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Epilepsy Flashcards

1
Q

What is a seizure?

A

A sudden, irregular discharge of electrical activity in the brain causing a physical manifestation such as sensory disturbance, unconsciousness or convulsions

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2
Q

What is a convulsion?

A

Motor signs of electrical discharge.

Uncontrolled shaking movements of the body due to rapid contraction and relaxation of muscles

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3
Q

What is epilepsy?

A

A neurological disorder marked by sudden, recurrent episodes of sensory disturbance, LOC or convulsions associated with abnormal electrical activity in the brain

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4
Q

What are the two main seizure classifications?

A

Partial and generalised

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5
Q

Describe partial (focal) seizures

A

Start in a specific area on one side of the brain.

SIMPLE: consciousness maintained
- with focal motor, sensory, autonomic or psychic symptoms. No post ictal symptoms

COMPLEX: consciousness impaired

  • May have a LOC or impaired awareness or responsiveness (don’t remember having seizure)
  • Most commonly arise from temporal lobe
  • Post ictal confusion is a feature
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6
Q

What symptoms are common in a temporal lobe seizure?

A 
Feeling of deja vu
Jamais vu - feeling of unfamiliarity 
Automatisms- complex motor phenomena with impaired awareness, vary from: lip smacking, chewing, swallowing or manual movements such as fiddling or grabbing, to complex actions 
Dysphasia 
Emotional disturbance- sudden terror, panic, anger, elation 
Hallucinations of smell, taste, sound 
Delusional behaviour 
Bizarre associations
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7
Q

What are secondary generalised seizures?

A

In 2/3 of patients with partial seizures, the electrical disturbance that starts focally spreads widely -> generalised seizure

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8
Q

Describe generalised seizures

A

Originate at some point within then rapidly distribute bilaterally leading to widespread electrical discharge with no localising features.

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9
Q

What types of generalised seizures are there?

A 
Tonic clonic
Tonic
Myoclonic 
Atonic 
Absence
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10
Q

Describe a tonic clonic seizure

A 
Muscle tense (tonic) then jerk (clonic) 
Described as rhythmic jerking
Tonic phase:
- 10 to 60 sec 
- rigid, epileptic cry, tongue biting, incontinence, hypoxia/cyanosis (no breathing in this phase)

Clonic phase:

  • jerking
  • eye rolling, tachycardia, random breathing

Often aura before
Afterwards post ictal state - confused, drowsy, headache, some enter coma

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11
Q

What is a tonic seizure

A

When the muscles increase in tone

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12
Q

What is a myoclonic seizure?

A

Sudden jerk of limb, face or trunk - shock like.

Patient may be thrown to ground or violently disobedient limb

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13
Q

What is an atonic seizure?

A

Sudden loss of muscle tone - drop attack

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14
Q

What is an absence seizure?

A

Brief < 10 second pauses, stop and carry on as if nothing happened
Unresponsive to stimuli but conscious
Patient stares, may go pale

Complete recovery without post ictal confusion or headache

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15
Q

When do absence seizures present?

A

In childhood
Likely to develop tonic clonic later in life
40% have relatives with epilepsy

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16
Q

Some patients experience a preceding prodrome before having a seizure. What is this characterised by?

A

Change in mood or behaviour

Can last from hours to days

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17
Q

Epilepsy most commonly occurs in isolation, but certain conditions are associated with it such as…

A

Cerebral palsy - 30% have epilepsy
Tuberous sclerosis
Mitochondrial diseases

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18
Q

When do febrile convulsions typically occur?

A

In children between 6 months and 5 years

Early in a viral infection as temperature rises rapidly

Typically brief and generalised tonic of tonic-clonic

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19
Q

What is an aura?

A

A focal awareness seizure that can precede another seizure type.

Usually occurs a few minutes before.
Sensory disturbances

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20
Q

An aura can mean what symptoms ?

A 
Feeling of deja vu 
Flashing lights
Strange smell or taste
Numbness or tingling 
Strange feeling in the gut

Can be any sensation

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21
Q

What can happen during a seizure?

A

Tongue biting

Incontinence

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22
Q

What can happen post ictally?

A 
Confusion 
Headache 
Nausea
Fatigue 
Myalgia

Weakness after focal seizure in motor cortex (Todd’s palsy)
Dysphasia after focal seizure in temporal lobe

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23
Q

In those with epilepsy, the seizure threshold is said to be…

A

Lowered - neurons are hyperexcitable

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24
Q

What triggers can push neuron excitation past the seizure threshold?

