Epilepsy Flashcards
What is epilepsy?
A neurological disorder where a person experiences recurrent seizures
At least two unprovoked seizures occuring more than 24 hours apart
A single seizure with investigation findings suggesting tendency to recurrence eg. abnormal image, abnormal EEG (spike and wave)
Examples of provoked seziures
Alcohol withdrawal Drug withdrawal Eclampsia Electrolye imbalance Within 24 hrs of stroke Within 24 hrs of surgery Within few days after head injury
Define a seizure
transient occurrence of signs or symptoms due to abnormal excessive or synchronous neuronal activity in the brain
Different ways seziures can manifest
Disturbance of consciousness, behaviour, cognition, emotion, motor function or sensation
What is a generalised seziure?
Originates in bilaterally distributed networks, can include cortical and subcortical structures - separate into motor and non-motor (abence)
What is a focal seziure?
Originates in networks limited to one hemisphere, can be localised or widely spread. Separate into those with retained awareness and those without
In how many people is the cause of epilepsy identified?
A third of people with epilepsy
Name some causes of epilepsy
Structural - stroke, trauma, malformation of cortical devlopment; visible on imaging
Genetic- not necessarily inherited, mutation in which seizures common to disorder - Dravet’s syndrome
Infection- tuberculosis, HIV, cerebral malaria, Zika virus
Metabolic - porphyria, amino acidopathies, pyridoxine deficiency
UK prevalence of epilepsy
5-10 per 1000
Risk factors for predisposition to epilepsy
Premature birth Complicated febrile seizure Genetic conditions - tuberous sclerosis or neurofibromatosis. Brain development malformations FH of neurological illness or epilepsy Head trauma, infections, tumours Cerebrovascular disease - stroke, dementia
Complications of epilepsy
Sudden Unexpected Death in Epilepsy (SUDEP)
Injuries - drowning, road accidents, falls (generalised tonic-clonic)
Depression and anxiety disorders
Absence from work and school
Assessment if presenting with first seizure
Any risk factors
Clinical features suggesting other cause of seizures
Patient and eyewitness account of before, during and after seizure
- any aura
- any triggers
- Short-lived (less than 1 minute), abrupt, generalised muscle stiffening (may cause a fall) with rapid recovery — suggestive of tonic seizure.
Generalised stiffening and subsequent rhythmic jerking of the limbs, urinary incontinence, tongue biting —suggestive of a generalised tonic-clonic seizure.
Behavioural arrest — indicative of absence seizure.
Sudden onset of loss of muscle tone — suggestive of atonic seizure.
Brief, ‘shock-like’ involuntary single or multiple jerks —suggestive of myoclonic seizure.
Residual symptoms after the attack (post-ictal phenomena), such as drowsiness, headaches, amnesia, or confusion (usually occur only after generalised tonic and/or clonic seizures).
Physical examination to diagnose epilepsy
Cardiac
Neurological
Mental state
Developmental assessment
Examine oral mucose for anyt tongue bites
Identify any injuries sustained during seizure
Baseline tests for investigating epilepsy
Bloods - FBC, u&Es, LFTs, glucose, calcium
12 lead ECG
Differential diagnoses
Vasovagal syncope. Cardiac arrhythmias. Panic attacks with hyperventilation. Non-epileptic attack disorders (psychogenic non-epileptic seizures, dissociative seizures, or pseudoseizures). Transient ischaemic attack. Migraine. Medication, alcohol, or drug intoxication. Sleep disorders. Movement disorders. Hypoglycaemia and metabolic disorders. Transient global amnesia. Delerium or dementia — altered awareness may be mistaken for seizure activity.
Differentials specifically in children
Febrile convulsions
Breath-holding attacks
Night terrors
Stereotype/ritualistic behaviours - particularly if LD
Managing suspected epilepsy
Referral to confirm diagnoses - details of first seizure
Family and patient education - how to recognise and manage seizures - epilepsy.org
Encourage recording of further episodes by diary and video
Driving and occupational advice
Activities such as swimming restricted
Find written safety advice from Eilepsy Action
Lifestyle factors - sleep, alcohol, drugs
Safety net - contact GP about further episodes
Managing a tonic-clonic seizure
Note the time seizure started, continue to time. If less than 5 minutes
- Look for epilepsy ID card
- Protect from injury; cushion head, remove objects (glasses), position away from danger
- Do not restrain
- Check airway, place inrecovery position
- Observe, examine, manage injuries
- Arrange emergency admission if first seizure, another seziure occurs shortly after, injured, having trouble breathing, difficult to wake up
Managing a tonic clonic seziure > 5 minutes/ more than 3 seizures in one hour
Buccal midazolam (not licensed for under 3 months or over 18 Rectal diazepam (not under 1 year old) IV lorazepam
Under which circumstances should an emergency call be made for person having seizures
No response to treatment Responds to treatment but seziures were prolonged/recurrent before treatment given First seizure High risk of recurrence Developed into status epilepticus Difficulty monitoring patients condition
Managing focal seizures
Protect from injury
Do not restrain
Reassure and inform what they have missed
Observe until fully recovered - nothing to eat or drink
Examine for injuries
Arrange emergency admission if first seizure/lasts longer than 5 minutes/ urgent medical attention needed
What is included in a routine epilepsy review and how often should they be carried out?
