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NSB! > Epilepsy - aetiology and management > Flashcards

Epilepsy - aetiology and management Flashcards

1
Q

What is a seizure?

1 - temporary disruption in brain function caused by abnormal firing of neurons
2 - temporary loss of consciousness
3 - temporary paralysis
4 - temporary contraction of all skeletal muscle

A

1 - temporary disruption in brain function caused by abnormal firing of neurons
- neurons fire when they shouldn’t and brain malfunctions

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2
Q

A seizure is a temporary disruptions of brain function, caused by uncontrolled synchronous, paroxysmal excessive neuronal activity. It can present as a stereotyped disturbance of consciousness, behaviour, emotion, motor function and/or sensation. How long do they generally last?

A
  • seconds to minutes
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3
Q

What is epilepsy?

A
  • a chronic condition of recurrent seizures
  • diagnosis is 2 or more unprovoked seizures
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4
Q

Epilepsy is a chronic condition of recurrent seizures, where >2 seizures is diagnostic. Are the seizures always of the vigorous shaking kind?

A
  • no
  • seizures can be brief and nearly undetectable symptoms to periods of vigorous shaking and convulsion
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5
Q

What % of the population are affected by epilepsy?

1 - 0.1 - 1%
2 - 10-15%
3 - 15-30%
4 - 30-50%

A

1 - 0.1 - 1%

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6
Q

When defining the term epilepsy we need to understand 2 terms; seizure and unprovoked. In relation to epilepsy what does unprovoked mean?

1 - cause of seizure is known
2 - cause of seizure is unknown
3 - cause of seizure or the precipitating factor is unknown

A

3 - cause of seizure or the precipitating factor is unknown
- no medically reversible cause (alcohol, blood glucose)

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7
Q

In epilepsy, seizures can range from seconds to minutes and can be almost non detectable to vigorous shaking and convulsions. Do all seizures present in the same way?

A
  • no
  • depends on the brain area affected
  • could affect olfactory area and patient may smell something without a stimulus
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8
Q

What is a provoked seizure?

1 - cause of seizure is known
2 - cause of seizure is unknown
3 - cause of seizure is identified but not the precipitating factor
4 - cause of seizure or the precipitating factor is known

A

4 - cause of seizure or the precipitating factor is known
- diabetes, neurological disorder, alcohol withdrawal

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9
Q

In epilepsy we know that seizures are caused by abnormal firing of the neurons in the brain. Which part of the brain is generally affected in up to 60% of cases?

1 - frontal
2 - parietal
3 - occipital
4 - temporal

A

4 - temporal
- presents with positive motor features

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10
Q

In epilepsy we know that seizures are caused by abnormal firing of the neurons in the brain. In up to 60% of cases it generally affected the temporal lobe, but can also spread/occur where?

A
  • frontal
  • can affect both hemispheres
  • parietal and occipital (rare)
  • where seizures occurs affects how the patient presents
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11
Q

What is the term given in epilepsy when a seizure affects both sides of the hemisphere?

1 - unprovoked
2 - generalised
3 - systemic
4 - central

A

2 - generalised

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12
Q

In epilepsy, if a seizure lasts longer than 5 minutes in duration, what is this called and why is this important?

1 - status epilepticus
2 -status provoctus
3 - status criticalis

A

1 - status epilepticus
- medical emergency
- mortality is between 10-15%

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13
Q

In epilepsy seizures can be focal (one specific location such as a lobe or even one hemisphere) or generalised (affecting the whole brain). How would a patient present with a focal seizures?

1 - positive motor and visual features, can be aware or unaware
2 - loss of awareness, synchronised movements, eyes open
3 - loss of all bodily functions
4 - body shuts down and becomes flaccid

A

1 - positive motor and visual features, can be aware or unaware
- patient can be aware of whats happening as the other parts of the brain are unaffected

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14
Q

In epilepsy seizures can be focal (one specific location) or generalised (affecting the whole brain). How would a patient present with a generalised seizures?

1 - positive motor and visual features, can be aware or unaware
2 - loss of awareness, synchronised movements, eyes open
3 - loss of all bodily functions
4 - body shuts down and becomes flaccid

A

2 - loss of awareness, synchronised movements, eyes open
- patient losses awareness as whole brain misfires

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15
Q

In epilepsy, in animals at least what does the Kindling hypothesis relate to?

