Epilepsy Flashcards by Soorya Thavaraj

Define epilepsy?

A tendency to recurrent unprovoked seizures

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What is the minimum amount of seizures you would need for Epilepsy to be diagnosed?

> 2 seizures

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What is the definition of a seizure?

Paroxysmal Synchronised Cortical Electrical Discharges

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What are the two main types of seizure?

Focal Seizure

Generalised Seizure

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What is a Focal Seizure?

Seizure localised to specific cortical regions (e.g. temporal lobe seizure)

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How can Focal Seizures be divided into?

Complex Partial Seizure - consciousness is affected

Simple Partial Seizure - consciousness is NOT affected

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What are generalised seizures?

Seizures that affect the whole of the brain

It also affects consciousness

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What are the different types of generalised seizures?

Tonic-Clonic
Absence 
Myoclonic 
Atonic
Tonic

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What are most cases of Epilepsy?

Idiopathic

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What is an example of a Primary Epilepsy Syndromes?

Idiopathic Generalised Epilepsy

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What are some of the causes that could cause secondary seizures?

Tumour
Infection
Inflammation
Toxic/Metabolic
Drugs 
Vascula 
Congenital Abnormalities 
Neurodegenerative Disease
Malignant Hypertension or eclampsia 
Trauma

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What are some common things that look like seizures?

Syncope
Migraine
Non-epileptiform Seizure Disorder (e.g. dissociative disorder)

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What is the pathophysiology of seizures?

Result from an imbalance in the inhibitory and excitatory currents or neurotransmission in the brain
Precipitants include anything that promotes excitation of the cerebral cortex
Often it is unclear why the precipitants cause seizures

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What is the epidemiology of epilepsy?

Common
1% of the general population
Typical age of onset: children and elderly

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What are the questions we should consider when taking a history from a potential epilepsy patient?

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

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What is the presentation of Frontal Lobe Focal Motor Seizure?

Motor convulsions
May show a Jacksonian march
May show Todd’s Paralysis

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What is 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

What is Todd’s paralysis?

Post-ictal flaccid weakness

What is the presentation of Temporal Lobe Seizures?

Aura (visceral or psychic symptoms)

Hallucinations (usually olfactory or affecting taste)

What is the presentation of Frontal Lobe Complex Partial Seizures?

Loss of consciousness
Involuntary actions/disinhibition
Rapid Recovery

What is the presentation of Tonic-Clonic (Grand Mal) Generalised Seizures?

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

What are the presenation of Absence (Petit Mal) Generalised Seizures?

Onset in CHILDHOOD
Loss of consiousness but MAINTAINED POSTURE
The patient will appear to stop talking and stare into space for a few seconds
No post-ictal phase

What are the presenations of Non-Convulsive Status Epilepticus Generalised Seizures?

Acute confusional state
Often fluctuating
Difficult to distinguish from dementia

What are the signs of epilepsy on physical examination?

Depends on aetiology

Patients tend to be normal in between seizures

What bloods would you do for epilepsy?

``` FBC U&Es LFTs Glucose Calcium Magnesium ABG Toxicology Screen Prolactin ```

Why do we do prolactin bloods in epilepsy?

Shows a transient increase shortly after seizures

Why do we do EEG for epilepsy?

Helps to confirm diagnosis Helps classify the epilepsy Ictal EEGs are particularly useful (i.e. during a seizure)

Why do we CT/MRI for epilepsy?

Shows structural, space-occupying or vascular lesions

When would we do other investigations in epilepsy?

If it is suspected to be a secondary seizure (e.g. due to infection)

Define Status Epilepticus?

A seizure lasting > 30 mins or repeated seizure without recovery and regain of consciousness in between

When is treatment for Status Epilepticus initiated?

Earlier then it stops | After around 5-10 mins

What approach do we have to treating Status Epilepticus?

``` ABC approach Check glucose (give glucose if hypoglycaemic) IV lorazepam or IV/PR diazepam - repeat again after 10 mins if seizure doesn't terminate ```

What do we do if seizures recur in Status Epilepticus following the next dose of lorazepam or diapzepam?

Consider IV phenytoin - an ECG monitor is required If this fails consider general anaesthesia - intubation and mechanical ventilation required Treat the CAUSE Check plasma levels of anticonvulsants

Why do we check plasma levels of anticonvulsants in status epilepticus?

Because status epilepticus is often caused by lack of compliance with anti-epileptic medications

What is the treatment of newly diagnosed epilepsy?

Only start anti-convulsant treatment after > 2 unprovoked seizures Focal Seizure 1st line: lamotrigine or carbamazepine Generalised Seizure 1st line: sodium valproate Start treatment with only one anti-epileptic drug

What are the other anti-convulsants that can be used to treat newly diagnosed epilepsy?

``` Phenytoin Levetiracetam Clobazam Topiramate Gabapentin Vigabatrin ```

How do we educate patients with epilepsy?

Avoid triggers Use seizure diaries Particular consideration for women of child-bearing age because the anti-epileptic drugs can have teratogenic effects Be careful of drug interactions (e.g. AEDs can reduce the effectiveness of the oral contraceptive pill)

What are the possible complications of epilepsy?

Fracture from tonic-clonic seiures Behavioural problems Sudden death in epilepsy (SUDEP)

What are the complications of anti-epileptic drugs?

Gingival hypertrophy (phenytoin) Neutropaenia and osteoporosis (carbamezapine) Stevens-Johnson Syndrome (lamotrigine)

What is the prognosis for patients with epilepsy?

50% remission at 1 year