Epilepsy

Question 1

what are the important parts of a seizures history

Answer 1

-Onset
-What were they doing?
-Environment, etc
-Light-head or other syncopal symptoms
-What did they look like
-Pallor, breathing (presyncope)
-Posturing of limbs, head turning (seizure)
Event itself
-Type of movements
-Tonic phase, clonic movements
-Corpopedal spasms, rigor
-Responsiveness and awareness throughout
Afterwards
-Speed of recovery (recover fast after faint), sleepiness/disorientation, deficits

Question 2

if there is bilateral movement and retained consciousness is it a seizure

Answer 2

no

Question 3

what type of seizure causes right hand to go up and the head to turn

Answer 3

frontal lobe seizures

Question 4

is biting your tongue and incontinence specific to seizures

Answer 4

no

Question 5

what are the risk factors for epilepsy

Answer 5

birth 
developmental delay 
previous seizures (inc 2+ more febrile seizures) 
head injury 
family Hx
drugs 
alcohol

Question 6

when can epilepsy be a problem for a patients occupation

Answer 6

if HGV driver or if they carry a firearm

Question 7

what medications can lower seizure threshold

Answer 7

antibiotics (penicillin, cephalosporins, quinolones)
analgesics (tramadol)
anti-emetics (prochlorperazine)
opioids (diamorphine, pethidine)
aminophyline/ theophyline

Question 8

what exams for seizures in clinic

Answer 8

don’t usually examine in first clinic
if diagnosis of syncope do cardio exam, lying and standing BP

can do neuro exam if see them shortly after event

Question 9

what investigations should you do for a collapse/ seizure

Answer 9

ALWAYS DO ECG

prolonged QT can provoke seizure

can do imaging- MRIb/ CTb if indicated

Question 10

what is an EEG useful for

Answer 10

classification of epilepsy
confirmation of non epileptic attacks
surgical evaluation
confirmation of non convulsive attacks= actually only time its used

never used in acute attack to diagnose

Question 11

when are CT scans done acutely

Answer 11

Clinical or radiological skull fracture Deteriorating GCS
Focal signs- might suggest stroke/ bleed
Head injury with seizure
Failure to be GCS 15/15 4 hours after arrival Suggestion of other pathology – eg SAH

Question 12

should you do an EEG

Answer 12

not really

positive/ negative test means nothing in diagnosis of epilepsy

Question 13

when after a seizures can you drive

Answer 13

1st seizure – car = 6 months, 5 years for HGV/PCV

Epilepsy – car = 1 year or 3years during sleep (nocturnal seizures), 10 years off medication for HGV/PCV

Question 14

what is epilepsy

Answer 14

a tendency to recurrent, usually spontaneous seizures

Question 15

what are the features of global (primary generalised) epilepsy
(who gets it, when, what are seizures like)

Answer 15

genetic predisposition
present in childhood and adolescence
can have tonic clonic, abscence, myoclonic, clonic and tonic seizures

Question 16

what is seen on EEG in global epilepsy

Answer 16

generalised spike wave abnormalities

Question 17

what is an epileptic seizures

Answer 17

abnormal synchronisation of neuronal activity (usually excitatory) which interrupts normal brain activity (can be focally or generalised) and is usually brief

Question 18

why do you get epileptic seizures

Answer 18

too much excitation 
too little inhibition 
changes: 
-cell number/ type 
-connectivity 
-synaptic function 
-voltage gates channel function 

genetic, acquired brain, metabolic, toxic and environmental factors

Question 19

what is juvenile myclonic epilepsy

Answer 19

form of primary generalised epilepsy
get early morning jerks
generalised seizures
risk factors- sleep deprivation, flashing lights

Question 20

what is the treatment for primary generalised epilepsy

Answer 20

sodium valproate (is teratogenic and cosmetic effects)
lamotrigine alternative

Question 21

what is focal epilepsy

Answer 21

seizures that occur around an abnormal area of brain (stroke/ tumour) which irritates the brain and causes abnormal electrical activity

Question 22

what is generalised epilepsy

Answer 22

when abnormal electrical activity hits a pathway and spreads to other part of brain (corticothalamic circuitry)
seizure can start from a focal point, and then secondary generalisation

Question 23

what are the types of partial/ focal epileptic seizures

Answer 23

simple- without impaired consciousness
complex- with impaired consciousness

or

• motor (rhythmic jerking, posturing, head and eye deviation, automatisms, volacisation)
• sensory (somatosensory, olfactory, gustatory, visual, auditory)
• pyschic (memories, deja vu, jamais vu, depersonalisation, aphasia, complex visual hallucinations)

Question 24

what are the types of generalised epileptic seizures

Answer 24

absence (go blank, stare into distance) 
myoclonic (jerking of limbs)
atonic (loose muscle tone) 
tonic 
tonic clonic

