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Systems: Neurology AB > Epilepsy > Flashcards

Epilepsy Flashcards

1
Q

What is the differential diagnosis for a blackout?

A
  • Syncope
  • First seizure
  • Hypoxic seizure
  • Concussive seizure
  • Cardiac arrhythmia
  • Non-epileptic attack
  • Less common reasons (narcolepsy, movement disorders, migraine)
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2
Q

How do you differentiate between the causes of blackout?

A
  • Detailed history from patient
  • Detailed history from witness
  • (Tests)
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3
Q

What history should you try to take from the patient?

A
  • What were they doing at the time?
  • What, if any, warning feelings did they get?
  • What were they doing the night before?
  • Have they had anything similar in the past?
  • How did they feel afterwards?
  • Any injury, tongue biting or incontinence?
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4
Q

What history should you try and take from the witness?

A
  • Detailed description of observations before and during attacks - including level of responsiveness, motor phenomena, pulse, colour, breathing, vocalisation
  • Detailed description of behaviour following attacks
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5
Q

What information about the patient may be relevant to differentiate the cause of a blackout?

A
  • Age
  • Sex
  • Past medical history including head injury, birth trauma and febrile convulsions
  • Past psychiatric history
  • Alcohol and drug use
  • Family history
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6
Q

What is the most common cause of fainting?

A

Vasovagal syncope

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7
Q

What is the prodrome to syncope?

A
  • Light-headed, nausea
  • Hot, sweating
  • Tinnitus
  • Tunnel vision
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8
Q

What are the potential triggers for vasovagal syncope?

A
  • Prolonged standing
  • Standing up quickly
  • Trauma
  • Venepuncture
  • Watching/experiencing medical procedures
  • Micturition
  • Coughing
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9
Q

In what posture does syncope usually occur?

A

Upright posture

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10
Q

In what posture does seizure usually occur?

A

Any posture

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11
Q

What is the onset speed of syncope?

A

Gradual onset

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12
Q

What is the onset speed of seizure?

A

Sudden onset

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13
Q

Does injury usually occur in syncope?

A

It is rare

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14
Q

Does injury usually occur in seizure?

A

It is quite common

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15
Q

Does incontinence usually occur in syncope?

A

It is rare

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16
Q

Does incontinence usually occur in seizure?

A

It is common

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17
Q

What is the recovery speed of syncope?

A

Rapid recovery

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18
Q

What is the recovery speed of seizure?

A

Slow recovery

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19
Q

Does syncope usually have a precipitant?

A

It is common

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20
Q

Do seizures usually have precipitants?

A

It is rare

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21
Q

Does pallor usually occur in syncope

A

It is common

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22
Q

Does pallor usually occur in seizure?

A

It is uncommon

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23
Q

When do hypoxic seizures occur?

A

Occur when individuals are kept upright in a faint

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24
Q

Where can hypoxic seizures occur?

A

Can occur in aircraft, at the dentist, when well-meaning passersby help people to their feet….

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25
Q

What may occur in hypoxic seizures?

A
  • Patient may have a succession of collapses

- Seizure like activity may occur

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26
Q

When can concussive seizures occur?

A

After any blow to the head

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27
Q

What can cause cardiac arrhythmias?

A
  • Structural cardiac abnormalities

- Functional cardiac problems e.g. Long QT syndromes

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28
Q

When should cardiac arrhythmias be considered as the cause of blackout?

A

Consider particularly when there is a family history of sudden death, when there is a cardiac history and when collapse occurs with exercise

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29
Q

What can initiate a cardiac arrhythmia?

A

Seizure

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30
Q

Who do non-epileptic attacks usually affect?

A

Women

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31
Q

Hoe do non-epileptic attacks usually present?

A
  • Can be frequent
  • May look bizarre
  • Can be prolonged
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32
Q

What may there be a history of in non-epileptic attacks?

A
  • May have a history of other medically unexplained symptoms

- May have history of abuse

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33
Q

What may non-epileptic attack resemble?

A
  • May superficially resemble a generalised tonic-clonic seizure
  • May resemble a swoon
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34
Q

What investigations should be carried out for a possible first seizure?

