Epilepsy

Question 1

Risk factors for epilepsy (7)

Answer 1

Birth
Development
Seizures in past inc. febrile 
Head injury
Family history
Drugs
Alcohol

Question 2

When do we do an ECG and why

Answer 2

Single seizure or first fit ALWAYS

Long QT syndrome can present with seizure

Question 3

Imaging in seizure

Answer 3

MRIb and CTb

MRIb subtle structural abnormalities in brain could be seizure focus

Question 4

Who gets a CT scan acutely (6)

Answer 4

• Clinical or radiological skull fracture
  • Deteriorating GCS
  • Focal signs
  • Head injury with seizure
  • Failure to be GCS 15/15 4 hours after arrival
  • Suggestion of other pathology – eg SAH

Question 5

When do we use EEG

Answer 5

Classify epilepsy, surgical evaluation, confirmation of non convulsive status, confirmation of non epileptic attack

Do not use to figure out cause of attack. USE HISTORY

Question 6

Driving and epilepsy - if you have 1 seizure

Answer 6

6months no car

5 years lorry

Question 7

Driving and epilepsy - Epilepsy diagnosed

Answer 7

1yr no car
3yrs no car if seizure in sleep
10 years off medication for lorry

Question 8

When do we counsel about SUDEP

Answer 8

At first diagnosis

Question 9

What is a seizure?

Answer 9

seizure is abnormal synchronisation of neuronal activity - usually excitatory with high frequency action potentials
Interruption of normal brain activity - focal or generalised
Usually brief - secs to mins

Question 10

If seizure area in brain affects right frontal lobe

Answer 10

Motor cortex

Left motor symptoms - left arm stiff

Question 11

If seizure in occipital lobe

Answer 11

Visual changes

Question 12

If seizure in temporal lobe

Answer 12

Abnormal memories, epileptic deja vu

Question 13

If seizure in limbic system

Answer 13

Fear and emotion

Question 14

Broad classifications of epilepsy (2)

Answer 14

Generalised

Partial/focal epilepsy

Question 15

Tx of choice for primary generalised epilepsy

Answer 15

Sodium Valproate

Question 16

Tx of choice for focal onset epilepsy and why

Answer 16

Carbemazepine
or lamotrigine
sodium valproate works but not 1st choice as side effects

Question 17

When do we use phenytoin

Answer 17

Anticonvulsant only used acutely - long term effects include gum hypertrophy

Question 18

When do we NOT use carbemazepine

Answer 18

Primary generalised epilepsies

Can make them worse

Question 19

What is sodium valproate

Answer 19

Domestos of anticonvulsants however with lots of side effects

Question 20

Side effects of sodium valproate (4)

Answer 20

Weight gain
Teratogenic
Hair loss
Fatigue

Question 21

Use of Lamotrigine

Answer 21

Well tolerated in generalized and focal epilepsies

Question 22

Anti convulsants that induce hepatic enzymes

Answer 22

Carbamazepine, oxcarbazepine, phenobarbitol, phenytoin, primidone, topiramate

Question 23

Why should we be aware of anti convulsants that induce hepatic enzymes

Answer 23

Can alter efficacy of COCP

Morning after pill dose must be increased

Question 24

What is status epilepticus?

Answer 24

• Recurrent epileptic seizures without full recovery of
  consciousness
• Continuous seizure activity lasting more than ?30
  minutes

Question 25

Types of status epilepticus (3)

Answer 25

– Generalized convulsive status epilepticus
– non convulsive status
• conscious but in “altered state”
– Epilepsia partialis continua
• continual focal seizures, consciousness preserved

Question 26

Precipitants of status (6)

Answer 26

• Severe metabolic disorders
– hyponatraemia, pyridoxine deficiency
• Infection
• Head trauma
• Sub-arachnoid haemorrhage
• Abrupt withdrawl of anti-convulsants
• Treating absence seizures with CBZ

Question 27

Complications of convulsive status

Answer 27

• Excess cerebral energy demand and poor substrate
delivery causes lasting damage
• Can cause
– respiratory insufficiency and hypoxia
– hypotension
– hyperthermia
– rhabdomyolysis

Question 28

Managing status

Answer 28

• Stabilize patient
– ABC
• Must identify cause!!
– Emergency blood tests +/- CT
• Anti-convulsants
– Phenytoin (check levels)
– Keppra
– valproate
– Benzodiazepines
• A quick way to admit to ITU

Question 29

Simple focal seizures

Answer 29

Small part of brain affected, person conscious, doesnt spread. A SFS are sometimes called auras as it can be a warning of another seizure -> secondary generalised

Question 30

Complex focal seizures

Answer 30

Affects a larger part of one hemisphere, consciousness may be affected

Question 31

Secondary generalised seizures

Answer 31

Focal start then generalises and moves across network in brain
Unconscious
Tonic colonic

Question 32

Absences (petit mal)

Answer 32

Unreactive to stimulus, unaware of what doing, may be confused with day dreaming

Question 33

Tonic seizures

Answer 33

Muscles suddenly become stiff

Question 34

Atonic seizures

Answer 34

Muscles relax suddenly

Question 35

Myoclonic seizures

Answer 35

Muscle jerks

Question 36

Tonic colonic (grand mal)

Answer 36

At the start of the seizure:

the person becomes unconscious
their body goes stiff and if they are standing up they usually fall backwards
they may cry out
they may bite their tongue or cheek.
During the seizure:

they jerk and shake (convulse) as their muscles relax and tighten rhythmically
their breathing might be affected and become difficult or sound noisy
their skin may change colour and become very pale or bluish
they may wet themselves.
After the seizure (once the jerking stops):

their breathing and colour return to normal
they may feel tired, confused, have a headache or want to sleep.