallowing, lipsmacking,
scratching, fumbling, running, disrobing and other stereotypic movements
ŠŠother forms: dysphasic, dysmnesic (déjà vu), cognitive (disorientation of time sense),
affective (fear, anger), illusions, structured hallucinations (music, scenes, taste, smells),
epigastric fullness

Question 10

Compare motor activity in seizure vs pseudoseizure

Answer 10

Seizure:
Synchronous, stereotypic, automatisms, lateral
tongue biting, eyes rolled back

Pseudoseizure/conversion:
Opisthotonos, rigidity, forced eye closure, irregular extremity movements, shaking
head, pelvic thrust, crying, geotropic eye movements, tongue biting at the tip

Question 11

Clinical features

Answer 11

Key diagnostic factors
presence of risk factors (common)
staring spells or inattention (common)
tonic-clonic convulsions (common)
brief, arrhythmic muscular jerking movements (common)
unexplained falls (common)
eyes rolling back in head (common)
apnoea (common)
intercurrent illness (common)

Other diagnostic factors
incontinence (common)
tongue biting (common)
post-ictal phenomena (common)
precipitated by fatigue or lack of sleep (common)
precipitated by light or noise (common)
developmental delay (common)
neurocutaneous stigmata (uncommon)

Question 12

Risk factors for generalised seizures

Answer 12

Strong
genetic predisposition or FHx
perinatal asphyxia
metabolic/neurodegenerative disorders
head trauma
structural abnormalities of the CNS

Weak
autistic spectrum disorder
CNS infection
neurocutaneous syndromes
Hx of febrile seizures

Question 13

How is diagnosis of epilepsy made

Answer 13

Clinical

Use of EEG has limited value is diagnostic process

Question 14

Four key questions to ask with possible epilepsy

Answer 14

1. Is the seizure epilepsy
2. What type of seizure
3. What type of epilepsy
4. What is the cause of the epilepsy

Question 15

Prognosis

Answer 15

Generally good

>70% will have resolution resolution when idiopathic

Question 16

Important components in the follow-up

Answer 16

1. Frequency of fits
2. Side effects
3. Psychosocial, schooling etc
4. Anticonvulsant levels if uncontrolled

Question 17

When a neurological problem is suspected but cannot be found, name given to this type of epilepsy

Answer 17

Cryptogenic

Question 18

Why is EEG not ideal to diagnose epilepsy

Answer 18

50% epileptics will have normal EEG and 5% of normal children will have abnormal findingd

Question 19

When might an EEG be appropriate for diagnostic purposes

Answer 19

Absence seizure

Infantile seizures

Question 20

Most common anticonvulsants started for children with generalised, for infantile, absence

Answer 20

Sodium valproate or carbamazepine

Steroid or vigabatrin in infantile

Ethosuxamide is alternative to valproate in absence seizures.

Question 21

When to check anticonvulsant levels

Answer 21

When control is inadequate

Question 22

Management overview

Answer 22

Treatment
• avoid precipitating factors
• indications for medical therapy (anticonvulsants): 2 or more unprovoked seizures, known
organic brain disease, EEG with epileptiform activity, first episode of status epilepticus,
abnormal neurologic examination or findings on neuroimaging
• psychosocial issues: stigma of seizures, education of patient and family, status of driver’s license,
pregnancy issues
• safety issues: driving, operating heavy machinery, bathing, swimming alone
• consider surgical treatment if focal and refractory

Question 23

Number of children having a seizure in their lifetime

Answer 23

5% will have at least one seizure, this is not considered epilepsy

Question 24

Causes of epilepsy

Answer 24

Most commonly unknown
May have genetic component
May follow head injury, stroke or infection
May be due to malformation, benign or cancerous, scar/cyst present at birth

Question 25

Parental advice for precautions to take at home

Answer 25

xSwimming, bathing alone
Showers
Turn on cold first
Caution hot things
Avoid heights
Appropriate education provided to other potential carers so know what to do
Need first aid kit at home
Ensure the bedroom door remains unlocked

Question 26

Counselling use of valproate

Answer 26

Mode of action
Multiple mechanisms. Prevents repetitive neuronal discharge by blocking voltage‑ and use-dependent sodium channels. Other actions include enhancement of GABA, inhibition of glutamate and blockade of T-type calcium channels.

Cautions: hepatic, pregnant/breastfeeding, pancreatic dysfunction, women (ensure on contraception)

Common (>1%)
nausea, vomiting, increased appetite, weight gain, tremor (dose-related), thinning or loss of scalp hair (usually temporary), paraesthesia, drowsiness, dizziness, memory impairment, ataxia, elevated aminotransferase concentrations (dose-related), asymptomatic hyperammonaemia, thrombocytopenia (dose-related), menstrual irregularities, polycystic ovaries, hyperandrogenism in females

Take with food
May make drowsy- avoid machiner
\+Appetite: may need to watch food
Tell doctor if develop rash, easy bruising/bleeding, jaundice, abdominal pain vomiting.
Do not stop suddenly

FBE prior to commencing
LFTs monitoring not indicated
BMD if long term use