SEIZURES

Question 1

Common causes of blackouts?

Answer 1

Syncope
Panic attacks
Epilepsy
Blank spells/microsleeps
Non-epileptic attack disorder
Narcolepsy
Hyperrekplexia
Idiopathic drop attacks
Migraine without headache
TIAs
Transient global amnesia
Cerebrovascular disorders
POTS

Question 2

What is syncope?

Answer 2

Loss of conciousness usually from a sudden decrease in cerebral blood flow

Question 3

Most common cause of syncope?

Answer 3

Vasovagal syncope

Question 4

Functions of vagus nerve?

Answer 4

Sensory: Innervates the skin of the external acoustic meatus and the internal surfaces of the laryngopharynx and larynx. Provides visceral sensation to the heart and abdominal viscera.
Special Sensory: Provides taste sensation to the epiglottis and root of the tongue.
Motor: Provides motor innervation to the majority of the muscles of the pharynx, soft palate and larynx.
Parasympathetic: Innervates the smooth muscle of the trachea, bronchi and gastro-intestinal tract and regulates heart rhythm. Its cardiac branches act to slow the rate of heartbeat; its bronchial branch acts to constrict the bronchi; and its esophageal branches control involuntary muscles in the esophagus, stomach, gallbladder, pancreas, and small intestine, stimulating peristalsis and gastrointestinal secretions

Question 5

Pathophysiology of Vasovagal syncope

Answer 5

Overstimulation of the vagus nerve which slows the heart rate down = loose consciousness
May also affect bladder/bowel = incontinence

Question 6

Typical triggers of Vasovagal syncope?

Answer 6

Prolonged standing
Rising suddenly
Emotional trauma
Pain
Sight of blood/something gory

Question 7

Symptoms of Vasovagal syncope?

Answer 7

Gradual onset light headedness, nausea, sweating, palpitations, greying of vision, muffled hearing, feeling distant
Rapid recovery with no confusion
They look pale, cold skin, may have uncoordinated jerks

Question 8

Who does orthostatic syncope occur in?

Answer 8

Olde people on multiple medications or those with autonomic neuropathy e.g. DM

Question 9

Characteristics of orthostatic syncope?

Answer 9

Occurs with changes in posture, after rising or after a large meal

Question 10

Characteristics of carotid sinus syncope?

Answer 10

Caused by hypersensitivity of the carotid sinus
Attributable to neck pressure e.g. tight collar, turning neck, shaving etc

Question 11

What are reflex anoxic attacks?

Answer 11

Occur in children 6 months-3 years in response to increased vagal tone with brief asystole
Often occurs in response to pain or emotional stimuli

The child will go pale, fall to the floor and rapidly recover

Question 12

Characteristics of cardiac syncope?

Answer 12

No prodrome
Occur in any posture
Can occur when awake or asleep, at rest or during exercise

Question 13

Causes of cardiac syncope?

Answer 13

Tachycarrhythmias e.g, WPW syndrome, long QT syndrome
Bradyarrhthmias e.g. complete heart block, sick sinus syndrome, swallow syncope
Structural heart disease e.g. aortic stenosis, HOCM, mitral stenosis, atrial myxoma, IHD

Question 14

Causes of respiratory syncope?

Answer 14

Cough syncope - stimulates Vargas nerve -> bradyarthhymia
Valsalva manoeuvre
Breath holding spells
Hyperventilation - drop in CO2 = vasoconstriction

Question 15

Primary CNS causes of syncope?

Answer 15

Note these are rare!!

Raised ICP e.g. obstructive hydrocephalus, 3rd ventricular colloid cyst, chiari malformation
Autonomic dysreflexia e.g. intermittent massive hypertension
Diencephalic attacks e.g. post head injury or hypoxia

Question 16

What are non-epileptic attack disorders?

Answer 16

Aka psychogenic nonepileptic seizures or pseudoseizures

These are dissociative phenomenon that often occur in people with LD, or those with a history of abuse and complex psychosocial problems
Sufferers often have other unexplained medical symptoms e.g. CFS or IBD

Note these are not malingering!!

Think of it like overwhelming stress causes the brain to reboot!

Question 17

Characteristics of non-epileptic attack disorder?

Answer 17

Often occurs in company
Pt often reluctant to discuss symptoms
Attacks are variable and not stereotyped i.e. seizures are different each time
Might verbalise during attacks and show some awareness
Normal pupil size
Movements are flailing, arched back, pelvic thrusting
Eyeslids are clenched with resistance to eye opening
Rapid recovery
Often cry’s after the seizure

(Seems like a generalised convulsion die to whole body convulsions but there is no loss of consciousness, no post ictal state and pt can remember what happened)

Question 18

What is transient global amnesia?

Answer 18

A temporary anterograde amnesia with an acute onset
Usually;y occurs in middle-aged or older activities
Often precipitated by strenuous activity, high-stress events or coitus

Question 19

What is POTS syndrome?

