Neurology - Epilepsy

Question 1

What is epilepsy?

Answer 1

Umbrella term for a condition where there is a tendency to have seizures

Question 2

What is a seizure?

Answer 2

Transient episode of abnormal electrical activity

Question 3

What are the different types of seizures?

Answer 3

Generalised tonic-clonic seizures
Focal seizures
Absence seizures
Atonic seizures
Myoclonic seizures
Infantile spasms
Febrile convulsions

Question 4

What is a generalised tonic-clonic seizure?

Answer 4

Loss of consciousness and tonic (muscle tensing) and clonic (muscle jerking) movements

Tonic usually before clonic

Question 5

What can happen during a generalised tonic-clonic seizure?

Answer 5

Tongue biting
Incontinence
Groaning
Irregular breathing

Question 6

What happens in the post-ictal period after a generalised tonic-clonic seizure?

Answer 6

Prolonged post-ictal period
- Confused
- Drowsy
- Irritable
- Low mood

Question 7

How are tonic-clonic seizures managed?

Answer 7

First line
Sodium valproate

Second line
Lamotrigine or carbamazepine

Question 8

What are focal seizures?

Answer 8

Seizures affecting
- Hearing
- Speech
- Memory
- Emotions

Question 9

Where do focal seizures start?

Answer 9

Temporal lobes

Question 10

How can a focal seizure present?

Answer 10

Hallucinations
Memory flashbacks
Déja vu
Strange things on autopilot

Question 11

How are focal seizures managed?

Answer 11

Reverse of tonic-clonic seizures

First line
Carbamazepine or lamotrigine

Second line
Sodium valproate or levetiracetam

Question 12

Who is typically affected by absence seizures?

Answer 12

Children

Question 13

What happens in absence seizures?

Answer 13

Patient becomes blank, stares into space then abruptly goes back to normal

Unaware of surroundings and won’t respond

Question 14

How long do absence seizures last?

Answer 14

10 to 20 seconds

Most patients stop having them as they get older

Question 15

How are absence seizures managed?

Answer 15

First line
Sodium valproate or ethosuximide

Question 16

How are atonic seizures also known?

Answer 16

Drop attacks

Question 17

What happens in an atonic seizure?

Answer 17

Brief lapses in muscle tone

Patient drops to the floor

Question 18

How long do atonic seizures last?

Answer 18

Usually less than 3 minutes

Question 19

When do atonic seizures usually start?

Answer 19

Childhood

Question 20

What can atonic seizures indicate?

Answer 20

Lennox-Gastaut syndrome

Question 21

How are atonic seizures managed?

Answer 21

First line
Sodium valproate

Second line
Lamotrigine

Question 22

How do myoclonic seizures present?

Answer 22

Sudden brief muscle contraction

Patient still awake

Question 23

When do myoclonic seizures happen?

Answer 23

Various forms of epilepsy

Typically part of juvenile myoclonic epilepsy

Question 24

How are myoclonic seizures managed?

Answer 24

First line
Sodium valproate

Second line
Lamotrigine or
Levetiracetam or
Topiramate

Question 25

How are infantile spasms also known?

Answer 25

West syndrome

Question 26

When do infantile spasms start?

Answer 26

In infancy at around 6 months

Question 27

How are infantile spasms characterised?

Answer 27

Cluster of full body spasms

Question 28

What is the prognosis in infantile spasms / West syndrome?

Answer 28

1/3 die by age 25 1/3 seizure free

Question 29

How are infantile spasms treated?

Answer 29

Prednisolone or vigabatrin

Question 30

What are febrile convulsions?

Answer 30

Seizures that occur in children while they have a fever **Not caused by epilepsy or other neuro pathology**

Question 31

By definition what age are children affected by febrile convulsions?

Answer 31

Between 6 months and 5 years

Question 32

What is the prognosis for febrile convulsions?

Answer 32

Usually no lasting damage 1/3 will have another convulsion Slight increased risk of developing epilepsy

Question 33

What investigations are used for epilepsy?

Answer 33

**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

Question 34

What investigations can be used to exclude other pathology that may cause seizures?

Answer 34

ECG Blood electrolytes - sodium, potassium, calcium and Mg Blood glucose - hypoglycaemia and diabetes Blood cultures, urine cultures and LP

Question 35

What general advice should be given to patients and families regarding epilepsy?

Answer 35

- 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

Question 36

Outline sodium valproate

Answer 36

Increases GABA effects - Teratogenic - Liver damage and hepatitis - Hair loss - Tremor Avoided in girls unless no alternatives Strict criteria regarding pregnancy

Question 37

Outline carbamazepine

Answer 37

First line for focal seizures - Agranulocytosis - Aplastic anaemia - CYP450 system

Question 38

Outline phenytoin

Answer 38

- Folate and Vitamin D deficiency - Megaloblastic anaemia - Osteomalacia

Question 39

Outline ethosuximide

Answer 39

Night terrors Rashes

Question 40

Outline lamotrigine

Answer 40

- **Steven-Johnson syndrome or DRESS syndrome** - Leukopenia

Question 41

How should seizures be managed immediately?

Answer 41

- 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

Question 42

What is status epilepticus?

Answer 42

Seizure lasting **more than 5 minutes** or **2 or more seizures without regaining consciousness** in interim

Question 43

How is status epilepticus managed?

Answer 43

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

Question 44

If seizures persist in status epilepticus what is the final step?

Answer 44

IV phenobarbital or phenytoin Intubate and ventilation ICU transfer

Question 45

What are the medical options in the community?

Answer 45

Buccal midazolam Rectal diazepam