Epilepsy and seizures

Question 1

what is a seizure?

Answer 1

short episode of symptoms caused by burst of abnormal electrical activity in the brain

Question 2

what is epilepsy?

Answer 2

ongoing liability to recurrent seizures

Question 3

focal cf generalised seizures?

Answer 3

focal: abnormal electrical activity in one part of brain only
generalised: affects both hemispheres, awareness always impaired

Question 4

T/F: focal seizures can sometimes progress to secondary generalised seizures

Answer 4

true

Question 5

some patients develop auras before a seizure which can take various forms including…

Answer 5

deja-vu, change in smell, vision or taste

Question 6

why is it important to ask patients about auras

Answer 6

auras are regarded as focal aware seizures- would help you decide whether they’re fit to be driving

Question 7

focal aware seizures are aka as __ __ seizures

Answer 7

simple focal seizures

Question 8

in focal aware seizures, symptoms depend on the anatomical localisation

1) frontal lobe
2) parietal lobe
3) occipital lobe
4) temporal lobe

Answer 8

1) predominantly motor signs: stiffness, twitching, spasm. Jacksonian march: focal seizure spreads from distal part of limb towards ipsilateral face
2) sensory manifestations: tingling, numbness, pain
3) visual phenomena: flashing lights, colours, hallucinations
4) changes in mood or behaviour. Rising epigastric sensation common

Question 9

focal impaired awareness seizures mainly arise from the ___ lobe

Answer 9

temporal

Question 10

mesial temporal lobe epilepsy

1) most common cause?
2) typically associated with what type of seizures?

Answer 10

1) hippocampal sclerosis

2) complex focal seizures

Question 11

In a complex focal seizure it may be possible to identify which three distinct components?

Answer 11

1) aura
2) absence (LOC)
3) automatism

Question 12

T/F: following a complex focal seizure the patient is usually total amnesic for the events of the automatism

Answer 12

true

Question 13

what is an automatism?

Answer 13

repetitive stereotyped movement e.g. lip smacking, chewing, fiddling, walking, whilsting

Question 14

T/F: following a complex focal seizure some patients can develop postictal confusion

Answer 14

true

Question 15

name 5 subtypes of generalised seizure

Answer 15

absence
myoclonic
clonic
tonic
tonic-clonic

Question 16

describe absence seizures

Answer 16

abrupt LOC and cessation of all motor activity

Question 17

T/F: absence seizures are typically associated with an episode of falling

Answer 17

false - tone is usually preserved and there is no fall

Question 18

how long do absence seizures typically last?

Answer 18

= 10s

Question 19

absence seizures usually develop when in life?

Answer 19

childhood/ adolescence

Question 20

typical EEG appearance of absence seizures?

Answer 20

3Hz generalised spike-wave

Question 21

describe myoclonic seizures

Answer 21

brief contraction of a muscle, muscle group of several muscle groups > small twitch/ severe jerk

Question 22

juvenile myoclonic epilepsy

1) is a subtype of idiopathic ___ epilepsy
2) characteristic seizure?
3) develops between the ages of __ and __
4) in most cases what kind of seizures also occur?
5) good or poor response to treatment?

Answer 22

1) generalised
2) brief myoclnoic jerks, usually occurring in first hour or so after awakening. Sudden shock-like jerks affecting mainly the shoulders and arms
3) 12-18
4) generalised tonic-clonic (usually months or years after onset of myoclonus)
5) complete response to treatment in 80-90%, but lifelong therapy may be needed

Question 23

describe a clonic seizure

Answer 23

muscle begin to jerk and spasm. Elbows, legs and head flex and relax rapidly

Question 24

clonic seizures are most frequent in what age group?

Answer 24

neonates and infants

Question 25

most common form of generalised seizures?

Answer 25

tonic-clonic

Question 26

describe tonic-clonic seizures

Answer 26

tonic phase: quick LOC, skeletal muscles become stiff
clonic phase: rapid contraction-relaxation of muscles. Tongue may be bitten from strong jaw contractions. In some cases may have cyanosis and incontinence.

Question 27

T/F: EEG is the diagnostic test of choice for epilepsy

Answer 27

false- Epilepsy is clinically diagnosed
EEG may be normal in some patients with epilepsy
EEG only used to support diagnosis and help determine seizure type/ epileptic syndrome

Question 28

T/F: neuroimaging is not routinely requested to diagnose epilepsy

Answer 28

true

Question 29

Principles of anti-epileptic drug treatment

1) first establish…
2) use MONOTHERAPY/ POLYTHERAPY
3) re titration of doses?
4) when is polytherapy generally used?

Answer 29

1) epilepsy diagnosis and subtype
2) monotherapy: one drug at a time
3) start low, go slow
4) if monotherapy with at least 3 first choice drugs has failed to control seizures

Question 30

First line therapy in adults for

1) tonic clonic seizure
2) absence seizure
3) myoclonic seizure
4) focal seizures
5) unclassified

Answer 30

1) sodium valproate (lamotrigine if unsuitable)
2) ethosuximide (it SUX to miss out), sodium valproate
3) sodium valproate
4) lamotrigine, carbamazepine (have to FOCUS in a car)
5) sodium valproate

Question 31

Second line therapy in adults for

1) tonic clonic seizure
2) myoclonic seizure
3) unclassified

Answer 31

1) levitiracetam, topiramate, clobazam
2) levitiracetam
3) lamotrigine, topiramate

Question 32

which anti-epileptics are teratogenic?

Answer 32

sodium valproate (NTD)
phenytoin (clef palate)
carbamazepine

Question 33

which anti-epileptic can cause a rash and Stevens-johnson syndrome?

Answer 33

lamotrigine

Question 34

which anti-epileptic is used in pregnancy because its not teratogenic?

Answer 34

lamotrigine

Question 35

which anti-epileptic may exacerbate myoclonic seizures?

Answer 35

lamotrigine

Question 36

define status epilepticus

Answer 36

convulsive seizure which continues >5 minutes or occur one after the other with no recovery between

Question 37

1st line treatment for status epilepticus

1) in the community?
2) in hospital?
3) what is 2nd line if seizures continue?

Answer 37

1) buccal/ rectal midazolam
2) IV lorazepam
3) IV phenytoin/ phenobarbital

Question 38

DVLA regulations group 1 vehicles (car, motorcycle)

1) if seizure occurs when awake
2) if seizure occurs when asleep
3) if seizure occurs when awake but doesn’t affect consciousness

Answer 38

1) stop driving 1 year
2) can drive if no awake attack for 3 years
3) may drive if its the only type of attack you’ve ever had and the first one was 12 months ago

Question 39

DVLA regulations group 2 vehicles (bus, lorry)

1) one off seizure
2) more than one seizure/ diagnosis of epilepsy

Answer 39

1) stop driving for 5 years

2) must be seizure and medication free for 10 years

Question 40

describe a tonic seizure

Answer 40

brief LOC, patient falls to ground and often there is extension of the neck with upturning of the eyes and arching of the back

Question 41

what neuroimaging is the modality of choice in some cases of epilepsy? when would this be indicated?

Answer 41

MRI is modality of choice when needed- particularly imp if epilepsy onset <2 y/o with any suggestion of focal onset and/or who don’t respond to 1st line treatments