Epilepsy

Question 1

Epilepsy - background

Answer 1

1. Def = at least two unprovoked seizures occurring more than 24 hours apart (not febrile seizures)
2. Epi = 0.4-0.8%
3. Etiology (3) = genetic, structural/metabolic, unknown

Question 2

Epilepsy - mx (general)

Answer 2

1. Explanation about condition and advice to family on lifestyle issues
2. Antiepileptic drugs
   a. Focal seizures = carbamazepine (first line)
   b. Generalised seizures = sodium valproate (first line)
   c. Uncertain = sodium valproate (first line)
   * If seizures continue, increase dose. If still not controlled, add second drug. Continue combination therapy, then gradually withdraw first drug to see if monotherapy with second drug will be effective
3. Intractable seizures (3) = ketogenic (fat-based) diets, vagal nerve stimulation (wire implanted around vagal nerve), surgery (e.g. temporal lobectomy for mesial temporal sclerosis)
4. Advise school of problem. Teachers need to be advised on the management of seizures
5. Lifestyle (3) = avoid deep baths/swimming alone in deep water, discuss driving issues with adolescents, educate adolescents about precipitation of seizures by alcohol/drugs/poor sleep

Question 3

West syndrome - overview (3)

Answer 3

1. Age 4-6mo
2. Dx based on triad:
   a. Infantile spasms (short tonic contraction of trunk with upward elevation of arms, may be confused with GOR or colic)
   b. Developmental delay or regression
   c. Hypsarrhythmia on EEG
3. Mx = prednisolone orally, or tetracosactrin depot, or vigabatrin orally, or benzodiazepine orally (e.g. nitrazepam)

Question 4

Lennox-Gastaut syndrome - overview (3)

Answer 4

1. 1-3y
2. a. Tonic seizures with trunk flexion (often evolving out of infantile spasms), atonic seizures, myoclonic jerks, atypical absences (less clear onset and resolution than typical absence)
   b. Slow spike wave pattern on EEG
   c. Developmental delay
3. Mx = poor prognosis, rarely responds to drugs, get expert help. Sodium valproate monotherapy, lamotrigine + sodium valproate, +/- additional therapy (e.g. clobazam, topiramate)

Question 5

Childhood/juvenile absence epilepsy - overview (3)

Answer 5

1. Age of onset for childhood absence = 4-9y, juvenile = 10-15y
2. a. Typical absences only, but very frequent
   b. Can be associated with mild myoclonia, asymmetry or automatisms
   c. EEG - regular bursts of 3 per second spike wave activity
3. Mx = ethosuximide orally, or sodium valproate orally

Question 6

Benign epilepsy with centrotemporal spikes (rolandic epilepsy) - overview (3)

Answer 6

1. 4-10y
2. a. Predominantly nocturnal sensorimotor seizures (awareness of abnormal feelings in tongue and distortion of the face - supplied by Rolandic area of brain). Infrequent, short seizures
   b. Onset in one side of face or hand, then spreading down one side and may generalise
   c. EEG relatively normal whilst awake. In slow wave sleep or drowsiness will develop frequent centrotemporal spike and wave discharges
3. Mx = same therapy as idiopathic generalised epilepsy (sodium valproate first line)

Question 7

Early onset benign childhood occipital epilepsy (Panayiotopoulos type) - overview (3)

Answer 7

1. Young children (1-7y)
2. a. Bizarre seizures - prolonged (

Question 8

Juvenile myoclonic epilepsy - overview (3)

Answer 8

1. Onset in second decade
2. a. Invariable myoclonic jerks classically within first hour of awakening
   b. High risk of generalised tonic-clonic seizures
   c. EEG may have absences and photosensitivity. Discharges more fragmented and irregular than in juvenile absence epilepsy with bursts of polyspike
   c. Mx = sodium valproate first line, lamotrigine second line, then clobazam/topiramate