Epilepsy Flashcards
what is the differential diagnosis for blackout?
> syncope > first seizure > hypoxic seizure > concussive seizure > cardiac arrhythmia > non-epileptic attack
what do you need to get from the history from the patient?
> what were they doing > any warning signs > what were they doing the night before > how did the feel afterwards > injury or incontinence?
what information do you need from witnesses?
detailed observations before and during the attacks: > responsiveness > colour > breathing > vocalisation > behaviour following the attacks
what information is relevant or important in the history?
> age > sex > head injury, birth trauma and febrile convulsions > past psychiatric history > alcohol and drug abuse > family history
what is the most common cause of syncope?
vasovagal syncope
what prodromes syncope?
> light headed > nausea > hot/sweating > tinnitus > tunnel vision
what are the trigger warnings for vasovagal syncope?
> prolonged standing > standing up quickly > trauma > venepuncture > watching medical procedures > micturition > coughing
what features of syncope differ from seizures?
> happens in upright posture > pallor is uncommon > there is gradual onset > injury is rare > incontinence is rare > rapid recovery > precipitants common
how do seizures differ from syncope?
> any posture > pallor uncommon > sudden onset > injury is quite common > incontinence common > slow recovery > precipitants rare
when do hypoxic seizures occur?
when individuals are kept upright in a faint, there may be a succession of collapses then seizure like activity may occur
when do concussive seizure occur?
after a blow to the head
can seizures cause cardiac arrhythmias?
yes
what should you consider in a family history of sudden death and when collapse occurs during exercise?
> functional cardiac problems (long QT syndrome)
describe non-epileptic attacks
> commoner in women > may be frequent > prolonged > superficially resemble generalised tonic-clonic seizure > may resemble a swoon > involves bizarre alternating movements
what might be found in the history of a patient with non-epileptic attacks?
> history of other unexplained symptoms
> may have a history of abuse
what investigations would you carry out for a possible first seizure?
> blood sugar
ECG
consider drugs and alcohol
CT head (criteria)
what advice should be given to the patient with a first seizure?
> safety information
employment (they may need to inform them)
potentially dangerous leisure activities
driving regulations
after their first seizure how long until a patient can drive again if their investigations are normal and they have no further events?
6 months
when can a patient drive a HGV or PSV after their first seizure?
after 5 years if their investigations are normal, they have no further events and the are not on any anti-epileptic medication
when is epilepsy normally diagnosed?
after a second unprovoked attack (sometimes on taking the history after a first seizure if it is clear they have undiagnosed epilepsy)
in epilepsy what might occur in the morning?
myoclonic jerks
what features in a history would be suggestive of primary generalised epilepsy?
> myoclonic jerks
> absences/feeling strange with flickering lights
what features of a history is suggestive of focal onset epilepsy?
> deja vu sensation from the abdomen
> episodes of blank look with fiddling
what is epilepsy?
a condition in which seizures recur, usually spontaneously
what is an epileptic seizure?
an intermittent stereotyped disturbance of consciousness, behaviour, emotion, motor function or sensation which, on clinical grounds is believed to result from abnormal neural discharges
what is the incidence of epilepsy?
50-120 per 100000 per year
what shaped curve is seen in epilepsy?
j shaped
what is the prevalence of epilepsy?
5-8 per 1000
name some generalised seizures
> tonic-clonic seizures > myoclonic seizures > clonic seizures > tonic seizures > atonic seizures > absence seizures
describe a tonic-clonic seizure
there is a tonic stage where they can stop breathing then they enter the clonic stage and begin to breath again
describe an atonic seizure
the patient can rapidly collapse to the floor, resulting in injury though there is quick recovery
describe an absence seizure
children will frequently drift away then come back, they can grow out of it
what are focal seizures characterised by?
> aura
motor features
autonomic features
degree of awareness or responsiveness
what can focal seizures evolve into?
generalised convulsive seizure
describe primary generalised epilepsy
> no warning > <25 years > history of absences and myoclonic jerks, and GTCS > generalised abnormality on EEG > family history?
describe focal/partial epilepsies
> aura > any age > cause can be any focal brain abnormality > focal abnormality on the EEG > MRI may show the cause
what focal epilepsies may become secondarily generalised?
simple partial and complex partial seizures
what can you get the patient to do when carrying out an EEG for primary generalised epilepsies?
> hyperventilate
photic stimulation
sleep deprivation
when would you carry out a MRI for epilepsy?
patients under the age of 50 with possible focal onset seizures
what could you carry out if you were uncertain of the diagnosis?
video telemetry
what is the first line treatment for primary generalised epilepsies?
> sodium valproate
lamotrigine
levetiracetam
what is the first line treatment for partial and secondary generalised seizures?
> lamotrigine
> carbamazepine
what is the first line treatment for absence seizures?
ethosuximide
what is the first line treatment for status epilepticus?
> lorazepam
> midazolam
what is the second line treatment for status epilepticus?
> valproate
> phenytoin
what is the second line treatment for generalised seizures?
> topiramate
> zonisamide
what does carbamezapine make worse?
myoclonic jerks
what is sodium valproate, topiramate and leviteracetam a second line treatment for?
partial seizures
what are the side effects of sodium valproate?
> tremor > weight gain > ataxia > nausea > drowsiness > transient hair loss > pancreatitis > hepatitis
what are the side effects of carbamazepine?
> ataxia > drowsiness > nystagmus > blurred vision > low serum sodium levels > skin rash
what are the side effects of lamotrigine?
> skin rash
> difficulty sleeping
what are the side effects of levetiracetam?
> irritability
> depression
what are the side effects of topiramate?
> weight loss
word finding problems
tingling of the hands and feet
what are the side effects of zonisamide?
> bowel upset
> cognitive problems
what is the side effect of lacosamide?
dizziness
what is the side effect of pregabilin?
weight gain
what are the side effects of vigabatrin?
> behavioural problems
> visual field defects
when can patients hold a group one licence after a year?
> if they have been seizure free for a year
> if they have only had seizures arising from sleep for a year
when must a patient wait three years before they can drive again?
> if they have ever had a daytime seizure then the pattern becomes nocturnal
when can epileptic patients hold a HGV or PSV licence?
if they have been seizure free for 10 years and are not on antiepileptic medication
what is status epilepticus?
prolonged or recurrent tonic-clonic seizures persisting for more than 30 minutes with no recovery period between seizures
in what patients does status epilepticus normally occur?
in patients with no previous history of epilepsy (stroke, tumour, alcohol)
what is the first line treatment for TCSE?
> midazolam: buccal/intranasal repeated after 10 mins if necessary
lorazepam: 4mg bolus repeated once after 10mins
diazepam: 10-20mg IV or rectally repeated after 15mins if necessary
what is the second line treatment for TCSE?
> phenytoin
> valproate
what is the third line treatment of TCSE?
anaesthesia usually with propofol or thiopentone. this shuts down brain activity, they are loaded with anticonvulsants then woken up in 24 hours
in what groups is mortality from TCSE the greatest?
in the very young and old
what is reported in 24% percent of children who have an episode of status?
neurological problems
