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Gwen - Neurology > Epilepsy and Fits/Funny turns/Seizures > Flashcards

Epilepsy and Fits/Funny turns/Seizures Flashcards

1
Q

What are types of generalised seizures?

A
  • Absence seizures
  • Generalised tonic-clonic seizures
  • Juvenile myoclonic epilepsy
  • Myoclonic seizure
  • Clonic seizure
  • Tonic/Atonic seizure
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2
Q

What are causes of a provoked seizure?

A
  • Alcohol withdrawal
  • Drug withdrawal
  • Within a few days of head injury
  • Within 24 hours of stroke
  • Within 24 hrs neurosurgery
  • Severe electrolyte disturbances
  • Eclampsia
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3
Q

What are the different types of focal seizures?

A
  • Simple partial Seizures
  • Complex Partial seizures
  • Partial seizures with secondary generalised
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4
Q

What are features of absence seizures?

A

“Petit-Mal”

Loss of awareness and a vacant expression for <10 seconds before returning abruptly to normal and continuing as though nothing had happened.

Apart from slight fluttering of the eyelids there are no motor manifestations.

Patients do not realise they have had an attack

Can lead to T-C in later life

PRESENTS IN CHILDHOOD

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5
Q

What can absence seizure be provoked by?

A
  • Hyperventilation
  • Photic stimulation
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6
Q

Who do absence seizures occur most commonly in?

A

Children

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7
Q

What are features of myoclonic seisures?

A

Sudden muscle jerking involving limb, face or trink. Usually followed by unconsciousness.

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8
Q

What is a myoclonic seizure?

A

https://www.youtube.com/watch?v=xzBBezFqVMo

Myoclonic seizures or ‘jerks’ take the form of momentary brief contractions of a muscle or muscle groups, e.g. causing a sudden involuntary twitch of a finger or hand.

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9
Q

What prodromal features of Tonic-Clonic seizures?

A
  • Often no warning
  • Can have an aura - strange feeling in gut, deja-vu, strange smell, flashing lights
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10
Q

What are features of the tonic phase of a tonic clinc seizure?

A

10-60 seconds

  • Rigidity
  • Epileptic cry
  • Tongue biting
  • Incontinence
  • Hypoxia/cyanosis – no breathing during this phase
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11
Q

What are features of the post-ictal phase of tonic-clonic seizures?

A

Period of flaccid unresponsiveness, followed by gradual return of awareness with Confusion + Drowsiness lasting from 15 minutes to 1 hour. Headache is common in tonic-clonic seizures

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12
Q

What do tonic clonic seizures look like?

A

https://www.youtube.com/watch?v=Nds2U4CzvC4

Rhythmic jerking in clonic phase

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13
Q

What are tonic seizures?

A

https://www.youtube.com/watch?v=vjnzFZ0wrJU

Seizures consisting of stiffening of the body, not followed by jerking

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14
Q

What is the definition of epilepsy?

A

A recurrent tendency to spontaneous, intermittent, abnormal electrical activity in part of the brain, manifesting as seizures. Convulsions are the motor manifestations of electrical discharge

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15
Q

What are the features of simple partial seizures?

A
  • Focal motor/sensory/autonomic/psychic symptoms
  • Awareness is unimpaired

No affect on consciousness or memory, awareness is unimpaired.

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16
Q

What are focal seizures most often seen in?

A

Structural disease in one hemisphere

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17
Q

What are the features of complex partial seizures?

A
  • Can have aura and post-ictal phase
  • Impaired awareness - lasting for 1–2 minutes on average
  • Retrograde amnesia
  • Speech arrest
  • Automatisms – semi-purposeful stereotyped motions such as lip smacking or dystonic limb posturing, or more complex motor behaviours such as walking in a circle or undressing.
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18
Q

What are examples of automatisms seen in complex partial seizures?

A
  • Lip smacking
  • Dystonic limb posturing
  • Walking round in circles
  • Undressing
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19
Q

Where do complex partial seizures most commonly originate from?

A

Temporal lobe (60%) or frontal lobe

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20
Q

What are aura features that individuals can experience when they have complex partial seizures?

