epilepsy Flashcards
whats the most common diagnoses in patients referred to first seizure clinics?
25% Epilepsy
23% Syncope
16% Single seizure (including provoked)
how do you assess episodes of collapse?
History preceding events
Context/timing
Posture
History of event itself
Warning symptoms
Level of awareness/recollection
Afterwards
First recollection
Seizure markers- prolonged disorientation, tongue biting, incontinence, muscle pains
How were they before?
Context
Description of episode Eyes open or closed Description of abnormal movements Pallor, alteration in breathing pattern, pulses Duration of LOC Time to recovery
what are the three categories of syncope?
Reflex
Orthostatic
Cardiogenic
what is a reflex syncope?
Taking blood/medical situations
Cough, Micturation
what is am orthostatic syncope?
Dehydration, medication related (anti-hypertensive)
Endocrine, autonomic nervous system
what is a cardiogenic syncope?
Arrhythmia, aortic stenosis
how would you assess syncope?
Examination Heart sounds, pulse Postural BPs Must have ECG Look for heart block QT ratio May need 24hr ECG May need to see cardiology if recurrent (5 day recordings, reveal devices) Consider Tilt table
how would you assess cardiogenic syncope?
Examination
Heart sounds, pulse
Must have ECG
Look for heart block
QT ratio
Refer to cardiology urgently/admission for telemetry
May need 24hr ECG/ECHO/prolonged monitoring
what is epilepsy?
the tendency to recurrent seizures
how might a seizure happen?
Our neurones have background electrical activity. If this is disrupted it can lead to a seizure
what are things that may provoke a seizure?
Alcohol withdrawal Drug withdrawal Within few days after a head injury Within 24hrs of stroke Within 24hrs of neurosurgery With severe electrolyte disturbance Eclampsia
what are the generalised seizure types?
Absence seizures Generalised tonic-clonic seizures Myoclonic seizures Juvenile myoclonic epilepsy Atonic seizures
what are the focal siezure types?
Simple partial seizures
Complex partial seizures
Secondary generalised
Or by localisation of onset (temporal lobe, frontal etc)
who is most likely to get a primary generalised seizure?
No warning < 25 years May have history of absences and myoclonic jerks as well as GTCS e.g in juvenile myoclonic epilepsy Generalised abnormality on EEG May have family history
who is likely to get a focal/partial siezure?
May get an “aura”
Any age – cause can be any focal brain abnormality
Simple partial and complex partial seizures can become secondarily generalised
Focal abnormality on EEG
MRI may show cause
what would you see if someone was having a generalised tonic clonic seizure?
Groaning sound
Tonic (rigid phase)
Then generalised jerking in all four limbs
Eyes open
Staring/ roll upwards
Foaming at the mouth
Jerking for a few minutes and then groggy for 15-30mins
May be agitated afterwards
May have a cluster of episodes, stopping and starting
what are abscence seizures provoked by?
hyperventillation/ Photic stimulation (light through trees while in car)
what happens to someone having an abscence seizure?
Sudden arrest of activity for a few seconds
Brief staring
May have eye-lid fluttering
Re-start what they were doing
what are juvenile myoclonic epilepsy provoked by?
alcohol, sleep deprivation
what happens to someone with Juvenile myoclonic epilepsy?
Will often have early morning myoclonus
Drop things in the mornings
Brief jerks in limbs
what are the preceding events leading up to a complex partial seizure?
Rising feeling in stomach, Funny smell/taste
De ja vu (familiar experience)
History of event itself
No recollection
what happens to someone having a complex partial seizure?
Sudden arrest in activity Staring blankly into space Automatisms Lip smacking Repetitive picking at clothes
May be disorientated for a spell afterwards
what are the clinical assessment siezures?
Refer to first seizure clinic
Do an ECG, routine bloods (Glc)
A+E will often arrange a CT
From Neurology clinic May arrange an MRI for focal lesion May arrange EEG (Usually in <40yrs) Discuss Anti-epileptic drugs Refer to Epilepsy nurse (post diagnostic information) Discuss driving (inform DVLA)
what is the incidence of epilepsy?
50 - 120 per 100 000 per year
what are the investigations for epilepsy?
EEG for primary generalised epilepsies including hyperventilation and photic stimulation: sometimes sleep deprivation
MRI for patients under age 50 with possible focal onset seizures: CT usually adequate to exclude serious causes over this age
Video-telemetry if uncertainty about diagnosis
what are the factorss influencing siezure risk?
Missed medications (most common)
Sleep disturbance, fatigue
Hormonal changes
Drug/alcohol use, drug interactions
Stress/Anxiety
Photosensitivity in a small group of patients
Other rarer reflex epilepsies (patterns, noise)
first line treatment of epilepsy for primary generalised epilepsies
Sodium Valproate, Lamotrigine, Levetiracetam
first line treatment of epilepsy for focal and secondary generalised seizures
Lamotrigine, Carbamazepine, Levetiracetam
first line treatment of epilepsy for absence seizures
Ethosuximide
what are the second line treatments for generalised epilepsy?
Topiramate
Zonisamide
Clobazam
what are the second line treatments for partial seizures?
Sodium valproate -Topiramate -Gabapentin -Pregabilin -Zonisamide -Lacosamide -Perampanel Long acting Benzodiazepines (Clobazam) Vigabatrin
what are the side effects to phenytoin
Arrythmia, hepatitis, medication interactions
what are the side effects to sodium valproate?
tremor, weight gain, ataxia, nausea, drowsiness, hepatitis
what are the side effects to carbamazepine?
ataxia, drowsiness, nystagmus, blurred vision, low serum sodium levels, skin rash.
what are the side effects to lamotrigine?
skin rash, difficulty sleeping
what are the side effects to levetiracetam?
irritability, depression
what are the driving regulations for someone that had a single seizure?
After a single seizure, a patient may drive a car after 6 months if their investigations are normal and they have had no further events
what are the driving regulations for someone that has epilepsy?
Patients with epilepsy can drive a car once they have been seizure free for a year or have only had seizures arising from sleep for a year.
what are the first line treatments for status epilepticus?
Midazolam: 10mg by buccal or intra-nasal route, repeated after 10mins if necessary
Lorazepam: 0.07mg/kg, usually 4mg bolus repeated once after 10 mins
Diazepam: 10 - 20mg iv or rectally, repeated after 15 mins if necessary
what are the second line treatment for status epilepticus?
Phenytoin - slow infusion of 15 – 18mg/kg at 50mg/min
Valproate – 20 -30mg/kg iv at 40mg/min
? Leviteracetam 30mg/KG
what are the preceding events of a non-epileptic attack?
Events may occur at times of stress or while at rest
Will often give lots of detail of others reaction and little of events themselves
History of event itself
May recall what people said during episode
May be prolonged episode, waxing and waining
May describe dissociation
