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Neurology STG > Epilepsy and Blackouts > Flashcards

Epilepsy and Blackouts Flashcards

1
Q

What is a seizure?

A

Sudden Synchronous Discharge of Cerebral Neurones that is apparent either to the patient
only (e.g. Simple Partial Seizure) or to an observer (e.g. Generalised Seizure); Definition
excludes Migraine Aura (more gradual onset, more prolonged, on EEG correlation)

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2
Q

What is epilepsy?

A

Ongoing liability to recurrent epileptic seizures; Common (0.7-0.8%, more common
in developed countries); Highest incidence at young/elderly; Often goes into remission

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3
Q

Generalised onset

A

Discharge arises from both hemispheres

o Includes Absence, Myoclonic, Tonic, Tonic-Clonic, Atonic; Combination or Sequential

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4
Q

Focal Onset

A

Arises from one or part of one hemisphere; LOC may be retained, lost or evolve
into secondary GTCS

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5
Q

Frontal Lobe Seizures

A

Motor or Premotor Cortex; Clonic movements which may travel proximally (Jacksonian march) or Tonic seizure (e.g. both upper limbs raised high for several seconds)

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6
Q

Temporal Lobe Seizures

A

Strange warning feelings, or Aura with Smell/Taste
abnormalities, Distortion of Sound and Shape etc
▪ Automatisms – Lip-smacking, Plucking, Walking in Non-purposeful manner;
due to spread to Pre-motor Cortex
▪ Consciousness can be impaired, usually longer than absence seizures

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7
Q

Occipital Lobe Seizures

A

Stereotyped Visual Hallucinations

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8
Q

Parietal Lobe Seizures

A

Contralateral dysaesthesia or distorted body image

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9
Q

ILAE 2017

A

– Focal (Awareness/Impaired, Motor/Non-motor, Focal to Bilateral Tonic-
Clonic), Generalised (Motor or Non-motor), or Unknown (Motor or Non-motor)

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10
Q

Epilepsy syndromes by age groups

A

In Adolescents, Genetic, Perinatal and Congenital Disorders predominate; In Younger Adults, Trauma, Drugs, Alcohol are common while in the Elderly, Cerebrovascular Disease and Mass Lesions (e.g. Brain Tumours) are commoner

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11
Q

Primary Generalised Epilepsies

A

Presents in Childhood and Early Adult life; Accounts for up to 20% of all patients with
Epilepsy; Polygenic with complex inheritance
Structurally normal brain but abnormal Ion Channels which lead to abnormal Neuronal,
Neurotransmitter and Synaptic Functioning

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12
Q

Juvenile Myoclonic Epilepsy

A

10% of all Epilepsy patients; Myoclonic Seizures start in teenage years; Followed by GTCS; 1/3 of patients also have Absence Seizures
o Often occur in the morning after waking; Lack of sleep, Alcohol, Strobe lighting are
triggers; Responds well to treatment
o Usually associated with EEG abnormalities and requires life-long therapy

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13
Q

Hippocampal Sclerosis

A

Major cause of Epilepsy; Damage leading to
Scarring and Atrophy of the Hippocampus (usually
visible on MRI) leading to Temporal Lobe Epilepsy,
leading cause of LRE
• Childhood Febrile Convulsions are the main Risk Factor; One of the commoner causes of Refractory Epilepsy; Surgical Resection of damaged Temporal Lobe might be useful

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14
Q

Causes of Epilepsy: TBI

A

Might cause Epilepsy, even years after; Risk is not increased for minor injury (LOC/Amnesia <30 mins); Depressed Skull Fracture, Penetrating Injury and ICH increases risk significantly

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15
Q

Causes of Epilepsy: Perinatal Brain Injury and Cerebral Palsy

A

Periventricular Leukomalacia and ICH associated

with Prematurity and Foetal Hypoxia can cause Early Onset Epilepsy; 1/3 of Cerebral Palsy patients have Epilepsy

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16
Q

Causes of Epilepsy: Brain neurosurgery

A

Seizures in up to 17% of cases; Prophylactic Anticonvulsant use
Postoperatively is not recommended (Risk of Altered Mental Consciousness>Benefits)

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17
Q

Causes of Epilepsy: Genetic Disorders

A

Genetic Disorders (>200 types) can cause Epilepsy; Only counts for 2% of Epilepsy causes;
Developmental Disorders E.g. Neuronal Migration detects during Brain development,
Dysplastic Cerebral Cortex and Hamartomas also contribute to Seizures

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18
Q

Causes of Epilepsy: Vascular Disorders

A

Stroke and Small Vessel Cerebrovascular Disease is the commonest cause of Epilepsy after 60yrs; AVMs including Cavernous Haemangiomas

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19
Q

Causes of Epilepsy: Neurodegenerative Disorders

A

Involvement of the Cerebral Cortex e.g. Alzheimer’s Disease is associated with increased risk for Epilepsy