A
  • Rising epigastric sensation and nausea
  • Hallucinations:
    • Déjà vu or jamais vu
    • Olfactory hallucinations
    • Formed visual hallucinations or misperceptions
    • Fear
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21
Q

What proportion of those with partial seizures develop secondary generalised seizures?

A

2/3rds

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22
Q

What features would localise seizure source to the temporal lobe?

A
  • Automatisms
  • Emotional disturbance
  • Hallucinations - olfactory or visual
  • Delusional behaviour
  • Bizarre associations
  • Dysphasia
  • Deja-vu/feeling of unreality
  • Post-ictal confusion
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23
Q

What features would localise a focal seizure to the frontal lobe?

A
  • Motor features - posturing, peddling movement
  • Typically beginin in cornery of mouth leading to involvement of limbs on opposite side of epileptic focus
  • Jacksonian march
  • Motor arrest
  • Subtle behaviour disturbance
  • Dysphasia/speech arrest
  • Todd’s Paralysis - limb weakness following seizure
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24
Q

What is jacksonian march?

A

https://www.youtube.com/watch?v=5OADO9ucNiM

Spreading of focal motor seizure with retained awareness, often starting with face or thumb

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25
Q

What features of a focal seizure would imply it origintaed in the parietal lobe?

A
  • Sensory disturbances - tingling, numbess, pain
  • Motor disturbance - spreda to precentral gyrus
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26
Q

What features of a focal seizure would point to it having originated in the occipital lobe?

A

Visual phenomena

  • Spots
  • Lines
  • Flashes
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27
Q

What is Todd’s paralysis

A

Transient neurological deficit (paresis) following a seizure. May have:

  • Weakness in face, arms, legs
  • Aphasia
  • Gaze palsy

Lasts for 30mins to 36 hrs

https://www.youtube.com/watch?v=UYG4bj4Lkkc

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28
Q

What would you differential diagnosis be for a fit/seizure?

A
  • Idiopathic epilepsy - known or new
  • Syncope, faint, vasovagal attack
  • Migraine
  • Cardiac arrhythmia
  • Stroke
  • Narcolpesy
  • Brain tumour
  • Meningitis
  • Hypoxia
  • Alcohol withdrawal
  • Hypoglycaemia
  • Hypotension
  • Severe electrolyte distrubance
  • Pseudoseizure
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29
Q

What are causes of epilepsy?

A
  • Idiopathic
  • Cortical scarring - due to previous head injury
  • Developmental problems
  • Degenerative conditions
  • SOLs
  • Stroke/Vascular malformations
  • Hippocampal sclerosis
  • Tuberous Sclerosis
  • SLE
  • Encephalitis
  • Metabolic abnormalities
  • Hydrocephalus
  • Drugs/Alcohol withdrawal
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30
Q

What is primary generalised epilepsy?

A

Epilepsy caused by a structurally normal brain but abnormalities of ion channels influencing neuronal firing, abnormalities of neurotransmitter release and synaptic connections.

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31
Q

What are features of the clonic phase of tonic clonic seizures?

A

Seconds to minutes

  • Convulsions/limb jerking
  • Eye rolling
  • Tachycardia
  • No breathing/random, uncoordinated breaths
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32
Q

What drugs can cause epilepsy?

A
  • Drugs for neurological/psychiatric disorders - e.g. TCA’s, MAO inhibitors, amphetamines, propofol
  • Drug withdrawal – e.g. anticonvulsants
  • Alcohol induced hypoglycaemia
  • Alcohol withdrawal
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33
Q

What are automatisms?

A

Complex motor phenomena with impaired wareness, from primative oral to manual movements/complex actions

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34
Q

What is the pathophysiology of epilepsy?

A

Abnormal SYNCHRONISED discharge of many neurons - Normal inhibitory mechanisms fail.

Sequence of events:

  • Paroxysmal discharge of cerebral neurones
  • Excitation of cerebral cortex
  • Seizure
  • Epilepsy (continuing seizures)
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35
Q

What is the main excitatory neurotransmitter involved in epilepsy?

A

Glutamate

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36
Q

What is the main inhibitory neurotransmitter involved in epilepsy?

A

GABA

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37
Q

What metabolic abnormalities can cause epilepsy?

