Epilepsy

Question 1

What is epilepsy?

Answer 1

a tendency to recurrent unprovoked seizures

>2 seizures

Question 2

What is a seizure? What are the 2 classes?

Answer 2

Paroxysmal synchronised cortical electrical discharges.
Focal
Generalised

Question 3

What is a focal seizure?

Answer 3

seizure localised to specific cortical region (e.g. temporal lobe). Types: 
Frontal lobe focal motor
Temporal lobe
Occipital 
Frontal lobe complex partial

Question 4

What is a generalised seizure?

Answer 4

seizure that affects consciousness + whole of brain. Types:
Tonic-clonic 
Absence  
Myoclonic  
Atonic  
Tonic

Question 5

What are primary epilepsy syndromes?

Answer 5

idiopathic generalised epilepsy
Temporal lobe epilepsy
Juvenile myoclonic epilepsy

Question 6

What are 10 causes of secondary epilepsy syndromes?

Answer 6

Tumour  
Infection (e.g. meningitis) 
Inflammation (e.g. vasculitis) 
Toxic/Metabolic (e.g. Na imbalance) 
Drugs (e.g. alcohol withdrawal) 
Vascular (e.g. haemorrhage) 
Congenital abnormalities (e.g. cortical dysplasia) 
Neurodegenerative disease (e.g. Alzheimer's) 
Malignant HTN or eclampsia 
Trauma

Question 7

List 3 conditions that mimic epilepsy

Answer 7

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

Question 8

What is the pathophysiology of epilepsy?

Answer 8

Imbalance in inhibitory + excitatory currents of neurotransmission
Precipitants include anything that promotes excitation of the cerebral cortex, but individual precipitant often unclear

Question 9

Describe the epidemiology of epilepsy

Answer 9

COMMON
1% of general population
Typical onset: CHILDREN + ELDERLY

Question 10

Give 3 characteristics of Frontal lobe focal motor seizures

Answer 10

Motor convulsions.
Jacksonian march (spasm spreading from mouth or digit).
Post-ictal flaccid weakness (Todds paralysis).

Question 11

What characterises Temporal lobe seizures?

Answer 11

Aura (visceral + psychic symptoms: fear/ deja-vu sensation)

Hallucinations (olfactory, gustatory)

Question 12

What characterises Frontal lobe complex partial seizures?

Answer 12

Loss of consciousness with associated automatisms + rapid recovery.

Question 13

What characterises tonic clonic seizures? What are these AKA?

Answer 13

Grand Mal
Vague Sx before attack (e.g. irritability)
followed by tonic phase (generalised muscle spasm),
followed by clonic phase (repetitive synchronous jerks) + associated faecal or urinary incontinence, tongue biting.
After seizure, there is often impaired consciousness, lethargy, confusion, headache, back pain, stiffness

Question 14

What characterises absence seizures? What are these AKA?

Answer 14

Petit mal
Usual onset in childhood.
Loss of consciousness but maintained posture (stops talking + stares into space for seconds)
Blinking or rolling up of eyes with other repetitive motor actions (e.g. chewing).
No postictal phase.

Question 15

What characterises non-convulsive status epilepticus?

Answer 15

Acute confusional state.
Often fluctuating.
Difficult to distinguish from dementia.

Question 16

What signs could you look for in epileptic patients?

Answer 16

Usually normal between seizures

Look for focal abnormalities indicative of brain lesions

Question 17

What should you establish from the history prior to the seizure?

Answer 17

Rapidity of onset?
Duration of episode
Alteration of consciousness?
Tongue-biting/ incontinence? 
Rhythmic synchronous limb jerking?
Post-ictal period? 
Drug hx (alcohol, recreational drugs)

Question 18

What bloods should be taken in epilepsy?

Answer 18

FBC 
U+E 
LFTs 
Glucose  
Calcium 
Magnesium 
ABG  
Toxicology screen  
Prolactin: transient increase shortly after seizures

Question 19

What investigation can help confirm the diagnosis of epilepsy?

Answer 19

EEG: to confirm dx + classify the epilepsy

Ictal EEGs are particularly useful

Question 20

What other investigations are performed when diagnosing epilepsy?

Answer 20

CT/ MRI: to exclude structural, space-occupying + vascular lesions.
LP to identify infectious aetiology
HIV serology

Question 21

What is status epilepticus? How is this treated?

Answer 21

seizure > 30min, failure to regain consciousness:
Resuscitate + protect ABC
Check glucose + give if hypoglycaemic. Consider thiamine.
IV lorazepam or IV/ PR diazepam (repeat after 15 min if needed).
If seizures recur or fail to respond, IV phenytoin (15mg/kg) + ECG monitoring.
If these fail, consider GA. Requires intubation + mechanical ventilation.
Treat the cause: e.g. correct hypoglycaemia/ hyponatraemia.
Check plasma levels of all anticonvulsants.

Question 22

Describe pharmacological management of epilepsy

Answer 22

Only started after 2 unprovoked seizures
FOCAL: lamotrigine or carbamazepine
GENERALISED: sodium valproate
Start tx with only 1 anti-epileptic drug

Question 23

What is included in the conservative approach of Patient Education for preventing seizures?

Answer 23

Avoid triggers
Use seizure diaries
Supervised swimming/ climbing
Driving permitted once seizure free for 6 months
Anti-epileptic drugs can have teratogenic effects (consider pregnancy)
Drug interactions (e.g. AEDs can reduce effectiveness of OCP)

Question 24

List 3 complications of anti-epileptic drugs

Answer 24

Gingival hypertrophy (phenytoin)
Neutropaenia + osteoporosis (carbamazepine)
Stevens-Johnson syndrome (lamotrigine)

Question 25

List 3 complications of epilepsy

Answer 25

Fractures (Tonic-clonic seizures)
Behavioural problems
Sudden Death in Epilepsy

Question 26

What is the prognosis in epilepsy?

Answer 26

50% remission at 1 year

Question 27

List 6 other anticonvulsants

Answer 27

Phenytoin
Levetiracetam
Clobazam
Topiramate
Gabapentin
Vigabatrin

Question 28

What surgical approaches can be used in epilepsy?

Answer 28

Removal of definable epileptogenic focus

Vagus nerve stimulator