1 - decreased seizures results in shorter duration of seizures
2 - increased seizures results in shorter duration of seizures
3 - increased seizures results in longer duration of seizures
4 - decreased seizures results in shorter duration of seizures

A

3 - increased seizures results in longer duration of seizures
- seizure leads to more seizures, this continues until the number of seizures plateaus and the brain burns out
- BUT we do not know if this occurs in humans

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16
Q

When conducting a history on a patient with suspected epilepsy, what are some risk factors that we need to ask about?

A
  • family history
  • duration and number of seizures
  • medical history (strokes, diabetes)
  • social history (drugs, alcohol)
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17
Q

The aetiology of epilepsy has a huge list including:

Antenatal / intrauterine – remote infection, trauma, hypoxia
Genetic
Electrolyte disturbances
Infection
Medications
Drugs
Tumours
Trauma
Congenital disorders
Neurodegenerative conditions
Stroke

What are the 4 most common in adults?

A
  • stroke
  • tumour
  • trauma
  • infection
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18
Q

The aetiology of epilepsy have a huge list including:

Antenatal / intrauterine – remote infection, trauma, hypoxia
Genetic
Electrolyte disturbances
Infection
Medications
Drugs
Tumours
Trauma
Congenital disorders
Neurodegenerative conditions

What are the 4 most common in children?

A
  • genetic
  • metabolic disorders
  • trauma
  • infection
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19
Q

If a patient has an acute seizure and epilepsy is suspected, what are the 3 most basic tests a patient may undergo to try and diagnose why they had the seizure?

1 - blood test, imaging, lumbar puncture
2 - blood test, cranial nerve examination, imaging
3 - blood test, cranial nerve examination, history
4 - imaging, cranial nerve examination, imaging

A

1 - blood test, imaging, lumbar puncture
- blood tests (infection, blood glucose)
- lumbar puncture (rule out infection)
- imaging (rule out stroke/tumour)

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20
Q

If someone has an acute seizure and the seizure does not go away, what core drug can be used, and what are the 3 methods they can be administered?

1 - diazepam administered by intravenously, mucosal or rectal
2 - naloxone administered by intravenously, mucosal or rectal
3 - aripiprazole administered by intravenously, mucosal or rectal
4 - clozapine administered by intravenously, mucosal or rectal

A

1 - diazepam administered by intravenously, mucosal or rectal
- acts as a GABA agonist on GABA-A receptors
- increase Cl- in cell causing hyperpolarisation

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21
Q

If someone has an acute seizure and the seizure does not go away, benzodiazepines can be used, and administered either intravenously or rectally. Which 2 core drug from the class benzodiazepines that we need to be aware of to treat epilepsy?

1 - diazepam and carbamazepine
2 - naloxone and carbamazepine
3 - aripiprazole and carbamazepine
4 - diazepam and aripiprazole

A

1 - diazepam and carbamazepine
- diazepam = bind to GABA-A receptors acting as an agonist
- carbamazepine = binds and inhibits opening of Na+ channels
- BOTH reduce action potential and neuronal firing

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22
Q

If someone has an acute seizure and the seizure does not go away, benzodiazepines can be used, and administered either intravenously or rectally. Carbamazepine is used to treat patients, what is the mechanism of action of carbamazepine?

1 - inhibit Na+ channels
2 - binds GABA-a receptor acting as agonist causing Cl- influx into the cell
3 - inhibits Ca2+ channels from opening
4 - increase K+ leaving the cell

A

1 - inhibit Na+ channels
- inhibition of Na+ stops action potentials

23
Q

If someone has an acute seizure and the seizure does not go away, benzodiazepines can be used, and administered either intravenously or rectally. Diazepam is used to treat patients, what is the mechanism of action of diazepam?

1 - inhibit Na+ channels
2 - binds GABA-a receptor acting as agonist causing Cl- influx into the cell
3 - inhibits Ca2+ channels from opening
4 - increase K+ leaving the cell

A
  • binds with gamma subunit on the GABA-A receptor
  • this opens the channel allowing Cl- to flow in
  • causes hyperpolarisation and no action potential
24
Q

Seizures in epilepsy can be provoked or unprovoked.

1 - Provoked immediate (known cause)
- toxin, medication, metabolic
- recurrence is low in the absence of the provoking factor
- acute symptomatic (close to the time of a brain insult)
- recurrence is 80% less likely than a remote symptomatic seizure

2 - Unprovoked (no known cause)
- remote symptomatic (pre-existing brain injury)
- associated with an epileptic syndrome

Why is it important to identify if the seizure is provoked or unprovoked?

