Epilepsy Flashcards
What are RFs for epilepsy?
Birth Development Past seizures Head injury (inc. LOC) FHx Drugs Alcohol
In 1st seizure clinic is examination important?
No- has little/no benefit
What should be examined if a diagnosis of syncope is suspected?
CVS examination
L+S BP important
What Ix should be considered in fallen patient?
ECG- mandatory
Imaging- MRIb vs CTb
Possible EEG- 0.5-4% of interictal EEGs are abnormal
What fallen patients will get a CT acutely?
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 another pathology- eg SAH
What conditions are commonly confused with epilepsy?
Syncope
Non-epileptic attack disorder (pseudoseizures, psychogenic non-epileptic attacks)
Panic attacks / Hyperventilation attacks
Sleep phenomena
What should be explain regarding seizures/epilepsy and driving?
1st seizure car- 6 months, 5y for HGV/PCV
Epilepsy car- 1y or 3y during sleep, 10y off medication for HGV/PCV
Discuss SUDEP
What is epilepsy?
A tendency to recurrent, usually spontaneous, epileptic seizures
Why do epileptic seizures occur?
Abnormal synchronisation of neuronal activity- usually excitatory with high frequency action potentials, sometimes predominantly inhibitory
Interruption of normal brain activity- focally, generalised
How long do epileptic seizures usually last?
Brief- seconds to minutes
What neurological changes occur in epilepsy?
Cell numbers/types
Connectivity
Synaptic function
Voltage gated ion channel function
What are the contributing factors to epilepsy?
Genetic Acquired Brain Metabolic Toxic Environmental
How common is epilepsy?
50-80/100000
At what age does epilepsy occur?
Any age, but most commonly infancy and old age
How many people die of epilepsy each year?
1 in 400, young adults with severe epilepsy being 1 in 100
Can a generalised seizure start from a focal point?
Yes
How is epilepsy classified?
Epileptic Seizures (Semiology, EEG)- generalised, partial-focal site of origin Epilepsy syndrome (seizure type, age, aetiology) Aetiology
What is the classification of partial epileptic seizures?
Simple: without impaired consciousness
Complex: with impaired consciousness
What is the classification of general epileptic seizures?
Absence Myoclonic Atonic Tonic Tonic clonic
How are epileptic seizures classified?
Partial
Generalised
Unclassified
What is the motor semiology of partial seizures?
Rhythmic jerking Posturing Head and eye deviation Other movements (e.g. cycling) Automatisms (eg plucking) Vocalisation
What is the sensory semiology of partial seizures?
Somatosensory Olfactory Gustatory Visual Auditory
What is the psychic semiology of partial seizures?
Memories Deja vu Jamais vu Depersonalisation Aphasia Complex visual hallucinations etc
What predisposition to do most generalised epilepsies have?
Genetic
What findings are usually seen on EEG in generalised epilepsy?
Spike-wave abnormalities
When does generalised epilepsy usually present?
Childhood and adolescence
What is the 1st line treatment of primary generalised epilepsy?
Sodium valproate (teratogen) Lamotrigine as alternative/if pregnant
What occurs in juvenile myoclonic epilepsy?
Early morning jerks
Generalised seizures
What are RFs for juvenile myoclonic epilepsy?
Sleep deprivation
Flashing lights
What is the cause of focal onset epilepsy?
Underlying structural cause
When does focal onset epilepsy present?
Any age
What occurs in focal onset epilepsy?
Frequent complex partial seizures with hippocampal sclerosis
What is the treatment of focal onset epilepsy?
Carbamazepine or lamotrigine (sodium valproate works well, but avoided due to S/Es)
What percentage of epilepsies are ‘drug resistant’?
35%
What system is targeted by antiepileptic drugs (AEDs)?
GABA
What is the initial treatment for partial seizures?
Carbamazepine and lamotrigine first line Oxycarbazepine Levetiracetam Topiramate Sodium valproate
What are ‘add on’ drugs for partial seizures?
Gabapentin Tiagabine Pregabalin Zonisamide Vigabatrin Clonazepam Clobazam
What is the first line treatment for absence generalised seizures?
Sodium valproate
Ethosuximide
What is the second line treatment for absence generalised seizures?
Topiramate
Levetiracetam
What is the first line treatment for myoclonic generalised seizures?
Sodium valproate
Levetiracetam
Clonazepam
What is the second line treatment for myoclonic generalised seizures?
Lamotrigine
Topiramate
What is the first line treatment for atonic, tonic and generalised tonic clonic seizures?
Sodium valproate
What is the second line treatment for atonic, tonic and generalised tonic clonic seizures?
Levetiracetam
Topiramate
Lamotrigine
When is phenytoin used in seizure management?
Acutely- rapid loading possible
What are some S/Es of sodium valproate?
Wt gain
Teratogenic
Hair loss
Fatigue
What can carbamazepine do to primary generalised seizures?
Make them worse
Does lamotrigine take a long time to titrate up?
Yes
Describe levetiracetam use
Few interactions with other medications
Well tolerated, though can cause mood swings
What are some S/Es of topiramate?
Sedation
Dysphasia
Wt loss
(Not particularly well tolerated)
When are drugs given in seizure management?
If diagnosed as epilepsy
If single seizure but high risk of recurrence
Only if patient wants drug
What anticonvulsants induce hepatic enzymes?
Carbamazepine Oxcarbazepine Phenobarbitol Phenytoin Primidone Topiramate
What can the enzyme induction properties of some anticonvulsants effect, and what does this mean?
Can alter efficacy of combined oral contraceptive pill
Shouldn’t use POP
Depot progesterone needs more frequent dosing, progesterone implants not effective
Morning after pill not adequate- increase dose
