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Yr 3 neuro > Epilepsy > Flashcards

Epilepsy Flashcards

1
Q

definition of epilepsy

A

epilepsy = >2 seizures

seizure: paroxysmal synchronised cortical electrical discharges

Epilepsy is a recurrent tendency to spontaneous, intermittent, abnormal electrical activity in part of the brain, manifesting as seizures.

Convulsions are the motor signs of electrical discharges

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2
Q

focal seizure

A

localised to specific cortcial regions eg temporal lobe, frontal lobe, occipital, complex partial

often seen w/o underlying structural disease

Older nomenclature divided into:

  • simple partial (does not affect consciousness)
    • awareness not impaired
    • focal motor, sensory (olfactory, visual etc)
    • autonomoic
    • psychic sx
    • no post-ictal sx
  • complex partial seizures (affects consciousness)
    • awareness impaired - either at seizure onset or following a simple partial aura
    • most commonly arise from temporal lobe - post-ictal confusion
  • secondary generalised (evolving to a bilateral convulsive seizure)
    • In ⅔ of patients with partial seizures, the electrical disturbance, which starts focally, spreads widely, causing a generalized seizure, which is typically convulsive.
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3
Q

generalised seizure

A

originate in and rapidly engalging bilaterally distributed networks = simultaneous onset of widespread electrical discharge with no localising feature to 1 hemisphere

affect consciousness

tonic clonic

absence attacks

myoclonic

atonic - drop attacks

tonic seizures

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4
Q

aetiology of epilepsy

A

mainly idiopathic

Primary epilepsy syndromes (e.g. idiopathic generalised epilepsy, temporal lobe epilepsy, juvenile myoclonic epilepsy)

secondary seizures (symptomatic epilepsy):

  • tumour
  • infection - meningitis, encephalitis, abscess
  • inflammation - vasculitis, rarely MS
  • toxic/metabolic - sodium imbalance, hyper- or hypoglycaemia, hypoxia, porphyria, liver failure
  • Drugs (e.g. including withdrawal e.g.alcohol, benzodiazepines).
  • vascular (stroke) - haemorrhage, infarction
  • vascular malformations
  • congenital abnormalities - cortical dysplasia or dysembryoplastic neuroepithelial tumour
  • neurodegenerative disease - Alzheimer’s
  • malignant htn or eclampsia
  • trauma - cortical scarring
  • hippocampal sclerosis (eg after febrile convulsion)
  • tuberous sclerosis
  • sarcoidosis
  • SLE
  • PAN
  • Ab to VGKC
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5
Q

common seizure mimics

A

syncope

migraine

non-epileptiform seizure disorder (e.g. dissociative disorder)

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6
Q

pathology of seizures

A

imbalance in inhib and excitatory currents eg Na or K ion channels, or neurotransmission ie glutamate or GABA neuro-transmitters in the brain

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7
Q

pricipitants of seizures

A

any trigger that promotes excitation of cerebral cortex:

  • flashing lights
  • drugs
  • sleep deprivation
  • metabolic
  • but often cryptogenic
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8
Q

epidemiology of epilepsy

A

common

prevalence 1%

peak age of onset is early childhood or elderly

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9
Q

key qns in epilepsy Hx

A

rapidity of onset

duration

alteration in consciousness

tongue biting or incontinence

rhythmic synchronous limb jerking

post-ictal period

drug history - alcohol, recreational drugs

if this is the 1st seizure ask about funny turns/odd behaviour previously - Deja vu and odd episodic feelings of fear

any triggers - alcohol, stress, flickering lights/TV - triggered attacks recur

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10
Q

focal seizures

A

frontal lobe focal motor seizures

temporal lobe

frontal lobe complex partial seizure

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11
Q

Sx of frontal lobe focal motor seizures

A

motor convulsions - posturing or peddling movement of the legs

Jacksonian march (spasm spreading from mouth or digit, retained awareness).

motor awareness

subtle bahvioural disturbances - often diagnosed as psychogenic

dysphasia or speech arrest

post-ictal flaccid weakness (Todd’s paralysis),

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12
Q

temporal lobe focal seizure sx

A

aura - visceral and psychic symptoms: fear or deja-vu sensation, feeling in gut, strange smells or flashing lights

hallucinations - olfactory, gustatory, sound

Automatisms—complex motor phenomena with impaired awareness, varying from primitive oral (lip smacking, chewing, swallowing) or manual movements (fumbling, fi ddling, grabbing) , to complex actions

dysphasia

jamais vu - everything seems strangely unfamiliar

Emotional disturbance, eg sudden terror, panic, anger, or elation, and derealization (out-of-body experiences).

