Epilepsy

Question 1

Seizure causes

Answer 1

Stroke
Developmental/Vascular malformations
Hippocampal sclerosis (made worse by seizures)
Vasculitis/SLE/Abs to voltage-gated K channels
Infection (HSV temporal lobe, encephalitis)

Question 2

Epilepsy definition

Answer 2

2 unprovoked seizures occurring >24hrs apart

1 unprovoked seizure with 2nd >60% likely to occur within 10 yrs

Question 3

Seizure classifications

Answer 3

Partial - one hemisphere at onset

Generalised - both hemispheres at onset

Question 4

Partial seizure classifications

Answer 4

Simple partial - conscious
Complex partial - unconscious
2° generalised - starts 1 then spreads to 2 hemispheres

Question 5

Generalised seizure classification

Answer 5

Atonic
Myoclonic - jerks
Tonic clonic
Absence (<10s pause then carries on)
Tonic
Clonic (rhytmic myoclonic jerks)

Question 6

Diagnosing epilepsy

Answer 6

Clinical diagnosis
Exclude other provoking causes
Biting tongue on sides tends to be epileptic, front tends to be syncope

Question 7

Focal seizure temporal lobe signs

Answer 7

Automatisms on ipsilateral side, dystonic on contra
Deja/jamais vu
Aura sometimes with epigastric feeling

Question 8

Focal seizure frontal lobe signs

Answer 8

Motor features
Dysphasia
Post-ictal Todd's palsy
SMA may show fencing positions
Prefrontal looks psychogenic

Question 9

Focal seizure parietal lobe signs

Answer 9

Sensory disturbances

Motor symptoms from precentral gyrus

Question 10

Focal seizure occipital lobe signs

Answer 10

Visual disturbances e.g. spots/lines/flashes

Question 11

Epilepsy general management

Answer 11

Must contact DVLA until seizure free >1yr
Advise against dangerous activities e.g. swimming/ driving/ heights
Referral to specialist for AEDs
Psychological therapies may benefit some
Surgery for some identified focal seizure causes
Vagal/deep brain stimulation

Question 12

Focal seizure AEDs

Answer 12

1st line - Carbamazepine/Lamotrigine

2nd line - Levetiracetam/ Oxcarbazepine/ Sodium valproate

Question 13

Generalised tonic-clonic AEDs

Answer 13

1st line - Sodium valproate/Lamotrigine

2nd line - Levetiracetam/ Clobazam/ Carbamazepine/ Topiramate

Question 14

Absence AEDs

Answer 14

1st line - Sodium valproate/ Ethosuximide

2nd line - Lamotrigine

Question 15

Myoclonic AEDs

Answer 15

1st line - Sodium valproate/Lamotrigine
2nd line - Levetiracetam/ Topiramate

Avoid carbamazepine/ oxcarbazepine

Question 16

Tonic/atonic AEDs

Answer 16

Sodium valproate/ Lamotrigine

Question 17

SUDEP

Answer 17

Sudden unexpected death in epilepsy

More common in uncontrolled, may be related to nocturnal seizure apnoea/asystole

Question 18

Epilepsy and pregnancy

Answer 18

Avoid sodium valproate as teratogenic
Enzyme-inducing AEDs (carbamazepine, phenytoin, barbiturates) reduces progesterone only contraception effectiveness
Oestrogen containing contraceptives lower lamotrigine levels

Question 19

Carbamazepine dose + SEs

Answer 19

Carbamazepine 100mg/12h increased by 200mg/d every 2wks up to 1000mg/12h

SE Vision/balance + not for myoclonic

Question 20

Lamotrigine dose + SEs

Answer 20

Lamotrigine 25mg/d increased by 50mg/d every 2 wks up to 250mg/12h

SE Stevens-Johnson

Question 21

Levetiracetam dose + SEs

Answer 21

Levetiracetam 250mg/24h inc by 250mg/12h every 2wks up to max 1.5g/12h

SE Depression, agitation

Question 22

Sodium valproate dose + SEs

Answer 22

Sodium valproate 300mg/12h inc by 100mg/12h every 3d up to 30mg/kg

SE teratogenic, liver failure