Epilepsy + Loss of Consciousness Flashcards
Wha is a seizure and how do you classify seizures
Seizure is abnormal electrical activity in the brain
Where it began
Level of awareness
Other features of seizure
What is a focal seizure
Specific area of brain affected
What is focal aware / simple partial
No post ictal phase
Aware during seizure
What is focal impaired consciousness / complex partial
Post-ictal phase
Aura
Loss of awareness / consciousness
What does aura suggest
Temporal lobe involvement
What is generalised seizure
Involves both side of brain
Consciousness loss = immediate
Motor vs non-motor
Can be primary or secondary to focal
What is secondary generalised
Starts on one side in specific area (focal)
Spreads to both lobes
What is post ictal phase
Any Sx after seizure Headache Confusion Myalgia Temporal weakness following focal seizure in motor cortex (frontal lobe) = Todd's palsy Dysphagia if temporal lobe
What are causes of seizure
Any insult to brain
Vascular Haemorrhage Stroke AV malformation Vasculitis Severe blood loss
Metabolic Hypoxia - when kept up straight after faint Any disturbance esp Na Hypoglycaemia Temperature Uraemia
Infectious TB Meningitis Encephalitis Neurosyphillis HIV
Autoimmune
SLE
Sarcoid
Iatrogenic TCA Cocaine Tramadol Withdrawal - alcohol
Raised ICP
Brain tumour
SOL
Pseudo
Non-epileptic
Other Epilepsy Febrile convulsion Concussive Arrhythmia - do ECG Vaso-vagal attack
What causes non-epileptic attack
Narcolepsy
Migraine
Movement disorders
How do non-epileptic attacks present
Well in-between attacks
Frequent prolonged and bizarre movement
May look like tonic-clonic
What do you do if someone is having a seizure
Check airway
Apply O2
Place in recovery position
Check O2 and BG
What is important in the Hx.
Any warning What were they doing previous night Has it happened before What happened after Any injury Tongue biting or incontinence What happened during attack
What is important in PMH
Head injury Traumatic birth Febrile convuslions Past psychatric Drug and alcohol
What are factors favouring syncope
Occurs upright Pallor = common Gradual onset Injury is rare Rapid recovery Hot / nausea / tinnitus / tunnel vision prior
What factors favour seizure
What can be raised after
Arise any position Pallor = uncommon Sudden Tongue biting + incontinence Slow recovery Precipitant rare May have raised serum prolactin
What factors favour pseudo-seizure
Pelvic thrusting Cry after FH epilepsy Don't occur alone Rapid breathing Eyes closed Gradual onset Fluctuating motor Quick return to norma Widespread convulsions with awareness Hx mental health CNS, CT, MRI and EEG normal
What is epilepsy
Recurrent tendency to spontaneous intermittent abnormal electrical activity which manifests as seizures
>2 seizures
or >1 + Ix is highly suggestive e.g. EEG changes
What type of generalised seizures can you get
Tonic clonic - stiff then jerky
Myoclonic - jerky in morning, associated with Juvenile myoclonic epilepsy
Tonic - stiff
Atonic - collapse, associated with Lennox Gastaut
Absence
What is focal temporal presentation
HEAD syndrome Hallucinations Epigastric rising / emotional Automatisms - lip smack / grabbing / fumbling Deja vu / dysphasia (post-octal)
What do frontal lobe seizures cause
Motor signs and speech Head / leg movement Posturing Post-ictal weakness Dysphasia or speech arrest
What do parietal lobe seizures cause
Paraesthesia
Tingling
Numbness
What do occipital seizures cause
Floaters
Flashes
How does primary generalised usually present
No warning <25 Myoclonic jerks Absences Hx tonic clonic Generalised abnormality on EEG
How does focal seizures usually present
Autonomic - high HR / sweating / GI Awareness Muscle twitching Tonic Clonic Repetitive movements
What should all patients with seizure have
Specialist assessment within 2 weeks
What do you do if first seizure
Routine bloods Blood sugar ECG Alcohol levels CT head to exclude trauma / bleed Only give rescue medication for 1st presentation if Hx of prolonged seizures
What other investigations can be done
Bloods - FBC, U+E, LFT, Ca, bone profile, Mg, glucose ECG - exclude heart problems MRI if <50 and focal CT to exclude other causes Video telemetry
Specialist
EEG - can be used to see different seizure patterns and support Dx
Video EEG = gold standard to Dx
LP
When are anti-epileptic drugs started
