Epilepsy: Seizures, Syndromes and Management Flashcards
what kind of questions would you ask about onset of fall?
what were they doing?
light-head or other syncopal symptoms?
what did they look like? eg pallor, breathing, posturing of limbs, head turning
what kind of questions would you ask about the event itself?
types of movements - tonic phase, clonic movements, carpopedal spasms, rigor
responsiveness and awareness throughout
what kind of questions would you ask about after the fall?
speed of recovery
sleepiness / disorientation
deficits
what are the risk factors for epilepsy?
birth development seizures in past (inc febrile fits) head injury (including LOC) family history drugs and alcohol
what drugs are most known to precipitate epileptic seizures?
aminophylline / theophylline
analgesics eg tramadol
antibiotics eg penicillins, cephalosporins, quinolones
anti-emetics eg prochlorperazine
opioids eg diamorphine, pethidine
you don’t usually examine patients in 1st seizure clinic as it has little benefit but when would an examination be important?
syncope - cardio exam and L + SBP
who with a fall gets a CT scan acutely?
clinical or radiological skull fracture deteriorating GCS focal signs head injury with seizure failure to be GCS15/15 after 4 hours suggestion of other pathology eg SAH
what investigations take place for the fallen?
ECG - mandatory
Imagine - MRIb vs CTb
what is EEG used for?
classification of epilepsy
confirmation of non-compulsive status
surgical evaluation
confirmation on non-epileptic attack
when should you never use EEG?
just because someone has collapsed and you are unsure about the cause
seizure does not always mean epilepsy - true or false?
true
how long should you wait until driving after 1st seizure?
6 months for car
5 years for HGV / PCV
how long should you wait until driving when you have epilepsy?
1 year seizure free
or 1 year with seizures that you still retain consciousness
or 3 years seizures only during sleep
10 years off medication for HGV/PCV
do most people have a genetic predisposition to generalised epilepsy?
yes
when does generalised epilepsy normally present?
in childhood and adolescence
what is the pattern on EEG in generalised epilepsy?
generalised spike wave abnormalities
what can be seen on ECG which is fatal and makes patients prone to seizures?
long QT
raising a limb and turning of the head indicates a seizure in what part of brain?
frontal lobe seizure phenomenon
tongue biting and loss of urinary continence are specific features of generalised seizures - true or false?
false
these symptoms are not seizure specific - patient can lose urinary continence during vaso-vagal episode
what are the differential diagnoses for epilepsy?
syncope
non-epileptic attack disorder
panic attacks
sleep phenomena
what is the treatment of choice for primary generalised epilepsy?
sodium valproate treatment of choice but is teratogenic
lamotrigine as alternative
describe the usual symptoms of juvenile myoclonic epilepsy?
early morning jerks
generalised seizures
what are the risk factors for juvenile myoclonic epilepsy?
sleep deprivation
flashing lights
describe the pathophysiology of focal onset epilepsy?
due to underlying structural cause (bran injury / haemorrhage)
area around this becomes irritated
causes abnormal discharges of energy - seizures
focal seizures can also become generalised - true or false?
true - if a focal seizure excited a neighbouring pathway which can spread activity around the brain, then seizures can become generalised
what treatment is first line for focal epilepsy?
carbamazepine (interacts with basically all drugs) or lamotrigine
sodium valproate works as well but not first line due to SE
what is the most common cause of focal / partial epilepsy in patients <30?
complex partial seizures due to hippocampal sclerosis
why should carbamazepine not be used for generalised seizures?
it can make them worse
what are the different types of generalised seizures?
myoclonic - jerks atonic - loss of tone tonic tonic / clonic absence - pt goes black
why is lamotrigine sometimes unsuitable at the beginning of generalised epilepsy treatment?
it can take around 2-3 months to reach peak action
what other treatment with less side effects than sodium valproate can be used in generalised epilepsy is lamotrigine is taking too long to work?
levetiracetam (keppra)
what age group is more likely to get focal seizures?
> 50 as they are more likely to have structural damage
carbamazepine is a well tolerated - true or false?
false - not well tolerated, patients feel dizzy and unsteady
why should sodium valproate and lamotrigine be given together with caution?
sodium valproate makes the lamotrigine dose higher, therefore a lower dose of lamotrigine should be prescribed if dural therapy used
what anticonvulsant medications are considered old?
phenytoin
sodium valproate
carbamazepine
what anticonvulsants are considered new?
lamotrigine
levetiracetam
topiramate
gabapentin / pregabalin (not widely used anymore)
what side effects can occur from older anticonvulsants?
phenytoin - unwanted cosmetic change
sodium valproate - above but also teratogenic
carbamazepine - dizzy / unsteady
what side effects can occur from newer anti-convulsants?
lamotrigine - steven johnson syndrome (check for rash)
levetiracetam - mood swings
topiramate - sedation, dysphasia and weight loss
gabapentin / pregabalin - addictive
when should anti convulsants be prescribed?
if patient has epilepsy - not just seizures
unless extremely high risk of seizure recurrent in non epileptic seizures
what anticonvulsants affect hepatic enzymes and therefore causing problems for females?
carbamazepine oxcarbazepine phenobarbitol phenytoin primidone topiramate
what contraceptives are affected by anticonvulsant drugs?
combined OCP
DONT use progesterone only pill
depot progesterone injection needs more frequent dosing
progesterone implants not effective
morning after pill dose should be increased or decreased in those on anticonvulsants?
increased
why should all females of child bearing age be given pre-conceptual counselling?
allows them to balance risk of uncontrolled seizures if not taking medication or teratogenicity if continue with medication
if females with epilepsy do wish to conceive, what medication must they start 3 months prior to conception?
folic acid and vitamin K
what is status epilepticus?
recurrent epileptic seizures without full recovery of consciousness between them
can last for over 30 mins
what are the different types of status epilepticus?
generalised convulsive
non convulsive status - conscious but in altered state
epilepsia partialis continua (continual conscious focal seizures)
what can precipitate a status epilepticus?
severe metabolic disorders - hyponatraemia, pyridoxine deficiency
infection
head trauma / sub arachnoid haemorrhage
abrupt withdrawal of anti-convulsants
generalised convulsive status epilepticus can cause what further effects on body?
respiratory insufficiency and hypoxia
hypotension
hyperthermia
rhabdomylosis
how should status epilepticus be investigated?
ABCDE
identify cause - emergency blood tests +/- CT
if suspicious of hypoglycaemia give 50mls 50% glucose
how is status epilepticus treated?
benzodiazepines x2 doses (10 mins, then 15 mins) - usually buccal midazolam
phenytoin if unresolving
+ sodium valproate
+ levetiracetam (keppra)
when should you consider transferring a patient in status epilepticus into ITU?
when requiring to give phenytoin as it has been unresolved for a prolonged period
how would you confirm a patient with acute confusion is in partial status epilepticus?
EEG
how do benzodiazepines work to reverse status epilepticus?
they suppress the area of the brain which is over-excited and impairing consciousness
consciousness returns when electrical activity is sedated
