Epilepsy

Question 1

What happens during the tonic phase of a tonic-clonic seizure?

Answer 1

lose consciousness
muscles stiffen - if standing, fall to floor
air pushes past voice box = sounds like person crying out
bite on tongue / inside of mouth

Question 2

What happens during the clonic phase of a tonic-clonic seizure?

Answer 2

limbs jerk quickly & rhythmically
lose control of bladder ± bowels
can stop breathing/apnoea = blue tinge around mouth

Question 3

What is an epileptic seizure?

Answer 3

an abnormal high-voltage, paroxysmal discharge of cerebral neurones due to cortical hyper-excitability

Question 4

Define epilepsy.

Answer 4

A tendency to recurrent, usually spontaneous, epileptic seizures.

Question 5

what are some risk factors for epilepsy?

Answer 5

birth
development
seizures in past (including febrile fits)
head injury (including LOC)
FH
drugs
alcohol

Question 6

list some drugs which may cause epilepsy

Answer 6

BP meds –> vasovagal
antibiotics e.g. penicillin, cephalosporin, quinolone
tramadol (hallucinations and precipitate fits)
opioids e.g. diamorphine, pethidine

Question 7

Why is an ECG essential in investigating seizures?

Answer 7

looking for prolonged QT syndrome

Question 8

Why would you do an EEG?

Answer 8

to confirm non-convulsive status epilepticus - e.g. patient has prolonged absence

Question 9

Patient had seizure not long after a change to their medication dose. How long until they can drive their car again?

Answer 9

6 months seizure free and back on previous meds for 6 months

Question 10

Patient presents having had their first ever (isolated) seizure. How long until they can drive a HGV again?

Answer 10

5 years (can’t have been prescribed AEDs in this time either) and low risk after assessment

Question 11

Patient has epilepsy and wants to know if they can keep their normal license. How long must they be free of seizures for?

Answer 11

1 year with/without taking AEDs

Question 12

Patient with epilepsy had their last attack 8 years ago and has came off their medication around this time. How long until they can reapply for their HGV license?

Answer 12

in 2 years - 10 years off medication and 10 years seizure free

Question 13

Patient had one-off seizure 2 years ago. How long until they can drive their lorry again?

Answer 13

3 more years - 5 years seizure free and off medication for 5 years

Question 14

Patient has epileptic seizures when asleep but it has been a while since their last awake seizure. Are they ok to drive?

Answer 14

If the last awake seizure was 3 years ago and since then they have only had asleep seizures then yes they can drive.

Question 15

What is SUDEP?

Answer 15

sudden unexpected death in epilepsy

Question 16

Describe the 2 types of partial epileptic seizures.

Answer 16

simple = without impaired consciousness
complex = with impaired consciousness

Question 17

Teenager is brought to clinic by mother who reports they have a jerking arm when they go to drink their tea in the morning. They also appear to be staring into space but the parent thought this might just be due to tiredness in the morning. Teenager has habit of staying up late watching tv and doesn’t recall these episodes / why mother has brought them into clinic.
Diagnosis and treatment?

Answer 17

juvenile myoclonic epilepsy (JME)
sodium valproate = 1st line
if ^ unsuitable (females) / not tolerated –> levetiracetam (or topiramate)
young people should be on mono therapy

Question 18

Treatment for focal onset epilepsy?

Answer 18

carbamazepine (affects liver and decreases efficacy of other drugs)
or
lamotrigine (2-3 months to reach effective dose and can exacerbate myoclonic seizures)

Question 19

How do AEDs that act on pre-synaptic Na+ channels reduce seizures?

Answer 19

inhibit voltage gated na+ channels –> reduces pre-synaptic excitability and ability of action potentials to spread.

Question 20

What is the effect of an AED increasing K+ channel activity in the pre-synaptic neurone?

Answer 20

enhancing K+ channel activity = opening them = stabilises neurone and reduces excitability = less seizure potential

Question 21

How does sodium valproate work?

Answer 21

enhances GABA synthesis

Question 22

Which AED takes 2-3 months to titrate up to full dose and why?

Answer 22

lamotrigine due to potential cause of steven-johnson syndrome

Question 23

Which AED has large weight loss as side effect and when might it be alternatively used?

Answer 23

topiramate –> idiopathic intracranial hypertension

however also sedation, dysphasia - not well tolerated

Question 24

Which older type of drug is for acute management only and in long term it “makes you ugly”?

Answer 24

phenytoin - rapid loading possible = acute management

Question 25

What is the 1st line drug for most generalised seizures?

Answer 25

sodium valproate

Question 26

Which anticonvulsants induce hepatic enzymes?

Answer 26

carbamazepine, oxcarbazepine, phenobarbital, phenytoin, primidone, topiramate

Question 27

Female patient with new diagnosis of epilepsy - what alteration to contraceptive medication do you need to consider?

Answer 27

progesterone only pill and progesterone implant don’t work with enzyme-inducing AEDs
morning after pill - higher dosage needed

Question 28

What supplements do females with epilepsy need to take for pregnancy?

Answer 28

high dose folic acid at least 3 months before conception

Question 29

what is the definition for status epilepticus?

Answer 29

recurrent epileptic seizures without full recovery of consciousness
or
continuous seizure activity lasting >30 mins

Question 30

Name the 3 types of status epilepticus.

Answer 30

generalised convulsive SE
non-convulsive status (conscious but in ‘altered state’)
epilepsia partialis continua

Question 31

What can precipitate status epilepticus?

Answer 31

hyponatraemia
infection
head trauma
Subarachnoid haemorrhage
abrupt withdrawal of anticonvulsants
treating absence seizures with CBZ

Question 32

Describe convulsive status and what causes the lasting damage.

Answer 32

generalised convulsions without cessation.

excess cerebral energy demand and poor substrate delivery –> lasting damage

Question 33

Patient in uncontrolled status epilepticus and suspected hypoglycaemia. management?

Answer 33

50ml 50% glucose on top of anticonvulsants

Question 34

What anticonvulsants are given to a patient in uncontrolled status epilepticus?

Answer 34

phenytoin / keppra / valproate

benzodiazepines - 10mg buccal midazolam

Question 35

How many doses of benzodiazepines can be given in uncontrolled status epilepticus before calling ITU? What is alternative to 1st line benzo?

Answer 35

2 DOSES ONLY

Lorazepam IV or diazepam IV/PR if can’t give buccal midazolam

Question 36

patient who is known alcoholic presents with status epilepticus - what specific medication do they get?

Answer 36

250mg IV thiamine

Question 37

When do you avoid using phenytoin/

Answer 37

if bradycardia or heart block