Epilepsy

Question 1

Define:

Answer 1

A disorder of seizures due to paroxysmal synchronised cortical electrical discharges

Need to have > 2 seizures to be diagnosed with epilepsy

Question 2

What are the different types of seizures:

Answer 2

Partial - this is a focal seizure. Can be simple or complex (loss of consciousness)

generalised (all have LOC):

• Tonic-clonic = stiffness followed by jerky movements
• Absence = staring into space but no loss of posture
• Myoclonic= sudden jerk of a limb, face or trunk.
• Atonic = sudden loss of muscle tone (will fall forwards)

Question 3

Aetiology:

Answer 3

Due to an imbalance in excitatory and inhibitory neurotransmitters.

Most are idiopathic (2/3) but may have a familial component

Question 4

What are structural causes of epilepsy?

Answer 4

o Developmental
o Space-occupying lesion
o Stroke
o Hippocampal sclerosis

Question 5

What are other causes of epilepsy?

Answer 5

o Tuberous sclerosis
o Sarcoidosis
o SLE
o PAN

Question 6

Epidemiology:

Answer 6

Common

1% of the population

Age of onset is usually the elderly or children

Question 7

What questions would you ask about the seizure?

Answer 7

o	Rapidity of onset
o	Duration of episode 
o	Any alteration in consciousness?
o	Any tongue-biting or incontinence?
o	Any rhythmic synchronous limb jerking?
o	Any triggers?
o	Any post-ictal abnormalities (e.g. exhaustion, confusion)?
o	Drug history (alcohol, recreational drugs) 

Take a collateral history from people around the pt

Question 8

What is the presentation of a partial seizures?

Answer 8

o Frontal Lobe Focal Motor Seizure
• Motor convulsions
• May show a Jacksonian march (when the muscular spasm caused by the simple partial seizure spreads from affecting the distal part of the limb towards the ipsilateral face)
• May show post-ictal flaccid weakness (Todd’s paralysis)

Temporal Lobe Seizures
• Aura (visceral or psychic symptoms)
• Hallucinations (usually olfactory or affecting taste)

Frontal Lobe Complex Partial Seizure
• Loss of consciousness
• Involuntary actions/disinhibition
• Rapid recovery

Question 9

What is the presentation of tonic-clonic seizures?

Answer 9

• Vague symptoms before attack (e.g. irritability)
• Tonic phase (generalised muscle spasm)
• Clonic phase (repetitive synchronous jerks)
• Faecal/urinary incontinence
• Tongue biting
• Post-ictal phase: impaired consciousness, lethargy, confusion, headache, back pain, stiffness

Question 10

What is the presentation of absence seizures?

Answer 10

• Onset in CHILDHOOD
• Loss of consciousness but MAINTAINTED POSTURE
• The patient will appear to stop talking and stare into space for a few seconds
• NO post-ictal phase

Question 11

Signs:

Answer 11

depends on the aetiology

Usually between the seizure the pt is normal

Question 12

Investigations:

Answer 12

Bloods:

• FBC
• U+Es
• Glucose
• LFTS
• Tox Screen
• Prolactin (this increases post seizures)
• Calcium and magnesium
• ABG

EEG (Confirms diagnosis and aids in classifying the epilepsy . Ictal EEGs are particularly useful)

CT/MRI - shows structural, space occupying and vascular lesions

Question 13

Management of status epilepticus:

Answer 13

a seizure lasting > 30 mins
o ABC approach
o Check GLUCOSE (give glucose if hypoglycaemic)
o IV lorazepam OR IV/PR diazepam - REPEAT again after 10 mins if seizure does not terminate
o If seizures recur following the next dose consider IV phenytoin - an ECG monitor is required
o If this also fails, consider general anaesthesia (e.g. thiopentone) - intubation and mechanical ventilation required
o Treat the CAUSE (e.g. hypoglycaemia or hyponatraemia)
o Check plasma levels of anticonvulsants (because status epilepticus is often caused by lack of compliance with anti-epileptic medications)

Question 14

Management of partial seizures:

Answer 14

carbamazepine or lamotrigine

Question 15

Management of generalised seizures:

Answer 15

Sodium valproate

Question 16

Management of absence seizures:

Answer 16

sodium valproate, lamotrigine or ethosuximide

Question 17

What should the pt be educated on?

Answer 17

o Avoid triggers
o Use seizure diaries
o Particular consideration for women of child-bearing age because the anti-epileptic drugs can have teratogenic effects – take folic acid and use lamotrigine instead of valproate
o Be careful of drug interactions (e.g. AEDs can reduce the effectiveness of the oral contraceptive pill)

Question 18

Complications:

Answer 18

•	Fractures from tonic-clonic seizures 
•	Behavioural problems 
•	Sudden death in epilepsy (SUDEP)
•	Complications of anti-epileptic drugs:
o	Gingival hypertrophy (phenytoin)
o	Neutropaenia and osteoporosis (carbamazepine)
o	Stevens-Johnson syndrome (lamotrigine)

Question 19

Prognosis:

Answer 19

50% remission in year one