Epilepsy Flashcards
When assessing episodes of collapse, wohat would be inportant in the patient acount regarding history preceding event?
contex/timing
posture
When assessing episodes of collapse, wohat would be inportant in the patient acount regarding history of the event itself?
Warning symptoms
Level of awareness/recollection
When assessing episodes of collapse, wohat would be inportant in the patient acount regarding what happened after the event?
First recollection
Seizure markers- prolonged disorientation, tongue biting, incontinence, muscle pains
When assessing episodes of collapse, what would be important in the any witnesses acount regarding how the person was before the event?
contex
When assessing episodes of collapse, what would be important in the any witnesses acount regarding the description of the event?
Eyes open or closed
Description of abnormal movements
Pallor, alteration in breathing pattern, pulses
Duration of LOC
Time to recovery
What is syncope?
a temporary loss of consciousness usually related to insufficient blood flow to the brain. It’s also called fainting or “passing out”
WHat are the 3 categories of syncope?
Reflex (neuro-cardiogenic)
Orthostatic
Cardiogenic
What is reflex syncope and its causes?
intermittent dysfunction of the autonomic nervous system, which regulates blood pressure and heart rate. Due to a neurologically induced drop in blood pressure
Taking blood/medical situations
Cough, Micturation
What is orthostatic syncope and its causes?
syncope resulting from a postural decrease in blood pressure. Occurs when there is a persistent reduction in blood pressure
Dehydration, medication related (anti-hypertensive)
Endocrine, autonomic nervous system
What is cardiogenic syncope and its causes?
Decreased blood flow to the brain
Arrhythmia, aortic stenosis
When taking a syncopal history, what would be important iinformation form the patient acount regarding history precending event?
Stimulus - blood being taken, defecation
Context- only in bathroom, only when standing
When taking a syncopal history, what would be important iinformation form the patient acount regarding history of the event itself?
Warning - felt lightheaded/clammy/vision blacking out
When taking a syncopal history, what would be important iinformation form the patient acount regarding what happened after the event?
Very brief LOC
Came round as I hit the ground, friend standing over them
Fully orientated quickly
Clammy/sweaty
Urinary incontinence
Further similar events aborted by sitting
When taking a syncopal history, what would be important information form the a witness regarding the description of the episode?
Looked a bit pale
Suddenly went floppy
- There may have been a few brief jerks
- Brief LOC
Rapid recovery
If more prolonged was the patient propped up
What is the assessment of syncope?
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) and consider tilt table (proceduce used to diagnose syncope)
When assessing episodes of cardiogenic syncope what would be important in the patient acount regarding history preceding events?
on exertion
When assessing episodes of cardiogenic syncope what would be important in the patient acount regarding history of the event itself?
Chest pain, palpitations, SOB
When assessing episodes of cardiogenic syncope what would be important in the patient acount regarding what happened after the event?
Chest pain, palpitations, SOB
Came round fairly quickly - recovery may be longer
Clammy/sweaty
When assessing episodes of cardiogenic syncope what would be important informatiom from a witness regarding the description of the episode?
ALWAYS TRY AND GET A WITNESS
Suddenly went floppy
Looked grey/ashen white
Seemed to stop breathing
Unable to feel a pulse
There may have been a few brief jerks
Variable duration of LOC
Rapid recovery
WHat is the assessment of a cardiogenic episode?
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 may be the ause of provoked seizures?
(Febrile convulsions in childhood)
Alcohol withdrawal
Drug withdrawal
Within few days after a head injury
Within 24hrs of stroke
Within 24hrs of neurosurgery
With severe electrolyte disturbance
Eclampsia - are but serious condition where high blood pressure results in seizures during pregnancy
Epilepsy is the tendency to ___________
recurrent seizures
Our neurones have background ___________. If this is ________ it can lead to a seizure
Our neurones have background electrical activity. If this is disrupted it can lead to a seizure
Epilepsy is termed when a patient has what?
usually if they have more than 1 unprovoked seizures
Sometimes also used after a single seizure if investigations suggest a tendency to recurrence (over 60% risk of recurrence over 10yrs)
Ie Abnormality on imaging (stroke, tumour)
Abnormality on EEG (spike and wave)
WHat are factors that increase seizure risk?
Missed medications (most common)
Sleep disturbance, fatigue
Hormonal changes
Drug/alcohol use, drug interactions
Stress/anxiety
Photosensitivity in a small group of patient
Rare reflex epilepsies (visual patterns, music)
What are the 2 main types of seizures?
Generalised seizures - affect both cerebral hemispheres (sides of the brain) from the beginning of the seizure
Focal seizures - occur when there is a disruption of electrical impulses in one part of the brain
What are examples of generalised seizures?
- Absence seizures
- Generalised tonic-clonic seizures
- Myoclonic seizures
- Juvenile myoclonic epilepsy
- Atonic seizures
What are examples of focal seizures?
- Simple partial seizures
- Complex partial seizures
- Secondary generalised
- Or by localisation of onset (temporal lobe, frontal etc)
What are the features of primary generalised epilepsy?
- 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
What are the features of focal-parietal epilepsy?
- 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 is a Generalised Tonic clonic seizure?
a disturbance in the functioning of both sides of your brain. This disturbance is caused by electrical signals spreading through the brain inappropriately. Often this will result in signals being sent to your muscles, nerves, or glands
When assessing episodes of Generalised Tonic clonic seizure, what would be important in the patient acount regarding history preceding event?