A
  • Blood sugar
  • ECG
  • Consider effects of alcohol and/or drugs
  • CT head
35
Q

What advice should be given to patients following a possible first seizure?

A
  • Give copies of safety information sheets and information about the first seizure clinic
  • Enquire about their employment – they may need to inform their employer
  • Enquire about potentially dangerous leisure activities
  • Explain the driving regulations
36
Q

What are the driving regulations for someone who has suffered a seizure?

A
  • After a first seizure, a patient may drive a car after 6 months if their investigations are normal and they have had no further events
  • They may drive an HGV or PSV after 5 years if their investigations are normal, they have no further events and they are not on anti-epileptic medication
37
Q

When is epilepsy usually diagnosed?

A

Normally diagnosed after a second unprovoked attack but sometimes on taking the history after a first seizure, it is clear that they have undiagnosed epilepsy.

38
Q

What features are suggestive of epilepsy?

A
  • History of myoclonic jerks, especially first thing in the morning, absences or feeling strange with flickering lights – in keeping with a primary generalised epilepsy
  • History of “deja vu”, rising sensation from abdomen, episodes where look blank with lip-smacking, fiddling with clothes – suggest a focal onset epilepsy
39
Q

What is an epileptic seizure?

A

An epileptic seizure is an intermittant stereotyped disturbance of consciousness, behaviour, emotion, motor function or sensation which, on clinical grounds, is believed to result from abnormal neuronal discharges

40
Q

What is epilepsy?

A

A condition in which seizures recur, usually spontaneously

41
Q

What is the incidence of epilepsy?

A

Incidence: 50 - 120 per 100 000 per year

42
Q

What is the prevalence of epilepsy?

A

Prevalence: 5 – 8 per 1000 (Aberdeen 0.9%)

43
Q

What is the correlation between learning disabilities and epilepsy?

A

22% of people with learning difficulties have epilepsy

44
Q

How is epilepsy classified?

A
  • The International League Against Epilepsy (ILAE) have classified epileptic seizures into groups using clinical data and electroencephalography (EEG) evidence
  • They have also produced a classification of epilepsy syndromes
45
Q

What are the ILAE epilepsy classifications of generalised seizures?

A
  • Generalised Seizures:
  • Tonic-clonic seizures
  • Myoclonic seizures
  • Clonic seizures
  • Tonic seizures (stiffening movements)
  • Atonic seizures (really rapid drop to the floor)
  • Absence seizures (looks as if they aren’t paying attention/may not even notice, short lasting)
46
Q

What are focal seizures characterised according to?

A
  • Aura
  • Motor features
  • Autonomic features
  • Degree of awareness or responsiveness
47
Q

What can focal seizures evolve into?

A

Generalised convulsive seizure

48
Q

Do you get a warning with a primary generalised seizure?

A

No warning

49
Q

Who is usually affected by primary generalised seizures?

A

<25 years

50
Q

What may there be a history of in primary generalised seizures?

A

May have history of absences and myoclonic jerks as well as GTCS e.g in juvenile myoclonic epilepsy

51
Q

What may be seen on EEG of primary generalised seizures?

A

Generalised abnormality on EEG

52
Q

Is there a family history in primary generalised seizures?

A

May have a family history

53
Q

What may you get before a focal/partial seizure?

A

May get an aura

54
Q

Who is usually affected by focal/partial seizures?

A

At any age as cause can be any focal brain abnormality

55
Q

What can simple partial and complex partial seizures become?

A

Secondarily generalised

56
Q

What may be seen on EEG of a focal/partial seizure?

A

Focal abnormality on EEG

57
Q

What may an MRI show with regards to focal/partial seizures?

A

MRI may show underlying cause

58
Q

How can epilepsy present in learning difficulties?

A
  • Patients can have unclassifiable seizures which are unique to them
  • They can also have repetitive movements and apparently fairly stereotyped events which are behavioural but which can be difficult to diagnose
59
Q

What investigations should be carried out when diagnosing epilepsy?

