Epilepsy Flashcards by Louise Emerson

what are the important parts of a seizures history

-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

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

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

frontal lobe seizures

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is biting your tongue and incontinence specific to seizures

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what are the risk factors for epilepsy

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

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when can epilepsy be a problem for a patients occupation

if HGV driver or if they carry a firearm

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what medications can lower seizure threshold

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

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what exams for seizures in clinic

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

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what investigations should you do for a collapse/ seizure

ALWAYS DO ECG

prolonged QT can provoke seizure

can do imaging- MRIb/ CTb if indicated

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what is an EEG useful for

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

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when are CT scans done acutely

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

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should you do an EEG

not really

positive/ negative test means nothing in diagnosis of epilepsy

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when after a seizures can you drive

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

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what is epilepsy

a tendency to recurrent, usually spontaneous seizures

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

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

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what is seen on EEG in global epilepsy

generalised spike wave abnormalities

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what is an epileptic seizures

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

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why do you get epileptic seizures

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

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what is juvenile myclonic epilepsy

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

what is the treatment for primary generalised epilepsy

sodium valproate (is teratogenic and cosmetic effects)
lamotrigine alternative

what is focal epilepsy

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

what is generalised epilepsy

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

what are the types of partial/ focal epileptic seizures

simple- without impaired consciousness
complex- with impaired consciousness

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)

what are the types of generalised epileptic seizures

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

what is the age of onset of focal onset epilepsy

can be any age- due to underlying structural cause

what is the treatment for focal onset epilepsy

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 ```

how do antiepileptic drugs work

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)

what is the treatment for generalised absence seizures

sodium valproate | ethosuximide

what is the treamtment for generalised myoclonic seizures

sodium valproate levetiracetam clonazepam

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

sodium valproate

when is phenytoin used

acute management only

when do you give carbamazepine

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

when do you medicate epilepsy

when patient wants drug- balance benefits and side effects | if high risk of recurrence

which anti convulsants induce hepatic enzymes | IMPORTANT KNOW THIS IN EXAM

``` carbamazepine oxcarbazepine phenobarbitol phenytoin primidone topiramate ```

how do anticonvulsants affect women in particular | IMPORTANT KNOW IN EXAM

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)

what does hippocampal sclerosis give

focal epilepsy

what is status epilepticus

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

what are the types of status epilepticus

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

when do you start treatment for status epilepticus

at 10 mins

what can precipitate status epilepticus

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

what is convulsive status

generalised convulsions without cessation

what can convulsive status cause

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

what happens pathologically in uncontrolled status epilepticus

Glutamate release Excitotoxicity Neuronal death

what is the treatment for status epilepticus | IMPORTANT WILL BE IN EXAM

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)

why should you be careful of benzodiazpeines

never give more than 2 doses - admit to ICU

what is parital status epilpeticus

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

when do you treat a seizure

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