Epilepsy, syncope and non-epileptic attacks

Question 1

What is an epileptic seizure

Answer 1

transient occurrence of signs or symptoms due to abnormal electrical activity in the brain, leading to a disturbance of consciousness, behaviour, emotion, motor function or sensation

Question 2

Types of focal seizure

Answer 2

With or without loss of consciousness

May be motor or sensory

Question 3

Types of generalised seizure

Answer 3

Impairment of consciousness
Tonic-clonic (= grand mal)
Absence (=petit mal)
Myoclonic
Clonic
Tonic
Atonic

Question 4

Causes of epilepsy

Answer 4

Mostly idiopathic. Focal seizures more likely to be 2ndary to brain disease
Cerebral-vascular attacks, head injury, CNS infections, neurodegenerative diseases, brain tumour

Question 5

Seizure aspects suggesting epilepsy

Answer 5

Lateral tongue biting
Post-ictal confusion and headache, longer recovery
Triggered by sleep deprivation and alcohol
Eyes open (rolled back)
Incontinence
Seizure preceeded by a cry

Question 6

What is syncope

Answer 6

transient loss of consciousness caused by transient global cerebral hypoperfusion characterised by rapid onset, short duration and spontaneous complete recovery

Question 7

Types of syncope

Answer 7

Neurally mediated
Vasovagal syncope (common faint)
Emotional reaction to something 
Situational - cough, micturition etc
Orthostatic stress - long time standing, hot, crowded places
Carotid sinus hypersensitivity

Orthostatic hypotension
Cardiac

Question 8

Features of a syncope faint

Answer 8

Prodrome - lightheaded, palpitations, nausea etc
Brief loss of consciousness, quick recovery
Situational trigger?

Question 9

Driving and epilepsy - can you drive after first seizure?

Answer 9

no - 6 month ban

Question 10

Non epileptic attacks

Answer 10

Can last quite a long time
eyes tend to be shut
tend to have psychological causes etc (psychotherapy mainstay of treatment)

Question 11

Seizure investigations

Answer 11

Video-electroencephalogram

ECG

Question 12

Drugs for generalised tonic clonic epileptic seizures

Answer 12

1st line - sodium valproate
2nd - lamotrigine (may exacerbate myoclonic seizures)

Adjuncts - clobazam, lamotrigine, topiramate

Question 13

Drugs for absence seizures - and which ones not to give

Answer 13

1st line - ethosuximide or sodium valproate
2nd line - lamotrigine

adjuncts - add these three drugs together

Do not give: carbamazepine, gabapentin, oxcarbazepine, phenytoin, pregabalin, tiagabine or vigabatrin.

Question 14

Overview - whats first line for both myoclonic and tonic/atonic seizures

Answer 14

sodium valproate

dont give
carbamazepine, gabapentin, oxcarbazepine, , pregabalin, tiagabine or vigabatrin. (phenytoin not in myoclonic)

Question 15

Drugs for focal seizures

Answer 15

First line - carbamazepine or lamotrigine
second line - Levetiracetam, oxcarbazepine or sodium valproate

Can add all as adjuncts as well as clobazam, gabapentin

Question 16

Sodium valproate

Answer 16

first line for generalised seizures and absence seizures
(also in acute bipolar treatment and prophylaxis)
\/Na channel excitability, ^GABA

SE’s - GI upset, tremor, ataxia, behavioural changes, thrombocytopenia

teratogenic in first trimester - 10% chance of problem

Question 17

Phenytoin

Answer 17

second line for status epilepticus after benzodiazepines

reduce frequency of seizures - but not commonly used

Question 18

carbamazepine

Answer 18

first line for focal seizures
(first line for trigeminal neuralgia)

SEs - nausea, dizziness, ataxia

Teratogenic

Question 19

Lamotrigine

Answer 19

For focal or generalised seizures either alone or valproate adjunct

SEs - blurred vision, agitation, diarrhoea, dizzy, sleepy, rash etc

Question 20

managing a seizure

Answer 20

time the seizure
nasopharyngeal airway
IV access, Sats monitoring
IV midazolam if >10mins (short acting)