Epilepsy Flashcards
What are the most common diagnoses in patients referred to first seizure clinics?
25% Epilepsy
23% Syncope
16% Single seizure (including provoked)
9% possible/probable seizure (unsure)
What information do you want to obtain from the patient who has collapsed?
Patient account
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
What information do you want to obtain from the witness account? (you should always try and get this)
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
3 causes of syncope
Reflex (neuro-cardiogenic)
Orthostatic
Cardiogenic
Arrhythmia, aortic stenosis
When might you get Reflex syncope?
Vasovagal - Taking blood (due to sight of it), Emotional stress, Prolonged standing
Carotid sinus - change in C.S pressure
Situational - Cough, urination
Nervous system alters HR and dilating blood vessels resulting in low BP which means not enough blood gets to the brain
When might you get Orthostatic syncope? (standing up)
Dehydration, medication related (anti-hypertensive)
Endocrine, autonomic nervous system
Why might you get cardiogenic syncope? (2)
Arrhythmia
Aortic stenosis
How is syncope assessed/examined?
Examination - Heart sounds, pulse, Postural BPs
Must have ECG - Look for heart block and QT ratio
May need 24hr ECG - May need to see cardiology if recurrent (5 day recordings, reveal devices)
Consider Tilt table
What is a tilt table test?
A tilt-table test involves changing a person’s positioning quickly and seeing how their blood pressure and heart rate respond.
Example cardiogenic syncope history
Patient account
History preceding events - On exertion
History of event itself - Chest pain, palpitations, SOB
Afterwards - Chest pain, palpitations, SOB. Came round fairly quickly. Clammy/sweaty
Witness account
Description of episode - Suddenly went floppy. Looked grey/ashen white. Seemed to stop breathing. Unable to feel a pulse. There may have been a few brief jerks
Further info
Family history important
Examination - Heart sounds, pulse. Must have ECG. Look for heart block and QT ratio
Refer to cardiology urgently/admission for telemetry
May need 24hr ECG/ECHO/prolonged monitoring
What is Epilepsy?
Epilepsy is the tendency to recurrent seizures
Our neurones have background electrical activity. If this is disrupted it can lead to a seizure
Usually we use the term Epilepsy if patients have more than one unprovoked seizure. Howevere, can also be used after single seizure if investigations suggest a tendency to recurrence (over 60% risk of recurrence over 10 yrs)
What are some causes of provoked seizures (7)
Alcohol withdrawal
Drug withdrawal
Within few days after a head injury
Within 24hrs of stroke
Within 24hrs of neurosurgery
With severe electrolyte disturbance
Eclampsia
Name 5 types of Generalised seizures
Absence seizures
Generalised tonic-clonic seizures
Myoclonic seizures
Juvenile myoclonic epilepsy
Atonic seizures
Name the 3 main types of Focal seizures
Simple partial seizures
Complex partial seizures
Secondary generalised - when focal disturbance spreads
Typical history of patient having had 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
Typical history of patient having had focal/partial seizure
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
Typical history of patient having had generalised tonic clonic seizure
Patient account
History preceding events:
Unpredictable, tend to cluster
PMH- complications at birth, Feb conv, trauma, menigitis, brain injuries
History of event itself:
May have vague warning
Irritability before them
Afterwards
Lateral (severe) Tongue biting, incontinence
First recollection in ambulance or hospital
Muscle pain
Witness account
- 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 is an absence seizure?
Causes you to blank out or stare into space for a few seconds - may have eye-lid fluttering. They then might re-start what they were doing.
often occurs in children (unaware of them)
may be provoked by hyperventilation / Photic stimulation (light through trees while in car)
Juvenile myoclonic epilepsy
A type of epilepsy that starts in adolescence/ early adulthood. People who have it wake up from sleep with quick, jerking movements of their arms and legs.
Provoked by alcohol, sleep deprivation
Can have absence and GTC seizures
Will often have early morning myoclonus (quick, involuntary muscle jerk)
Drop things in the mornings
Brief jerks in limbs
Typical history of patient having had complex partial seizure
rising feeling in stomach, funny smell/taste. May feel like de ja vu
History of event itself - no recollection
Afterwards - disorientated for a spell
Witness acount
Sudden arrest in activity
Staring blankly into space
Automatisms - lip smacking, repetitive picking at clothes
How are seizures clinically assessed?
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 % of the population will experience at least one seizure in their lifetime
3-5%
Who gets an electroencephalogram investigation?
EEG for primary generalised epilepsies including hyperventilation and photic stimulation: sometimes sleep deprivation
Who should get an MRI done?
Patients under age 50 with possible focal onset seizures: CT usually adequate to exclude serious causes over this age
What is done if there’s uncertainty about the diagnosis?
Video-telemetry - video EEG. It videos patient while simultaneously recording brainwave activity. It has the advantage of being able to see what they’re doing while they are having a seizure.
Factors influencing seizure risk (6)
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)
What is 1st line treatment for primary generalised epilepsies? (3)
Sodium Valproate, Lamotrigine, Levetiracetam
What is 1st line treatment for focal and secondary generalised seizures? (3)
Lamotrigine, Carbamazepine, Levetiracetam
What is 1st line treatment for absence seizures?
Ethosuximide
Acute seizure first line treatment of epilepsy?
1st = Lorazepam, midazolam (diazepam)
2nd = Valproate or phenytoin
2nd line treatment for generalised epilepsy (3)
Topiramate
Zonisamide
Clobazam
Side effects of Phenytoin (3)
Arrythmia
hepatitis
medication interactions
Side effects of Sodium Valproate (6)
tremor weight gain ataxia nausea drowsiness hepatitis
try avoid in women of childbearing age
Side effects of Carbamazepine (6)
Ataxia drowsiness nystagmus blurred vision low serum sodium skin rash
Side effects of Lamotrigine (2)
skin rash
difficulty sleeping
Side effects of Levetiracetam (2)
Irritability
depression
What are the regulations regarding driving after a 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 - may drive an HGV or PSV after 5 years (can’
t be on anti-epileptic medication)
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.
If they have ever had a day time seizure but then the pattern becomes noctural, this must be established for three years before they can drive
They can only hold a HGV or PSV licence if they have been seizure free for 10 years and are not on anti-epileptic medication
What is status epilepticus
Prolonged or recurrent tonic-clonic seizures persisting for more than 30 minutes with no recovery period between seizures
usually occurs in patients with no previous history of epilepsy (stroke, tumour, alcohol)
Mortality 5-10% - greatest in very young and very old.
Mortality is highest secondary to strokes, encephalitis, mass lesions and trauma
Be wary of non-convulsive status epilepticus - Prolonged unresponsiveness following a seizure
First line treatment of status epilepticus? (3)
Midazolam: buccal or intra-nasal route
Lorazepam
Diazepam: iv or rectally
2nd and 3rd line treatment for status epilepticus?
2nd = phenytoin, valproate
3rd = anaesthesia
What is a non-epileptic attack/pseudoseizure like?
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
What are the 2 types of epilepsy?
Generalised - occurs across the brain
Focal - specific to one area of the brain but can spread (secondary generalised)