After 2nd epileptic fit or 1st if Focal neuro deficit Structural abnormality on brain imaging EEG shows unequivocal activity Abnormal neurodevelopment Risk unacceptable May receive stat dose in A+E
What is 1st line for focal seizures (opposite to tonic clonic)
Carbamazepine
Lamotrigine
What is 2nd line for focal
Levetiracetam
Sodium valproate
What is 1st line generalised tonic clonic
Sodium valproate
Lamotrigine in young women
What is 2nd line
Carbamazepine
Lamotrigine
Levetiracetam
What is 1st line in absence
Sodium valproate
Ethosuximide
What is 2nd line
Lamotrigine
What is 1st and 2nd line myoclonic
Sodium valproate = 1st line
Levetiracetam = 2nd line
What should you avoiding myoclonic and atonic
Carbamazepine - also doesn’t work in absence
What do you use for atonic
Sodium valproate
Lamotrigine
What are common SE of AED
All cause CNS depression
- Drowsy
- Cerebellar toxicity (ataxia / dysarthria / diplopia)
Rash / SJS
Aplastic anaemia
IN OSCE ALWAYS WARN ABOUT RASH / SIGNS OF INFECTION
All induce p450 except valproate which inhibits
Foetal abnormlaity N+V Ataxia Tremor Weight gain Hair loss
What should you do when starting AED
Use one drug
Build up dose over 2-3 months till seizure is controlled
Switch to another
What are other options
CBT
Surgery if focus identified
Vagal nerve stimulation
DBS
What are driving regulations for seizure
If first seizure = 6 months
Or seizure free 1 year
Or only nocturnal seizures 3 years
10 years and on no AED if HGV
What do you do if still believe to be driving
Report DVLA
What is SUDEP
Sudden Unexplained Death in Epilepsy
More common in uncontrolled
What are RF for epilepsy
FH Learning difficulty Cerebral palsy TS Mitochondrial diseases
How do absence seizures typically present
Last few seconds
Quick recovery
Child unaware
Good prognosis
What can provoke
Hyperventilation
Stress
How do you Dx
EEG
What is status epileptics
Prolonged tonic clonic seizure
Seizure lasting >5 minutes or >3 seizures in 1hour with no return to baseline
No recovery
Often no Hx of epilepsy
What can cause
Stroke
Tumour
Alcohol
Trauma
What does it cause
Irreversible damage to brain cells
What do you do after 5 minutes of seizing
Buccal Midazolam or rectal diazepam if in community
Another dose after 5 minutes
IV lorazepam if have access= next line
Repeat after 10 minutes
If hospital ABCDE Check BG and Rx Consider thiamine Get IV access
What is 2nd line if no response within 10 minutes
Sodium valproate
Phenytoin - require cardiac monitoring
Levetriactem IV
What is 3rd line if no response after 30 minutes
Anaesthesia to shut of brain activity
RSI - propofol
What is restless leg syndrome
Spontaneous LL movement Urge to move (akathisia) Typically occurs at night Worse at rest May have associated paraesthesia
What are RF
FH Iron deficiency anaemia CKD - Uraemia DM Pregnancy
How do you Dx
Clinical
Bloods for anaemia
How do you Rx
Walking / stretching Treat anaemia Dopamine agonist = 1st line (ropriprazole / aripriprazole) Benzodiazpine = diazepam Gabapenitn
What can cause collapse / LOC
Vasovagal = most common Situational Carotid sinus hyperactivity Hypoxia Epilepsy Arrhythmia Hypoglycaemia DKA Alcohol / drugs Sepsis Raised ICP MI Blood loss Stroke Anxiety Drop attack Factitious
How do you investigate initially
CVS + neuro exam
BP lying and standing
ECG + 24 hour holter
FBC, U+E, Mg, Ca, glucose
What are other tests
Tilt table EEG ECHO CT / MRI ABG
What does drop in CO2 suggest
Hyperventilation
What lowers seizure threshold
Focal brain damage Toxins Drug withdrawal / alcohol withdrawal Metabolic Sleep deprivation Stress Non-adherance to meds
When do you consider stopping AED’s
After 2 years seizure free
Withdraw over 2-3 months
What is most important to rule out first if in status
Hypoxia
Hypoglcyaemia
Epilepsy in pregnancy
Folic acid Sodium valproate = avoid Lamotrigine = 1st line Levetricatam = 2nd line Most AED transferred in breast milk Enzyme inducing AED make progesterone only pills unreliable and OCP lowers levels
How does sodium valproate work
Increases GABA = relaxing
What are SE
p450 inhibitor Teratogenic Liver damage Hair loss Tremor
What are SE of carbamazepine
Agranulocytosis
Aplastic anaemia
p450 inducer
SE of phenytoin
Folate and vit D deficiency
Megaloblastic anaemia
Osteomalacia
SE of lamotrigdine
SJS
Leukopenia
