neurology

Question 1

A 7-year-old boy is seen by his general practitioner after his teacher has been noticing that the young boy often stares blankly at the wall for a few seconds. During these episodes, he is usually unresponsive and unable to speak.

What is the most likely diagnosis?

Answer 1

absence seizure

Question 2

what are the factors used to classify seizures

Answer 2

basic seizure classification is based on 3 key features:
1. Where seizures begin in the brain
2. Level of awareness during a seizure (important as can affect safety during seizure)
3. Other features of seizures

Question 3

how are seizures classified

Answer 3

focal
generalised
unknown onset
focal to bilateral seizure

Question 4

what are the features of focal seizures

Answer 4

previously termed partial seizures

these start in a specific area, on one side of the brain
the level of awareness can vary in focal seizures.

The terms focal aware (previously termed ‘simple partial’), focal impaired awareness (previously termed ‘complex partial’) and awareness unknown are used to further describe focal seizures

focal seizures can be classified as being motor (e.g. Jacksonian march), non-motor (e.g. déjà vu, jamais vu; ) or having other features such as aura

Question 5

what are the motor features of focal seizures

Answer 5

e.g. Jacksonian march

Question 6

what are the non-motor features of focal seizures

Answer 6

(e.g. déjà vu, jamais vu; ) or having other features such as aura

Question 7

what are the features of generalised seizures

Answer 7

these engage or involve networks on both sides of the brain at the onset

consciousness lost immediately.

The level of awareness in the above classification is therefore not needed, as all patients lose consciousness

generalised seizures can be further subdivided into motor (e.g. tonic-clonic) and non-motor (e.g. absence)

Question 8

what are the specific examples of generalised seizures

Answer 8

generalised seizures can be further subdivided into motor (e.g. tonic-clonic) and non-motor (e.g. absence)

tonic-clonic (grand mal)
tonic
clonic
typical absence (petit mal)
atonic

Question 9

what are seizures of unknown onset

Answer 9

this termed is reserved for when the origin of the seizure is unknown

Question 10

what is focal to bilateral seizures

Answer 10

starts on one side of the brain in a specific area before spreading to both lobes

previously termed secondary generalized seizures

Question 11

what is epilepsy

Answer 11

neurological condition characterised by recurrent seizures

Question 12

what diseases is epilepsy associated with

Answer 12

cerebral palsy: around 30% have epilepsy

tuberous sclerosis

mitochondrial diseases -

Question 13

what are the causes of seizures?

Answer 13

can develop one-off seizures following any insult to the brain, for example, infection, trauma or metabolic disturbance.

1. febrile convulsions
2. alcohol withdrawal seizures
3. psychogenic non- epileptic seizures

Question 14

what are febrile convulsions

Answer 14

typically occur in children between the ages of 6 months and 5 years

around 3% of children will have at least one febrile convulsion

usually occur early in a viral infection as the temperature rises rapidly

seizures are typically brief and generalised tonic/tonic-clonic in nature

Question 15

what are alcohol withdrawal seizures, what is the peak incidence of these seizures

Answer 15

ccur in patients with a history of alcohol excess who suddenly stop drinking, for example following admission to hospital

the peak incidence of seizures is at around 36 hours following cessation of drinking

Question 16

what can patients be given to reduce risk of alcohol withdrawal seizures

Answer 16

benzodiazepines following cessation of drinking to reduce the risk

Question 17

what are psychogenic non-epileptic seizures

Answer 17

previously termed pseudoseizures

describes patients who present with epileptic-like seizures but do not have characteristic electrical discharges

patients may have a history of mental health problems or a personality disorder

Question 18

what are the signs and sx of epilepsy

Answer 18

loss of consciousness - ‘blackout’ or ‘collapse’.

bite their tongue
experience incontinence of urine
motor jerks

Question 19

what is the postictal phase in epilepsy

Answer 19

where they feel drowsy and tired for around 15 minutes following seizure

Question 20

investigations in patient presenting with blackout/ suspected seizure

Answer 20

electroencephalogram (EEG) and neuroimaging (usually a MRI).

Question 21

describe management of seizures

Answer 21

meds started after the second seizure

As a general rule:

sodium valproate is used first-line for patients with generalised seizures

carbamazepine is used first-line for patients with focal seizures

Question 22

what is status epilectus and how is it managed

Answer 22

If a patient continues to fit benzodiazepine medication

a medical emergency requiring hospital treatment.

Management options include further benzodiazepine medication, infusions of antiepileptics or even the use of general anaesthetic agents.

Question 23

describe the acute management of epilepsy

Answer 23

seizures can resolve spontaneously

when seizures don’t terminate after 5-10 minutes then it is often appropriate to administer medication to terminate the seizure. Patients are often prescribed these so family members may administer them in this eventuality

‘rescue medication’ = Benzodiazepines such as diazepam are typically used are may be administered rectally or intranasally/under the tongue.

Question 24

which groups of patients should be considered when prescribing anti epileptics

Answer 24

1. pt who drive
2. pt taking other meds
3. women wishing to get pregnant
4. women on contraception

Question 25

advice to patients who drive on ant epileptics

Answer 25

generally patients cannot drive for 6 months following a seizure. For patients with established epilepsy they must be fit free for 12 months before being able to drive

Question 25

advice to patients who drive on ant epileptics

Answer 25

generally patients cannot drive for 6 months following a seizure. For patients with established epilepsy they must be fit free for 12 months before being able to drive

Question 26

advice to patients who on other meds on antiepileptics

Answer 26

antiepileptics can induce/inhibit the P450 system resulting in varied metabolism of other medications, for example warfarin

Question 27

advice to patients who wishing to get pregnant antiepileptics

Answer 27

antiepileptics are generally teratogenic, particularly sodium valproate. It is important that women take advice from a neurologist prior to becoming pregnant, to ensure they are on the most suitable antiepileptic medication. Breastfeeding is generally considered safe for mothers taking antiepileptics with the possible exception of the barbiturates

Question 28

advice to patients who are on contraception and on antiepileptics

Answer 28

both the effect of the contraceptive on the effectiveness of the anti-epileptic medication and the effect of the anti-epileptic on the effectiveness of the contraceptive need to be considered

Question 29

drugs used in epilepsy

Answer 29

sodium valporate
carbamepezine
Lamotrigine
phenytoin