Seizures

Question 1

Definition seizure

Answer 1

transient episodes of abnormal electrical activity in the brain

Question 2

Diagnosis of epilepsy

Answer 2

Usually require at least two unprovoked seizures occurring more than 24 hours apart.

Question 3

triggers of seizures

Answer 3

Poor sleep, alcohol and drugs (and their withdrawal), stroke, intracranial haemorrhage, space-occupying lesions, metabolic disturbances, psychological and emotional stress, metabolic derangements (sodium, calcium) , hormonal changes esp oestrogen

Question 4

Generalised Tonic-Clonic Seizures features

Answer 4

loss of consciousness and tonic (muscle tensing) and clonic (muscle jerking) episodes
tongue biting, incontinence, groaning and irregular breathing, drooling, foaming
prolonged post-ictal period

Question 5

Absence Seizures features

Answer 5

typically happen in children
Patient becomes blank, stares into space and then abruptly returns to normal
Lasts 10-20 seconds
Provoked by hyperventilation

Question 6

Myoclonic seizures features

Answer 6

Sudden brief muscle contractions, like a sudden “jump”
Patient usually remains awake during the episode.
Happen in children as part of juvenile myoclonic epilepsy.

Question 7

Atonic Seizures features

Answer 7

“drop attacks”.
Characterised by brief sudden lapses in muscle tone causing the patient to fall, whilst retaining consciousness
Don’t usually last more than 3 minutes
They typically begin in childhood

Question 8

Management of tonic-clonic seizures

Answer 8

First line: sodium valproate
Second line: lamotrigine or levetiracetam

Question 9

Management of Absence Seizures

Answer 9

First line: ethosuximide
Second line: sodium valproate

Question 10

Management Myoclonic Seizures

Answer 10

First line: sodium valproate
Other options: levetiracetam
Avoid Carbamazepine as it worsens seizures.

Question 11

Management Atonic seizures

Answer 11

First line: sodium valproate
Second line: lamotrigine

Question 12

Management of specific focal seizures

Answer 12

First line: lamotrigine or levetiracetam
Second line: carbamazepine

Question 13

West syndrome/ Infantile spasms

Answer 13

Occurs in 6m old infants
Clusters of full body spasms. Motor symptoms, such as head nodding
More common in patients with tuberous sclerosis
First line treatments are Prednisolone and Vigabatrin
There is a poor prognosis

Question 14

Epilepsy Ix

Answer 14

History
Blood investigations - To make sure metabolic derangements not a cause of seizure
EEG
ECG- Arrhythmias can trigger syncope which can trigger seizure
MRI - Always required in focal onset epilepsy

Question 15

Counselling for epilepsy

Answer 15

Education
Avoiding stimulants
Effects on lifestyle, job
Triggers for seizures
Safety: driving, heights, open water swimming

Question 16

sodium valproate MOA

Answer 16

first line option for most forms of epilepsy (except focal seizures). Increases activity of GABA and reduce Ca current
Avoided in girls or women

Question 17

Key side effects of Sodium valproate

Answer 17

Teratogenic 
Liver damage and hepatitis
Hair loss which grows back curly 
Neuro features: Tremor,ataxia
Weight gain, Oedema
Headache
Hyponatraemia
Blood dyscrasias include anaemia and thrombocytopenia
GI disturbance - N+V, anorexia, abdominal pain, bowel disturbance to pancreatitis and hepatotoxicity

Question 18

Carbamazepine MOA

Answer 18

Block sodium channels

Question 19

Key side effects of Carbamazepine

Answer 19

Agranulocytosis
Aplastic anaemia
Induces the P450 system
SIADH
Drowsiness
Diplopia
Ataxia
Blurring of vision
Hyponatremia
Oedema
Skin problems (allergic skin reactions/dermatitis/urticaria)

Question 20

Phenytoin MOA

Answer 20

Block sodium channels

Question 21

Key side effects of Phenytoin

Answer 21

Folate and vitamin D deficiency
Megaloblastic anaemia (folate deficiency)
Osteomalacia (vitamin D deficiency)
Hirutism
Parsthesia
Rash
Tremor
Dizziness
Gingival hypertrophy and tenderness
constipation
acne

Question 22

Ethosuximide MOA

Answer 22

Reduces t type calcium channel cell current

Question 23

Key side effects of ethosuximide

Answer 23

Night terrors
Rashes

Rashes

Question 24

Key side effects of lamotrigine

Answer 24

Stevens-Johnson syndrome or DRESS syndrome. 
Leukopenia
CNS effects: Tremor, Diplopia
Blurred vision, Dizziness
Headache,ataxia 
Aggression/agitation
Arthralgia
Back pain
Diarrhoea
Insomnia
Nausea and vomiting

Question 25

Lamotrigine MOA

Answer 25

suppresses release of excitatory amino acid glutamate

Question 26

Status Epilepticus definition

Answer 26

Seizures lasting more than 5 minutes or more than 3 seizures in one hour

Question 27

Satus epilepticus blood Ix

Answer 27

arterial blood gas, and a routine panel of venous bloods including FBC, U&E, LFT, CRP, Calcium and magnesium, and clotting.
Patients should have a serum and urine save for toxicology, and antiepileptic drug levels should be sent as appropriate

Question 28

Management of status epileptics

Answer 28

IV lorazepam 4mg, repeated after 10 minutes if the seizure continues
In the absence of IV access, buccal midazolam can be administered or PR diazepam
If seizures persist: 2nd line is levetiracetam, phenytoin or sodium valproate
3rd line: Phenobarbital or general anaesthesia
Refractory status involves general anaesthesia and propofol/midazolam/thoipental sodium

Question 29

DVLA and epilepsy

Answer 29

Car / motorbike license:
one off seizure = reapply in 6 months
more than one seizure = reapply in one year
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
Bus / coach / lorry licence
one off seizure = reapply in 5 years or if you haven’t taken anti epileptic medications for 5 years
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