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Neurology > Lecture 28 Epilepsy > Flashcards

Lecture 28 Epilepsy Flashcards

1
Q

Common diagnoses in patients referred to first seizure clinics

A
  • Epilepsy
  • Syncope
  • Single seizure
  • Possible/Probable seizure
  • Possible/probable syncope
  • Psychiatric/psychological
  • Confirmed non-epileptic attacks
  • Uncertain
  • Other- Sleep disorders (Narcolepsy
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2
Q

How do you assess episodes of collapse

A

Patient account- preceding, during and after

Witness account

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3
Q

What are the 3 categories of causes of syncope

A

Reflex (neuro-cardiogenic)
Orthostatic
Cardiogenic

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4
Q

What can cause Reflex syncope

A

Takin blood/medical situations
Cough
Micturation

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5
Q

What can cause orthostatic syncope

A

Dehydration
Anti-hypertensive medication
Endocrine, autonomic nervous system

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6
Q

What can cause cariogenic syncope

A

Arrhythmia

Aortic stenosis

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7
Q

Syncope patient account

A

• History preceding events
o Stimulus- blood being taken, defecation
o Context- only in bathroom, only when standing
• History of event itself
o Warning- felt lightheaded/clammy/vision blacking out
• Afterwards
o Very brief LOC
o Came round as I hit the ground, Friend standing over them
o Fully orientated quickly
o Clammy/sweaty
o Urinary incontinence
o Further similar events aborted by sitting

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8
Q

Witness account of syncope

A 
•	Description of episode
–	Looked a bit pale
–	Suddenly went floppy
•	Looked pale
•	There may have been a few brief jerks
•	Brief LOC
–	Rapid recovery
–	If more prolonged was the patient propped up
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9
Q

How is Syncope assessed

A 
•	Examination
–	Heart sounds, pulse
–	Postural BPs
•	Must have ECG
–	Look for heart block
–	QT ratio
•	May need 24hr ECG
–	May need to see cardiology if recurrent (5 day recordings, reveal devices)
–	Consider Tilt table
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10
Q

Patient account of cardioigenic syncope

A 
–	History preceding events
•	On exertion
–	History of event itself
•	Chest pain, palpitations, SOB
–	Afterwards
•	Chest pain, palpitations, SOB
•	Came round fairly quickly
–	Recovery may be longer
•		Clammy/sweaty
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11
Q

Witness account of cariogenic syncope

A 
•	Description of episode
–	Suddenly went floppy
–	Looked grey/ashen white
–	Seemed to stop breathing
–	Unable to feel a pulse
•	There may have been a few brief jerks
•	Variable duration of LOC
–	Rapid recovery
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12
Q

Assessment of Cariogenic syncope

A 
•	Family history important
•	Examination
–	Heart sounds, pulse
•	Must have ECG
–	Look for heart block
–	QT ratio
•	Refer to cardiology urgently/admission for telemetry
•	May need 24hr ECG/ECHO/prolonged monitoring
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13
Q

Define Epilepsy

A

Tendency to have recurrent seizures

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14
Q

Name causes of provoked seizures

A 
Alcohol withdrawal
Drugs withdrawal
Within few days of head injury
24 hours after stroke
24 hours after neurosurgery
Electrolyte disturbances
Eclampsia
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15
Q

Classification of Seizures

A

Generalised

Focal Seizures

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16
Q

Name examples of generalised seizures

A
  • Absence seizures
  • Generalised tonic-clonic seizures
  • Myoclonic seizures
  • Juvenile myoclonic epilepsy
  • Atonic seizures
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17
Q

Name examples of focal seizures

A
  • Simple partial seizures
  • Complex partial seizures
  • Secondary generalised
  • Or by localisation of onset (temporal lobe, frontal etc.)
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18
Q

Name clinical features of Primary generalised

A
  • No warning
  • < 25 years
  • May have history of absences and myoclonic jerks as well as GTCS e.g in juvenile myoclonic epilepsy
  • Generalised abnormality on EEG
  • May have family history
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19
Q

Name features of Focal/Partial seizures

A
  • May get an “aura”
  • Any age – cause can be any focal brain abnormality
  • Simple partial and complex partial seizures can become secondarily generalised
  • Focal abnormality on EEG
  • MRI may show cause
20
Q

Patient account of Tonic Clonic Seizure

A

– History preceding events
• Unpredictable, tend to cluster
• PMH- complications at birth, Feb conv, trauma, menigitis, brain injuries
– History of event itself
• May have vague warning
• Irritability before them
– Afterwards
• Lateral (severe) Tongue biting, incontinence
• First recollection in ambulance or hospital
• Muscle pain

21
Q

Witness account of generalised tonic clonic seizure

A

– Groaning sound
– Tonic (rigid phase)
– Then generalised jerking in all four limbs
– Eyes open
– Staring/ roll upwards
– Foaming at the mouth
– Jerking for a few minutes and then groggy for 15-30mins
– May be agitated afterwards
– May have a cluster of episodes, stopping and starting