A
  • important for prognosis and treatment
  • if its provoked what provoked it and treat that
  • if we know the cause we know how to treat it
25
Q

Seizures are common in epilepsy, but it is important to differentiate if this is an epileptic seizure or not. What are the 6 most common differential diagnosis that are not seizures?

A

1 - non-epileptic
2 - syncope (can have twitches)
3 - sleep attack
4 - cataplexy (loss of muscle tone)
5 - migraine
6 - transient ischaemic attack

26
Q

What are the 3 steps to classify epilepsy?

A

1 - classify type of seizure
2 - classify type of epilepsy (provoked or seizure)
3 - diagnosis of epilepsy syndrome

27
Q

To look at a patients seizures in real time, what technique can be used, and what part of the brain is monitored?

1 - ECG and cerebral cortex
2 - ECG and brain stem
3 - EEG and cerebral cortex
4 - EEG and brain stem

A

3 - EEG and cerebral cortex
- cerebral cortex as this is closest to monitors

28
Q

What type of electrical signal is required to generate an EEG?

A
  • dipole
  • signal from excitatory postsynaptic potential must exceed the inhibitory postsynaptic potential to detect a signal
29
Q

In EEG placement of electrodes, what is the 10-20 system?

A
  • system to allow comparison of EEGs worldwide
30
Q

What does montage relate to on an EEG?

A
  • logical, orderly arrangements of electroencephalographic derivations or channels
31
Q

How long does a standard EEG last and what intervals is it read at?

1 - lasts 10-20 minutes, read at 10 second intervals
2 - lasts 20-30 minutes, read at 10 second intervals
3 - lasts 30-40 minutes, read at 10 second intervals
4 - lasts >60 minutes minutes, read at 10 second intervals

A

3 - lasts 30-40 minutes, read at 10 second intervals

32
Q

When considering different rhythms on an EEG, which of the following would only be present during sleep?

  • alpha
  • beta
  • theta
  • delta
A
  • theta and delta
  • alpha and beta are only present when awake
33
Q

Does a normal EEG rule out epilepsy?

A
  • no, seizure could have passed and brain has returned to normal
  • depends on when the seizure was and soon EEG can be done following the seizure
34
Q

Epileptiform discharges are used to identify if a patient has epilepsy. What are epileptiform discharges?

1 - abnormal signals on an ECG characterised by large spike waves
2 - abnormal signals on an EEG characterised by large spike waves

A

2 - abnormal signals on an EEG characterised by large spike waves

35
Q

If a seizure is no longer happening, can epileptiform discharges still be detected to help diagnosis epilepsy?

A
  • yes, providing close to time of seizure otherwise neuronal activity returns to normal
  • called interictal (in between seizures) epileptiform discharges (IED)
36
Q

When trying to measure epileptiform discharges on an EEG to help diagnosis epilepsy, why is it important to ask about medication?

A
  • medication can affect action potentials and therefore the EEG trace
  • benzodiazepine can inhibit neuronal activity through GABA
37
Q

What is the only time an EEG rule out epilepsy?

1 - when we know the cause and precipitating factor
2 - when we know the full medical history and medication of the patient
3 - <30 minutes from a seizure occurring
4 - when a seizure is occurring

A

4 - when a seizure is occurring
- if epileptiform discharges are not present (uncommon EEG patterns characterised by lateralised or generalised; periodic or near periodic; or spike, spike-wave, or sharp-wave complex presentations throughout most or all of the recording) then epilepsy is unlikely the cause of the seizure

38
Q

EEGs are not great at detecting epileptiform discharges. Therefore, clinicians can ask patients to do certain things in an attempt to induce a seizure. What are the 4 most common methods of doing this?

A
  • sleep deprivation
  • hyperventialtion
  • photic stimulation
  • medication withdrawal
39
Q

Interictal epileptiform discharges (IEDs), meaning uncommon spikes, polyspikes, sharp waves, or spike and slow-wave complexes in between seizures are commonly observed in children with epilepsy. However, they can also be detected in what % of adults and children who are healthy. Why is this important?

