Epilepsy Flashcards
What should you always ask the patient about a suspected seizure?
What happened before?
During?
After?
Was there an eye witness who could describe their before, during and after?
What should you ask the patient and eye witness about the onset of a suspected seizure?
- What were they doing? Environment (flashing lights?)
- Symptoms (syncope?)
- What did they look like? (Pale, deep breathing, limb posture, head turning)
What should you ask the patient/ eyewitness about during the event?
- Making movements? (Tonic/clonic, Corpopedal spasms, rigors)
- Was pt responsive/aware throughout?
What should you ask the patient/eye witness about after the event?
- Speed of recovery
- sleepiness/disorientation
- Neurological deficits
What are potential risk factors for epilepsy?
- Birth/ developmental problems
- seizures in past (inc. febrile fits)
- head injury (inc. LOC)
- family history
- drugs, alcohol
If you suspect a patient is just experiencing syncope, what examinations are important?
cardiovascular examination
Lying + Standing BP important
Even if you are suspective of a seizure, what investigation should always be done and why?
ECG
- may diagnose Long QT which is fatal AND can make patients prone to seizures
What patients get an acute CT?
- skull fracture
- Deteriorating/unresolving GCS
- Focal signs
- Head injury with seizure
- Suggestion of other pathology – eg Subarachnoid Haemorrhage
Why are EEGs usually not necessary?
Many of the general population have an abnormal EEG despite not having epilepsy
How long must epileptic patients wait after a seizure to drive again?
1st SEIZURE (not epilepsy) – car = 6 months, 5 years for HGV
Epilepsy – car = 1 year or 3 years during sleep
1 yr if conscious seizures exclusively
10 years off medication for HGV
Raising a limb and turning of the head indicates a seizure in what part of the brain?
Frontal lobe seizure phenomenon
Tongue biting and loss of urinary continence are specific features of generalised seizures. TRUE/FALSE?
FALSE
these symptoms are NOT seizure specific
e.g. pt can lose urinary continence during a vaso-vagal episode
Why should you check a patient’s drug history before making a diagnosis of seizure?
Incase they are on medication which could cause syncope/ fall
e.g. BP meds
What classes of drug are known to induce seizures?
antibiotics - penicillins, quinolones etc
painkillers (tramadol) and opioids
Anti-emetics e.g. prochlorperazine
What indicates the need for an EEG?
- to classify epilepsy
- to confirm non-epileptic attacks
- to confirm non-convulsive status epilepticus
What are the differential diagnoses for epilepsy?
Syncope
Non-epileptic attack disorder
Panic attacks
Sleep phenomena
When does generalised epilepsy normally present, and what is the diagnostic pattern of this on EEG?
Present in childhood and adolescence
- generalised spike-wave abnormalities on EEG
What is the treatment of choice for Primary Generalised epilepsy?
Sodium valproate treatment of choice, but teratogenic.
=> Lamotrigine as alternative.
Describe the usual symptoms of juvenile myoclonic epilepsy
- Early morning jerks
- Generalised seizures
- Risk factors: sleep deprivation/flashing lights
Describe the pathophysiology of focal onset epilepsy.
- Due to underlying structural cause (brain injury/haemorrhage etc)
- Area around this becomes irritated
- Causes abnormal discharges of energy
=> seizure
Focal seizures can also become generalised. TRUE/FALSE?
TRUE
if a focal seizure excites a neighbouring pathway which can spread activity around the brain, then the seizures can become generalised
What treatment is first line for focal epilepsy?
Carbamazepine or lamotrigine
Sodium valproate works as well, but not first choice because of side effects
What is the most common cause of focal/partial epilepsy in patients <30 years?
complex partial seizures
due to hippocampal sclerosis
Why should carbamazepine not be used for generalised seizures?
It can make them worse
What are the different types of generalised seizures?
myoclonic - jerks atonic - loss of tone tonic tonic/clonic absence - pt goes blank
Why is lamotrigine sometimes unsuitable at the beginning of generalised epilepsy treatment?
It can take around 2-3 months to reach peak action
What other treatment, with less side effects than Sodium Valproate, can be used in generalised epilepsy if lamotrigine is taking too long to work?
Levetiracetam (Keppra)
What age group is more likely to get focal seizures?
> 50 as they are more likely to have the structural damage
Carbamazepine is a well tolerated drug. TRUE/FALSE?
FALSE
NOT well tolerated
patients feel dizzy and unsteady
Why should sodium valproate and lamotrigine be given together with caution?
Sodium valproate makes the lamotrigine dose higher, therefore a LOWER dose of lamotrigine should be prescribed if dual therapy is used.
What anticonvulsant medications are considered “old”?
Phenytoin
Sodium Valproate
Carbamazepine
What anticonnvulsant medications are considered “new”?
Lamotrigine
Levetiracetam
Topiramate
Gabapentin/pregabalin (not widely used anymore)
What side effects can occur from older anticonvulsants?
Phenytoin - causes unwanted cosmetic change
Sodium Valproate - see above and also teratogenic
Carbamazepine - dizzy/unsteady
What side effects do the new anti-convulsant drugs have?
Lamotrigine - Steven Johnson Syndrome => check for rash
Levetiracetam - mood swings
Gabapentin/Pregabalin - addictive
When should anticonvulsants be prescribed?
- if patient has EPILEPSY not just seizures
- UNLESS extremely high risk of seizure recurrence in non-epileptic patient
What anticonvulsants affect hepatic enzymes, therefore causing problems for females?
Carbamazepine oxcarbazepine phenobarbitol phenytoin primidone topiramate
What contraceptives are affected by anticonvulsant drugs?
- combined oral contraceptive pill
- Should NOT use progesterone only pill
- Depot progesterone inj. needs more frequent dosing
- Progesterone implants not effective
- Morning after pill needs increased dose to be effective
Why should all females of child bearing age be given pre-conceptual counselling?
Allows them to balance the risk of uncontrolled seizures if NOT taking medication OR teratogenicity if they continue with medication
If females with epilepsy do wish to conceive, what medication must they start 3 months prior to conception?
Folic acid and vitamin K
What is status epilepticus?
Recurrent epileptic seizures without full recovery of consciousness
Can last for over 30 mins
What are the different types of status epilepticus
Generalized convulsive
Non convulsive status => conscious but in “altered state”
Epilepsia partialis continua (continual conscious focal seizures)
What can precipitate a status epilepticus?
- Severe metabolic disorders – hyponatraemia, pyridoxine deficiency
- Infection
- Head trauma / Sub-arachnoid haemorrhage
- Abrupt withdrawl of anti-convulsants
Generalised convulsive status epilepticus can cause what further effects on the body?
respiratory insufficiency and hypoxia
hypotension
hyperthermia
rhabdomyolysis
How is status epilepticus treated?
- ABCDE
- identify cause!! => Emergency blood tests +/- CT
- if suspicious of hypoglycaemia give 50mls 50% glucose
- Benzodiazepines x2 doses (10 mins, then 15 mins) (buccal midazolam usually)
- Phenytoin if unresolving
+ Sodium Valproate
+ Levetiracetam (Keppra)• A quick way to admit to ITU
When should you consider transferring a patient in status epilepticus into ITU?
When requiring to give them phenytoin as it has been unresolved for a prolonged period
How would you confirm a patient with acute confusion is in partial status epilepticus?
EEG
How do benzodiazpines work to reverse status epilepticus?
They suppress the area of the brain which is over-excited and impairing consciousness
=> consciousness returns when electrical activity in that area is sedated