A
  • EEG for primary generalised epilepsies including hyperventilation and photic stimulation: sometimes sleep deprivation
  • MRI for patients under age 50 with possible focal onset seizures: CT usually adequate to exclude serious causes over this age
  • Video-telemetry if uncertainty about diagnosis
60
Q

What is the first line treatment for primary generalised seizures?

A
  • Sodium valproate
  • Lamotrigine
  • Levetiracetam
61
Q

What is the first line treatment for partial and secondary generalised seizures?

A

Lamotrigine or carbamazepine

62
Q

What is the first line treatment for absence seizures?

A

Ethosuximide

63
Q

What is the first line treatment for status epilepticus?

A
  • Midazolam: 10mg by buccal or intra-nasal route, repeated after 10mins if necessary
  • Lorazepam: 0.07mg/kg, usually 4mg bolus repeated once after 10 mins
  • Diazepam: 10 - 20mg iv or rectally, repeated after 15 mins if necessary
64
Q

What is the second line treatment for status epilepticus?

A
  • Phenytoin - slow infusion of 15 – 18mg/kg at 50mg/min

- Valproate – 20 -30mg/kg iv at 40mg/min

65
Q

What can be used IV for status/near status?

A

Levetiracetam

66
Q

What is the second line treatment for generalised epilepsy?

A
  • Topiramate
  • Zonisamide
  • (Carbamazepine)
67
Q

What is the second line treatment for partial seizures?

A
  • Sodium valproate
  • Topiramate
  • Leviteracetam
  • Gabapentin
  • Pregablin
  • Zonisamide
  • Lacosamide
  • Perampanel
  • Benzodiazepines
68
Q

What are the possible side effects of sodium valproate?

A
  • Tremor
  • Weight gain
  • Ataxia
  • Nausea
  • Drowsiness
  • Transient hair loss
  • Pancreatitis
  • Hepatitis
69
Q

What are the possible side effects of carbamazepine?

A
  • Ataxia
  • Drowsiness
  • Nystagmus
  • Blurred vision
  • Low serum sodium levels
  • Skin rash
70
Q

What are the possible side effects of lamotrigine?

A
  • Skin rash

- Difficulty sleeping

71
Q

What are the possible side effects of levetiracetam?

A
  • Irritability

- Depression

72
Q

What are the possible side effects of topiramate?

A
  • Weight loss
  • Word-finding difficulties
  • Tingling hands and feet
73
Q

What are the possible side effects of zonisamide?

A
  • Bowel upset

- Cognitive problems

74
Q

What are the possible side effects of lacosamide?

A

-Dizziness

75
Q

What are the possible side effects of pregablilin?

A

-Weight gain

76
Q

What are the possible side effects of vigabatrin?

A

Behavioural problems and visual field defects

77
Q

What is the driving restriction for someone with epilepsy?

A
  • Patients can hold a Group 1 licence once they have been seizure free for a year or have only had seizures arising from sleep for a year. If they have ever had a day time seizure but then the pattern becomes noctural, this must be established for three years before they can drive
  • They can only hold a HGV or PSV licence if they have been seizure free for 10 years and are not on anti-epileptic medication
78
Q

What is status epilepticus?

A

Prolonged or recurrent tonic-clonic seizures persisting for more than 30 minutes with no recovery period between seizures

79
Q

How many cases of status are there a year?

A

9,000 - 14,000 cases /year in the U.K

80
Q

Who does status usually occur in?

A

Usually occurs in patients with no previous history of epilepsy (stroke, tumour, alcohol)

81
Q

What is the mortality rate of status?

A

5-10%

82
Q

What is the 3rd line treatment for status epilepticus?

A

Anaesthesia usually with propofol of thiopentone

83
Q

What is the outcome of status?

A
  • Mortality greatest in very young and very old (29% of those < 1 year)
  • 90% of deaths are a result of the underlying cause
  • Mortality is highest secondary to strokes, encephalitis, mass lesions and trauma
  • However in children the status itself is important - neurological problems reported in 24% following episode of status.
84
Q

What does SUDEP stand for?

A

Sudden unexplained death in epilepsy

Systems: Neurology AB (51 decks)

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