22
Q

Features of absence Seizures

A

• Often in children (unaware of them)
• May be provoked by hyperventillation/ Photic stimulation (light through trees while in car)
• Sudden arrest of activity for a few seconds
– Brief staring
– May have eye-lid fluttering
• Re-start what they were doing

23
Q

Features of Juvenile Myoclonic Epilepsy

A 
•	Adolescence/early adulthood
–	Provoked by alcohol, sleep deprivation
•	Can have absence and GTC seizures
•	Will often have early morning myoclonus
–	Drop things in the mornings
–	Brief jerks in limbs
24
Q

Patient account of Complex Partial Seizures

A 
1)	Patient account
–	History preceding events
•	Rising feeling in stomach, Funny smell/taste
•	De ja vu (familiar experience)
–	History of event itself
•	No recollection
–	Afterwards
•	Disorientated for a spell
25
Q

Witness account for complex partial seizures

A 
•	Sudden arrest in activity
•	Staring blankly into space
•	Automatisms
–	Lip smacking
–	Repetitive picking at clothes
•	May be disorientated for a spell afterwards
26
Q

Clinical assessment of seizures

A 
First seizure clinic
ECG
Routine bloods
CT
MRI- focal lesion
EEG
Discuss anti-epileptic drug
Epilepsy nurse
Driving- DVLA
27
Q

When would you do an EEG

A

Primary generalised epilepsies

28
Q

When would you do a MRI

A

Under 50 with possible focal onset seizures

CT is usually sufficient

29
Q

Factors influencing seizure risk

A

• Missed medications (most common)
• Sleep disturbance, fatigue
• Hormonal changes
• Drug/alcohol use, drug interactions
• Stress/Anxiety
• Photosensitivity in a small group of patients
– Other rarer reflex epilepsies (patterns, noise)

30
Q

First line treatment of primary generalised epilepsies

A

• Sodium Valproate, Lamotrigine, Levetiracetam

31
Q

First line treatment for focal and secondary generalised seizures

A

• Lamotrigine, Carbamazepine, Levetiracetam

32
Q

First line treatment for absence seizures

A

• Ethosuximide

33
Q

Second line treatment for generalised epilepsy

A
  • Topiramate
  • Zonisamide
  • Clobazam
34
Q

Second line treatment for partial seizures

A 
•	-Sodium valproate
•	-Topiramate
•	-Gabapentin
•	-Pregabilin
•	-Zonisamide
•	-Lacosamide
•	-Perampanel
o	Long acting Benzodiazepines (Clobazam)
o	Vigabatrin
35
Q

Side effects of phenytoin

A

Arrythmia, hepatitis, medication interactions

36
Q

Side effects of Sodium valproate

A

tremor, weight gain, ataxia, nausea, drowsiness, hepatitis

37
Q

Side effects of Carbamazepine

A

ataxia, drowsiness, nystagmus, blurred vision, low serum sodium levels, skin rash

38
Q

Side effects of Lamotrigine

A

Skin rash

Difficulty sleeping

39
Q

Side of effects of Levetiracetam

A

Irritability

Depression

40
Q

Driving regulations for seizures

A
  • After single seizure- drive car after 6 months
  • May drive HGV or PSV after 5 years with no further events and not on anti-epileptic medication
  • Patient with epilepsy can drive car once seizure free for 1 year
41
Q

Define Staus Epilepticus

A
  • Prolonged or recurrent tonic-clonic seizures persisting for more than 30 minutes with no recovery period between seizures
  • Usually occurs in patients with no previous history of epilepsy (stroke, tumour, alcohol)
42
Q

First line treatment for Status Epilepticus

A
  • Midazolam: 10mg by buccal or intra-nasal route, repeated after 10mins if necessary
  • Lorazepam: 0.07mg/kg, usually 4mg bolus repeated once after 10 mins
  • Diazepam: 10 - 20mg iv or rectally, repeated after 15 mins if necessary
43
Q

Second line treatment for status epileptics

A

– Phenytoin - slow infusion of 15 – 18mg/kg at 50mg/min
– Valproate – 20 -30mg/kg iv at 40mg/min
– ? Leviteracetam 30mg/KG

44
Q

Third line treatment for status epileptics

A

– Anaesthesia usually with propofol or thiopentone

45
Q

Outcomes of Status Epilepticus

A

Mortality in very young and very old

Avoid secondary damage

46
Q

Patent account of Non-Epileptic Attack/Pseudoseizure

A

– History preceding events
• Events may occur at times of stress or while at rest
• Will often give lots of detail of others reaction and little of events themselves
– History of event itself
• May recall what people said during episode
• May be prolonged episode, waxing and waining
• May describe dissociation
– Afterwards
• Others reactions

47
Q

Witness account of Non-Epileptic Attack/Pseudoseizure

A

Description
– May recognise stress as a trigger (even if patient doesn’t)
– May report signs of patient retaining awareness
• Tracking eye movements, still some verbalisation during episodes
• Movements not typical of seizures
– Pelvic thrusting
– Asynchronous movements, tremor
– Episodes waxing and waining
Ideally we try and capture a typical episode on EEG
-Important to make diagnosis to avoid iatrogenic harm

Neurology (44 decks)

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