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Neurology > Epilepsy: Seizures and Syndromes > Flashcards

Epilepsy: Seizures and Syndromes Flashcards

1
Q

important features of fall history?

A 
onset (what were they doing? where? symptoms before? what did they look like?)
event itself (any movements? responsiveness/consciousness throughout?)
afterwards (speed of recovery, sleepiness/disorientation, deficits)
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2
Q

how do you take a history of a seizure?

A

ask eye witness to demonstrate the movements

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3
Q

general features of vasovagal syncope?

A

feeling unwell and unsteady
go pale and grey
hit the ground then BP restored very quickly and back to normal

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4
Q

tongue biting and urination are features of seizure?

A

no
not specifically
can be caused by lots of things

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5
Q

name 7 risk factors for epilepsy?

A 
birth problems
delayed development
seizures in past (including febrile fits)
head injury
family history
drugs
alcohol
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6
Q

how is examination used in seizures?

A

often no examination in 1st seizure as little benefit
if syncope is diagnosed then do cardio exam and L+SBP
always do an ECG

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7
Q

examples of drugs which can cause seizures

A

analgesics (tramadol, opioids)
antibiotics (penicillins, cephlasporins, quinolones)
antiemetics (prochlormezapine)

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8
Q

important ECG sign to look out for after a fall or seizure?

A

long QT syndrome

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9
Q

who requires an urgent CT scan after a seizure?

A 
clinical or radiological skull fracture
deteriorating GCS
focal signs
head injury with seizure
failure to be GCS 15/14 4 hrs after arrival
suggestion of other pathology
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10
Q

how useful is an EEG in epilepsy?

A

not useful so not used
many people have abnormal EEG with no epilepsy
30% of epilepsy patients have normal EEG

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11
Q

indications for EEG?

A

classification of epilepsy
confirmation of non-epileptic attacks
surgical evaluation
confirmation of non-convulsive status

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12
Q

differential diagnoses for seizures?

A 
syncope
non-epileptic attack
TIA
migraine
hypoglycaemia
parasomnias
paroxysmal movement disorders
MS tonic spasms
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13
Q

first step after a fall diagnosis?

A

counselling

  • explain diagnosis (seizure vs syncope vs epilepsy etc)
  • explain seizure doesn’t mean epilepsy
  • discuss risk of recurrence
  • discuss driving and safety
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14
Q

rules for driving and seizures?

A

single seizure = cant drive car for 6 months, cant drive HGV for 5 years
epilepsy diagnosis = 1 year seizure free, 3 years of only nocturnal seizures, 10 years off medication to drive an HGV

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15
Q

what is epilepsy?

A

tendency to recurrent, usually spontaneous, epileptic seizures

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16
Q

what are epileptic seizures?

A

abnormal discharge of electricity in the brain
abnormal synchronisation of neuronal activity (usually excitatory with high frequency APs, sometimes predominantly inhibitory)
interruption of normal brain activity (general or focal)

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17
Q

why do people have epileptic seizures?

A

too much excitation or too little inhibition
can be due to changes in
- cell number/types
- connectivity
- synaptic function
- voltage gated ion channel function
genetic, acquired brain, metabolic, toxic and environmental factors

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18
Q

how common is epilepsy?

A

most common in infancy and old age but can be at any age

50-80 per 100,000

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19
Q

epilepsy mortality?

A

1 in 400 chance of death in a year

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20
Q

what is SUDEP?

A

sudden unexpected death from epilepsy

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21
Q

most common cause of death in epilepsy?

A

can often be a consequence of the underlying cause of the epilepsy (brain tumour, stroke etc)
suicide in younger patients (<50)

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22
Q

2 main classifications of epileptic seizures?

A 
focal/partial = (abnormality in a part of the brain which irritates surrounding area of brain causing abnormal discharge of electricity =  focal seizure, can hit a pathway causing it to spread causing a secondary generalised seizure
generalised = discharge immediately hits pathways causing whole brain to "light up"
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23
Q

features of generalized?

A

most have genetic predisposition

present in childhood and adolescence, generalised spike-wave abnormalities on EEG

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24
Q

types of partial seizure?

A 
simple = without impaired consciousness
complex = with impaired consciousness
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25
Q

types of generalised?

A 
absence (go blank, loose consciousness?)
myoclonic
atonic
tonic
tonic clonic
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26
Q

different seizure types can cause same features, true or false?

A

true can present the same

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27
Q

focal epilepsy is what?

A

tendency to have recurrent focal seizures

can also give 2ndary generalised seizures

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28
Q

generalised epilepsy is what?

A

discharge happens directly on network so can only have generalised seizures
“tendency to have recurrent generalised seizures”

29
Q

implication of epilepsy classification?

A

only important in terms of medication really

30
Q

how is generalised epilepsy managed?

A

sodium valproate = best

alternative = lamotrigine

31
Q

side effects of sodium valproate?

A

weight gain
balding
- often patients don’t want to take it
teratogenic

32
Q

example of generalised epilepsy and how does it present?

A

juvenile myoclonic epilepsy
early morning jerks
generalized seizures
risk factors = sleep deprivation, flashing lights

33
Q

what is focal onset epilepsy?

A

most common epilepsy in over 50s
underlying structural cause
complex partial seizures with evidence of hippocampal sclerosis

34
Q

management of focal onset epilepsy?

