Epilepsy

Question 1

What is Epilepsy?

Answer 1

Epilepsy is an umbrella term for a condition where there is a tendency to have seizures. Seizures are transient episodes of abnormal electrical activity in the brain. There are many different types of seizures.

Question 2

What investigations are done in epilepsy?

Answer 2

Epilepsy is diagnosed by the clinical picture
An EEG can be used to show different forms of epilepsy and can support the diagnosis

MRI brain can be used to visualise the structure of the brain

ECG for heart problems

Question 3

What happens in a generalised tonic clonic seizure?

Answer 3

There is loss of consciousness with muscle tension (tonic) and muscle jerking (clonic)
May be associated tongue biting, incontinence, groaning, irregular breathing

After the seizure there is a prolonged post ictal period where the person is confused, drowsy and feels irritable or depressed

Question 4

How do you manage tonic clonic seizures?

Answer 4

First line- sodium valproate

Second line- lamotrigine, carbamazepine

Question 5

What are focal seizures?

Answer 5

They start in the temporal lobes, they affect hearing, speech, memory and emotions. 
They can present with...
1) hallucinations
2) memory flashbacks
3) deja vu 
4) doing strange things on autopilot

Question 6

How do you treat focal seizures?

Answer 6

Carbamazepine or lamotrigine as first line

Second line= sodium valproate or levetiracetam

Question 7

How do absence seizures present?

Answer 7

They typically happen in children
The Patient becomes blank, stares into space and then abruptly returns to normal, during the episodes they are unaware of the surroundings and eon’t respond.
They usually last 10-20 seconds

Most patients, acually more than 90% stop having these seizures as they get older.

First line= sodium valproate or ethosuximide

Question 8

What is an atonic seizure?

Answer 8

They are also known as ‘drop attacks’ and are characterised by brief lapses in muscle tone, they don’t usually last more than 3 minutes
They typically begin in childhood
They may be indicative of Lennox- Gastaut syndrome

First line management= sodium valproate
Second line management= lamotrigine

Question 9

How does a myoclonic seizure present?

Answer 9

They present as sudden brief muscle contractions, often described like a ‘sudden jump’ the patient remains awake during the episode.

They occur in various forms of epilepsy, but typically happen in children as part of juvenile myoclonic epilepsy

Question 10

How do you treat a myoclonic seizure?

Answer 10

First line= sodium valproate

Other options= lamotrigine, levetiracetam, topiramate

Question 11

What is an infantile spasm?

Answer 11

This is also known as west syndrome, it is rare (1 in 4000) disorder which starts in infancy at around 6 months of age.
It is characterised by clusters of full body spasms.

There is a poor prognosis…
1/3 die by age 25

First line treatments= prednisolone, vigabatrin

Question 12

How does Sodium valproate work? What are the side effects?

Answer 12

It works by increasing the activity of GABA which has relaxing effects on the brain

Notable side effects…

Teratogenic (patients need advice about contraception
Liver damage and hepatitis
Hair loss
Tremor

Question 13

What is the first line treatment for focal seizures and what are the side effects?

Answer 13

Agranulocytosis
Aplastic anaemia
Induces the P450 system so there are many drug interactions

Question 14

What are the side effects of phenytoin?

Answer 14

Folate and vit D deficiency 
Megaloblastic anaemia (folate deficiency)
Osteomalacia (vitD deficiency)

Question 15

What are the side effects ethosuximide?

Answer 15

Night terrors

Rashes

Question 16

What are the side effects of lamotrigine?

Answer 16

Steven johnson syndrome or dress syndrome, these are life threatening skin rashes

Leukoplakia

Question 17

What is status epilepticus?

Answer 17

Status epilepticus is an important condition you need to be aware of and how to treat. It is a medical emergency. It is defined as seizures lasting more than 5 minutes or more than 3 seizures in one hour.

Status epilepticus can be convulsive or non convulsive (with few symptoms- usually focal)

Question 18

What is the management of status epilepticus?

Answer 18

Take an ABCDE approach:

Secure the airway
Give high-concentration oxygen
Assess cardiac and respiratory function
Check blood glucose levels
Gain intravenous access (insert a cannula)
IV lorazepam 4mg, repeated after 10 minutes if the seizure continues
If seizures persist: IV phenobarbital or phenytoin

Medical options in the community:

Buccal midazolam
Rectal diazepam

Question 19

What is a seizure and what is meant by generalized and focal seizures?

Answer 19

Uncontrolled firing of nerves in the brain

If it involves both cerebral hemispheres then a seizure is generalized

If it involves one hemisphere or one area then it is focal

Question 20

What may a patient have after experiencing a seisure?

Answer 20

They may have a post ictal period- a period of sleepiness

They also may have paralysis of one side of the body- todds paralysis

Question 21

What ix would you do for seizures, particularly in children?

Answer 21

You need to rule out a metabolic cause of the seizure…

Infection- brain abscess, encephalitis, meningitis, febrile seizure, TB, toxoplasma, HIV

Neurologic- birth injury, congenital anomaly, tuberous sclerosis, hydrocephalus, degenerative cerebral disease, neurofibromatosis

Metabolic- hypercarbia, hypocalcaemia, hypoglycaemia, hyponatraemia, hypomagnesemia, inborn errors of metabolism,pyridoxine deficiency

Traumatic/vascular- cerebral contusion, stroke, child abuse, trauma, intracranial haemorrhage

Epilepsy!!

Question 22

What can look like seizures but actually aren’t in children?

Answer 22

Breath holding spells- children can pass out and turn blue
Syncope
Panic attacks
Tics
Benign myoclonus in babies falling asleep
Pseudoseizures

Question 23

When do absence seizures usually present and who do they usually affect?

Answer 23

Most commonly seen in children
Typical age of onset is 3-10 years old
Girls are affected twice as much as boys

Question 24

What are triggers of absence seizures?

Answer 24

Hyperventilation or stress

Question 25

What would the EEG show for absence seizures?

Answer 25

Would show bilateral, symmetrical 3Hz spike and wave pattern.