A

Sleep deprivation
Alcohol - intake and withdrawal
Drug misuse
Flickering lights
CNS Infection
Metabolic disturbance e.g hypoglycaemia, hypoxia, thyroid dysfunction, electrolyte imbalance e.g hypocalcaemia
Less common: loud noises, hot bath, strange smells and sounds

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25
All people who have had a seizure should be referred to a neurologist and seen within how many weeks?
2 weeks
26
How is epilepsy diagnosed?
Thorough history - collateral important Establish type Rule out provoking causes - most people would have a seizure given sufficient provocation, but not classified as epileptic
27
What investigations should be done?
``` EEG - not to diagnose, but can support it ECG - cardiac cause of syncope MRI - structural lesions Drug screen LP if infection suspected Bloods ```
28
Until diagnosis known, what should be avoided?
Swimming Heights Driving
29
How long should driving be stopped for after having seizure?
First unprovoked/ isolated seizure : 6 months off if no structural abnormalities on imaging and no definite epileptiform activity on ECG If these conditions not met this is increased to 12 months If established epilepsy or multiple unprovoked seizures - may qualify for driving licence if free from seizure for 12 months Withdrawal of epilepsy medication-should not drive for 6 months after last dose
30
When should anti epileptic drugs be commenced?
Most neurologists start AEDs following second epileptic seizure NICE suggests starting them after first seizure if: - a neurological deficit - brain imaging shows structural abnormality - EEG show unequivocal epileptic activity - patient of family consider risk of having further seizure unacceptable
31
What are some differentials?
``` Vascular: stroke Infection: abscess, meningitis Trauma: intracerebral haemorrhage Autoimmune: SLE Metabolic: hypoxia, electrolyte imbalance, hypoglycaemia, thyroid dysfunction Iatrogenic: drugs, alcohol Neoplastic: intracerebral mass ```
32
If seizure is due to mediation change, how long can patient not drive for?
Need to be 6 months seizure free
33
What drug is first line for generalised seizures?
Sodium valproate
34
What are the side effects of sodium valproate?
``` Teratogenic Nausea is common - take with food Liver failure - monitor LFTs Pancreatitis Hair loss Oedema Ataxia Tremor Thrombocytopenia P450 enzyme inhibitor ```
35
What is the first line treatment for focal seizures?
Carbamazepine | Binds to sodium channels to increase refractory period
36
Carbamazepine may exacerbate what types of generalised seizures?
Myoclonic | Absence
37
What are the side effects of carbamazepine?
``` Dizziness Ataxia Drowsiness Visual disturbance - especially diplopia Leukopenia Mild generalised erythematous rash SIADH ``` P450 enzyme inducer e.g warfarin more rapidly metabolised and hormone contraception
38
When can lamotrigine be used?
First line instead of SV for tonic clonic, tonic or atonic | Can be used instead of carbamazepine for partial
39
What are the side effects of lamotrigine?
Maculopapular rash - in rare cases SJS or TEN Visual disturbance Tremor Agitation Vomiting
40
When can levetiracetam be used?
Second line for focal, tonic clonic and myoclonic
41
What are the side effects of levetiracetam?
Psychiatric side effects common - depression, agitation D&V Drowsiness
42
Why is phenytoin no longer first line?
Due to toxicity and side effect profile
43
Over how many months should the dose of AEDs be built up?
2 to 3 months
44
When switching drug what approach should be taken?
Introduce new drug slowly and only withdraw first once established on second
45
Epilepsy carries what percentage risk of fetal abnormalities?
5% - good seizure control prior to conception and during pregnancy is vital
46
What should be avoided in pregnancy?
Sodium valproate Polytherapy And avoid prior to conception
47
What is the preferred AED in pregnancy?
Lamotrigine
48
What advice should be given to women of child bearing age?
Take folic acid 5mg/d
49
What AEDs are present in breast milk?
Most except carbamazepine and valproate | Lamotrigine not thought to be harmful to infants
50
Which AEDs are liver enzyme inducing?
Carbamazepine Phenytoin Barbiturates
51
Enzyme inducing AEDs make which type of contraception unreliable?
Progesterone only
52
What is status epilepticus?
Seizure lasting more than 5 minutes or recurrent without regaining consciousness
53
Prolonged seizure activity can lead to what?
Irreversible brain damage
54
How should status epilepticus be managed?
Secure airway Give oxygen IV bolus lorazepam 4mg, 2nd dose if no response after 10 to 20 minutes (Buccal midazolam if no IV access or rectal diazepam if not available) If seizure continues start phenytoin infusion (not if bradycardia or heart block)
55
What percentage of cases have no identifiable cause?
70%
56
When does it normally present?
Childhood/teenage years
57
What percentage have a first degree relative with epilepsy?
30%
58
What can cause seizures?
``` Genetic component Trauma Cortical scarring e.g head injury years before Space occupying lesion Raised ICP Alcohol and benzodiazepine withdrawal Vascular abnormalities eg stroke Metabolic disturbance e.g hypoxia, low calcium, hyper/hypoglycaemia, uraemia, liver disease Infection - meningitis, encephalitis Drugs - tricyclics, cocaine ```
