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year 2 neuro - Robbie > Epilepsy > Flashcards

Epilepsy Flashcards

1
Q

When assessing episodes of collapse, wohat would be inportant in the patient acount regarding history preceding event?

A

contex/timing

posture

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2
Q

When assessing episodes of collapse, wohat would be inportant in the patient acount regarding history of the event itself?

A

Warning symptoms

Level of awareness/recollection

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3
Q

When assessing episodes of collapse, wohat would be inportant in the patient acount regarding what happened after the event?

A

First recollection

Seizure markers- prolonged disorientation, tongue biting, incontinence, muscle pains

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4
Q

When assessing episodes of collapse, what would be important in the any witnesses acount regarding how the person was before the event?

A

contex

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5
Q

When assessing episodes of collapse, what would be important in the any witnesses acount regarding the description of the event?

A

Eyes open or closed

Description of abnormal movements

Pallor, alteration in breathing pattern, pulses

Duration of LOC

Time to recovery

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6
Q

What is syncope?

A

a temporary loss of consciousness usually related to insufficient blood flow to the brain. It’s also called fainting or “passing out”

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7
Q

WHat are the 3 categories of syncope?

A

Reflex (neuro-cardiogenic)

Orthostatic

Cardiogenic

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8
Q

What is reflex syncope and its causes?

A

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

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9
Q

What is orthostatic syncope and its causes?

A

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

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10
Q

What is cardiogenic syncope and its causes?

A

Decreased blood flow to the brain

Arrhythmia, aortic stenosis

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11
Q

When taking a syncopal history, what would be important iinformation form the patient acount regarding history precending event?

A

Stimulus - blood being taken, defecation

Context- only in bathroom, only when standing

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12
Q

When taking a syncopal history, what would be important iinformation form the patient acount regarding history of the event itself?

A

Warning - felt lightheaded/clammy/vision blacking out

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13
Q

When taking a syncopal history, what would be important iinformation form the patient acount regarding what happened after the event?

A

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

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14
Q

When taking a syncopal history, what would be important information form the a witness regarding the description of the episode?

A

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

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15
Q

What is the assessment of syncope?

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) and consider tilt table (proceduce used to diagnose syncope)

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16
Q

When assessing episodes of cardiogenic syncope what would be important in the patient acount regarding history preceding events?

A

on exertion

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17
Q

When assessing episodes of cardiogenic syncope what would be important in the patient acount regarding history of the event itself?

A

Chest pain, palpitations, SOB

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18
Q

When assessing episodes of cardiogenic syncope what would be important in the patient acount regarding what happened after the event?

A

Chest pain, palpitations, SOB

Came round fairly quickly - recovery may be longer

Clammy/sweaty

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19
Q

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

A

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

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20
Q

WHat is the assessment of a cardiogenic episode?

A

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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21
Q

What may be the ause of provoked seizures?

A

(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

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22
Q

Epilepsy is the tendency to ___________

A

recurrent seizures

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23
Q

Our neurones have background ___________. If this is ________ it can lead to a seizure

A

Our neurones have background electrical activity. If this is disrupted it can lead to a seizure

24
Q

Epilepsy is termed when a patient has what?

A

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)

25
Q

WHat are factors that increase seizure risk?

A

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)

26
Q

What are the 2 main types of seizures?

A

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

27
Q

What are examples of generalised seizures?

A
  • Absence seizures
  • Generalised tonic-clonic seizures
  • Myoclonic seizures
  • Juvenile myoclonic epilepsy
  • Atonic seizures
28
Q

What are examples of focal seizures?

A
  • Simple partial seizures
  • Complex partial seizures
  • Secondary generalised
  • Or by localisation of onset (temporal lobe, frontal etc)
29
Q

What are the features of primary generalised epilepsy?

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
30
Q

What are the features of focal-parietal epilepsy?

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
31
Q

What is a Generalised Tonic clonic seizure?

A

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

32
Q

When assessing episodes of Generalised Tonic clonic seizure, what would be important in the patient acount regarding history preceding event?

A

Unpredictable, tend to cluster

PMH- complications at birth, Febrile convulsions, trauma, menigitis, brain injuries

33
Q

When assessing episodes of Generalised Tonic clonic seizure, what would be important in the patient acount regarding history of the event itself?

A

May have vague warning

Irritability before them

34
Q

When assessing episodes of Generalised Tonic clonic seizure, what would be important in the patient acount regarding what happened after the event?

A

Lateral (severe) Tongue biting, incontinence

First recollection in ambulance or hospital

Muscle pain

35
Q

When assessing episodes of Generalised Tonic clonic seizure, what would be important information from a witness regarding what happened?

A

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

36
Q

What is an absence seizure?

A

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

37
Q

What is Juvenile myoclonic epilepsy?

A

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

38
Q

When assessing complex parietal seizures (temporal lobe seizure), what would be important in the patients acount regarding histroy preceding event?

A

Rising feeling in stomach, Funny smell/taste

De ja vu (familiar experience)

39
Q

When assessing complex parietal seizures (temporal lobe seizure), what would be important in the patients acount regarding histroy of the event itself?

A

no recollection

40
Q

When assessing complex parietal seizures (temporal lobe seizure), what would be important in the patients acount regarding what happened after the event?

A

disorientated for a spell

41
Q

When assessing complex parietal seizures (temporal lobe seizure), what would be important information forma witness acount regarding what happened?

A

Sudden arrest in activity

Staring blankly into space

Automatisms - Lip smacking, Repetitive picking at clothes

May be disorientated for a spell afterwards

42
Q

What is the clinical assessment of seizures?

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)

43
Q

What is the incidence and prevelnce of epilepsy?

A

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

44
Q

What are different investigations used for seizures?

A

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

45
Q

What is the first line treatment for epilepsy?

A
  • 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
46
Q

What is the second line treatment for generalised epilepsy?

A

Topiramate

Zonisamide

Clobazam

(carbamazepine)

47
Q

What is the second line treatment for parietal sezuires?

A

Sodium valproate

Topiramate

Gabapentin

Pregabilin

Zonisamide

Lacosamide

Perampanel

Long acting Benzodiazepines (Clobazam)

Vigabatrin

48
Q

What are side effects of therapy?

A
  • 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
49
Q

What are the driving regulations in regards to seizures?

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

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

50
Q

What is Status Epilepticus?

A

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

51
Q

What is the treatment of Status Epilepticus?

A

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

52
Q

What are the outcomes of status epilepticus?

A

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

53
Q

When assessing a Non-Epileptic attack/Pseudoseizure, what would be important in the patients acount regarding histroy preceding event?

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

54
Q

When assessing a Non-Epileptic attack/Pseudoseizure, what would be important in the patients acount regarding histroy of the event itself?

A

May recall what people said during episode

May be prolonged episode, waxing and waining

May describe dissociation

55
Q

When assessing a Non-Epileptic attack/Pseudoseizure, what would be important in the patients acount regarding what happened after the event?

A

others reactions

56
Q

When assessing a Non-Epileptic attack/Pseudoseizure , what would be important information from a witness regarding what happened?

A

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

57
Q

Tongue biting, particularly if it is lateral, is highly specific to _____________ seizures

A

Tongue biting, particularly if it is lateral, is highly specific to generalized tonic-clonic seizures

year 2 neuro - Robbie (48 decks)

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