Epilepsy Flashcards
Definition of an epileptic seizure
An intermittent stereotyped disturbance of consciousness, behaviour, emotion and motor function or sensation which, on clinical grounds, is believed to result from abnormal neuronal discharges
Definition epilepsy
A condition in which seizures recur, usually spontaneously
What age does epilepsy occur?
J shaped curve
- high in infancy and - childhood
- then falls in adulthood
- increases when older (mostly due to CVS problems)
What % of people with learning disorders have epilepsy?
22%
What classifies epilepsy?
International league against epilepsy (ILAE)
What classifies epilepsy into groups?
Clinical data
EEG
What does EEG stand for?
Electroencephalogram
Two broad types of epileptic seizures
Generalized
Focal
Types of generalised seizures
Tonic-clonic Myoclonic Clonic Tonic Atonic Absence
Features of tonic clonic seizures
Usually start tonic (stiff - may stop breathing for a while)
Then go into jerking clonic (and start breathing again)
Features of myotonic seizures
Very clumsy and jerky especially in the mornings
Features of clonic seizures
Jerking movements
Features of tonic seizures
Stiffening movement
Features of atonic seizures
Collapse to the floor very rapidly
Features of absence seziures
Lasts seconds, may not see even see if not looking for it
What age do children usually grow out of absence seizures?
12
What is very common with atonic seizures?
Facial / head injuries
What are focal seizures characterised by?
Aura
Motor features
Autonomic features
Degree of awareness or responsiveness
What may focal seizures evolve into?
Generalized convulsive seizures
Definition of status epilepticus
Prolonged or recurrent tonic-clonic seizures persisting for more than 30 minutes with no recovery period between seizures
What will status epilepticus cause unless intervention?
Brain damage
Who does status epilepticus usually occur in?
No previous history or epilepsy (r.g. caused by stroke, tumour, alcohol)
Mortality of status epilepticus
5 - 10%
Do most people who have a first seizure go onto develop epilepsy?
NO
Where does epilepsy develop in the brain?
Grey matter
What does SUDEP stand for?
Sudden unexplained death in epilepsy
What does TCSE stand for?
Tonic clonic status epilepticus
Who has the greatest mortality in TCSE?
Very young
Very old
How many people with epilepsy have SUDEP?
1 in 1000 every year
Differential diagnosis of blackouts
Syncope First seizure Hypoxic seizure Concussive seizure Cardiac arrythmia Non-epileptic attack (narcolepsy, movement disorder, migraine)
What questions should be asked in the history about a seizure from the patient?
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?
What questions should be asked in the history about a seizure from a witness?
Detailed description of observations before and during attacks - including level of responsiveness, motor phenomena, pulse, colour, breathing, vocalisation
Detailed description of behavior following the attack
What additional information to ask about which may potentially be relevant?
Age Sex PMH - head injury - birth trauma - febrile convulsions Past psychiatric history Alcohol and drug use FH
What is the most common cause of fainting?
Vasovagal syncope
Prodrome for vasovagal syncope
Light headedness Nausea Tinnitus Hot, sweating Tunnel vision
Triggers for vasovagal syncope
Prolonged standing Standing up quickly Trauma Venepuncture Watching/experiencing medical procedures Micturition Coughing
Definition of micturition
Act of passing urine
Presentation of syncope
Upright posture
Pallor common
Prodromal symptoms
Onset of syncope
Gradual onset
Results of syncope
Injury rare
Incontinence rare
Are precipitants common in syncope?
Yes
How quick is recovery in syncope?
Rapid
Presentation of seizure
Any posture
Pallor uncommon
Movements
Onset of seziure
Sudden onset
Results of a seizure
Injury common
Incontinence common
Recovery time of a seizure
Slow
Are precipitants common for a seizure?
No
When do hypoxic seizures occur?
When individuals are kept upright in a faint - then the faint turns into a seizure
Where are common places for hypoxic seizures to occur?
Aircrafts on the upright chairs
Someone catching someone who is fainting and help them to their feet
When do concussive seizures occur?
After any blow to the head
Why are you unlikely to have a seizure during exercise?
Because the brain is very busy
Can seizures cause cardiac arrythmias?
Yes
Which gender are non epileptic attacks more common in?
Women
Most epileptic attacks are over in how long?
5 minutes
If a seizure if over 5 minutes long, what is it not likely to be?
An epileptic attack
Clues in the history pointing towards a non epileptic attack
History of other medically unexplained symptoms
History of abuse
Presentation of a non epileptic attack
Well in between attacks
May look bizarre
May superficially resemble a generalised tonic clonic seizure
Movement of arm and legs and movement of head from side to side
May resemble a “swoon” (flat on the ground looking pale)
May involve bizarre movements
What is the most common ages for getting primary generaised seziures?
< 25 y/o
What is common to get before a focal/partial seizure?
Aura
What age is common for getting focal seizures?
Any age
What can simple partial and complex partial seizures become?
Secondary generalised
Types of focal seizures
Simple partial
Complex partial
What is a simple partial seizure?
You are still aware but e.g. arm may be jerking
What is a complex partial seizure?
When there is any loss of consciousness at all
What may show a cause when there is a focal/partial seizure?
