Neurology - Epilepsy Flashcards
What is epilepsy?
Umbrella term for a condition where there is a tendency to have seizures
What is a seizure?
Transient episode of abnormal electrical activity
What are the different types of seizures?
Generalised tonic-clonic seizures
Focal seizures
Absence seizures
Atonic seizures
Myoclonic seizures
Infantile spasms
Febrile convulsions
What is a generalised tonic-clonic seizure?
Loss of consciousness and tonic (muscle tensing) and clonic (muscle jerking) movements
Tonic usually before clonic
What can happen during a generalised tonic-clonic seizure?
Tongue biting
Incontinence
Groaning
Irregular breathing
What happens in the post-ictal period after a generalised tonic-clonic seizure?
Prolonged post-ictal period
- Confused
- Drowsy
- Irritable
- Low mood
How are tonic-clonic seizures managed?
First line
Sodium valproate
Second line
Lamotrigine or carbamazepine
What are focal seizures?
Seizures affecting
- Hearing
- Speech
- Memory
- Emotions
Where do focal seizures start?
Temporal lobes
How can a focal seizure present?
Hallucinations
Memory flashbacks
Déja vu
Strange things on autopilot
How are focal seizures managed?
Reverse of tonic-clonic seizures
First line
Carbamazepine or lamotrigine
Second line
Sodium valproate or levetiracetam
Who is typically affected by absence seizures?
Children
What happens in absence seizures?
Patient becomes blank, stares into space then abruptly goes back to normal
Unaware of surroundings and won’t respond
How long do absence seizures last?
10 to 20 seconds
Most patients stop having them as they get older
How are absence seizures managed?
First line
Sodium valproate or ethosuximide
How are atonic seizures also known?
Drop attacks
What happens in an atonic seizure?
Brief lapses in muscle tone
Patient drops to the floor
How long do atonic seizures last?
Usually less than 3 minutes
When do atonic seizures usually start?
Childhood
What can atonic seizures indicate?
Lennox-Gastaut syndrome
How are atonic seizures managed?
First line
Sodium valproate
Second line
Lamotrigine
How do myoclonic seizures present?
Sudden brief muscle contraction
Patient still awake
When do myoclonic seizures happen?
Various forms of epilepsy
Typically part of juvenile myoclonic epilepsy
How are myoclonic seizures managed?
First line
Sodium valproate
Second line
Lamotrigine or
Levetiracetam or
Topiramate
How are infantile spasms also known?
West syndrome
When do infantile spasms start?
In infancy at around 6 months
How are infantile spasms characterised?
Cluster of full body spasms
What is the prognosis in infantile spasms / West syndrome?
1/3 die by age 25
1/3 seizure free
How are infantile spasms treated?
Prednisolone or vigabatrin
What are febrile convulsions?
Seizures that occur in children while they have a fever
Not caused by epilepsy or other neuro pathology
By definition what age are children affected by febrile convulsions?
Between 6 months and 5 years
What is the prognosis for febrile convulsions?
Usually no lasting damage
1/3 will have another convulsion
Slight increased risk of developing epilepsy
What investigations are used for epilepsy?
Good history
Identify seizures vs vasovagal episodes or febrile convulsions
EEG
- Performed after second simple tonic-clonic seizure
- Children allowed one simple seizure before being investigated for epilepsy
MRI brain
- Visualise brain structures
- When child under 2
- Focal seizures
- No response to first line anti-epileptics
What investigations can be used to exclude other pathology that may cause seizures?
ECG
Blood electrolytes - sodium, potassium, calcium and Mg
Blood glucose - hypoglycaemia and diabetes
Blood cultures, urine cultures and LP
What general advice should be given to patients and families regarding epilepsy?
- Showers rather than baths
- Cautious swimming unless seizures well controlled
- Careful with heights
- Cautious with traffic
- Avoid heavy, hot or electric equipment
- Avoid driving unless seizure free for 2 years
Outline sodium valproate
Increases GABA effects
- Teratogenic
- Liver damage and hepatitis
- Hair loss
- Tremor
Avoided in girls unless no alternatives
Strict criteria regarding pregnancy
Outline carbamazepine
First line for focal seizures
- Agranulocytosis
- Aplastic anaemia
- CYP450 system
Outline phenytoin
- Folate and Vitamin D deficiency
- Megaloblastic anaemia
- Osteomalacia
Outline ethosuximide
Night terrors
Rashes
Outline lamotrigine
- Steven-Johnson syndrome or DRESS syndrome
- Leukopenia
How should seizures be managed immediately?
- Patient in recovery position
- Something soft under head to protect against head injury
- Remove obstacles
- Make note of time at start and end of seizure
- Ambulance if over 5 minutes or first seizure
What is status epilepticus?
Seizure lasting more than 5 minutes or 2 or more seizures without regaining consciousness in interim
How is status epilepticus managed?
A-E
- Secure airway
- High concentration oxygen
- Assess cardiac and respiratory function
- Check BMs
- IV access
- IV lorazepam, repeated after 10 minutes if seizure continues
If seizures persist in status epilepticus what is the final step?
IV phenobarbital or phenytoin
Intubate and ventilation
ICU transfer
What are the medical options in the community?
Buccal midazolam
Rectal diazepam
