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Stage 3 > Neurology: Epilepsy + Febrile Seizures > Flashcards

Neurology: Epilepsy + Febrile Seizures Flashcards

1
Q

Most common form of focal epilepsy/partial seizure?

A

Temporal lobe epilepsy (TLE)

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2
Q

What is the commonest form of TLE?

A

Mesial temporal sclerosis

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3
Q

What condition is there often a history of in temporal lobe epilepsy?

A

Febrile seizures

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4
Q

How long can seizure auras last before consciousness is lost?

A

Seconds to 1-2 minutes

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5
Q

What three ways can auras manifest in temporal lobe epilepsy?

A

1) Viscerosensory symptoms e.g. rising epigastric sensation
2) Experiential phenomena e.g. fear, deja vu, visual and auditory illusions
3) Hallucinations - complex auditory or visual, gustatory, or olfactory

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6
Q

Which type of epilepsy is post-ictal amnesia (presents as disorientation) a feature of?

A

Temporal lobe epilepsy

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7
Q

Why does post-ictal amnesia occur in temporal lobe epilepsy?

A

Bilateral impairment of hippocampal function

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8
Q

Which type of seizures are automatisms associated with?

A

Temporal lobe seizures (automatisms occur in ⅔ of TLE cases)

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9
Q

What are automatisms?

A

Coordinated, involuntary motor activity, stereotyped, almost always accompanied by altered consciousness and subsequent amnesia

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10
Q

What are the two types of automatisms?

A

1) Release phenomena - include actions normally socially inhibited
2) Reactive phenomena - appear to be reactions to external stimuli

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11
Q

Which two body parts do automatisms often involve?

A

1) Hands e.g. fumbling, picking, fidgeting
2) Mouth e.g. chewing, lip smacking, swallowing

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12
Q

What are two types of complex automatisms that can occur in frontal lobe seizures if prefrontal regions are involved?

A

1) Vocalisations
2) Behavioural e.g. crying (dacrystic) or laughing (gelastic)

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13
Q

What is the key feature of occipital lobe seizures?

A

Visual hallucinations

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14
Q

What is a key feature of brainstem-onset seizures?

A

Myoclonus (sudden, brief involuntary twitching or jerking of a muscle or group of muscles. The twitching cannot be stopped or controlled by the person experiencing it)

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15
Q

What type of investigation is abnormal in ⅓ of individuals with TLE?

A

Inter-ictal EEGs

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16
Q

What is the imaging modality of choice in TLE and why?

A

MRI - looking for underlying cause

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17
Q

What can be underlying causes of TLE?

A

Hippocampal or temporal sclerosis, temporal lobe dysplasia or tumour

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18
Q

What is the key feature of frontal lobe seizures?

A

Prominent motor signs

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19
Q

What are two additional features that can be seen in frontal lobe seizures?

A

1) Speech arrest
2) Dystonic posturing

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20
Q

What is the rarest type of focal seizure?

A

Parietal lobe seizure

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21
Q

What is the key feature of a parietal lobe seizure?

A

Somatosensory phenomena e.g. abnormal sensation travelling up limb over the course of a seizure

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22
Q

What are the two main types of epileptic syndromes?

A

1) Focal
2) Generalised

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23
Q

How are focal seizures classified (not by location)?

A

1) Complex - with impairment of consciousness
2) Simple - without impairment of consciousness
3) Secondary generalised - evolving to a bilateral, convulsive seizure

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24
Q

What are the clinical features of a complex focal seizure?

A

1) Patients lose consciousness either after an aura, or at seizure onset
2) These seizures most commonly originate at the temporal lobe
3) Post-ictal symptoms are common e.g. confusion in temporal lobe seizures