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20
Q

Causes of Epilepsy: Inflammatory Conditions

A

Encephalitis, Cerebral Abscess, Tuberculomas; Also occurs in Chronic TB Meningitis and rarely Acute Bacterial Meningitis; Parasitic infections commoner in
less developed countries

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21
Q

Causes of Epilepsy: Chronic Alcohol Use

A

Common cause; Occur while heavy drinking or during withdrawal; Induced Hypoglycaemia and Head Injury also can cause seizures

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22
Q

Causes of Epilepsy: Drugs

A

Antipsychotics, TCAs, SSRIs, Lithium, Class Ib Anti-Arrhythmics (Lidocaine), Ciclosporin and Mefloquine; Stimulants e.g. Cocaine

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23
Q

Causes of Epilepsy: Metabolic

A

Hypocalcaemia, Hypoglycaemia, Hyponatraemia, Acute Hypoxia, Uraemia
and Hepatic Encephalopathy, Porphyria

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24
Q

Management of First Fit

A

Clinical diagnosis based on History taking; Majority of patients referred to First Fit
clinic have not had a seizure; Most commonly misdiagnosed Syncope
If not doubt, do not diagnose Epilepsy
• Bloods (FBC, U/Es, Serum Calcium), ECG
• EEG – Most useful to categorise Epilepsy rather than confirm diagnosis; High False Negative Rate and low False Positive Rate
o Focal Cortical Spikes (e.g. Temporal Lobe Epilepsy) or Generalised Spike-and-Wave Activity (e.g. in PGE); Continuous in Status
Epilepticus

• MRI Brain indicated in most patients after
first Seizure; Especially for Partial Onset or
Elderly (Greater risk of Focal Brain Lesions);
Not essential if <30yrs with definite EEG/Clinical Diagnosis of PGE

25
Q

Distinguishing Syncope from Seizure

A

Distinguishing from Syncope – Seizures
have prolonged recovery period, tongue
may be bitten, colour change (Cyanosis
occurs in Seizure, Pallor in Syncope)

26
Q

Advice for First Seizure

A

Avoid precipitants, Advice on safety, stop driving and ask patients to inform DVLA
• Recurrence after first fit in 70-80% of people; Risk highest 6 months after initial seizure; Risk is significantly increased by features of PGE on EEG, Partial Seizures and Structural Brain Lesion

27
Q

Management of Continuous Seizure

A

Seizure >5mins or repeated Seizure treated with Rectal Diazepam, IV Lorazepam or Buccal Midazolam; O2 and monitor Airway

28
Q

Status Epilepticus

A

Continuous Seizures for >30mins; Mortality 10-15%;
Longer duration of status increases risk of Permanent
Cerebral Damage; Rhabdomyolysis leads to AKI in convulsive Status Epilepticus

29
Q

What kind of form can SE take

A

Status can be Convulsive, Absence or Focal; Epilepsia Partialis Continua is continuous Seizure
activity in one part of the limb without loss of Consciousness; Often due to Cortical Neoplasm
or Cortical Infarct (especially in the Elderly)

30
Q

How are antiepileptic drugs given?

A

Indicated if firm clinical diagnosis of Epilepsy and Substantial Risk of Recurrent Seizures;
Introduced at low dose and titrated upwards until Seizures controlled or SE intolerable
• 70% of patients only require monotherapy
• If seizures not controlled with first drug, introduce second agent and withdraw first drug; if not seizure free, combination therapy required
• Non-Generic prescribing to ensure consistent drug levels
• Routine monitoring not required; For assessing compliance and toxicity

31
Q

SE of AEDs?

A

Unsteadiness, Nystagmus, Drowsiness; Skin rashes in Lamotrigine, Carbamazepine
and Phenytoin; Variety of Idiosyncratic drug reactions

32
Q

AEDs and pregnancy?

A

Increased risk of Birth Defects; Recommend switching to Monotherapy at low-dose; Folate
and Vitamin K supplementation; Risk of Birth Defect < Risk of Seizures to Foetus

33
Q

AEDs and oral contraception?

A

Phenytoin, Carbamazepine, Phenobarbital are liver inducers; Oral contraception affected

34
Q

AED withdrawal

A

Withdrawal after at least 2-3yrs seizure free; 50% Recurrence Rate after withdrawal

35
Q

Management of GTCS

A 
1st Line: 
Valporate,
Carbamazepine,
Lamotrigine
2nd Line
Clobazam,
Levetiracetam,
Topiramate
36
Q

Management of Generalised Absence

A 
1st Line
Valporate,
Ethosuximide,
Lamotrigine
2nd Line
Clobazam,
Levetiracetam,
Topiramate
37
Q

Management of Generalised Myoclonic

A 
1st Line
Valporate,
Levetiracetam,
Topiramate
2nd Line
Clobazam,
Piracetam
38
Q

Management of Focal Seizures

A 
1st Line
Carbamazepine,
Valporate,
Levetiracetam,
Lamotrigine
2nd Line
Clobazam,
Topiramate,
Gabapentin,
Tiagabine
39
Q

