Epilepsy Flashcards
What are the risk factors for epilepsy? (6)
FH
Previous Head injury (including perinatal)
Childhood febrile convulsions
CNS infection
Stroke
Cancer
What are the common triggers for epileptic attacks? (6)
Adherence***
Lack of sleep***
Illness
Recreational drugs & ETOH
Drugs that interact with AED
Flashing lights
Epilepsy - PRICMCP?
P: duration, seizure type (generalised [tonic-clonic, absent, myoclonic], focal [aware vs. unaware]), prodrome (aura - deja vu, feeling of dread, feeling of abdominal pain that spread to the chest) - description of what happens (convulsion, incontinence, tongue biting) - postdrome (Todd’s paresis - where patient has temporary stroke-like symptoms following the seizures).
R: FH, childhood febrile convulsions, previous injury, infection, stroke, SOL. Precipitating factors: lack of sleep, ETOH, drugs, illness, flashing lights.
I: EEG (plain, video or ambulatory), MRI (structural)
C: serious injury, esp. RTA, medication side effects. Generally: GIT, rash, and central - drowsiness, dizziness, mood (depression/anxiety), cognition, weight changes.
M: current & previous regime, are they working? no. of seizures last 12 months.
C: impact on work, social life, stigma, inability to do swimming, climbing…etc. Family planning, driving, independence, carer burden.
P: insight
What are adverse reactions/side effects to monitor for AEDs? (4 major categories)
Rash/hypersensitivity - Anaphylaxis, SJS/TEN/DRESS
Bone marrow: Agranulocytosis, Aplastic anaemia, Cytopaenia
GIT/Liver: Hepatitis/Liver failure/GIT side effects
Central effects - mood, cognition, weight changes
What investigations would you like to review in this patient with epilepsy?
T: confirm dx - EEG (epileptiform activity - focal? generalised? specific epilepsy syndromes? exclude mimics). Video, ambulatory or standard EEG.
Drug levels: ?adherence ?toxicity (valproate, CBZ, phynytoin)
Exclude MRI-B (SOL, stroke, MS - secondary causes), previous LP results (r/o infection - protein, glucose, cell counts). Cardiac investigations to rule out cardiac syncope (ECG, TTE, Loop recorder)
Severity: collateral from family: frequency of events, seizure diary, videos
Treatment: bloods looking for evidence of drug side effects & metabolic derrangements - FBC, EUC, CMP, glucose
Screen for complications: screen for depression, anxiety, MMSE, driving issues.
What is your approach in managing this patient with recurrent attacks of epilepsy?
Goals: minimize recurrent attacks, ensure psychosocial well being, fitness to drive, prevent complications.
Confirm dx: ambulatory, video, standard EEG. Confirm type of epilepsy.
A: screen for secondary causes (MRI-B, LP, metabolic derangement), r/o cardiac syncope, confirm compliance with family, drug levels.
Screen complications: depression/anxiety questionnaire, MMSE, driving status, bloods to monitor side effects (metabolic derangement)
T: non-pharm
- Educate***: the importance of adherence given the associated risk of serious injury + mortality. Drug interaction. Written information about when to take meds, potential side effects so that they don’t just stop it. Must tell the clinician before starting any new drugs, OTC, herbal…etc.
- Seizure diary / calendar***
- Driving: must be seizure-free for 12 months
- Promote health-life style: smoking cessation, ETOH (Trigger for attack), exercise, healthy diet to promote general well-being
- Vaccinate & infection precautions
- Epilepsy foundation, Epilepsy nurse
T: Pharm
- Start low & go slow
- AEDs guided by comorbidities
- R/o adherence issues & triggers (e.g. infection) - if truly refractory, involve neurologist with a view for up-titration, switch or add-on AEDs
- Consider surgery for focal seizures from a single focus + amenable for surgery
Involve: epilepsy nurse, epilepsy foundation, psychology/psychiatry, SW, neuropychology.
Ensure F/U: review seizure diaries, compliance, fitness to drive, provide support, bloods to monitor for adverse effects.
How would you decide what pharmacological AEDs you would use for patients with epilepsy? (4) - give specific examples
Choice of AEDs are often based on comorbidities, concomitant medications & patient-related factors.
Asian - avoid CBZ (or test for HLA-B1502)
Psychiatric history - avoid Keppra
Weight gain problem - consider Topiramate
Dosing - daily, BD, TDS
What is your approach to managing Refractory seizures? - brief principles. (5)
- Rule out compliance + other seizure triggers (e.g. infection, flashing lights - avoid)
- Rule out interactions with other medications
- Reassess epilepsy diagnosis & type
- If truly refractory - up titrate, switch or add-on
- Surgery - need to be a good surgical candidate, psychological ability to cope with surgery, social support, need to have a matching structural lesion on MRI + focus on PET/SPECT + EEG and must be amenable for surgery.
What are 2 indications for treating the Seizure? In which situations would you treat the patient after the 1st seizure (5)?
- Recurrent seizure with unknown aetiology
- Recurrent seizure with a cause that cannot be fixed
Generally don’t treat after 1st seizure unless
- Abnormal neuro exam
- Status epilepticus
- Todd’s paresis
- FH
- Abnormal EEG
What are the driving restrictions for patient with 1st seizure?
Can’t drive for 6 months
12 months if patient had a car crash
If known epileptic, 12 months of seizure free minimum.
What is your approach to managing this epileptic patient who is planning on getting pregnant?
Difficult Mx problem - most are theratogenic so there is no drug of choice. 1st priority is to prevent seizures - which can have serious impact for the patient and the unborn child.
Educate: interaction between OCP, importance of folic acid replacement to prevent NTD.
Folic acid replacement throughout pregnancy: up to 4mg/day
If the patient has been seizure-free for 2-4 years, maybe reasonable to attempt drug withdrawal, conception should be at least 6-12 months of seizure-free periods after withdrawal.
Simplify drug regime: stop valproate, avoid most others, include Levatiracetam or Lamotrigine (least risky)
How common is misdiagnosis of epilepsy?
upto 25%.
Usually 90% psychogenic non-epileptic events
misinterpretation of EEG is a common factor!
SUDEP?
Sudden Unexplained Death in Epilepsy Patient
- Uncontrolled seizure is a major RF for mortality
How would you distinguish from syncope from seizure? (4)
- Prodromal symptoms are different: syncope (dizziness, lightheadedness, fading vision) vs. seizure (no warning [generalised tonic-clonic], deja vu, jamais vu, feeling of dread, abdominal pain that spreads to the chest)
- Twitching/tonic/clonic movements are typically brief with syncope. seizure - clear tonic then clinic phase.
- Seizures = coordinated, syncope - uncoordinated movements
- Post-ictal: brief in syncope.
DDx for Vertigo? (5) what clinical feature tells you that this patient does not have BPPV?
BPPV - if patient has persistent vertigo at rest, dx is not vertigo!
Meniere’s
Vestibular neuritis/labyrinthitis
Posterior infarct
MS
