Epilepsy Flashcards
Differential diagnoses for blackouts
Syncope First seizure Hypoxic seizure Concussive seizure Cardiac arrythmia Non-epileptic attack e.g. narcolepsy
Important features of the history of a patient presenting with a blackout
What they were doing at the time
What (if any) warning feelings did they get
What they were doing the night before
Have they had anything similar in the past
How did they feel after
Any injury, tongue biting or incontinence
Details of history to obtain from a witness of a blackout
Detailed description of observations before and during attacks, including level of responsiveness, motor phenomena, pulse, colour, breathing, vocalisation
Detailed description of behaviour following attack
Additional potentially relevant information from the history of a patient presenting with a blackout
Age Sex PMH including head injury, birth trauma and febrile convulsions Past psychiatric history Alcohol and drug use Family history
What is the most common cause of fainting?
Vasovagal syncope
Prodrome of syncope
Light-headedness Hot Sweating Nausea Tinnitus Tunnel vision
Triggers of vasovagal syncope
Prolonged standing Standing up quickly Trauma Venipuncture Micturition Coughing
Features of syncope
Upright position Pallor common Gradual onset Injury rare Incontinence rare Rapid recovery Precipitants common
Features of seizure
Any posture Pallor uncommon Sudden onset Injury quite common Incontinence common Slow recovery Precipitants rare
Typical patient/presentation of primary generalised seizures
Under 25 years old May have a family history No warning May have history of absences and myoclonic jerks as well as GTCS Generalised abnormality on EEG
When do hypoxic seizures occur?
When individuals are kept upright when in a faint e.g. in an aircraft, at the dentist, when helping someone to their feet
When do concussive seizures occur?
After any blow to the head
When should cardiac arrhythmias be considered in patients presenting with blackouts
FH of sudden death, cardiac problems
History of collapse with exercise
Give an examples of a functional cardiac problem that could cause collapse
Long QT syndrome
Features of non-epileptic attacks
More common in women than in men Can be frequent May look strange Can be prolonged History of other medically unexplained symptoms History of abuse Superficial resemblance of tonic clonic seizure or "swoon" May involve strange movements
Investigations of possible first seizures
Blood sugar
ECG
Consider alcohol and drugs
CT head
Features of focal/partial seizures
May have an aura
Can occur at any age
Cause can be any focal brain abnormality
Simple partial and focal seizures can become secondarily generalised
Focal abnormality on EEG
Cause may be seen on MRI
When is epilepsy usually diagnosed?
After a second unprovoked attack
May sometimes be diagnosed on history taking after a first seizure if history is clearly indicative of epilepsy
Features suggestive of epilepsy
History of myoclonic jerks
Absences
Feeling “strange” with flickering lights
History of déjà vu
Rising sensation from abdomen
Episodes of looking blank with lip-smacking
Fiddling with clothes
What is an epileptic seizure?
Intermittent stereotypes disturbance of consciousness, behaviour, emotion, motor function or sensation which is believed to be from abnormal neuronal discharge
Seizure types
Generalised seizures Tonic-clonic seizures Myoclonic seizures Clonic seizures Tonic seizures Atonic seizures Absence seizures
Classification of focal seizures
Characterised according to aura, motor features, autonomic features and a degree of awareness or responsiveness
May evolve into generalised convulsive seizure
Investigations for seizures
EEG for primary generalised epilepsies
MRI for patients under the age of 50 with possible focal onset seizures
CT
Video-telemetry if uncertainty about diagnosis
First line treatment of primary generalised epilepsies
Sodium valproate
Lamotrigine
Levetiracetam
First line treatment for partial and secondary generalised seizures
Lamotrigin
Carbamazepine
First line treatment for absence seizures
Ethosuximide
First line treatment for status epilepticus
Lorazepam
Midazolam
Second line treatment for status epilepticus
Sodium valproate
Phenytoin
Second line treatment for generalised epilepsy
Topiramate
Zonisamide
Carbamazepine
Second line treatment for partial seizures
Sodium valproate Topiramate Leviteracetam Gabapentin Pregabilin Zonisamide Lacosamide Perampanel Benzodiazepines
Side effects of sodium valproate
Tremor Weight gain Ataxia Nausea Drowsiness Transiet hair loss Pancreatitis Hepatitis
Side effects of carbamazepine
Ataxia Drowsiness Nystagmus Blurred vision Low serum sodium levels Skin rash
Side effects of lamotrigine
Skin rash
Difficulty sleeping
Side effects of levetiracetam
Irritability
Depression
Side effects of topiramate
Weight loss
Word-finding difficulties
Tingling hands and feet
Side effects of zonisamide
Bowel upset
Cognitive problems
Side effects of lacosamide
Dizziness
Side effects of pregabilin
Weight gain
Side effects of vigabatrin
Behavioural problems
Visual field defects
What is an arteriovenous malformation?
Congenital collection of swollen blood vessels that can rupture and cause cerebral haemorrhage, leading to epilepsy and a focal cerebral syndrome
What is status epilepticus?
Prolonged or recurrent tonic-clonic seizures persisting for more than 30 minutes with no recovery period in between seizures
Mortality of status epilepticus
5-10%
What is tonic-clonic status epilepticus?
Condition in which prolonged or recurrent tonic-clonic seizures persist for 30 minutes or more
First line treatment of status epilepticus
Midazolam 10mg by buccal or intranasal route
Lorazepam 0.07mg/kg
Diazepam 10-20mg IV or rectally
Second line treatment of status epilepticus
Phenytoin slow infusion of 15-18mg/kg at 50mg/min
Valproate 20-30mg/kg at 40mg/min
Third line treatment of status epilepticus
Anaesthesia, usually with propofol or thiopentone
Possible consequences of arteriorveous malformation (AVM)
Stroke, disability and death if bleeding injures surrounding brain tissue
Headaches
Seizures
Progressive paralysis
Investigations to diagnose AVM
Cerebral angiography
MRI
CT
Treatment of AVM
Embolisation
Radiation treatment
Surgical removal of AVM
Most serious complication of AVM
Bleeding
What percentage of bleeds of AVM results in permanent disability?
50%
other 50% result in death
DVLA regulations in relation to epilepsy
Patients can hold group 1 licence once they have been seizure free for a year or have an established pattern of only sleep related attacks for a year
Can only hold HGV or PSV licence if they have been seizure free for 10 years and are on anti-epileptic medication