Unpredictable, tend to cluster
PMH- complications at birth, Febrile convulsions, trauma, menigitis, brain injuries
When assessing episodes of Generalised Tonic clonic seizure, what would be important in the patient acount regarding history of the event itself?
May have vague warning
Irritability before them
When assessing episodes of Generalised Tonic clonic seizure, what would be important in the patient acount regarding what happened after the event?
Lateral (severe) Tongue biting, incontinence
First recollection in ambulance or hospital
Muscle pain
When assessing episodes of Generalised Tonic clonic seizure, what would be important information from a witness regarding what happened?
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?
Often in children (unaware of them)
Sudden arrest of activity for a few seconds
- Brief staring
- May have eye-lid fluttering
May be provoked by hyperventillation/Photic stimulation (light through trees while in car)
Re-start what they were doing
What is Juvenile myoclonic epilepsy?
Adolescence/early adulthood
Provoked by alcohol, sleep deprivation
Can have absence and GTC seizures
Will often have early morning myoclonus
Drop things in the mornings
Brief jerks in limbs
When assessing complex parietal seizures (temporal lobe seizure), what would be important in the patients acount regarding histroy preceding event?
Rising feeling in stomach, Funny smell/taste
De ja vu (familiar experience)
When assessing complex parietal seizures (temporal lobe seizure), what would be important in the patients acount regarding histroy of the event itself?
no recollection
When assessing complex parietal seizures (temporal lobe seizure), what would be important in the patients acount regarding what happened after the event?
disorientated for a spell
When assessing complex parietal seizures (temporal lobe seizure), what would be important information forma witness acount regarding what happened?
Sudden arrest in activity
Staring blankly into space
Automatisms - Lip smacking, Repetitive picking at clothes
May be disorientated for a spell afterwards
What is the clinical assessment of seizures?
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 and prevelnce of epilepsy?
Incidence: 50 - 120 per 100 000 per year
“J-shaped” curve
3 - 5% of the population will experience at least one seizure in their lifetime
Prevalence: 5 – 8 per 1000 (Aberdeen 0.9%)
22% of patients with LD have Epilepsy
There are over 300 000 people in the UK with active epilepsy
What are different investigations used for seizures?
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 is the first line treatment for epilepsy?
- Sodium Valproate, Lamotrigine, Levetiracetam for primary generalised epilepsies
- Lamotrigine, Carbamazepine, Levetiracetam for focal and secondary generalised seizures
- Ethosuximide for absence seizures
Acutely:
- Lorazepam, midazolam (diazepam) first line:
- Valproate or phenytoin second line for status epilepticus
What is the second line treatment for generalised epilepsy?
Topiramate
Zonisamide
Clobazam
(carbamazepine)
What is the second line treatment for parietal sezuires?
Sodium valproate
Topiramate
Gabapentin
Pregabilin
Zonisamide
Lacosamide
Perampanel
Long acting Benzodiazepines (Clobazam)
Vigabatrin
What are side effects of therapy?
- Phenytoin – Arrythmia, hepatitis, medication interactions
- Sodium Valproate - tremor, weight gain, ataxia, nausea, drowsiness, hepatitis - try and avoid in women of childbearing age
- Carbamazepine - ataxia, drowsiness, nystagmus, blurred vision, low serum sodium levels, skin rash.
- Lamotrigine –skin rash, difficulty sleeping
- Levetiracetam – irritability, depression
What are the driving regulations in regards to seizures?
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
They may drive an HGV or PSV after 5 years if their investigations are normal, they have no further events and they are not 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
9 000 - 14 000 cases /year in the U.K.
usually occurs in patients with no previous history of epilepsy (stroke, tumour, alcohol)
Mortality : 5-10%
Be wary of non-convulsive status epilepticus - Prolonged unresponsiveness following a seizure
What is the treatment of Status Epilepticus?
First line:
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
Second line
Phenytoin - slow infusion of 15 – 18mg/kg at 50mg/min
Valproate – 20 -30mg/kg iv at 40mg/min
? Leviteracetam 30mg/KG
Third line
Anaesthesia usually with propofol or thiopentone
What are the outcomes of status epilepticus?
Mortality greatest in very young and very old (29% of those < 1 year)
90% of deaths are a result of a underlying cause
Mortality is highest secondary to strokes, encephalitis, mass lesions and trauma - 90% of deaths are a result of the underlying cause
Avoid secondary damage - neurological problems reported in 24% of children following episode of status
When assessing a Non-Epileptic attack/Pseudoseizure, what would be important in the patients acount regarding histroy preceding event?
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
When assessing a Non-Epileptic attack/Pseudoseizure, what would be important in the patients acount regarding histroy of the event itself?
May recall what people said during episode
May be prolonged episode, waxing and waining
May describe dissociation
When assessing a Non-Epileptic attack/Pseudoseizure, what would be important in the patients acount regarding what happened after the event?
others reactions
When assessing a Non-Epileptic attack/Pseudoseizure , what would be important information from a witness regarding what happened?
May recognise stress as a trigger (even if patient doesn’t)
May report signs of patient retaining awareness
Tracking eye movements, still some verbalisation during episodes
Movements not typical of seizures - Pelvic thrusting, Asynchronous movements, tremor, Episodes waxing and waining
Ideally we try and capture a typical episode on EEG - Important to make diagnosis to avoid iatrogenic harm
Tongue biting, particularly if it is lateral, is highly specific to _____________ seizures
Tongue biting, particularly if it is lateral, is highly specific to generalized tonic-clonic seizures
