Epilepsy Flashcards
Light headedness before a collapse is suggestive of what cause
Cardiac cause
Vertigo before a collapse is suggestive of what cause
ENT
Unsteadiness before a collapse is suggestive of what cause
Neurological issue
What features need to be covered in the history of a collapse
Any symptoms before hand Environmental factors What did they look like - pallor, breathing Type of movement Responsiveness throughout Speed of recovery
People will usually lose awareness in a tonic clonic seizure - true or false
True
Therefore need a collateral history
After syncope recovery is usually fast - true or false
True
Will come round quickly and wont be too disorientated
Describe recovery after a seizure
Takes a while to fully recovery
Will be drowsy or disorientated for a significant time after
What are the risk factors for epilepsy
Difficult birth Time in the ICU as a baby Past seizures including febrile Head injury Family history Drug and alcohol use
Febrile seizures increase your risk of epilepsy - true or false
True
2 or more febrile seizures leads to an increased risk
What are the rules for driving with epilepsy
Can’t drive for 6 months after 1 seizure and 1 year if you’ve had 2
If you’ve only had nocturnal seizures for 3 years you can return to driving
HGV drivers are more restricted even if well controlled - cant drive for 5 years after 1st one
Which common drugs can precipitate epileptic seizures
Antibiotics – penicillin, cephalosporins, quinolones Painkillers – tramadol Anti-emetics Opioids – diamorphine Aminophylline/theophylline
What investigation must always be carried out when someone collapses
ECG
Who need an acute CT scan
If there are clinical or radiological signs of a skull fracture
Deteriorating GCS
Focal signs
Head injury with a seizure
Failure to be at GCS 15/15 after 4hrs in hospital
How is EEG used
Classify epilepsy
Confirms non-epileptic attacks and non-convulsive states
Can be used for surgical evaluation
Is an EEG diagnostic for epilepsy
Not really
Can have positive result but not be epileptic
Some epileptics will have a normal EEG
Which other common conditions can present like epilepsy/seizures
Syncope Non-epileptic disorders - pseudo seizures Panic attacks Sleep phenomena TIAs Migraines Hypoglycaemia Paroxysmal movement disorders etc etc
What is the risk of having a further seizure in the year after your 1st
Around 1 in 5 chance
Does a seizure always mean its epilepsy
NO
What is epilepsy
A tendency to recurrent, usually spontaneous, epileptic seizures
What is an epileptic seizure
Abnormal discharge of electrical activity in the brain
It interrupts normal brain activity
Usually excitatory
What causes an epileptic seizure
Too much excitation or too little inhibition of electrical activity
Changes in synaptic function or the channels
Genetics - in kids
Electrolyte abnormalities - metabolic
Toxins
Some environmental factors
Acquired brain injuries
Which age groups tend to get epilepsy
Seen in infants
Also peaks in the elderly
What is SUDEP
Sudden unexplained death in epilepsy
What is the normal underlying reason for death in older epileptics (over 60s)
Usually due to the underlying cause of the epilepsy – e.g. brain tumour or injury
Suicide is a big killer in those with epilepsy - true or false
TRUE
Slightly higher than population average
Seen in the younger patients
Focal seizures can lead onto a generalised one - true or false
TRUE
Some seizures will start in a certain area but can trigger a specific pathway that triggers a secondary generalised one
How are seizures classified by location
Generalised - affects whole brain
Focal/partial - specific site of origin
How can you determine the location of origin of a seizure
EEG
Will tell you if its generalised or focal
What are the further classifications of partial epilepsy
Simple: without impaired consciousness
Complex: with impaired consciousness
What are the further classifications of generalised epilepsy
Absence Myoclonic Atonic Tonic Tonic clonic
These are all generalised seizure types
What are the motor signs of epileptic seizures
Rhythmic jerking Other involuntary movement - cycling Posturing Head and eye deviation Vocalisations
What are the sensory/psychological signs of a seizure
Altered memory Depersonalisation Aphasia Complex visual hallucinations Somatosensory disturbance Olfactory and gustatory changes