A
  • healthy adults = 0.5%
  • healthy children = 2-6%
  • important to ensure diagnosis is correct
40
Q

Patients can have multiple seizures within a 24 hour window, but this does not increase the risk of re-occurrence of seizures. What does increase the risk of re-occurrence in unprovoked (unknown) seizures?

1 - when seizure re-occurrence occurs in first 6 months
2 - when seizure re-occurrence occurs in first year
3 - when seizure re-occurrence occurs in first 2 years
4 - when seizure re-occurrence occurs in first 5 years

A

3 - when seizure re-occurrence occurs in first 2 years
- 21-45% occur within first 2 years
- higher if there are epileptiform discharges on EEG

41
Q

When a patient has a seizure, what should patients be told about their lifestyle changes in an attempt to reduce seizures occurring again?

1 - take medication regularly
2 - lose weight, avoid lack of sleep, reduce alcohol
3 - avoid lack of sleep, reduce alcohol and reduce risk of infections
4 - gain weight, avoid lack of sleep, reduce alcohol

A

3 - avoid lack of sleep, reduce alcohol and reduce risk of infections

42
Q

Why is it important to ensure patients at risk of seizures do not do the following:

  • unsupervised activities
  • bathing, swimming, working at heights, operating heavy machinery
  • driving
A
  • pose a risk to the individual and others
43
Q

Patients who have epilepsy are more susceptible to neuropsychiatric co-morbidities, such as what?

A
  • depression
  • anxiety
  • suicide risk
  • psychosis
44
Q

What does inter-ictal (latin for blow or stroke) mean in relation to epilepsy?

1 - occurring between seizures
2 - occurring before seizures
3 - occurring after seizures

A

1 - occurring between seizures

45
Q

What does prodrome mean in relation to epilepsy?

1 - symptoms between seizures
2 - lack of symptoms before seizures
3 - early signs that may cause seizures

A

3 - early signs that may cause seizures

46
Q

What does pre-ictal (latin for blow or stroke) mean in relation to epilepsy?

1 - occurring between seizures
2 - occurring before seizures
3 - occurring after seizures

A

2 - occurring before seizures
- brain activity/illness occurring prior to seizure

47
Q

What does post-ictal (latin for blow or stroke) mean in relation to epilepsy?

1 - occurring between seizures
2 - occurring before seizures
3 - occurring after seizures

A

3 - occurring after seizures

48
Q

What is sudden unexplained death of epilepsy (SUDEP)?

A
  • unexplained death in epilepsy, but is rare
  • 2-18% incidence (higher in children)
  • more severe epilepsy are a higher risk
49
Q

What are the 3 drugs that can be used to treat epilepsy that we need to know?

1 - Amitriptyline, Carbamazepine, Phenytoin
2 - Diazepam, Carbamazepine, Citalopram
3 - Diazepam, Carbamazepine, Phenytoin
4 - Diazepam, Citalopram, Phenytoin

A

3 - Diazepam, Carbamazepine, Phenytoin
- Diazepam (binds to gamma GABA-A receptors and inhibits action potential)
- Carbamazepine (inhibits Na+ channels)
- Phenytoin (inhibits Na+ channels)

50
Q

Who helps determine what medication is given to patients with epilepsy?

A
  • NICE guidelines
51
Q

Which of the 3 core drugs Diazepam, Carbamazepine and Phenytoin are classed as broad spectrum drug and why are they called this?

1 - Diazepam able to treat all seizure types
2 - Carbamazepine able to treat all seizure types
3 - Phenytoin able to treat all seizure types

A

1 - Diazepam able to treat all seizure types
- diazepam (GABA-A agonist)

52
Q

Which of the 3 core drugs Diazepam, Carbamazepine and Phenytoin are classed as narrow spectrum drugs and why are they called this?

1 - Diazepam used for a specific type of epilepsy
2 - Carbamazepine used for a specific type of epilepsy
3 - Phenytoin used for a specific type of epilepsy

A

2 - Carbamazepine used for a specific type of epilepsy
3 - Phenytoin used for a specific type of epilepsy

53
Q

Which of the 3 core drugs Diazepam, Carbamazepine and Phenytoin have been shown to have adverse events in asian populations?

1 - Diazepam
2 - Carbamazepine
3 - Phenytoin

A

2 - carbamazepine
- asians (Chinese) are higher risk due to genetic risk

54
Q

Is epilepsy permanent?

A
  • no
  • patients can be remission
  • normally if a patient does not have a seizure within 1 year

NSB! (53 decks)

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