A
  • Hypoglycaemia
  • Hypocalcaemia
  • Hyponatraemia
  • Hypoxia
  • Uraemia
  • Mitochondrial disease
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38
Q

What are triggers of epileptic seizures?

A
  • Sleep deprivation
  • Alcohol (alcohol intake AND alcohol withdrawal)
  • Drug misuse
  • Physical/mental exhaustion, stress
  • Flickering lights – cause primary generalised epilepsy only
  • Infection / metabolic disturbance
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39
Q

What are the different primary generalised seizures in children?

A
  • Childhood abscence epilepsy
  • Juveniale absence epilepsy
  • Juvenile myoclonic Epilepsy
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40
Q

What is the age of onset of childhood absence epilepsy?

A

4-8 years - 80% remit by age 18

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41
Q

What is the age of onset of juvenile absence epilepsy?

A

10-15 years

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42
Q

What is the age of onset of juvenile myoclonic epilepsy?

A

15-20 years

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43
Q

What are features of juvenile myoclonic spilepsy?

A
  • Morning Myoclonic seizures
  • Progress to GTCS
  • Can also have absence
44
Q

Describe presentation of atonic seizure

A

Sudden hypotonia (all muscles relax) causing a fall (normally forwards)

45
Q

Describe feautres of clonic seizures

A

Same as myoclonic but lasts up to 2 mins

46
Q

Describe features of tonic seizures

A

Intense stiffneing of body (normally fall backwards)

47
Q

What can trigger epileptic seizures in juvenile myoclonic epilepsy?

A
  • Sleep deprivation
  • Alcohol/Alcohol withdrawal
  • Flickering lights
48
Q

Does juvenile myoclonic epilepsy remit without treatment?

A

No - usually require lifelong treatment

49
Q

What is the main pathological cause of temporal lobe epilepsy?

A

Hippocampal sclerosis - damage with scarring and atrophy of the hippocampus and surrounding cortex

50
Q

What is the commonet cause of epilepsy after the age of 60?

A

Vascular disorders - stroke/CVA

51
Q

How would you approach taking a history for someone who had had a first seizure?

A
  • Pre/Ictal/Post-ictal experiences - seizure or syncope
  • Collateral history - seizure form, tongue biting, incontinence etc.
  • Previous fits/funny turns - including other types of seizures
  • Triggers - seizures or syncopal
  • Epilepsy risk factors - significant head injury, meningitis/encephalitis, FH
  • Alcohol excess/Medications
  • Driving

Ie before, during (how long?), after

PMH - any prev medical condition, DM

FH epilepsy

SH - alcohol

52
Q

What investigations would you consider doing in someone who had presented with a seizure?

A
  • Thorough neuro exam and basic observations (esp. temperature)
  • ECG
  • EEG
  • Consider CT/MRI - DONE IN ALL NEW CASES
  • Bloods - U+E’s, Glucose, LFTs, Ca2+, CK, Prolactin
  • Consider Blood Cultures/LP
  • Toxicology screen
53
Q

Why is it important to measure temperature in someone presenting with a seizure?

A

Look for sign of infection as a cause. Could also indicate illicit drugs e.g. amphetamine use

54
Q

Why is a thorough neuro exam impiortant when investigating someone presenting with a seizure?

A

Look for signs of a cause:

  • Signs of SOL
  • Signs of stroke
  • Signs of degenerative disease
55
Q

Why might you do an ECG in someone presenting with a seizure?

A

Look for cardiogenic causes of LOC

56
Q

Why might you do a serum calcium level in someone presenting with seizures?

A

Look for hypocalcaemia as a cause

57
Q

Why might you do serum U+E’s in someone presenting with seizures?

A

Look for metabolic causes of seizures:

  • Uraemia
  • Hypo/hypernatraemia
58
Q

Why would you measure blood glucose in someone who had presented with a suspected seizure?

A

Look for signs of hypoglycaemia

59
Q

Why might you do an LP in someone presenting with a suspected seizure?

A

Look for signs of meningitis/infection

60
Q

Why might you consider doing a toxiclogy screen on someone presenting with suspected seizures?

A

Look for drug intoxication e.g. amphetamines

61
Q

Why might you look at drug levels (e.g. anti-epileptic drugs) in the blood of someone presenting with suspected seizures?