delusional behaviour

bizarre associations

post-ictally - dysphasia

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13
Q

frontal lobe complex partial seizure sx

A

loss of consciousness with automatisms and rapid recovery

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14
Q

types of generalised seizure

A

tonic clonic (grand mal)

absence (petit mal)

non-convulsive status epilepticus

myoclonic

atonic (akinetic)

infantile spasms

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15
Q

sx of tonic clonic seizure

A

vague symptoms before attack - irritability

loss of consciousness

tonic phase - generalised muscle spasm, limbs stiffen

clonic phase - repetitive synchronised jerks

may have 1 w/o other

faecal/urinary incontinence

tongue biting

after - usually impaired consciousness, lethargy, confusion, headache, backpain, stiffness

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16
Q

absence seizure sx

A

usual onset in childhood

loss of consciousness but maintained posture - stop talking and stare into space for a few seconds

blinking or rolling of eyes

repetitive motor actions - chewing

no post-ictal phase

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17
Q

sx of myoclonic seizures

A

sudden jerk or a limb, face or trunk

pt may be thrown suddenly to the ground, or have a violently disobedient limb

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18
Q

non-convulsive status epilepticus sx

A

acute confusional state

often fluctuating

difficult to distinguish from dementia

19
Q

signs of epilepsy

A

depends on aetiology

normal between seizure

focal abnormalities indicative of brain lesions

20
Q

Ix for epilepsy

A

blood

  • FBC
  • UE
  • LFT
  • glucose
  • Ca, Mg
  • ABG
  • toxicology screen
  • prolactin - transient increase shortly after a true seizure

EEG

  • confirm or refute diagnosis
  • helps classify epileptic syndrome
  • Usually performed inter-ictally and often normal and does not rule out epilepsy.
  • can be false +ve
  • ictal EEGs combined with video telemetry are more useful but requires adequate facilities.
  • only do emergency EEG if non-convulsive status is the problem

CT/MRI

  • for structural, space-occupying and vascular lesions

LP - if infection suspected

HIV serology

drug levels - are they compliant to anti-epileptic

21
Q

what is status epilepticus

A

seizure>30min, failure to regain consciousness

22
Q

Mx for status epilepticus

A

treatment started in 5-10min - higher success

resus and protect airway, breathing and circ

check glucose - give if hypo, consider thiamine

IV lorazepam or IV/PR diazepam - repeat once after 15min if needed

if recur/fail to respond - IV phenytoin (15mg/kg) under ECG monitoring

Alternative IV agents include phenobarbitone, levetiracetam or sodium valproate.

if fail - GA - requires intubation and mechanical ventilation

treat cause eg hypoglycaemia, or hyponatraemia

check plasma levels of all anticonvulsants

23
Q

medical Mx of epilepsy

A

only start anti-epileptic drugs after >2 unprovoked seizures

lamotrigine or carbamazepine - first line for focal. 2nd line: levetiracetam, oxcarbazepine, or sodium valproate

sodium valproate or lamotrigine - generalised. 2nd line: carbamazepine, clobazam, levetiracetam, or topiramate.

  • Absence seizures: 1st line: sodium valproate or ethosuximide. 2nd line: lamotrigine.
  • Myoclonic seizures: 1st line: sodium valproate. 2nd line: levetiracetam, or topiramate (but more SE). Avoid carbamazepine and oxcarbazepine—may worsen seizures.

Tonic or atonic seizures: Sodium valproate or lamotrigine.

Other commonly used agents include phenytoin, levetiracetam, clobazam, topiramate, gabapentin, vigabatrin, ethosuximide (absence)

start treatment with single anti-epileptic drug (AED) - slowly build up doses over 2-3mo until controlled/max dose

. To switch drugs, introduce the new drug slowly, and only withdraw the 1st drug once established on the 2nd

24
Q

pt education for epilepsy

A

avoid triggers eg alcohol

encourage seizure diaries

Recommend supervision for swimming or climbing, driving is only permitted if seizure free for 6 months.

counselling on employment, sport, insurance

women of childbearing age should be counseled regarding possible teratogenic effects of AEDs and should consider taking supplemental folate to limit the risk.

Drug interactions e.g. enzyme-inducing AEDs can limit the effectiveness of oral contraception.