MRI
Investigations of possible first seizures
Blood glucose
ECG
Alcohol / drugs
CT head
Features suggestive of primary generalised epilepsy
History of myoclonic jerks, especially first thing in the morning
Absences of feeling strange with flickering lights
Features suggestive of focal onset epilepsy
History de ja vu rising in sensation from abdomen
Episodes where look blank with lip smacking, fiddling with clothes
Stimulants for EEG for primary onset epilepsy
Hyperventilation
Photic stimulation
Sleep deprivation
What % of primary generalised seizures are picked up on EEG?
70%
What do patients need to get advise on when have a seizure?
Employment
Potentially dangerous leisure activities
Driving regulations
First line treatment of juvenile myoclonic epilepsy
Sodium valproate
Who is sodium valproate avoided in and why?
Young women
Teratogenic
First line treatment for primary generalised epilepsy
Levetiracetam
First line treatment for partial and secondary generalised seizures
Lamotrigine
Carbamazepine
First line treatment for absence seziures
Ethosuximide
First line treatment for status epilepticus
Lorazepam Midazolam (diazepam) Valproate phenytoin Levetiracetam IV
Second line treatment for generalised epilepsy
Topiramate
Zonisamide
Second line treatment for partial seziures
Sodium valproate Topiramate Leviteraetam Gabapentin Pregabilin Zonisamide Lacosamide perampanel Benzodiazepines
Side effects of sodium valproate
Tremor (in high doses) Weight gain Ataxia Nausea Drowsiness Transient hair loss Pancreatitis Hepatitis
Side effects of carbamazepine
Ataxia Drowsiness Nystagmus Blurred vision Low serum sodium levels Skin rashes
Side effects of lamotrigine
Skin rash
Sleep difficulties
Side effects of levetiracetam
Irritability
Depression
Side effects of topiramate
Weight loss
Word finding difficulties
Tingling in 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
Treatment of TCSE
1st line - midazolam - lorazepam - diazepam 2nd line - phenyotin - valproate 3rd line - anaesthesia usually with propofol or thopentone
What are the driving regulations with epilepsy?
After a first seizure
- can drive after 6 months if investigations are normal and have no further events
- if scan or EEG abnormal or seizure likely alcohol related, cannot drive for one year
- can drive HGV or PSV after 5 years if investigations are normal, have no further events and are not on anti-epileptic medication
What is the most common first line medication for terminating acute seizures?
Benzodiazepines
1st line treatment for focal seizures
Carbamazepine
Lamotrigine
1st line treatment for a male with generalised tonic clonic seizures
Sodium valproate
1st line treatment for a male with myoclonic seizures
Sodium valproate
What is the protocol for stopping anti epileptic drugs?
Can be considered if seizure free > 2 years, with AEDs being stopped over 2 - 3 months
If a one of seizure (no diagnosis of epilepsy), how long can they not drive for?
6 months
If diagnosis of epilepsy, how long do they have to be seizure free before driving?
12 months
What is carbamazepine generally INEFFECTIVE in treating?
Absence seizures
What are localising features of a temporal lobe seizure?
Lip smacking
Post ictal dysphagia
What do jacksonian movements in children indicate?
Frontal lobe epilepsy
Indications of temporal lobe seizure
Aura
Lip smacking
Clothes plucking
Indications of parietal seizures
Sensory abnormalities
First line treatment for patients with early status epilepticus
IV lorazepam
What is likely to represent a pseudoseizure / psychogenic non epileptic seizure?
Widespread convulsions without conscious impairment
Stepwise treatment of paediatric status elipticus
- Buccal midazolam / IV lorazepam
- IV lorazepam
- IV phenytoin
- Rapid sequence induction of anaesthesia using thiopental sodium
Anti epileptic medication should NOT be started after a first seizure before review except in certain cases, which are….
- Seizure activity observed on EEG
- Presence of a neurological deficit
- Presence of a structural brain abnormality
- Patient, carer or parent considers the risk of a further seizure to be unacceptable
What would buccal midazolam be used for and who would it be prescribed to?
For status elipticus
Only prescribed to patients who have had a previous episode of prolonged or sequential generalised seizures
When a patient is in status elipticus, what two most important causes should be ruled out 1st as a cause?
Hypoxia
Hypoglycaemia
What are psychogenic non epileptic seizures also known as?
Pseudoseizures
Factors favouring pseudoseizures
Pelvic thrusting Family member with epilepsy Much more common in females Crying after seizure Don't occur when alone Gradual onset
What blood test can indicate that it was a true epileptic seizure and not a pseudoseizure?
Raised serum prolactin 10 - 20 mins after an episode
Describe jacksonian march with secondary generalisation
Characteristically starts by affecting a peripheral body part such as a big toe, finger or section of the lip and then spreads quickly ‘ marches ‘ over the respective foot, hand or face
The electrical disorder can then spread over larger areas of the brain causing the seizure to develop into a tonic clonic seizure
What type of seizure is a jacksonian march?
Focal aware seizure
What diet is used in treatment of epilepsy in children that is hard to control and is generally unresponsive to antiepileptic medications?
Ketogenic diet
What does the ketogenic diet consist of?
High fat
Low carb
Controlled protein