A

Look to see if they have therapeutic levels in their blood i.e. are they compliant??

62
Q

Why might you consider doing a CK in someone presenting with a suspected seizure?

A

Raised in true epileptics after clonus and tonic seizures, normal in pseudoseizures

63
Q

Why might you look at the serum prolactin levels in someone presenting with suspected seizures?

A

Raised in true seziures, not raised in pseudo-seizures

64
Q

Why can EEG be a useless test?

A

EEG is usually normal inbetween fits, and an abnormal EEG between fits does NOT confirm the suspected event as epilepsy either

65
Q

How might you elicit an abnormal interictal EEG?

A
  • Sleep deprivation EEG
  • ‘Activated EEG’ – after the patient has been given procyclidine
  • 24-48 hour EEG – often with simultaneous video of patient to asses clinical signs – called videotelemetry.
66
Q

What is EEG most useful for?

A

Categorizing epilepsy and understanding its cause, rather than as a means of confirming a doubtful diagnosis of epilepsy.

67
Q

What are indications for CT/MRI in someone presenting with suspected seizures?

A
  • Late onset disease
  • Partial seizures
  • Associated with abnormal clinical signs
68
Q

What tests can you do to differentiate a true seizure from a pseudoseizure?

A
  • Serum CK
  • Serum Prolactin
  • Consider EEG…
69
Q

What is the commonest error in diagnosis in someone presenting with a suspected seizure?

A

Misdiagnosis of a syncopal blackout as a seizure.

70
Q

What advise would you give someone after a first confirmed seizure?

A
  • Avoid/remove precipitants - drugs, alcohol, sleep deprivation
  • Safety advise - swimming, baths, working with weights etc
  • Stop driving/Inform DVLA
  • Discuss recurrence risk
  • Individualised advice - employment, insurance, sports
71
Q

What is the recurrence risk of a seizure after a first seizure?

A
  • 70-80% - within first 6 months
  • Unprovoked - 30-50%
72
Q

What are risk factors for recurrent seizures?

A
  • Features of PGE on EEG
  • Partial seizures
  • Presence of structural brain lesions
73
Q

When should someone be commenced on anti-epileptic drugs?

A

After >/= 2 seizures, confirmed epilepsy diagnosis and detialed discussion with patient regarding treatment

74
Q

What are the first line treatments for Focal (partial) seizures?

A

Carbemazepine (liver enzyme enhancer) or Lamotrigine

75
Q

What are second line AEDs for treating Focal (partial) seizures?

A
  • Sodium Valproate
  • Leviteracetam
  • Oxcarbazepine
  • Topiramate
  • Gabapentin
76
Q

What are first line AEDs for treating Generalised Tonic-Clonic Seizures?

A

Try in this order

  1. Sodium Valproate
  2. Lamotrigine

Then consider second line

77
Q

What are second line AEDs used to treat Generalised tonic-clonic seizures?

A
  • Carbemazepine
  • Clobazam
  • Lamotrigeine
  • Leviteracetam
  • Topiramate
78
Q

What are first line AEDs for treating Absence seizures?

A
  • Sodium Valproate
  • Ethosuximide
79
Q

What second line AEDs would you consider for treating Absence seizures?

A

Lamotrigine

80
Q

What AEDs would you use first line as treatment for Myoclonic seizures?

A

Sodium valproate

(as for tonic clonic but avoid carbamezapine and oxcarbazepine as they may worsen)

81
Q

What AEDs woule you use as second line treatment for myoclonic seizures?

A
  • Leviteracetam
  • Topiramate
  • Clonazepam
82
Q

What AEDs would you consider using to treat tonic/Atonic seizures?

A
  • Sodium Valproate
  • Lamotrigine
83
Q

What medications would you avoid using when treating myoclonic seizures?

A

May worsen seizures

  • Carbemazepine
  • Oxcarbazepine
84
Q

How would you initiate someone with epilepsy on AED treatment?

A

Build-up doses over 2-3 months, until seizures controlled/max dose reached

85
Q

If, when testing treatment effectiveness for treating someone with epilepsy, they either did not tolerate the drug or reached the maximum recommended dose with no/limited effectiveness, what would you consider doing?

