Nervous System Flashcards
What is epilepsy/epileptic seizures?
A transient occurrence of signs or symptoms due to abnormal electrical activity in the brain. This manifests itself as a disturbance of consciousness, behaviour, emotion, motor function, or sensation.
What is status epilepticus?
A continuous seizure for 30 minutes or longer, or recurrent seizures without regaining consciousness lasting 30 minutes or longer
Idiopathic epilepsy accounts fo what % of people in the UK with epilepsy?
66% (two thirds) - it is also the most common cause of epilepsy in younger people
What % of people with epilepsy have a first degree relative with the condition?
30%
Older people who develop epilepsy are more likely to have ‘symptomatic epilepsy’ aka it has a cause. What are the common causes of epilepsy in older people? (3)
- Cerebrovascular disease
- Cerebral tumour
- Post-traumatic epilepsy
How many people in the UK have a diagnosis of epilepsy and take anti-epileptic treatment?
600,000
How many people are diagnosed with epilepsy each year in the UK?
32,000
When is the peak incidence for diagnosis of epilepsy?
In children or in people over the age of 60
1 in how many people with epilepsy also have a learning disorder?
1 in 5
What are the risk factors that can predispose someone to having epilepsy? (5)
- A family history of epilepsy
- A genetic condition known to be associated with epilepsy e.g. tuberous sclerosis or neurofibromatosis
- Previous febrile seizures in childhood
- Previous intracranial infections, brain trauma, or surgery
- Co-morbid conditions such as cerebrovascular disease or cerebral tumours
What are the possible seizure triggers? (6)
- Sleep deprivation
- Flashing lights
- Stress
- Not taking medication
- Alcohol/recreational drugs
- Music
What are the symptoms of auras (simple partial seizures with no loss of consciousness) which can be associated with epilepsy? (4)
Unexpected:
- Tastes
- Smells
- Paraesthesia
- Rising abdominal pressure
What are the features of a tonic seizure?
Cause impairment of consciousness and stiffening; the trunk may be either straight or flexed at the waist
What are the features of a clonic seizure?
A clonic seizure causes jerking and impairment of consciousness
What are the features of a typical absent seizure?
- Sudden onset and offset with no residual symptoms
- Normal activity is interrupted and the child stares for a few seconds
- The eyelids may twitch and some very small jerking movements of the fingers may occur
- The duration is typically 5-10 seconds
- They can occur dozens - hundreds of times daily in some children
What are the features of a myoclonic seizure?
Brief, shock-like contractions of the limb, without apparent impairment of consciousness
What are the features of atonic seizures?
Cause sudden brief attacks of loss of tone, associated with falls and impairment of consciousness
What are the differentials for epilepsy? (6)
- Syncope
- Cardiac arrhythmias
- Panic attacks with hyperventilation
- Non-epileptic attack disorders
- Night terrors
- Breath-holding attacks
When collecting a seizure history, what information is important to ask about before the seizure itself? (5)
- Did anything trigger the seizure e.g. tired, hungry, unwell?
- Any warning seizure was going to happen?
- Did they make any sounds - crying or mumbling?
- Any unusual sensations e.g. odd smell, taste or rising feeling in stomach?
- What were they doing before the seizure?
What questions are important to ask about during the seizure itself? (8)
- Did they stare into space?
- Loss of consciousness?
- Did their colour change? - pale or flushed?
- Did their breathing change?
- Any part of the body move/jerk/twitch?
- Did they fall down/go stiff/go floppy
- Incontinence?
- Bite tongue or cheek?
What questions are important to ask about after experiencing a seizure?
- How did they feel after the seizure? - tired, worn out, need to sleep?
- How long was it before they felt back to normal?
- Notice anything else?
- How long did the seizure last?
What is the treatment for an epileptic seizure lasting more than 5 minutes?
One of the following:
- Buccal midazolam
- Rectal diazepam
- IV lorazepam
How is cerebral palsy defined?
