Epilepsy

Question 1

What are the different types of focal seizures?

Answer 1

Focal (partial):

• Frontal: involves the motor or premotor cortex and leads to clonic movements which may become full tonic-clonic or tonic seizures. (Jacksonian march)
• Temporal: Auditory, olfactory or gustatory aura. Automatisations such as lip-smacking and pulling at clothing are seen along with déjà-vu.
• Occipital: causes visual distortion. (+ve or -ve phenomenon)
• Parietal: causes contralateral dysaesthesias (altered sensation) or distorted body image

Question 2

What can an EEG tell us about epilepsy in an individual?

Answer 2

EEG’s show specific patterns during seizure activity only.

Question 3

What is the classical appearance of a absent (petit mal) seizure on an EEG?

Answer 3

Regular 3Hz wave spikes.

Question 4

What is the classical appearance of a tonic clonic (gran mal) seizure on an EEG?

Answer 4

Lots of activity large spikes.

Question 5

When is an MRI useful in epilepsy?

Answer 5

For focal seizure (more likely due to a brain insult) therefore may see SOL, Infarct etc.

If there are neurological signs in alongside generalised seizures.

Question 6

How would you initially investigate a patient that has had an afebrile seizure?

Answer 6

Rule out reversible causes of seizures:

• Hypoglycaemia
• Check electrolyte imbalance

ECG to rule out cardiac syncope

EEG: Only useful if you capture a seizure

• Can use 24hr EEG
• Can use sleep deprived EEG (more likely to have a seizure)

MRI/CT head if focal or neurological symptoms

Ask patients relatives to try and record future seizures

Question 7

What is the treatment for absent seizures?

Answer 7

Ethosuximide

Question 8

What is the treatment for tonic clonic seizures?

Answer 8

Sodium Valproate (teratogen) must be on long term contraceptives

Question 9

What is the treatment for absent and tonic clonic seizures?

Answer 9

Valproate

Question 10

What is the treatment for focal seizures?

Answer 10

Carbamazepine

Question 11

Which anticonvulsant is safest in pregnancy?

Answer 11

Lamotrigine (efficacy is worse than other anticonvulsants though)

Question 12

What is SUDEP (sudden unexpected death in epilepsy)?

Answer 12

Sudden unexpected death in epilepsy (SUDEP) is defined as:

• Sudden/unexpected
• Unwitnessed
• Non-traumatic/non-drowning

Death of a person with epilepsy with or without a seizure, excluding documented status epilepticus and in whom post-mortem examination does not reveal a structural or toxicological cause of death.

It is most common in people with chronic generalised tonic clonic seizures.

Patients must be councilled about the small risk of SUDEP

Question 13

What is the treatment for status epilepticus in children?

Answer 13

0-5 mins:
High flow O2
ABC
BM

5-10mins:
Buccal Midazolam 0.5mg/kg/Rectal diazepam
or
IV lorazepam 0.1mg/kg

15mins:
IV lorazepam second dose
(prepare phenytoin for next step)

25mins:
Phenytoin infusion given over 20mins.
(if already on phenotype can give phenobarbitol)

45mins:
Anaesthetic intubation using thiopentol sodium.
Transfer to PICU

Question 14

What are the different types of generalised seizure?

Answer 14

Generalised:

• Tonic-clonic (grand mal)
• Myoclonic (sudden jerk of a limb)
• Absent (petit mal)
• Tonic: goes stiff and contracts but no jerking
• Atonic (loss of tone, fall forward)