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25
From which type of seizure does a complex focal seizure most commonly originate?
Temporal lobe seizure
26
What is a common post-ictal symptom in a temporal lobe complex seizure?
Confusion
27
What are the clinical features of a simple focal seizure?
1) Patients do not lose consciousness 2) Patients only experience focal symptoms 3) Post-ictal symptoms do not occur
28
What are the clinical features of a secondary generalised seizure?
1) Patients experience a focal seizure, which then evolves to a generalised seizure which is typically tonic-clonic 2) This occurs in ⅔ of patients with focal seizures
29
What type of generalised seizure typically occurs in a secondary generalised seizure?
Tonic-clonic
30
What are the specific features of temporal lobe focal seizures?
1) Automatisms (stereotyped behaviours) e.g. lip smacking 2) Deja vu or jamais vu 3) Emotional disturbance e.g. sudden terror 4) Olfactory, gustatory or auditory hallucinations
31
What are the specific features of frontal lobe focal seizures?
1) Motor features e.g. Jacksonian features/march (due to propagation of electrical activity through the primary motor cortex) 2) Dysphasia 3) Todd's palsy/paresis (unilateral temporary focal paralysis/weakness following a seizure)
32
What are the specific features of parietal lobe focal seizures?
1) Sensory symptoms e.g. tingling and numbness 2) Motor symptoms - due to spread of electrical activity to the pre-central gyrus in the frontal lobe
33
What are the specific features of occpital lobe focal seizures?
Visual symptoms e.g. spots and lines in the visual field
34
What is first line treatment for focal seizures?
Lamotrigine or levetiracetam
35
What are second line treatments for focal seizures?
Carbamazepine, oxcarbazepine or zonisamide (third line = lacosamide)
36
What are the four types of generalised seizure?
1) Absence 2) Tonic-clonic 3) Myoclonic 4) Atonic
37
How do absence seizures present?
Patients, often children, pause briefly for < 10 seconds and then carry on where they left off
38
How do you treat absence seizures?
Sodium valproate or ethosuximide first line
39
Which treatment do you avoid in absence and myoclonic seizures and why?
Carbamazepine - worsens seizures
40
What are the features of tonic-clonic seizures?
1) Patients lose consciousness 2) Limbs stiffen (tonic) and start jerking (clonic) 3) Post-ictal confusion is common
41
What are the first line treatments for tonic-clonic seizures?
Sodium valproate or lamotrigine
42
How does a myoclonic seizure present?
Sudden jerk of a limb, trunk or face
43
What is first line treatment for myoclonic seizures?
Sodium valproate unless patient is female of childbearing age where levetiracetam or topiramate is first line
44
How do atonic seizures present?
Sudden loss of muscle tone, causing the patient to fall, whilst retaining consciousness
45
What is first line treatment for atonic seizures?
Sodium valproate or lamotrigine
46
What are examples of seizure triggers?
1) Poor sleep 2) Alcohol and drugs (and their withdrawal) 3) Stroke 4) Intracranial haemorrhage 5) Space-occupying lesions 6) Metabolic disturbances
47
What are complications of epilepsy?
1) Status epilepticus 2) Depression 3) Suicide 4) Sudden unexpected death in epilepsy (SUDEP) - thought to be due to excessive electrical activity causing a cardiac arrhythmia and death
48
What is status epilepticus?
> 5 minutes of continuous seizures or repetitive seizures without regaining consciousness, life threatening
49
How do you manage status epilepticus?
1) IV lorazepam/buccal midazolam 2) If 2 doses of benzodiazepines doesn't work - IV phenytoin/levetiracetam/valproate/phenobarbital + call anaesthetist
50
What is the focus of drug therapy in epilepsy?
Optimisation of quality of life with control of seizure activity
51
What are the principles of epilepsy management?
1) Any treatment must be balanced against potential side effects (in particular teratogenesis in women of childbearing age) 2) Initiation of medication is not always appropriate, especially after a "provoked" first seizure, and should be discussed with a specialist 3) Choice of antiepileptic drugs is a complex area, and often involves a degree of trial and error as very few randomised trials compare different medications head-to-head, and no single drug is clearly more effective or better tolerated
52
What are the general rules of thumb for epilepsy management?
1) Lamotrigine, levetiracetam and valproate are good for all seizure types 2) Carbamazepine, gabapentin and phenytoin are better for focal (including secondary generalised) seizures 3) Ethosuximide is the drug of choice for absence seizures 4) Carbamazepine may worsen myoclonic seizures
53
Which antiepileptic is a good choice in women of childbearing age and why?
Lamotrigine - issues regarding teratogenicity should be considered, particularly in the context of valproate use which has a high risk of neural tube defects
54
What is the teratogenic risk with sodium valproate?
Neural tube defects
55
Interaction with which medications in particular should be considered when deciding epilepsy management?
Phenytoin, carbamazepine
56
What are side effects of topiramate?
Weight loss Renal stones Cognitive and behaviour changes
57
What are side effects of lamotrigine?
Skin rash Rarely Stevens-Johnson syndrome
58
What are side effects of carbamazepine?
Ataxia Skin rash Dysarthria Nystagmus
59
What are side effects of sodium valproate?
Weight gain Tremor Teratogenicity
60
What are side effects of phenytoin?
Ataxia Peripheral neuropathy Osteomalacia Gum hypertrophy Hirsutism
61
What must you do with regards to the DVLA once you have had a seizure?
Surrender your license to the DVLA - you can reapply to get your license back depending on the seizures and certain timeframes