A disorder of movement, tone and posture caused by permanent but non-progressive brain injury. It is often accompanied by various cognitive, learning, emotional, neurological, GI and MSK impairments.
What is the incidence of cerebral palsy?
1 in 500
Which gender is affected more by cerebral palsy?
Males
What are the risk factors associated with cerebral palsy?
- Infection (maternal, respiratory, chorioamnionitis, neonatal sepsis)
- Hypoxia (placental insufficiency, birth asphyxia)
- Neonatal encephalitis (hypoxic ischaemic encephalopathy)
What is the Sarnat staging used for and what are the components?
To distinguish the severity of hypoxic ischaemic encephalopathy - it includes:
- RR
- Muscle tone
- Alertness
- Presence of seizures
- Duration of symptoms
In addition to Sarnat staging, how else is hypoxic ischaemic encephalopathy investigated? (2)
- EEG
2. Umbilical blood sampling for gases
What are the four groups of babies statistically at higher risk of developing cerebral palsy? (4)
- Boys
- Premature
- IUGR (pathological SGA)
- Multiple births
How may babies with cerebral palsy present? (6)
- Floppy baby (low Apgar score)
- Persistence of primitive reflexes
- Abnormal movements (fidgety, asymmetrical, paucity)
- Abnormal tone (hyper/hypo/dystonia)
- Difficulty feeding
- Delayed developmental milestones
What are the subtypes of cerebral palsy? (4)
- Spastic (80%)
- Dyskinetic (10%)
- Ataxic (10%)
- Mixed (10%)
What is the name of the syndrome for infantile spasms?
West syndrome
Infantile spasms are a form of what type of epilepsy?
Myoclonic epilepsy
At what age do infantile spasms generally occur?
Between 3 to 8 months
How do infantile spasms present?
The majority show typical flexion spasms; ‘jack-knife’ or ‘salaam’ spasms, lasting a few seconds and occurring in clusters lasting up to half an hour.
When in the day do infantile spasms often occur?
On waking from sleep
What perinatal complications are often associated with infantile spasms?
- Asphyxia
2. Meningitis
What is development like in a baby once it experiences infantile spasms?
Development before the infantile spasm may have been good or delayed, but following the onset, there is generally a regression of developmental skills and the prognosis is poor
What is the pattern seen on an EEG in a baby with infantile spasms?
Hypsarrhythmic (chaotic) pattern
What time of treatment approach is preferable when treating epilepsy?
Monotherapy
What are the drugs of choice for treating/preventing tonic-clonic epileptic seizures? (3)
- Carbamazepine
- Valproate
- Lamotrigine
What are the drugs of choice for treating absence seizures? (3)
- Ethosuxamide
- Lamotrigine
- Valproate
Which drug is the treatment of choice for myoclonic epilepsy?
Valproate
Which drug is the treatment of choice for focal epilepsy? (2)
- Carbamazepine
2. Lamotrigine
Which drug is used to treat infantile spasms?
Vigabatrin
What are the common side effects caused by valproate? (5)
- Vomiting
- Anorexia
- Lethargy
- Hair loss
- Hepatotoxicity
What are the common side effects caused by ethosuximide? (4)
- Abdominal discomfort
- Skin rash
- Liver dysfunction
- Leucopenia
What are the side effects of carbamazepine? (6)
- Dizziness
- Drowsiness
- Diplopia
- Liver dysfunction
- Anaemia
- Leucopenia
In addition to an EEG, which other investigation can be performed in someone with epilepsy or suspected to have epilepsy - and when is it indicated? (3) (NICE guidance)
MRI (or CT if MRI is contraindicated)
- In those who develop epilepsy before 2 or in adulthood
- Who have any suggestion of focal onset
- In whom seizures continue despite first-line medication
When is pharmacological treatment for epilepsy indicated? (5) (NICE guidance)
- When the patient has had two epileptic seizures or more
- The patient has a neurological deficit after the first seizure
- The EEG shows unequivocal epileptic activity
- The risk of having another seizure is unacceptable
- Brain imaging shows a structural abnormality
What is the first-line treatment for patients with newly diagnosed focal seizures? (2) (NICE guidance)
- Carbamazepine OR
2. Lamotrigine
If first-line treatment of focal seizures is not tolerated, what are the second-line treatments available? (5) (NICE guidance)
- Clobazam
- Gabapentin
- Levetiracetam
- Sodium valproate
- Topiramate
What is the first-line treatment for generalised tonic-clonic seizures?
