Epilepsy

Question 1

Define Epilepsy

Answer 1

Recurring tendency to have seizures:

• At least 2 unprovoked seizures >24 hours apart
• 1 unprovoked seizure + probability of further seizures 60%

Question 2

Define seizure, status epilepticus and pseudo-seizure

Answer 2

Seizure = excessive, abnormal and synchronised electrical activity that leads to external manifestations. may be provoked or unprovoked

Status eplilepticus = continuous seizure activity ≥ 5 minutes or repetitive seizures with no intervening recovery of consciousness

Pseudo-Seizure = patient believes to be having a seizure

Question 3

What may cause a provoked seiziure

Answer 3

Alcohol withdrawal

Encephalitis

Question 4

What are the types of Epilepsy

Answer 4

Generalised
Convulsive: tonic, clonic, tonic-clonic, myoclonic
Non-convulsive: absent, atonic

Partial/focal 
Simple partial (No LOC)
Complex partial (May have LOC)

Question 5

Aetiology of Epilepsy

Answer 5

Idiopathic
Primary epilepsy syndrome e.g. idiopathic generalised, temporal lobe, juvenile myoclonic

Secondary: 
Tumours
Infection e.g. meningitis, encephalitis, abscess
Inflammation e.g. vasculitis
Toxin/metabolite e.g. Na, glucose, Ca
Drugs e.g. alcohol withdrawal, benzos
Vascular e.g. haemorrhage, infarction
Malignant HTN or eclampsia 
Traumatic brain injury
Dementia

Question 6

What is the aetiology of Status epilepticus

Answer 6

Non-adherence to medication
Alcohol abuse
Overdose
Toxicity

Question 7

Epidemiology of Epilepsy

Answer 7

Common, 1% prevalence
Peak age of onset <20 or >60
Focal seizures are the most common seizure type in adults (>50%)
Males > females

Question 8

Symptoms of Epilepsy in general

Answer 8

Triggers: flashing lights, strange feeling in the gut, strange smell

Before: Epileptic aura, triggers e.g. flashing lights

During: stiffness, jerking, incontinence, tongue-biting, sweating, palpitations, mouth frothing, pallor, cyanosis

After: Muscle ache, post-ictal confusion, drowsiness

Normal between seizures

Question 9

What are the symptoms of focal/partial seizures

Answer 9

=> Frontal
Behaviour change
Motor change (posture, peddling motor arrest -> dysphasia, speech arrest)
Jacksonian March (seizure increases in size -> more of the homunculus becomes affected)
Todd’s paralysis: post-ictal flaccid weakness

=> Temporal
Aura (fear or deja vu sensation)
Hallucination (smell, taste)
Emotional disturbance
Deperanolisation
Automatisms e.g. lip smacking, fumbling, fiddling, chewing, singing, kissing

=> Parietal
Sensory disturbance: tingling + numbness
Motor: abnormal movements, rhythmic muscle contractions

=> Occipital
Visual phenomena: spots, lines, flashes

Question 10

What are the symptoms of the generalised seizures

Answer 10

Tonic: Limb stiffening
Clonic: limb jerking
Tonic-Clonic (Grand mal): LOC followed by stiff body with flexed elbows and extended legs following by violent shaking with eyes rolling (Grand Mal), incontinence LOC, postictal confusion and drowsiness
Myoclonic: sudden isolated jerk of limb/face/trunk, disobedient limb e.g. thrown to ground

Absence (petit mal): < 10s of vacancy ± myoclonic jerk, presents in childhood, no post-ictal
Atonic (Akinetic): sudden loss of muscle tone, drop attacks, no LOC

Question 11

Investigations for Epilepsy

Answer 11

EEG: Spokes or sharp wave
Serum prolactin: raised after a seizure

FBC: Check for infection - raised WCC
Glucose: rule out hypoglycaemia
Electrolytes: Test for provoked seizure
Toxicology: ?alcohol/illicit /substance

CT head: intracranial haemorrhage, skull fracture, rule out SOL
MRI brain: may show lobe abnormalities

LP + CSF analysis: test for CNS infection

fMRI scan: area of seizure activity and brain function localised
MEG scan: localise epileptic focus

Question 12

Management for acute seizure termination

Answer 12

1. Lorazepam/diazepam PR/Intranasal/under-tongue + airway maintenance
2. Phenytoin
3. Phenobarbital, propofol, midazolam (buccal)

Question 13

Management for epilepsy in adults

Answer 13

Indicated after the 2nd seizure/1st seizure + abnormal test

Generalised - Sodium valproate
Focal - Carbamazepine

2. Alternative e.g. Oxcarbazepine, Lamotrigine, Levetiracetam, Topiramate, Valproic acid
3. Anti-epileptic polytherapy
4. Resective epilepsy surgery or Vagus nerve stimulation or responsive neurostimulation system

Question 14

Management for epilepsy in children

Answer 14

1. Anti-epileptic or Benzodiazepine

2. Resective epilepsy surgery or Vagus nerve stimulation or responsive neurostimulation system

Question 15

Management for Status Epilepticus

Answer 15

1. ABCDE
2. Lorazepam IV bolus or PR if out of hospital
3. Continues -> IV infusion with phenytoin/diazepam OR diazepam PR
4. Phenobarbital
5. 45 mins - general anaesthesia

Question 16

Complications of Epilepsy

Answer 16

Falls and injuries → Fractures
Aspiration
Status epilepticus - respiratory arrest
SUDEP - sudden death in epilepsy