Question 25

what is the age of onset of focal onset epilepsy

Answer 25

can be any age- due to underlying structural cause

Question 26

what is the treatment for focal onset epilepsy

Answer 26

initially:
lamotrigine (1st line)/ carbamazepine

(sodium valproate works well but not given because of SEs)

can then add on:
Gabapentin
Tiagabine
Pregabalin
Zonisamide
Vigabatrin
Clonazepam
Clobazam

Question 27

how do antiepileptic drugs work

Answer 27

inhibit v activates Na+ channels (reduces pre synaptic excitability and the ability of APs to spread) (carbamazepine, oxcarbazepine, phenytoin, lamotrigine)
enhances activity of v gated K+ channels (stabilises neurone, reduces its excitability) (retigabine)
inhibition of V activates Ca+ channels that trigger neurotransmitter release (gabapentin and prehabalin)

Question 28

what is the treatment for generalised absence seizures

Answer 28

sodium valproate

ethosuximide

Question 29

what is the treamtment for generalised myoclonic seizures

Answer 29

sodium valproate
levetiracetam
clonazepam

Question 30

what is the treamtment for generalised Atonic, Tonic, Generalised tonic clonic
seizures

Answer 30

sodium valproate

Question 31

when is phenytoin used

Answer 31

acute management only

Question 32

when do you give carbamazepine

Answer 32

Focal onset seizures
Can make primary generalized epilepsies worse
Dont give in generalized epileosy

Question 33

when do you medicate epilepsy

Answer 33

when patient wants drug- balance benefits and side effects

if high risk of recurrence

Question 34

which anti convulsants induce hepatic enzymes

IMPORTANT KNOW THIS IN EXAM

Answer 34

carbamazepine 
oxcarbazepine 
phenobarbitol 
phenytoin 
primidone 
topiramate

Question 35

how do anticonvulsants affect women in particular

IMPORTANT KNOW IN EXAM

Answer 35

Can alter efficacy of combined oral contraceptive pill
Shouldn’t use progesterone only
pill
Morning after pill not adequate if taking enzyme inducing AEDs – dose should be increased
Balance risk of uncontrolled seizures vs teratogenicity
Folic acid and vitamin K- high dose folic acid 3 months before conception
Side effects may not be as acceptable in ladies (sodium valporate- fat and bald)

Question 36

what does hippocampal sclerosis give

Answer 36

focal epilepsy

Question 37

what is status epilepticus

Answer 37

recurrent epileptic seizures without full recovery of consciousness
continuous seizure activity lasting more than 30 mins

Question 38

what are the types of status epilepticus

Answer 38

generalised convulsive status epilepticus
non convulsive (conscious but in altered state)
epilepsia partialis continua (continual focal seizures, consciousness preserved)

Question 39

when do you start treatment for status epilepticus

Answer 39

at 10 mins

Question 40

what can precipitate status epilepticus

Answer 40

severe metabolic disorders (hyponatraemia, pyridoxine deficiency)
infection
head trauma
sub arachnoid haemorrhage
abrupt withdrawal of anti convulsants
treating abscence seizures with carbamazepine

Question 41

what is convulsive status

Answer 41

generalised convulsions without cessation

Question 42

what can convulsive status cause

Answer 42

Excess cerebral energy demand and poor substrate delivery causes lasting damage:

• respiratory insufficiency and hypoxia
• hypotension
• hyperthermia
• rhabdomyolysis

death due to metabolic hyperpyrexia (50-69mins) or after this due to organ failure

Question 43

what happens pathologically in uncontrolled status epilepticus

Answer 43

Glutamate release
Excitotoxicity
Neuronal death

Question 44

what is the treatment for status epilepticus

IMPORTANT WILL BE IN EXAM

Answer 44

ABC- stabilise patient, always check glucose
IDENTIFY CAUSE- bloods, CT

for immediate control: (anticonvulsants)
1st line- benzodiazepines (lorazepam, diazepam, midazolam)
2nd- phenytoin
3rd- valproate 
4th- keppra 

for sustained control
-if established epileptic re establish AED Tx via Ng tube/ orally/ IV for phenytoin 
- in other patients/ if ongiong seizures
--fosphenytoin with ECG monitoring 
--phenytoin with ECG monitoring 
--phenobarbital
maintain levels with NG/IV/orally 

give 50mls 50% glucose if any suggestion of hypo
give thiamine if alcoholism/ impaired nutritional status

if status persists transfer to ICU within 1 hour. monitor with full EEGs or cerebral function monitor

control status with anaesthesia (thiopentone or propofol)

Question 45

why should you be careful of benzodiazpeines

Answer 45

never give more than 2 doses - admit to ICU

Question 46

what is parital status epilpeticus

Answer 46

should be considered in acute confusion
confirm with EEG
tx same as status epilepticius (minus anaesthesia and ICU)

Question 47

when do you treat a seizure

Answer 47

at 10 mins
most get better
only after 10 mins think about benzodiazepams