62
For a car/motorbike license when can you reapply after surrendering your license to the DVLA after a one off seizure?
Reapply in 6 months
63
For a car/motorbike license when can you reapply after surrendering your license to the DVLA after more than one seizure?
Reapply in one year
64
For a car/motorbike license when can you reapply after surrendering your license to the DVLA after a seizure following change in antiepileptic medications?
Reapply to drive if seizure was more than 6 months ago or you've been back on previous medication for 6 months
65
For a bus/coach/lorry license when can you reapply after surrendering your license to the DVLA after a one off seizure?
Reapply in 5 years or if you haven't taken anti epileptic medications for 5 years
66
For a bus/lorry license when can you reapply after surrendering your license to the DVLA after more than one seizure?
Reapply once you haven't had a seizure for 10 years or you haven't taken any anti-epileptic medication for 10 years
67
Who does the DVLA epilepsy driving guidelines apply for?
The guidelines apply for all categories of license and are more strict for those that are Taxi and HGV drivers
68
What are the features of a Jacksonian march (frontal lobe focal seizure)?
1) May complain of generic weird movements 2) Gradual onset and spread of motor symptoms e.g. right leg starts twitching, this movement moves up her right trunk to involve her right arm 3) Completely aware of these symptoms 4) May be no other symptoms and normal examination
69
What % of children experience febrile seizures?
3% - relatively common
70
Which age group are most susceptible to febrile seizures?
6 months-5 years
71
How do febrile seizures present?
1) Short-live tonic-clonic seizure e.g. 2 mins episode of stiffness + shaking all 4 limbs + LOC, full recovery and fully alert 2) History of fever ± coryzal symptoms
72
How are febrile seizures diagnosed?
History
73
What is the prognosis of febrile seizures?
1) 1 in 3 children will have at least one more febrile convulsion 2) Simple febrile convulsions do not affect development and do not hugely increase the child's likelihood of developing epilepsy (1% to 2%) 3) Complex febrile convulsions are associated with a significantly increased risk of epilepsy (around 4-12%)
74
What are the features complex febrile convulsions?
Last for a long time and/or multiple times in the same febrile illness ( >1 seizure in < 24h as part of the same febrile illness)
75
How do you manage febrile seizures?
1) Acute management is like all other seizures 2) Find the source of the fever - the suspected/confirmed source will depend on if the underlying cause requires any treatment 3) If complex seizure - consider admission for further observation
76
What advise should be given to parents of children with febrile convulsions?
Parents should be advised on: 1) Appropriate anti-pyretic usage 2) Not to give anti-pyretics prophylactically 3) To avoid sponging a child to cool them down 4) Appropriate safetynetting advice should another seizure occur
77
How do you manage status epilepticus in children?
1) Roll on side (if safe to do so) + high flow oxygen + check glucose 2) If seizure not resolved in 5 mins - IV lorazepam or buccal midazolam or rectal diazepam 3) If seizure continuing after 10 minutes - IV lorazepam, call for senior support incl. anaesthesia if not already done so 5) IV phenytoin 6) Rapid sequence induction with sodium thiopentone/propofol
78
What medication do you give in status epilepticus instead of IV phenytoin if the patient normally takes phenytoin?
IV phenobarbitone
79
What are complications of status epilepticus?
1) Focal neurological deficit (normally temporary) 2) Memory loss 3) Behavioural problems 4) Hypoxic brain injury
80
What are side effects of phenytoin and therefore what should you monitor?
Bradycardia + hypotension so must monitor BP + ECG
81
How is epilepsy diagnosed?
EEG - MRI and CT only to exclude structural abnormalities of the brain
82
What is West syndrome also called?
Infantile spasms
83
What is West syndrome?
Seizure syndrome which starts around age 4-8 months
84
How does West syndrome present?
1) Children have seizures with myoclonic jerking, referred to as 'jack knife' spasms that occur in clusters 2) Violent spasms of the head and limbs which occur in bouts of 10-20
85
What is the prognosis of West syndrome?
Associated with developmental regression/learning difficulties or disability and high morbidity
86
How is West syndrome diagnosed?
History + characteristic EEG finding of hypsarrhythmia
87
Which age group is affected by benign rolandic seizures?
Children aged 3-10 years
88
How do benign rolandic seizures present?
Occur almost exclusively during sleep 1) Children characteristically have a tonic seizure overnight 2) Might be noticed by the parents if the child makes noises or falls out of bed 3) They might also go unrecognised, but parents note that they find the child sleeping on the floor or with messy bedsheets in the morning
89
How is benign rolandic seizures diagnosed?
History + characteristic EEG findings during sleep of centro-temporal spikes
90
What is the prognosis of benign rolandic seizures?
Excellent - most children completely outgrow the condition around puberty + no significantly increased risk of developing another seizure disorder later in life
91
Which patients are typically affected by absence epilepsy
Girls aged 4-12 years
92
What are drop attacks?
Sudden falls while walking or standing - child recovers in seconds or minutes, may be provoked
93
What are the clinical features of juvenile myoclonic epilepsy?
1) Typically occurs in adolescence 2) Myoclonic episodes, usually in the morning 3) Absences and generalised tonic-clonic seizures may occur 4) Remission is rare

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