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2ND YEAR SYSTEMS: Neuro > Epilepsy > Flashcards

Epilepsy Flashcards

1
Q

What are the most common diagnoses in patients referred to first seizure clinics?

A

25% Epilepsy

23% Syncope

16% Single seizure (including provoked)

9% possible/probable seizure (unsure)

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2
Q

What information do you want to obtain from the patient who has collapsed?

A

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

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3
Q

What information do you want to obtain from the witness account? (you should always try and get this)

A

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
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4
Q

3 causes of syncope

A

Reflex (neuro-cardiogenic)

Orthostatic

Cardiogenic
Arrhythmia, aortic stenosis

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5
Q

When might you get Reflex syncope?

A

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

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6
Q

When might you get Orthostatic syncope? (standing up)

A

Dehydration, medication related (anti-hypertensive)

Endocrine, autonomic nervous system

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7
Q

Why might you get cardiogenic syncope? (2)

A

Arrhythmia

Aortic stenosis

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8
Q

How is syncope assessed/examined?

A

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

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9
Q

What is a tilt table test?

A

A tilt-table test involves changing a person’s positioning quickly and seeing how their blood pressure and heart rate respond.

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10
Q

Example cardiogenic syncope history

A

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

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11
Q

What is Epilepsy?

A

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)

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12
Q

What are some causes of provoked seizures (7)

A

Alcohol withdrawal

Drug withdrawal

Within few days after a head injury

Within 24hrs of stroke

Within 24hrs of neurosurgery

With severe electrolyte disturbance

Eclampsia

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13
Q

Name 5 types of Generalised seizures

A

Absence seizures

Generalised tonic-clonic seizures

Myoclonic seizures

Juvenile myoclonic epilepsy

Atonic seizures

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14
Q

Name the 3 main types of Focal seizures

A

Simple partial seizures

Complex partial seizures

Secondary generalised - when focal disturbance spreads

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15
Q

Typical history of patient having had primary generalised seizure

A

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

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16
Q

Typical history of patient having had focal/partial seizure

A

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

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17
Q

Typical history of patient having had generalised tonic clonic seizure

A

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

18
Q

What is an absence seizure?

A

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)

19
Q

Juvenile myoclonic epilepsy

A

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

20
Q

Typical history of patient having had complex partial seizure

A

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

21
Q

How are seizures clinically assessed?

A

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)
22
Q

What % of the population will experience at least one seizure in their lifetime

A

3-5%

23
Q

Who gets an electroencephalogram investigation?

A

EEG for primary generalised epilepsies including hyperventilation and photic stimulation: sometimes sleep deprivation

24
Q

Who should get an MRI done?

A

Patients under age 50 with possible focal onset seizures: CT usually adequate to exclude serious causes over this age

25
Q

What is done if there’s uncertainty about the diagnosis?

A

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.

26
Q

Factors influencing seizure risk (6)

A

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)

27
Q

What is 1st line treatment for primary generalised epilepsies? (3)

A

Sodium Valproate, Lamotrigine, Levetiracetam

28
Q

What is 1st line treatment for focal and secondary generalised seizures? (3)

A

Lamotrigine, Carbamazepine, Levetiracetam

29
Q

What is 1st line treatment for absence seizures?

A

Ethosuximide

30
Q

Acute seizure first line treatment of epilepsy?

A

1st = Lorazepam, midazolam (diazepam)

2nd = Valproate or phenytoin

31
Q

2nd line treatment for generalised epilepsy (3)

A

Topiramate
Zonisamide
Clobazam

32
Q

Side effects of Phenytoin (3)

A

Arrythmia
hepatitis
medication interactions

33
Q

Side effects of Sodium Valproate (6)

A 
tremor
weight gain
ataxia
nausea
drowsiness
hepatitis

try avoid in women of childbearing age

34
Q

Side effects of Carbamazepine (6)

A 
Ataxia
drowsiness
nystagmus
blurred vision
low serum sodium 
skin rash
35
Q

Side effects of Lamotrigine (2)

A

skin rash

difficulty sleeping

36
Q

Side effects of Levetiracetam (2)

A

Irritability

depression

37
Q

What are the regulations regarding driving after a seizure?

A

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

38
Q

What is status epilepticus

A

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

39
Q

First line treatment of status epilepticus? (3)

A

Midazolam: buccal or intra-nasal route

Lorazepam

Diazepam: iv or rectally

40
Q

2nd and 3rd line treatment for status epilepticus?

A

2nd = phenytoin, valproate

3rd = anaesthesia

41
Q

What is a non-epileptic attack/pseudoseizure like?

A

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

42
Q

What are the 2 types of epilepsy?

A

Generalised - occurs across the brain

Focal - specific to one area of the brain but can spread (secondary generalised)

2ND YEAR SYSTEMS: Neuro (32 decks)

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