(NICE guidance) (3)
- Sodium valproate (d best)
- Lamotrigine (if SV not tolerated)
- Carbamazepine
(Be aware lamotrigine & carbamazepine may exacerbate myoclonic/absence seizures if the patient also experiences these)
What is the first-line treatment for absence seizures? (2) (NICE guidance)
- Ethosuximide
- Sodium valproate
(lamotrigine if above two are unsuitable)
What is the first-line treatment for myoclonic seizures? (3) (NICE guidance)
- Sodium valproate (d best)
- Levetiracetam
- Topiramate
What are breath holding spells?
They refer to two distinct condition that can occur when a child is frightened, upset or angry, or experiences a sudden shock or pain. The child seems to stop breathing on exhalation and turns a pale grey or blue colour and momentarily loses consciousness.
How long do breath holding spells normally last?
Less than a minute
Which age range is most commonly affected by breath holding spells?
6 - 18 months
What are the two distinct types of breath holding spells?
- Blue breath-holding spells
2. Reflex anoxic seizures
Which of the two breath holding spells is more common and what does it involve?
The blue breath-holding spells are the most common type, often occurring due to vigorous crying or sobbing that’s triggered by pain, frustration, anger or fear
Do children do blue breath-holding spells on purpose?
No they are an involuntary reflex that’s part of the crying mechanism.
What happens during a blue breath-holding spell?
The child usually cries vigorously for less than 15 seconds and then becomes silent, their breath held on the outward breath and unable to take a breath inwards. They turn blue, particularly around the lips, and lose consciousness. The child with be floppy or stiff and remain unconscious for up to a minute before regaining consciousness and breathing normally, but may be tired.
What is important to inform parents whose children have breath holding spells? (4)
- The episodes are involuntary, they are not dangerous, and don’t cause brain damage.
- They’re not a sign of a difficult child or poor parenting.
- They are not epileptic seizures.
- The episodes will improve with age but may get more frequent before they become less frequent and disappear
What is a reflex anoxic seizure?
A reflex anoxic seizure is often triggered by a sudden unexpected fright or pain, such as a fall with a minor head injury. The seizure isn’t caused by the injury itself, but by the sudden fright or pain
What happens during a reflex anoxic seizure?
The child will often open their mouth as if they’re going to cry, but make no sound before turning a pale grey colour and losing consciousness. They’ll become either limp or more often stiff, with their eyes rolling upwards and their fingers clawed. Their body may also jerk a few times.
How long does a reflex anoxic seizure typically last?
Less than a minute
Why does a reflex anoxic seizure happen?
It is an involuntary process when the heart rate slows down to such an extent that the heart stops beating for 5 to 30 seconds. It is stimulated by the vagus nerve releasing a strong reflex signal, causing the heart to stop. Once the vagus nerve loses its signal strength, the heart starts being again on its own.
What deficiency might the child have, if they are experiencing breath holding spells?
Iron deficiency - may need treatment for anaemia.
What advice is given to parents when a child is having a breath holding spell? (7)
- Stay calm - it should pass in less than a minute
- Lie them on their side - don’t pick them up
- Make sure they can’t hit their head, arms of legs
- Avoid shaking or hitting them
- Avoid putting anything in their mouth
- Avoid splashing them with water
- Avoid mouth-to-mouth resuscitation or chest compressions
