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Year 3 Clinical > Epilepsy > Flashcards

Epilepsy Flashcards

1
Q

How to approach a consultation with a falls patients?

A

HISTORY (phone eye witness if necessary):
• Before
• During
• After

Examination:
• In epilepsy, exam has little/no benefit
• In syncope, CV examination, lying and standing BP are important

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2
Q

Important features in the onset of the event?

A

What were the doing?, e.g: environment
• Hot, stuffy or stressful environment is more suggestive of syncope

Symptoms:
• Light-headed or other syncopal symptoms (suggest syncope rather than a seizure)

What did they look like?
• Pallor, breathing
• Posturing of limbs, head turning (epilepsy type signs)

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3
Q

Important features during the event itself?

A

Types of movements:
• Tonic phase, clonic movements
• Carpopedal spasms (suggestive of hyperventilation), rigor

Responsiveness and awareness throughout:
• Epilepsy patients do not have any awareness (blank)

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4
Q

Important features after the event?

A

Speed of recovery:
• Syncopal patients recover immediately
• Epilepsy patients feel sleep, disorientated and take minutes-hours to recover
• Deficits

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5
Q

What are urinary incontinence and tongue biting a sign of?

A

Can occur in both syncope and epilepsy

These are not distinguishing signs

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6
Q

Risk factors for epilepsy?

A

Premature birth and peri-natal illness

Developmental delay

Seizures in the past (≥2 febrile seizures)

Head injury, inc. LOC

+ve FH

Illicit drugs (esp. benzodiazepines; these are used in treatment but, when used illicitly, doses vary so users suffer benzo withdrawal seizures)

Alcohol

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7
Q

Drugs that can trigger epileptic seizures?

A

All drugs can do this; often, a person with stable epilepsy can have a seizure due to a new drug

Examples:
• Antibiotics, esp. penicillins, cephalosporins, quinolones
• Aminophylline, theophylline
• Analgesics, commonly tramadol
• Anti-emetics, like prochlorperazine 
• Opiods, like diamorphine and pethidine
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8
Q

Ix in falls patients?

A

MANDATORY ECG - cardiac arrhythmias should not be missed (important cause of young adult death syndrome)

Imaging - MRI vs CT scan

EEG (mostly useless, unless specific situation)

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9
Q

Which presenting patients receive a CT scan acutely?

A

Those with:
• Clinical / radiological skull fracture
• Deteriorating GCS
• Focal signs
• Head injury with seizure
• Failure to have a 15/15 GCS, 4 hours after arrival
• Suggestion of other pathology, like SAH (sub-arachnoid haemorrhage)

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10
Q

Why is an EEG mostly useless?

A

Many normal, healthy patients have an abnormal EEG; it is not specific or sensitive

Healthy patients can have active epilepsy on their EEG; patients with epilepsy can have normal EEGs

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11
Q

Specific situations where an EEG is helpful?

A

Classifying epilepsy

Confirming non-epileptic attacks, e.g: elderly patient with acute confusional state; an EEG can be used if unsure about delirium, etc

Surgical evaluation

Confirmation of non-convulsive status

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12
Q

Differential diagnosis of epilepsy (conditions that are commonly confused with it)?

A

Syncope

Non-epileptic attack disorder:
• Pseudoseizures
• Psychogenic, non-epileptic attacks

Panic attacks / hyperventilation attacks

Sleep phenomena

Others:
• TIA
• Migraine
• Hypoglycaemia
• Parasomnias
• Paroxysmal movement disorders
• Cataplexy
• Periodic paralyses
• Tonic spasms of MS
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13
Q

Driving rules with seizures?

A

On 1st seizure:
• Car ban for 6 months
• HGV/PCV ban for 5 years

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14
Q

Driving rules with a diagnosis of epilepsy?

EXAMS

A

Car ban for 1 year; 3 years if during sleep

HGV/PCV drivers must be off medication for 10 years before they can regain their license

EXAMS

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15
Q

What is SUDEP?

A

Sudden Unexplained Death in Epilepsy

Higher risk if epileptic patient does not take their medication, misuses drugs or has no bed partner

Now, doctors are legally obliged to tell patients about SUDEP and allow them to make the decision on whether or not they want a bed partner

If well-controlled epilepsy, risk of sudden death is population-level

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16
Q

What is epilepsy?

A

A tendency to have recurrent, usually spontaneous, epileptic seizures

There is abnormal synchronisation of neuronal activity; this is typically excitatory, with high frequency APs, although it is sometimes inhibitory

Usually, epileptic seizures are brief, lasting only seconds - minutes; if >5 minutes, this is a worrying sign of status epilepticus

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17
Q

What is a seizure?

A

This does not always mean epilepsy; a patient may have a seizure and never have one again

However, always assume BRAIN TUMOUR until proven otherwise; this is one of the most common causes

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18
Q

Theories on why epilepsy occurs?