A

Switch to next most appropriate

86
Q

When switching AED in someone with epilepsy, what are important things to do?

A
  • Introduce second drug slowly
  • Remove 1st drug once second drug has established effect
87
Q

What proportion of epileptics require dual adjunct therapy?

A

<10%

88
Q

When would you consider stopping an AED in someone with epilepsy?

A
  • Patient has been seizure free for >/= 2 years
  • Risk/benefit assessment
  • 25-40% risk of recurrence
89
Q

What surgical options are available in epileptics?

A
  • Temporal lobectomy
  • Corpus collosal section
  • Hemispherectomy
  • Selective amygdalo-hippocampectomy
90
Q

Who would benefit most from a temporal lobectomy?

A

Epileptics with epilepsy caused by hippocampal sclerosis

91
Q

What are side effects of carbemazepine?

A
  • Leucopenia
  • Diplopia
  • Blurred vision
  • Impaired balance
  • Drowsiness
  • Mild generalised erythematous rash
  • SIADH
92
Q

What are side effects of lamotrigine?

A
  • Maculopapular rash
  • Diplopia
  • Blurred vision
  • Photophobia
  • Tremor
  • Agitation
  • Vomiting
  • Aplastic anaemia
  • TEN (toxic epidermal necrolysis)
93
Q

What are side effects of leviteracetam?

A
  • Depression/agitation
  • D+V
  • Dyspepsia
  • Drowsiness
  • Diplopia
  • Blood dyscarias
94
Q

What are side effects of sodium valproate?

A

VALPROATE

  • Valportate SEs
  • Appetite increased, weight gain, nausea
  • Liver failure (inhibits liver metabolism)
  • Pancreatitis
  • Reversible hair loss
  • Oedema
  • Ataxia
  • Teratogenicity, Tremor, Thrombocytopenia
  • Encephalopathy
95
Q

If you started someone on sodium valproate, what would you want to monitor for (especially in the first 6 months)?

A

LFTs - watch for liver failure

96
Q

What is the risk of foetal abnormalities in someone who is pregnant with epilepsy?

A

5% - good seizure control prior to conception and during pregnancy is therefore vital!!!

97
Q

What epileptic drugs are teratogenic?

A

Sodium Valproate

98
Q

What drugs used in the management of epilepsy induce liver enymes?

A
  • Carbemazepine
  • Phenytoin/Phenobarbital
  • Barbituates
99
Q

What implication does a woman of child bearing age who has epilepsy and is on carbemazepine have for her?

A

May need to adjust dose of contraceptive pill - carbemazepine is liver enzyme inducer

100
Q

What advise should you give pregnant women with regard to managing their epilepsy and reducing risk of harm to the foetus?

A
  • Folic acid - 5mg/day - before conception and during first trimester
  • Avoid sodium valproate and polytherapy - conception and pregnancy
  • Advise most AED drugs are present in breast milk
101
Q

When are patients with epilepsy not allowed to drive?

A
  • Medication change in the last 6 months
  • Seizure in the last 12 months
  • If the patient has ‘night-time’ only seizures, they can drive, if they have not had a ‘day time’ seizure for the last 3 years
  • If the risk is >2% of having a seizure, then you are not allowed to drive (normal lifetime risk is 1-2%)
102
Q

When are patients with epilepsy allowed to drive?

A

Situation specific - consider if safe if:

  • Seizures which do not affect consciousness (simple partial)
  • Seizures only during sleep and no daytime seizures for 3 years
103
Q

Are epileptic patients safe to fly on aeroplanes?

A

Yes

104
Q

What questions might you ask in a collateral history of epilepsy?

  • Loss of awareness?
  • Injure themselves?
  • Move or go stiff/floppy?
  • Incontinence, tongue biting?
  • Cahnge in complexion? (cyanosis suggests epilespy, white or red suggests arrhthmia)
  • Any associated symptoms? (palpitations, chest pain, sweats, pallor)
  • How long did attack last?
A
105
Q

What is important to remeber about OCP and antiepileptic medication?

A

Increased dpse of OCP needed

Gwen - Neurology (38 decks)

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