Which drugs should be avoided in absence, myoclonic and JME

A

Avoid Carbamazepine, Gabapentin and Tiagabine

40
Q

SE Valproate

A

Weight gain, Hair loss, Teratogenic, Rare Idiosyncratic Liver Failure

41
Q

SE Carbamazepine

A

Rash, Hyponatraemia, Ataxia, Liver Enzyme Induction, Interference with other medications including Oral Contraception

42
Q

Management of Refractory Epilepsy

A
  • Re-evaluate Diagnosis, Consider drug concordance, Combination therapy to maximum tolerable dose, Referral for Epileptic Surgery (e.g. Temporal Lobectomy, Cure in 50-70%)
  • Vagal Nerve Stimulation, Ketogenic Low Carbohydrate Diet might be useful
43
Q

Vasovagal syncope

A

Simple faint due to sudden reflex tachycardia with vasodilation of peripheral and splanchnic vasculature
Precipitated by Prolonged Standing,Fear, Venesection or Pain
o Brief Prodrome of Dizziness, Nausea,
Sweating, Heart and Visual Grey-out
o Blackout may be accompanied with
jerking/twitching movements; Pallor
o Rapid recovery (usually seconds) by followed by a feeling of general fatigue

44
Q

Cardiac Syncope (Stokes-Adams Attacks)

A

Cardiac Arrhythmias E.g. Heart Block, LVOT

Obstruction; Syncope during exercise is cardiac in origin

45
Q

Micturition Syncope

A

More common in men, particularly at night

46
Q

Cough Syncope

A

Venous Return to the heart obstructed by coughing; Also, laughter

47
Q

Postural Hypotension

A

Occurs in the Elderly, patients with Autonomic Neuropathy, or drugs
e.g. Antihypertensives especially β-Blockers

48
Q

Carotid Sinus Syncope

A

Vagal response to pressure on Carotid Sinus Baroreceptors

49
Q

Convulsive Syncope

A

Collapsing in a propped-up position results in delayed restoration of
Cerebral Blood Flow; Secondary Anoxic Seizure following Syncope

50
Q

Management of Syncope

A

• 12-lead ECG – Identify Heart Block, Pre-Excitation, Long QT syndrome
• Cardiac ECG Holter Monitoring and Echo if Cardiac Syncope suspected; alternatively,
Implantable Loop Recorder for infrequent events
• Tilt table testing sometimes diagnostic but low sensitivity

51
Q

Non-Epileptic Attack Disorder (Pseudoseizures)

A

Presents similarly to Grand Mal Seizures;
Bizarre thrashing, non-synchronous Limb Movements; No rise in Prolactin (No rise also seen
in Partial Seizures) and no EEG changes even during attack

52
Q

Panic Attacks

A

Sudden Sympathetic Activation; Often Hyperventilation leading to Respiratory Alkalosis; Dizziness, Chest Pain/Tightness, Feeling or Choking, SOB, Facial Tingling and Extremities, Trembling, Feeling of dissociation
o Consciousness is usually preserved, attacks easily recognised

53
Q

Hypoglycaemia

A

Confusion followed by LOC, Convulsion, Dysphasia, Hemiparesis; Often
warning with Hunger, Malaise, Shaking and Sweating; Prompt recovery with IV/PO Glucose
o Prolonged Hypoglycaemia can cause widespread Cerebral Damage; Usually related to underlying Diabetes

54
Q

Vertigo

A

Acute Vertigo might be severe enough to cause prostration

55
Q

Migraine

A

Severe Basilar Migraine and Familial Hemiplegic Migraine may cause LOC

56
Q

Drop Attacks

A

Instant, Unexpected episodes of LL Weakness with Falling; Due to sudden drop
in LL Tone? Brainstem origin; More common in 60+ Women; Also occurs in Hydrocephalus

57
Q

Narcolepsy

A

Abnormalities of orexin, unusually low, autoimmune hypothalamic damage
Tetrad of excessive daytime sleepiness, cataplexy (sudden loss of tone), dream like hallucinations peri sleep often frightening and sleep paralysis

58
Q

Management of Narcolepsy

A

• Multiple Sleep Latency Testing – Demonstrate rapid transition from Wakefulness to Sleep,
Short time to onset from REM sleep
• HLA testing for HLA-DR2 and HLA-DQBI*0602 Antigens (Strong Association)
• Good sleep hygiene advice; CNS Stimulants like Modafinil (? Dopamine Reuptake Inhibitor)
and Methylphenidate (Dopamine-Noradrenaline Reuptake Inhibitor) for treatment although
often only partial response
• TCAs (especially Clomipramine) or SSRIs to improve Cataplexy; Sodium Oxybate also used

59
Q

Parasomnias

A

Disruptive Motor/Verbal Behaviours – REM and non-REM parasomnia depending on what
stage of sleep it occurs in
• Includes Sleepwalking, Night Terrors, Confusional Arousals and REM Sleep Behaviour Disorder
o REM Sleep Behaviour Disorder might be early feature of Parkinson’s Disease

Neurology STG (15 decks)

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