Initial Presentation of Seizures

Question 1

What is the chief characteristic of seizures?

Answer 1

They are stereotyped, recurrent events (i.e. each episode is the same)

Question 2

Is there usually a trigger or prodrome associated with a seizure?

Answer 2

No (this is more a sign of syncope)

Question 3

If, after a collapse, a patient is not aware of what happened - does this suggest a seizure or syncope?

Answer 3

Seizure (in syncope, the patient will generally know what has happened)

Question 4

If, after a collapse, there is rapid recovery - does this suggest a seizure or syncope?

Answer 4

Syncope (in a seizure, the patient will be drowsy for a long time after)

Question 5

When dealing with a possible seizure history, it is really important to get information from who? What can you ask them to do?

Answer 5

A witness (i.e. take a collateral history), ask them to take a video if it happens again

Question 6

What are some important questions to ask about the onset of a collapse?

Answer 6

What was the person doing at the time? Were there any triggers? What was the environment like? What did they look like before? Were there any preceding symptoms?

Question 7

What is a syncopal seizure?

Answer 7

When a person faints but doesn’t lie flat which results in small jerks

Question 8

If there is a description of someone collapsing, being stiff and rigid followed by jerky movements, what does this suggest?

Answer 8

Generalised tonic clonic seizure

Question 9

What are two things which may occur during a collapse which (despite belief) are not specific for epilepsy?

Answer 9

Tongue biting and urinary incontinence

Question 10

What should you ask about the duration of a collapse?

Answer 10

How long the whole episode was, and how long any particular components lasted for i.e. tonic phase/clonic phase

Question 11

What are some important things to ask about regarding the aftermath of the collapse?

Answer 11

Speed of recovery? Drowsiness/disorientation? Any residual deficits?

Question 12

What are some risk factors for epilepsy that you may want to ask about when taking a history from a person with collapse?

Answer 12

Premature or very late birth/any time in special care, seizures in the past, head injury, family history, drugs/alcohol

Question 13

What are some important things to ask about in the social history of a person possibly presenting with epilepsy?

Answer 13

Driving and occupation

Question 14

When taking a collateral history for a possible seizure, what should you ask the person to do?

Answer 14

Describe the episode in simple terms, and ask for a demonstration of movements if possible

Question 15

What is important to remember about nocturnal seizures?

Answer 15

The same thing will happen every time (this is a good question to ask a bed partner)

Question 16

What are some drugs which may precipitate an epileptic seizure?

Answer 16

Aminophylline/thiophylline, analgesics e.g. tramadol, antibiotics, anti-emetics, opioids (and loads more)

Question 17

Obviously it is impossible to remember every drug that can cause a seizure, but what is one important thing you should check for?

Answer 17

Has there been any recent changes to drugs taken (medically and recreationally)

Question 18

If a patient comes to an epilepsy clinic for the first time, are they usually examined?

Answer 18

No (the history is much more important)

Question 19

If a patient presents to A+E with collapse, what examination should be done?

Answer 19

Neurological

Question 20

If a collapse turns out to be syncope, what examinations should be done? Who should they be referred to?

Answer 20

Cardiovascular, including a lying to standing BP measurement. Refer to cardiology

Question 21

If anyone presents with a seizure, what is the most important investigation to perform?

Answer 21

ECG

Question 22

Why is it so important to perform and ECG in patients presenting with a seizure?

Answer 22

Because seizures can be caused by arrhythmias which can be fatal (e.g. long QT)

Question 23

Should brain imaging always be performed on someone presenting with a seizure?

Answer 23

No

Question 24

When is most imaging for a seizure done?

Answer 24

After the patient has been seen in clinic

Question 25

When should an acute CT scan be done for someone presenting with a seizure?

Answer 25

In any case where there is a chance that the person may require neurosurgical intervention in the next few days

Question 26

Give some specific examples of reasons why a person presenting with a seizure may require an acute CT scan?

Answer 26

Clinical skull fracture, deteriorating GCS or failure to be GCS 15/15 4 hours after presentation, focal signs, head injury with seizure, suggestion of other pathology

Question 27

What investigation should never be done to establish the cause of a seizure?

Answer 27

EEG

Question 28

When are the only times that an EEG should be done?

Answer 28

To classify epilepsy, confirmation of non-epileptic attacks, surgical evaluation for severe epilepsy and confirmation of non-convulsive status

Question 29

What are some conditions which are commonly confused differentials of epilepsy?

Answer 29

Syncope, non-epileptic attack, panic attacks/hyperventilation, sleep phenomena

Question 30

How should you manage patients who have had a one off seizure?

Answer 30

Counsel the patient and explain what has happened, explain that one seizure doesn’t necessarily mean epilepsy. Explain the risk of recurrence of future seizures and driving rules.

Question 31

What are the DVLA rules for a one-off seizure in someone who drives a car?

Answer 31

You can reapply for your license after 6 seizure free months if medical advisors decide there isn’t high risk of you having another seizure

Question 32

What are the DVLA rules for a one-off seizure in someone who drives an HGV?

Answer 32

You can reapply for your license if you haven’t had a seizure in 5 years and you haven’t taken any anti-epilepsy medication in 5 years

Question 33

What are the DVLA rules for epilepsy in someone who drives a car, who gets seizures while awake and loses consciousness?

Answer 33

You can reapply for your license if you have been seizure free for 1 year

Question 34

What are the DVLA rules for epilepsy in someone who drives a car, who gets all their seizures at night?

Answer 34

You may still qualify for a license if it has been more than 12 months since your last attack

Question 35

What are the DVLA rules for epilepsy in someone who drives an HGV?

Answer 35

You can reapply for your license if you haven’t had an epileptic attack in 10 years and haven’t taken any anti-epileptic medication for 10 years