Lecture 28 Epilepsy Flashcards
Common diagnoses in patients referred to first seizure clinics
- Epilepsy
- Syncope
- Single seizure
- Possible/Probable seizure
- Possible/probable syncope
- Psychiatric/psychological
- Confirmed non-epileptic attacks
- Uncertain
- Other- Sleep disorders (Narcolepsy
How do you assess episodes of collapse
Patient account- preceding, during and after
Witness account
What are the 3 categories of causes of syncope
Reflex (neuro-cardiogenic)
Orthostatic
Cardiogenic
What can cause Reflex syncope
Takin blood/medical situations
Cough
Micturation
What can cause orthostatic syncope
Dehydration
Anti-hypertensive medication
Endocrine, autonomic nervous system
What can cause cariogenic syncope
Arrhythmia
Aortic stenosis
Syncope patient account
• 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
Witness account of syncope
• 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
How is Syncope assessed
• 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
Patient account of cardioigenic syncope
– 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
Witness account of cariogenic syncope
• 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
Assessment of Cariogenic syncope
• 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
Define Epilepsy
Tendency to have recurrent seizures
Name causes of provoked seizures
Alcohol withdrawal Drugs withdrawal Within few days of head injury 24 hours after stroke 24 hours after neurosurgery Electrolyte disturbances Eclampsia
Classification of Seizures
Generalised
Focal Seizures
Name examples of generalised seizures
- Absence seizures
- Generalised tonic-clonic seizures
- Myoclonic seizures
- Juvenile myoclonic epilepsy
- Atonic seizures
Name examples of focal seizures
- Simple partial seizures
- Complex partial seizures
- Secondary generalised
- Or by localisation of onset (temporal lobe, frontal etc.)
Name clinical features of Primary generalised
- 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
Name features of Focal/Partial seizures
- 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
Patient account of Tonic Clonic Seizure
– 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
Witness account of generalised tonic clonic seizure
– 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
Features of absence Seizures
• 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
Features of Juvenile Myoclonic Epilepsy
• 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
Patient account of Complex Partial Seizures
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