At least once a year in primary care
Point of contact established for support with epilepsy specialist nurse
Seizure control - frequency, severity, any changes since last review
(explore every seizure type)
Assess impact on daily functioning and wuality of life
- memory, depression, anxiety, cognitive deficit
-work, education, leisure; explore risks and supervision
- ask about driving, ensure entitilement, DVLA
Ensure carer knows how to recognise and manage seizures- when to give oral midazolam, rectal diazepam
Adverse effects and compliance with medication
- importance of compliance in reducing seizures, SUDEP
If seizures controlled and on long-term carbamazepine, phenytoin, primidone, phenobarbital, or sodium valproate. - advise about osteoporosis risk
- lifestyle and dietary advice,calcium, vit D supplements
Women and girls who are of childbearing age - contraception options, risks of antiepileptics during pregnancy, managing risk when planning pregnancy
Contraceptive advice for woman with epilepsy
Some antiepileptic drugs may limit contraceptive options
Options the same as other women if not taking antiepileptic or on non enzyme inducing antiepileptic (except lamotrigine)
Which anti-epileptic drugs can reduce effects of oral contraceptives, transdermal patches, the vaginal ring, and progestogen-only implants?
Enzyme- inducing anti-epileptic drugs
Which contraceptive options are unaffected by enzyme-inducing anti-epileptic drugs?
medroxyprogesterone acetate injections or an intrauterine method (copper intrauterine device or the levonorgestrel-releasing intrauterine system).
What is the preferred option of contraceptive as alternative to emergency contraception?
Copper Intrauterine (CuIUD)
What drugs can reduce the effects of lamotrigine?
Oestrogen-containing contraceptives
Recution in circulating lamotrigine levels increases seizure activity
What do women on progestogen only contraceptives need to be aware of on lamotrigine?
Signs of lamotrigine toxicity - need to report symptoms
SIGN advice on prescribing anti-epileptic drugs
Stick to consistent supply of particular manufacturer’s preparation
Routine switching to be avoided
MHRA 3 categories of anti-epileptic drugs
Category 1 (ensure the person is maintained on a specific manufacturer's product) — phenytoin, carbamazepine, phenobarbital, primidone. Category 2 (use clinical judgement and discuss seizure frequency and treatment history with the person and/or carer) — valproate, lamotrigine, perampanel, rufinamide, clobazam, clonazepam, oxcarbazepine, eslicarbazepine, zonisamide, topiramate. Category 3 (usually unnecessary to maintain the person on a specific manufacturer's product unless there is patient anxiety, risk of confusion or dosing errors) — levetiracetam, lacosamide, tiagabine, gabapentin, pregabalin, ethosuximide, vigabatrin, brivaracetam.
Which group of patients are more likely to experience adverse effects of antiepileptic drugs?
Older patients
Adverse effects of antiepileptics drugs
Exacerbation of seizures Sedation Dizziness Suicidal thoughts/behaviour Acute psychotic reactions Weight gain or loss Skin rash Impaired bone health Minor blood dyscrasias Elevated liver enzymes
Which antiepileptic drugs are more commnly associated with acute psychotic reactions?
Topiramate
Vigabitrin
Tiagabine
Which anti-epileptic drugs are more commonly associated with skin rashes
carbamazepine, phenytoin, or lamotrigine
Enzyme inducing anti-epileptic drugs
Carbamazepine Eslicarbazepine acetate Oxcarbazepine Perampanel (at a dose of 12 mg daily or more) Phenobarbital Phenytoin Primidone Rufinamide Topiramate (at a dose of 200 mg daily or more)
Non-enzyme inducing anti-epileptic drugs
Acetazolamide Clobazam Clonazepam Ethosuximide Gabapentin Lacosamide Lamotrigine Levetiracetam Perampanel (at a dose of less than 12 mg daily) Pregabalin Sodium valproate Tiagabine Topiramate (at a dose of less than 200 mg daily) Vigabatrin Zonisamide
Examples of seziure markers
Bitten tongue
Prolonged disorientation
Incontinence
Muscle pain
3 types of syncope
Reflex (neurocardiogenic)
Orthostatic
Cardiogenic
Examples of triggers of reflex syncope
Taking blood/medical appointment/procedure
Cough
Micturition
Examples of triggers of orthostatic syncope
Dehydration
Medication related (antiHT)
Endocrine causes
ANS
Conditions where cardiogenic syncope may occur
Arrhythmia
Aortic stenosis
Assessment of syncope
Examination - heart sounds, pulses, postural BPs
ECG - heart block QT ratio
Could do 24 hour ECG and refer to cardiology
Preceding event of cardiogenic syncope
Exertion
Symptoms of cardiogenic syncope
Chest pain
SOB
Palpitations
Symptoms remain after event, clammy and sweaty
Signs of cardiogenic syncope
Floppy Grey/ashen complexion Pulse not palpable Brief jerks Variable duration loss of consciousness Rapid recovery
Assessment of cardiogenic syncope
Family history Exam - heart sounds, pulse ECG- heart block, QT ratio Cardiology referral for telometry 24 hr ECG/ECHO/Prolonged monitoring
What is eclampsia?
Convulsions in pregnant woman suffering high BP
Onset of seizures in woman with pre-eclampsia (high BP,proteinuria, organ dysfunction)
Examples of generalised seizures
Absence Tonic clonic Myoclonic Juvenile myoclonic epilepsy Atonic
Examples of focal seizures
Simple partial
Complex partial
Secondary generalised
Localisation of onset (temporal, frontal lobe)
Which type of seizure is more likely to occur with aura preceding?
Focal/partial
At what age are focal seziures most common?
Can occur at any age
At what age is a generalised seizure most likely to occur?
Under 25