A

Too much excitation or inhibition

Changes in cell no. / types, in connectivity, in synaptic function, in voltage-gated ion channel function

Genetic cause

Acquired brain, metabolic, toxic and environmental factors

NO DEFINITIVE MECHANISM

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19
Q

Occurrence of epilepsy?

A

May occur at any age but most common in:
• Infancy (tends to be generalised epilepsy)
• Old age (tends to be focal epilepsy)

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20
Q

Classification of epilepsies?

A

FOCAL epilepsy - there is a focused discharge of electrical activity in a specific part of the brain that is structurally abnormal; in this region, the neurones are more sensitive and irritable:
• Seizures tend to stay in one area, leading to a focal seizure
OR
• Seizures can spread via a cortical network, leading to a generalised seizure
i.e: focal epilepsy can give rise to both focal and generalised seizures

GENERALISED - discharge of electrical activity starts on a cortical network, potentially at a focal point, and the seizure immediately propagates to become generalised
i.e: generalised epilepsy can only cause generalised seizures

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21
Q

Previous terminology for a focal epileptic seizure?

A

AKA partial seizure

2 types:
• Simple partial seizure - without impaired consciousness (AKA focal seizure without impaired consciousness)
• Complex partial seizure - with impaired consciousness (AKA focal seizure with impaired consciousness)

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22
Q

Motor signs of a partial seizure (depends on where the focal point is)?

A

Rhythmic jerking

Posturing

Head and eye deviation

Other movements, e.g: cycling

Automatisms, e.g: plucking

Vocalisation

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23
Q

Sensory signs of a partial seizure (depends on where the focal point is)?

A

Can have somatosensory, olfactory, gustatory, visual and auditory signs

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24
Q

Psychic signs of a partial seizure (depends on where the focal point is)?

A

Memories, déjà vu, jamais vu

Depersonalisation

Aphasia

Complex visual hallucinations

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25
Q

Types of generalised epileptic seizures?

A

Absence

Myoclonic

Atonic

Tonic

Generalised tonic clonic seizures

26
Q

Describe what happens during a generalised tonic clonic seizure

A

AKA primary generalised epileptic seizure

There are 2 components:
• Tonic - all muscles become rigid, due to massive discharge of both motor cortices; patients can stop breathing for short periods and become hypoxic
• Clonic - period of muscle relaxation
i.e: patient becomes tight and then relax, repeatedly, creating jerking movements

Initially, the jerking movements are of low amplitude; gradually, amplitude increases due to increased relaxation from a state of increased tone

27
Q

Cause of generalised epilepsy?

A

Most have a GENETIC predisposition; it tends to occur in childhood or teen years and does not occur >30 years

28
Q

EEG appearance of generalised epilepsy?

A

Spike-wave abnormalities on EEG

29
Q

Specific types of primary generalised epilepsy (AKA generalised tonic clonic seizures)?

A

Juvenile myoclonic epilepsy - presents with:
• Early morning jerks
• Generalised seizures

Risk factors for this inc. sleep deprivation and flashing lights

30
Q

Treatment of primary generalised epilepsy?

A

Treatment of choice - sodium valproate (excellent treatment choice); however, it is teratogenic and so cannot be used in young females

Alternative treatment - Lamotrigine

31
Q

Cause of focal onset epilepsy?

A

Underlying structural cause; these have a focal onset and may then potentially generalise (AKA secondary generalisation)

Onset at any age

A certain type (temporal lobe epilepsy) is characterised by complex partial seizures (AKA focal seizure with impaired consciousness); here, the structural abnormality is hippocampal sclerosis

32
Q

Treatment of focal onset epilepsy?

A

Most effective is Carbamazepine but poorly tolerated; an alternative is Lamotrigine

Sodium valproate also works well but it is not 1st choice, due to the side effects

33
Q

Effectiveness of anti-epileptic drugs (AEDs)?

A

55% seizure free with monotherapy

10% seizure free with polytherapy

35% have drug-resistant epilepsy

34
Q

Mechanisms of action of the AEDs?

A 
Inhibition of voltage-gated Na+ channel activity, reducing pre-synaptic excitability and ability of APs to spread:
• Carbamezapine
• Oxcarbazepine
• Eslicarbazepine
• Pheyntoin
• Lamotrigine
• Topiramate

Enhancing activity of voltage-activated K+ channels; channels opens and neurone is stabilised, reducing its excitability:
• Retigabine

Inhibition of N-type voltage-gated Ca2+ channels, which trigger NT release:
• Gabapentin
• Pregabalin

Inhibition of T-type Ca2+ channels:
• Ethosuximide

Bind to SV2A, interfering with synaptic vesicles and inhibit NT release:
• Levetiracetam

Enhance GABA A receptor to GABA:
• Benzodiazepines
• Barbiturates
• Topiramate

35
Q

Treatment of partial (focal) seizures?

