NEURO

Question 1

What is epilepsy?

Answer 1

recurrent tendency to spontaneous, intermittent, abnormal electrical activity in part of the brain, manifesting as seizures

Question 2

What is a prodrome?

Answer 2

A prodrome lasting hours or days may rarely precede the seizure. It is not part of the seizure itself: the patient or others notice a change in mood or behaviour.

Question 3

What is an aura?

Answer 3

An aura is part of the seizure of which the patient is aware, and may precede its other manifestations. The aura may be a strange feeling in the gut, or an experience such as déjà vu (disturbing sense of familiarity), or strange smells or flashing lights. It implies a partial (focal) seizure, often, but not necessarily, from the temporal lobe.

Question 4

How should you administer first aid for seizures?

Answer 4

• Move the person away from danger (fire, water, machinery, furniture)
• After convulsions cease, turn the person into the ‘recovery’ position (semi-prone)
• Ensure the airway is clear but do NOT insert anything in the mouth (tongue-biting occurs at seizure onset and cannot be prevented by observers)
• If convulsions continue for more than 5 mins or recur without the person regaining consciousness, summon urgent medical attention
• Do not leave the person alone until fully recovered (drowsiness and delirium can persist for up to 1 hr)

Question 5

2014 the International League Against Epilepsy definition for epilepsy

Answer 5

At least two unprovoked (or reflex) seizures occurring more than 24 hours apart.
One unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk after two unprovoked seizures (at least 60% over the next 10 years); or
Diagnosis of an epilepsy syndrome.

Question 6

In the first presentation of a seizure what must you assess first?

Answer 6

Is it really the first? Ask the family and patient about past funny turns/odd behaviour. Déjà vu and odd episodic feelings of fear may well be relevant.
• Was the seizure provoked? (see ‘Non-epileptic causes’ above) Provoked 1st seizures are less likely to recur (3–10%, unless the cause is irreversible, eg an infarct or glioma); if it was unprovoked, recurrence rates are 30–50%.209
NB: provocations are different to triggers: most people would have a seizure given sufficient provo- cation, but most people do not have seizures however many triggers they are exposed to, so triggered seizures suggest epilepsy. Triggered attacks tend to recur.

Question 7

Seizures Ix

Answer 7

eg with admission for 24h for bloods, drugs screen, LP (if safe), EEG. CT/MRI+enhancement (or else infective causes, eg TB, may be missed).
Admit to substantiate ideas of pseudoseizures, or for recurrent seizures.

Question 8

Epilepsy MDT approach: which HCP may you wish to enlist in managing a patient with epilepsy?

Answer 8

epilepsy nurse specialist, who can provide telephone advice and annual reviews to monitor drug efficacy and side-effects, to address employment, leisure, and re- productive issues, and, after a few seizure-free years, to consider drug withdrawal.

Question 9

When thinking about drugs, what factors must you take into account?

Answer 9

seizure type and epilepsy syndrome
other medications and co-morbidities
plans for pregnancy
patient preference

Question 10

General tonic-clonic seizures: drugs

Answer 10

Sodium valproate or lamotrigine (often better tolerated and less teratogenic) are 1st-line,
then carbamazepine or topiramate.
Others: levetiracetam, oxcarbazepine, clobazam.

Question 11

absence seizures: drugs

Answer 11

Sodium valproate, lamotrigine or ethosuximide

Question 12

Tonic, atonic and myoclonic seizures: drugs

Answer 12

As for generalized tonic-clonic seizures, but

avoiding carbamazepine and oxcarbazepine, which may worsen seizures.

Question 13

Partial seizures ± secondary generalization: drugs

Answer 13

Carbamazepine is 1st-line, then sodium valproate, lamotrigine, oxcarbazepine or topiramate.
Others: levetiracetam, gabapentin, tiagabine, phenytoin, clobazam.

Question 14

How must you switch drugs in px with epilepsy?

Answer 14

To switch drugs, introduce the new drug, and only withdraw the 1st drug once established on the 2nd.

Question 15

Valproate SE

Answer 15

Valproate side-effects 
increased Appetite, weight gain 
Liver failure (watch LFT
esp. during 1st 6 months) 
Pancreatitis
Reversible hair loss (grows back curly) 
Oedema
Ataxia
Teratogenicity, tremor,thrombocytopenia 
Encephalopathy (due to hyperammonaemia)

Question 16

Carbamazepine SE

Answer 16

leucopenia, diplopia, blurred vision, impaired bal- ance, drowsiness, mild generalized erythematous rash, SIADH (rare;

Question 17

Carbamazepine dose

Answer 17

(as slow-release) Initially 100mg/12h, increase by 200mg/d every 2wks up to max 1000mg/12h

Question 18

Lamotrigine dose

Answer 18

As monotherapy, initially 25mg/d, increase by 50mg/d every 2wks up to 100mg/12h (max 250mg/12h). CAUTION: Halve monotherapy dose if on valproate; double if on carbamazepine or phenytoin (max 350mg/12h)

Question 19

What is a focal aware seizure?

Answer 19

In the classification of seizures ‘aware’ means no loss of awareness during the clinical event.
Symptoms depend on the region of the cortex from which the attack arises.
Focal aware seizures are also known as ‘auras’. These symptoms usually last for several seconds. Their stereotypical nature is the key feature.
These seizures can progress to other types of seizure.

Question 20

What are impaired awareness seizures?

Answer 20

In the classification of seizures ‘impaired awareness’ means a loss of awareness during the event.
The patient may display automatisms, such as plucking at clothes, smacking lips, swallowing repeatedly and may wander around.
Amnesia (although may not be appreciated by the patient) commonly occurs for part of, or the entire event. An aura may be recollected prior to amnesia.
Confusion is common in the postictal period.
Focal impaired awareness seizures may progress to a secondary generalised seizure.

Question 21

Which drugs can provoke seizures?

Answer 21

Analgesics
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Opioids (e.g. tramadol); Nefopam
Antiemetics: Cyclizine; Prochlorperazine
Quinolones (e.g. levofloxacin)
Selective serotonin re-uptake inhibitors (SSRIs)
Clozapine; Haloperidol
Hypnotics/Anxiolytics: Benzodiazepines (especially in withdrawal); Non-benzodiazepines (e.g. zopiclone)
Recreational drugs: Alcohol(especially in withdrawal)
Amphetamines
Cocaine

Question 22

What is a first-line treatment option for the management of all generalised epilepsies in adults and children, provided they are not a woman or girl of child-bearing potential?

Answer 22

Sodium Valproate