Epilepsy Flashcards
What is a seizure?
A sudden, irregular discharge of electrical activity in the brain causing a physical manifestation such as sensory disturbance, unconsciousness or convulsions
What is a convulsion?
Motor signs of electrical discharge.
Uncontrolled shaking movements of the body due to rapid contraction and relaxation of muscles
What is epilepsy?
A neurological disorder marked by sudden, recurrent episodes of sensory disturbance, LOC or convulsions associated with abnormal electrical activity in the brain
What are the two main seizure classifications?
Partial and generalised
Describe partial (focal) seizures
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
What symptoms are common in a temporal lobe seizure?
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
What are secondary generalised seizures?
In 2/3 of patients with partial seizures, the electrical disturbance that starts focally spreads widely -> generalised seizure
Describe generalised seizures
Originate at some point within then rapidly distribute bilaterally leading to widespread electrical discharge with no localising features.
What types of generalised seizures are there?
Tonic clonic Tonic Myoclonic Atonic Absence
Describe a tonic clonic seizure
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
What is a tonic seizure
When the muscles increase in tone
What is a myoclonic seizure?
Sudden jerk of limb, face or trunk - shock like.
Patient may be thrown to ground or violently disobedient limb
What is an atonic seizure?
Sudden loss of muscle tone - drop attack
What is an absence seizure?
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
When do absence seizures present?
In childhood
Likely to develop tonic clonic later in life
40% have relatives with epilepsy
Some patients experience a preceding prodrome before having a seizure. What is this characterised by?
Change in mood or behaviour
Can last from hours to days
Epilepsy most commonly occurs in isolation, but certain conditions are associated with it such as…
Cerebral palsy - 30% have epilepsy
Tuberous sclerosis
Mitochondrial diseases
When do febrile convulsions typically occur?
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
What is an aura?
A focal awareness seizure that can precede another seizure type.
Usually occurs a few minutes before.
Sensory disturbances
An aura can mean what symptoms ?
Feeling of deja vu Flashing lights Strange smell or taste Numbness or tingling Strange feeling in the gut
Can be any sensation
What can happen during a seizure?
Tongue biting
Incontinence
What can happen post ictally?
Confusion Headache Nausea Fatigue Myalgia
Weakness after focal seizure in motor cortex (Todd’s palsy)
Dysphasia after focal seizure in temporal lobe
In those with epilepsy, the seizure threshold is said to be…
Lowered - neurons are hyperexcitable
What triggers can push neuron excitation past the seizure threshold?
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
All people who have had a seizure should be referred to a neurologist and seen within how many weeks?
2 weeks
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
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
Until diagnosis known, what should be avoided?
Swimming
Heights
Driving
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
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
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
If seizure is due to mediation change, how long can patient not drive for?
Need to be 6 months seizure free
What drug is first line for generalised seizures?
Sodium valproate
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
What is the first line treatment for focal seizures?
Carbamazepine
Binds to sodium channels to increase refractory period