A

carbamazepine or lamotrigine
- carbamazepine has interactions and side
levotorazopam can also be used?
effects, if so swap to lamotrigine

35
Q

when are anticonvulsants used?

A

only if recurrent seizures or single seizure with high risk of recurrence
most only need 1 drug, few need 2-3
35% are drug resistant

36
Q

AED target what?

A

GABA system

  • target GABA receptor
  • target GABA transaminase
  • target GABA transporter
  • enhances GABA synthesis (sodium valproate)
37
Q

only which 2 drugs work well together in epilepsy?

A

sodium valproate and lamotrigine

sodium valproate inhibits metabolism of lamotrigine

38
Q

focal seizures initial treatment?

A

carbamazepine
lamotrigine
(or oxycarbazepine, levetiracetam, topiramate, sodium valproate)

39
Q

add on drugs in partial seizures?

A

gabapentin
pregabalin
tiagabine
zonisamide

40
Q

absence generalised seizures management?

A

sodium valporate

ethosuximide

41
Q

myoclonic generalized seizure management?

A

sodium valproate
levetiracetam
clonazepam

42
Q

atonic, tonic or tonic clonic generlaised epilepsy management?

A

sodium valporate

43
Q

describe 3 old anticonvulstants and their use?

A

phenytoin (enzyme inducer only for acute management)
sodium valproate (like bleach, lots of side effects - weight gain, teratogenic, hair loss, fatigue)
carbamazepine (only for focal, never generalised as can make worse)

44
Q

name 4 new anticonvulsants and their use?

A

lamotrigine (good for focal and generalised, takes long time to titrate)
levetiracetam (popular but can cause mood swings)
topiramate (causes sedation/dysphasia/weight loss, not well tolerated)
gabapentin, pregabalin (more for pain)

45
Q

which anticonvulsants induce hepatic enzymes (important)

A 
carbamazepine
oxcarbazepine
phenobarbital
phenytoin
primidone
topiramate
46
Q

what is the impact of hepatic enzyme inducing anticonvulsants?

A

can alter efficacy of combined oral contraceptive pill and morning after pill
therefore shouldn’t use
progesterone only pill
progesterone implants not effective
depot progesterone needs more frequent dosing

47
Q

what must females with epilepsy be counselled on?

A 
preconceptual counselling (risk of birth defects from condition itself and some drugs - sodium valproate)
risk of uncontrolled seizures and risk of drug to baby must be balanced in pregnancy (seizure can also harm baby)
48
Q

all epileptic females getting pregnant must be taking what?

A

high dose folic acid and vit K for 3 months before

49
Q

sodium valproate not really used in young females, why?

A

high risk to foetus if pregnant

therefore not used if any chance of pregnancy or becoming pregnant

50
Q

carbamazepine not given in which type?

A

generalised

51
Q

what is status epilepticus?

A

recurrent epileptic seizures without full recovery of consciousness
or
continuous seizre activity lasting more than 30 mins

52
Q

when is treatment for status started?

A

from 5-10 mins of seizure as unlikely to recover after that point

53
Q

3 types of status?

A

generalised convulsive status epilepticus
non-convulsive status (conscious but in altered state)
epilepsia partialis continua (continual focal seizures, consciousness preserved)

54
Q

what can cause staus?

A

severe metabolic disorders (hyponatraemia, pyridoxine deficiency)
infection
head trauma
sub-arachnoid haemorrhage
abrupt withdrawal of anticonvulsants
treating absence seizures with carbamazepine

55
Q

what kills first in status?

A

peripheral metabolic effects from effort of long term tension of muscles etc (hyperpyrexia, hypoxia, hypotension, hyperthermia, rhabdomyolysis)

56
Q

what kills you later?

A

multi organ failure

brain failure

57
Q

what causes cell death in status?

A

glutamate > excitotoxicity > neuronal cell death

58
Q

management of status?

A

stabilize (ABCDE)
identify cause (emergency blood tests +/- CT)
anticonvulsants

59
Q

what anticonvulsants are used in status?

important

A 
1 = phenytoin
2 = Keppra
3 = sodium valproate
always trial benzodiazepines first
(1 dose, wait 5 mins, another dose, wait 5 mins, if not working then start phenytoin etc)
call ICU if not working after 30 mins
60
Q

max benzodiazepines?

A

2 doses

61
Q

what is given if hypoglycaemia suspected as cause of status?

A

50mg 50% glucose

62
Q

management of alcohol induced status?

A

IV thiamine

63
Q

which benzodiazepines can be used for immediate control of status?

A

lorazepam 4mg IV
diazepam 10-20mg IV or rectal
midazolam 5-10mg IM

64
Q

what is used for sustained control of status?

A 
if established epilepsy
- re-establish AED by ng tube/orally/IV for phenytoin
other patients or continuing seizures
- fosphenytoin 
- phenytoin
- phenobarbital
65
Q

what is done if status persists over an hour?

A

transfer to ICU
control with general anaesthesia with thiopentone or Propofol
monitor control with full EEGs etc

66
Q

what do you do if called to a seizure?

A

nothing unless they go into status
don’t give benzodiazepines unless going on for more than 10 mins
just do ABCDE

67
Q

how does partial status epilepticus present and how is it diagnosed?

A

acute confusion

confirm with EEG

68
Q

how is partial status epilepticus managed?

A

treat same as generalized tonic-clonic status (benzodiazepines > phenytoin etc)

Neurology (53 decks)

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