59
Describe a simple partial seizure
Patient remains conscious Isolated limb jerking common May be isolated head turning - away from side of seizure May be isolated paraesthesia (there can be any isolated motor or sensory sign) Weakness of the limbs may follow = Todd’s paralysis
60
What may indicate pseudo seizures (psychogenic non-epileptic seizures)?
Gradual onset Prolonged duration and abrupt termination Closed eyes +/- resistance to eye opening Rapid breathing Fluctuating motor activity Episodes of motionless unresponsiveness CNS examination normal, CT, MRI and EEG all normal May have history of mental health problems or a personality disorder
61
What features indicate a frontal lobe focal seizure?
``` Motor symptoms- posturing, peddling movements of legs Jacksonian march Motor arrest Dysphasia or speech arrest Post ictal Todd’s palsy ```
62
What features suggest a parietal lobe focal seizure?
Sensory disturbances - tingling, numbness, pain (rare) | Motor symptoms due to spread to pre central gyrus
63
What features occur in an occipital local focal seizure?
Visual phenomena- spots, lines, flashes
64
What is a Jacksonian march?
A spreading focal motor seizure with retained awareness | Starting with face or a thumb, ipsilateral spread
65
What can be done as an adjunct to medication?
Psychological therapies - relaxation, CBT
66
When could surgical intervention be considered?
If single epileptogenic focus identified e.g in hippocampal sclerosis or small low grade tumour Vagus nerve stimulation Deep brain stimulation
67
Sudden unexpected death in epilepsy is more common in...
Uncontrolled epilepsy | May be related to nocturnal seizure associated apnoea or asystole
68
Oestrogen containing contraceptives lower what AED levels?
Lamotrigine - an increased dose may be required to achieve seizure control
69
What mnemonic can be used for cytochrome P450 inducers?
``` CRAPS our drugs Carbamazepine Rifampin bArbituates Phenytoin St Johns wort ```
70
What mnemonic can be used for cytochrome P450 inhibitors?
Some Certain Silly Compounds Annoyingly Inhibit Enzymes, Grrrrrr ``` Sodium valproate Ciprofloxacin Sulphonamide Cimetidine/omeprazole Antifungals, amiodarone Isoniazid Erythromycin Grapefruit juice ```
71
How does sodium valproate work?
Increased GABA activity - an inhibitory neurotransmitter | Inhibits sodium channels
72
How does carbamazepine work?
Binds to sodium channels increasing their refractory period
73
How does lamotrigine work?
Sodium channel blocker, thus reducing action potential propagation
74
How does phenytoin work?
Binds to sodium channels increasing their refractory period
75
What are some side effects of phenytoin?
Toxicity: nystagmus, diplopia, tremor, dysarthria, ataxia Later: confusion, seizures ``` Side effects: Reduced intellect Depression Coarse facial features Gingival hyperplasia Hirsutism Peripheral neuropathy Blood dyscrasias - megaloblastic anaemia (due to altered folate metabolism) Osteomalacia - enhanced vit D metabolism Lymphadenopathy ``` Blood levels required for dosage (narrow therapeutic window)
76
When can ethosuximide be used?
Can be used instead of SV for absence seizures
77
What is the main excitatory neurotransmitter in the brain?
Glutamate
78
What receptor does glutamate act on and what affect does it have?
Acts on NMDA receptors - causes calcium influx (tells the cell to send signals) Some with epilepsy may have fast or long lasting activation of these receptors
79
When can AEDs be stopped?
If seizure free for more than 2 years with AEDs being stopped over 2-3 months
80
What features suggest temporal lobe involvement?
HEAD Hallucinations - auditory, olfactory, gustatory Epigastric rising/emotional Automatisms - lip smacking, grabbing, chewing Deja vu/jamais vu /dysphasia
81
Do patients typically outgrow absence seizures?
One third of patients outgrow them, one third continue to have simple absence and one third go on to occasional concomitant generalized tonic-clonic seizures
82
What is another term for absence seizures?
Petit mal (old term)
83
What is topiramate used for?
Second line for generalised tonic clonic and myoclonic
84
What are the side effects of topiramate?
``` Nausea Drowsiness and dizziness Diarrhoea Depression Loss of appetite, weight loss Hair loss Increased ammonia leading to encephalopathy or kidney stones Blurred vision, eye pain - glaucoma ```
85
When is phenobarbitone used?
Seizures in young children | The injectable form may be used for status epilepticus
86
What are the side effects of phenobarbital?
``` Decreased level of consciousness Decreased respiratory effort Dizziness Ataxia Nystagmus ```
87
How does phenobarbital work?
Increases the activity of the inhibitory neurotransmitter GABA
88
Is phenobarbital a CYP450 inhibitor or inducer?
Inducer | It can be used to reduce the toxicity of some drugs
89
Oestrogen containing contraceptives lower... levels, so an increased dose may be needed to achieve seizure control
Lamotrigine

Neurology (31 decks)

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