A

CARBAMEZAPINE or LAMOTRIGINE

Other options inc:
• Oxcarbazepine
• Topiramate
• Levetiracetam
• Sodium valproate
36
Q

‘Add on’ drugs in the treatment of partial / focal seizures?

A

Gabapenin, pregabalin, tiagicine, zonisamide, vigabatrin, clonazepam, clobazma

37
Q

Older drugs (not frequently used anymore) in the treatment of partial / focal seizures?

A

Phenytoin, phenobarbitone, primidone

38
Q

Treatment of generalised absence seizures?

A

Sodium valproate

OR

Ethosuximide

39
Q

Treatment of generalised myoclonic seizures?

A

Sodium valproate

OR

Levetiracetam

OR

Clonezapam

40
Q

Treatment of atonic, tonic or generalised tonic clonic seizures?

A

SODIUM VALPROATE

Other options:
• Levetiracetam
• Topiramate
• Lamotrigine

41
Q

Why is phenytoin no longer used in the long-term management of epilepsy?

A

Only used for acute management only

It is an enzyme inducer, so it can make other drugs metabolising through the liver less effective

42
Q

Side effects of sodium valproate?

A

TERATOGENIC

Other are weight gain, hair loss and fatigue

It remains an excellent anti-convulsant and one of the best

43
Q

Cautions with carbamazepine?

A

Only used for focal onset seizures

It can make primary generalised epilepsies worse

44
Q

Use of Lamotrigine?

A

Well-tolerated in both generalised and focal epilepsies

However, it takes a long time to titrate up (as it causes skin rash, Steven-Johnson Syndrome, etc)

45
Q

Use of Levetiracetam?

A

Popular as it has few interactions and is well-tolerated

It can cause mood swings

46
Q

Side effects of topiramate?

A

Sedation, dysphasia, weight gain

Unmasks underlying psychiatric disorders

It is not part. well tolerated

47
Q

Use of gabapentin and pregabalin?

A

Not often used as anti-convulsants

Usually used for neuropathic pain

48
Q

Indications for AED use?

A

If the patient has epilepsy

If the patient had a single seizure but was at a high risk of recurrence

Only give if the patient wants the drug

49
Q

Which anti-convulsants induce hepatic enzymes?

A

Carbamazepine, oxcarbazepine, phenobarbitol, phenytoin, primidone, topiramate

50
Q

Side effects of anti-convulsants that are hepatic enzyme inducers and how this is significant for women?

EXAMS

A

Can alter efficacy of combined oral contraceptive pill

Should not use progesterone only pill; also, depot progesterone needs more frequent dosing

Progesterone implants no longer effective

Morning after pill not adequate with enzyme-inducing AEDs (dose should be increased)

51
Q

Other issues with anti-convulsants that should be considered in women?

A

Preconceptual counselling and potential risk of teratogenecity

Supplementation of folic acid and vitamin K

52
Q

What is status epilepticus?

A

Recurrent epileptic seizures, without full recovery of consciousness; it is an acute, prolonged epileptic crisis

There is continuous seizure activity lasting more than >30 minutes OR 2/more seizures without full recovery of consciousness between

53
Q

Categories of status epilepticus?

A

Convulsive status - generalised convulsions without cessation; there is excess cerebral energy demand and poor substrate delivery, causing lasting damage

Non-convulsive status - patient is conscious but the level is altered (almost like an altered state)

54
Q

Types of convulsive status

A

Generalised convulsive status epilepticus - essentially have continuous and recurrent generalised tonic clonic seizures

Epilepsia partialis continua - continual focal seizures where the consciousness preserved

55
Q

Consequences of convulsive status?

A

Respiratory insufficiency and hypoxia

Hypotension

Hyperthermia

Rhabdomyolysis

56
Q

Precipitants of status epilepticus?

A

ABRUPT WITHDRAWAL of anti-convulsants

Severe metabolic disorders:
• Hyponatraemia
• Pyridoxine deficiency

Infection

Head trauma

Sub-arachnoid haemorrhage (SAH)

Treating absence (generalised) seizures with carbamazapine (can make primary generalised epilepsies worse)

57
Q

Mortality of status epilepticus?

A

~15%

58
Q

Management of status epilepticus?

A

ABCDE (stabilise patient) and identification of a cause (emergency blood tests +/- CT scan)

Anti-convulsants:
• Phenytoin (check levels beforehand)
• Keppra
• Sodium valproate (given acutely regardless of side effects)
• Benzodiazepines (lorazepam or diazepam)

If status persists, transfer to ITU

59
Q

Cautions with use of benzos acutely for status epilepticus?

A

It is given controlled, i.e: given acutely in the first 10 minutes; no more than 2 doses of 10mg are given

This is because any more is unlikely to help and may cause respiratory depression, aspiration, etc

60
Q

Treatment of a seizure acutely?

A

Nothing other than waiting and removing dangers; benzos are not given unless it is status epilepticus

If it persists for >5 minutes, suspect status; treat and transfer to ITU

Year 3 Clinical (100 decks)

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