25
Q

surgery for refractory epilepsy

A

removal of definable epileptogenic focus - determined from EEG, intracortical recordings, ictal SPECT, neuropsychometry. Risk of causing focal neurological deficits

vagus nerve stimulator

deep brain stimulation

26
Q

complications of epilepsy

A

Fractures with tonic-clonic seizures, behavioural problems, suddendeath in epilepsy (SUDEP).

Complications of AEDs (e.g. gingivial hypertrophy with phenytoin, neutropenia or osteoperosis with carbamazepine, Stevens-Johnson syndrome with lamotrigine).

27
Q

prognosis for epilepsy

A

50% mortality at 1yr

mortality 2/100000/yr, directly related to seizure or secondary to injury

28
Q

seizure prodrome

A

lasts hours or days before seizure

may be change in mood or behaviour

29
Q

general post-ictal sx/signs

A

headache

confusion myalgia

30
Q

why do you have to rule out provoking causes for seizures

A

most people will have a seizure with enough provocation

not many provoked seizures recur

provocations:

  • trauma
  • stroke
  • haemorrhage
  • raised ICP
  • alcohol or benzodiazepine withdrawal
  • metabolic disturbance (hypoxia, low/high Na, low ca, low/high glucose, uraemia, liver disease)
  • infection (meningitis, encephalitis)
  • high temp
  • drugs - tricyclics, cocaine

unprovoked seizures have a higher recurrence rate

31
Q

atonic seizure sx

A

sudden loss of muscle tone = fall

no LOC

32
Q

infantile spasms

A

commonly associated with tuberous sclerosis

33
Q

parietal lobe focal seizure sx

A

sensory disturbances - tingling, numbness, pain (rare)

motor sx (due to spread to the pre-central gyrus)

34
Q

occiptal love focal seizure sx

A

visual phenomona eg spots, lines, flashes

35
Q

stopping AEDs

A

under specialist supervision if been seizure free for >2yrs and after assessing risks and benefits

dose must be decreased slowly over 2-3mo or >6mp for benzodiazepines and barbituates

36
Q

psychological therapy for epilepsy

A

relaxation

CBT

might benefit some people - dont reduce seizure frequency so use as adjunct

37
Q

sudden unexpected death in epilepsy

A

more common in uncontrolled epilepsy

may be related to nocturnal seizure-associated apnoea or asystole

Those with epilepsy have 3x increased mortality.

>700 epilepsy-related deaths are recorded/ yr in the UK; up to 17% are SUDEPs.

38
Q

carbamazepine

A

(As slow-release.)

Initially 100mg/12h, increase by 200mg/d every 2wks up to max 1000mg/12h.

SE: leucopenia, diplopia, blurred vision, impaired balance, drowsi ness, mild generalized erythematous rash, SIADH

39
Q

lamotrigine

A

As monotherapy,

initially 25mg/d, increase by 50mg/d every 2wks up to 100mg/12h (max 250mg/12h).

Halve monotherapy dose if on valproate; double if on carbamazepine or pheny toin (max 350mg/12h).

SE: maculopapular rash—occurs in 10% (but 1/1000 develop Stevens-Johnson syndrome or toxic epidermal necrolysis) typically in 1st 8wks, especially if on valproate; warn patients to see a doctor at once if rash or flu symptoms develop;

Other SES: diplopia, blurred vision, photosensitivity, tremor, agitation, vomiting, aplastic anaemia.

40
Q

levetiracetam

A

Initially 250mg/24h, increase by 250mg/12h every 2wks up to max 1.5g/12h (if eGFR >80).

SE: psychiatric side effects are common, eg depression, agitation.

Other SES: D&V, dyspepsia, drowsiness, diplopia, blood dyscrasias.

41
Q

sodium valproate

A

Initially 300mg/12h, increase by 100mg/12h every 3d up to max 30mg/kg (or 2 . 5g) daily.

SE: teratogenic. Nausea is very common (take with food).

Other SES: liver failure (watch LFT especially during 1st 6 months), pancreatitis, hair loss (grows back curly), oedema, ataxia, tremor, thrombocytopenia, encephalopathy (hyperammonaemia).

42
Q

phenytoin

A

No longer 1st line due to toxicity (nystagmus, diplopia, tremor, dysarthria, ataxia)

SE: reduced intellect, depression, coarse facial features, acne, gum hyper trophy, polyneuropathy, blood dyscr asias.

Blood levels required for dosage.

43
Q

which AEDs are liver enzyme inducing

A

Carbamazepine, phenytoin, and barbiturates

Yr 3 neuro (32 decks)

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