Epilepsy

Question 1

What is epilepsy?

Answer 1

Epilepsy is an umbrella term for a condition where there is a tendency to have seizures

Question 2

What is a seizure?

Answer 2

Seizures are transient episodes of abnormal electrical activity in the brain

Question 3

Investigation used in Epilepsy

Answer 3

• An EEG (electroencephalogram) can show typical patterns in different forms of epilepsy and support the diagnosis
• An MRI brain to diagnosis structural problems that may be associated with seizures and other pathology such as tumours

Question 4

Types of seizures

Answer 4

• Generalised tonic clinic seizures
• Focal seizures
• Absence seizures
• Atonic seizures
• Myoclonic seizures
• Infantile spasms

Question 5

Describe the features of a generalised tonic clonic seizure

Answer 5

There is loss of conciousness and tonic (muscle tensing) and clonic (muscle jerking) episodes. Typically the tonic phase comes before the clonic phase.

There may be associated tongue biting, incontinence, groaning and irregular breathing.

There is a prolonged post-ictal period.

Question 6

Management of tonic clonic seizures is with:

Answer 6

• First line: sodium valproate
• Second line: lamotrigine or carbamazepine

Question 7

Describe the features of focal seizures

Answer 7

Focal seizures start in temporal lobes. They affect hearing, speech, memory and emotions.

There are various ways that focal seizures can present:

• Hallucinations
• Memory flashbacks
• Déjà vu
• Doing strange things on autopilot

Question 8

Management of focal seizures

Answer 8

• First line: carbamazepine or lamotrigine
• Second line: sodium valproate or levetiracetam

Question 9

Describe the features of abscence seizures

Answer 9

Absence seizure typically happen in children. The patient becomes blank, stares into space and then abruptly returns to normal. These typically last 10-20 seconds. Most patients (>90%) stop having absence seizures as they get older.

Question 10

Management of absence seizures

Answer 10

Sodium valproate or ethosuximide

Question 11

Describe the features of an atonic seizure

Answer 11

Also known as drop attacks

• brief lapses in muscle tone
• don’t usually last more than 3 minutes
• they typically begin in childhood
• usually remain conscious

Question 12

Management of atonic seizures

Answer 12

• First line: sodium valproate
• Second line: lamotrigine

Question 13

Describe the features of myoclinic seizures

Answer 13

Present as sudden brief muscle contractions, like a sudden “jump”. The patient usually remains awake during the episode.

Question 14

Myoclinic seizures management

Answer 14

• First line: sodium valproate
• Second line: lamotrigine, levetiracetam or topiramate

Question 15

Describe the features of infantile spasms

Answer 15

Also known as West syndrome

• Starts in infancy at around 6 months old
• Characterised by clusters of full body spasms
• Poor prognosis: 1/3 die by the age of 25, however 1/3 are seizure free

Question 16

What is sodium valproate used for?

How does it work?

Answer 16

This is a first line option for most forms of epilepsy (except focal seizures).

It works by increasing the activity of GABA, which has a relaxing effect on the brain.

Question 17

Side effects of sodium valproate?

Answer 17

• Teratogenic so patients need careful advice about contraception
• Liver damage and hepatitis
• Hair loss
• Tremor

Question 18

What is Carbamazepine used for?

Notable side effects

Answer 18

First line for focal seizures

Side effects:

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

Question 19

Phenytoin side effects

Answer 19

• Folate and vitamin D deficiency
• Megaloblastic anaemia (folate deficiency)
• Osteomalacia (vitamin D deficiency)

Question 20

Ethosuximide side effects

Answer 20

• Night terrors
• Rashes

Question 21

Lamotrigine side effects

Answer 21

• Steven-Johnson syndrome or DRESS syndrome (life threatening skin rashes)
• Leukopenia