Who gets generalised epilepsy
Those with a genetic predisposition
Presents in childhood and adolescence
How do you treat generalised epilepsy
Sodium valproate is the first choice
Lamotrigine as an alternative
What are the potential triggers/risk factors for a seizure in generalised epilepsy
Sleep deprivation
Flashing lights
What are the side effects of sodium valproate
Extremely teratogenic
Makes you gain weight
Hair loss
Fatigue
What are the drawbacks of using lamotrigine
It takes about 2/3 months of treatment before it reaches the target dose
How do you treat focal/partial seizures
Carbamazepine or lamotrigine first line
Sodium valproate works but isn’t as used due to side effects
What are the adverse effects of carbamazepine
It reduces the efficacy of all types of contraception
Including the morning after pill
Can make generalised epilepsy worse
What causes focal onset epilepsy
Usually an underlying structural cause - e.g. following a stroke or injury
Therefore can affect any age
Which drugs reduce pre-synaptic excitability
Carbamazepine
Lamotrigine
These reduce the ability of AP’s to spread
What is the mechanism of action of sodium valproate
It enhances GABA synthesis
As this is an inhibitory NTT it reduces excitation
How do you treat absence seizures
sodium valproate
ethosuximide
How do you treat myoclonic seizures
sodium valproate
levetiracetam
clonazepam
How do you treat atonic, clonic and tonic clonic seizures
sodium valproate
levetiracetam
topiramate
lamotrigine
How is phenytoin used in the treatment of epilepsy
For acute management only
6 weeks to 3 months as it causes significant cosmetic changes if taken long term
How is levetiracetam used in the treatment of epilepsy
Very popular - used in certain types of generalised seizures
Few interactions
Well tolerated
Can cause mood swings
How is topiramate used in the treatment of epilepsy
Used for tonic clonic, clonic and atonic
Quite effective
Not well tolerated - sedation, dysphasia and weight loss
When is someone given anti-epileptics
If they have a confirmed diagnosis of epilepsy
If they have had one seizure but a high chance of recurrence - brain tumour
Why do some anti-epileptics affect contraception
They induce hepatic enzymes so the efficacy of contraceptive drugs is reduced
Will need higher dose
What must you consider in an epileptic female who wants to get pregnant
Many of the drugs are teratogenic - need to alter
Uncontrolled seizures are also very risky for pregnancy – damage to placenta or foetus themselves - so must balance this with drugs side effecst
Must put them on high dose folic acid for at least 3 months prior to conception
What is status epilepticus
Continuous seizure activity lasting more than 30mins
Recurrent seizures without full recovery of consciousness
Can occur with generalised or focal seizures
At what point would you start treating status epilepticus
Treat after 10 mins of seizure activity as they wont stop by themselves after that point
Early treatment is key - ABCDE
What can precipitate status epilepticus
Severe metabolic disorders Infection - CNS particularly Head trauma SAH Abrupt withdrawal of anti-epileptics Treating an absence seizure with carbamazepine
What is a convulsive status
Ongoing tonic-clonic activity without stopping - generalised convulsions
This puts a huge metabolic demand on the body
What are the outcomes of convulsive status epilepticus
Huge metabolic and fluid shifts - massive energy demand
Use up all glycogen, hyperthermia, can lead to rhabdomyolysis etc within 30-60mins
Can go onto organ failure after 60mins
Cerebral oedema and brain exhaustion can occur after hours
How do you manage status epilepticus
Stabilise patient - ABC
Must find the underlying cause – bloods and CT
Check blood glucose to exclude hypo
MUST start treatment early – after 10 mins
Give benzodiazepines to stop - can give a second dose after 5mins
DO NOT give more than 2 doses
Give phenytoin or normal AED treatment at full dose
Send to intensive care if they don’t recover after 30mins
If someone has just starting seizing what do you do
Monitor the person carefully
It should stop on its own, but treat as status if it goes on longer than 10 mins
At what age does generalised epilepsy typically present
Commonly presents in
childhood & adolescence