Answer 19

Postural orthostatic tachycardia syndrome
Uncommon but diagnosis is often missed
Characterised by orthostatic tachycardia that can cause LOC - do a standing and sitting HR measurement

This does not cause hypotension!!

Question 20

Seizure vs syncope features?

Answer 20

Trigger common in syncope e.g. standing, sight of blood
Prodrome in seizure is common with aura, dejavu. Prodrome in syncope is almost always present with nausea, sweating, palpitations, light headedness, visual greying, muffled hearing
Seizures are sudden but syncope is more gradual
Seizures last 1-2 minutes but syncope < 30 seconds
Both can cause convulsive jerks but likely to be very brief in syncope
Both commonly cause incontinence
Seizures often cause tongue biting but this is rare in syncope
Postictal recovery is much slower after a seizure and person will be confused
Seizures can happen at night whereas this is rare for syncope, unless its a cardiac cause

Question 21

What is epilepsy?

Answer 21

A neurological disorder characterised by recurring seizures
At least 2 unprovoked seizures occurring >24 hours apart
OR
One unprovoked seizure and a probability of further seizures similar to the general recurrence risk after 2 unprovoked seizures over the next 10 years (>60%)

Question 22

Epidemiology of epilepsy?

Answer 22

3% of general population
Note 8-10% of the genrral population will have one seizure in their lifetime

Incidence is higher in LIC
Highest risk is in childhood and people >50
People with LD have higher rates

About 2/3rds of patients achieve satisfactory seizure control with AEDs

Question 23

Classification of seizures?

Answer 23

Focal vs generalised vs unknown
If its focal, is it focal aware or focal impaired awareness
Does seizure remain focal or does it evolve into a bilateral seizure?

Focal onset:
Motor onset vs non-motor onset seizures

Generalised onset:
Motor vs non-motor (i.e absence)

Question 24

Frontal lobe epilepsy symptoms?

Answer 24

Brief
Hand and leg movements
Posturing
Eyes deviate away from side of brain
Jacksonian march
Explosive screams, profanities or laughter
Post-octal weakness

Tend to occur at night

Question 25

Temporal lobe epilepsy symptoms?

Answer 25

Last about 1 minutes Rising epigastric sensation or abdominal discomfort Psychic or experimental phenomen e.g. Deja vu, jamais vu Hallucinations - auditory, gustatory or olfactory changes in emotions e.g. feelings of fear Vertigo Automatisms e.g. lip smacking, swallowing, grabbing, plucking Dysphasia if from the language dominant side of the brain

Question 26

Occipital lobe epilepsy symptoms?

Answer 26

Distortion of vision - floaters and flashers

Question 27

Parietal lobe epilepsy symptoms?

Answer 27

Alteration of sensual sensation e.g. paraesthesia, pain

Question 28

Types of motor generalised onset seizures?

Answer 28

Atonic Tonic Clonic Tonic-clonic Myoclonic Epileptic spasms Myoclonic-tonic-clonic

Question 29

Types of non-motor generalised onset seizures?

Answer 29

Typical Atypical Myoclonic Eyelid myoclonia (These are all types of absence seizures)

Question 30

Epilepsy syndromes?

Answer 30

Childhood absence epilepsy Juvenile absence epilepsy Juvenile myoclonic epilepsy Generalised tonic-clonic epilepsy Genetic generalised epilepsy West syndrome Dravet syndrome Lennox gastaut Lundborg syndrome Benign Rolandic epilepsy

Question 31

Juvenile myoclonic epilepsy?

Answer 31

typical onset is in the teenage years - more common in girls features: infrequent generalized seizures, often in morning//following sleep deprivation daytime absences, sudden, shock-like myoclonic seizure (these may develop before seizures) treatment: usually good response to sodium valproate

Question 32

Aetiology of epilepsy?

Answer 32

Most often idiopathic - 2/3rds of cases Structural - stroke, trauma, malformation of cortical development Genetic Infectious e.e. TB, cerebral malaria, HIV, congenital infections Metabolic e.g. porphyria, pyridoxine deficiency Immune disorders e.g. anti-NMDA receptor encephalitis and anti-LG11 encephalitis

Question 33

Channelopathies and genetic examples

Answer 33

Tuberous sclerosis Neurofibromatoiss Juvenile myoclonus epilepsy Autosomal dominant nocturnal frontal lobe epilepsy Dravet syndrome

Question 34

Investigtaions for epilepsy?

Answer 34

History is most important ECG Bloods: full blood count, urea and electrolytes, liver function tests, glucose, and calcium. Brain imaging - MRI best EEG

Question 35

Types of EEGs?

Answer 35

Standard awake and sleep EED Ambulatory EEG Video EED telemetry Cortical mapping Depth electrode EED

Question 36

Triggers for seizures?

Answer 36

Lack of sleep Psychological and emotional stress Depression Medications Metabolic derangements - sodium, K+, Ca2+ Hormonal changes - worst around periods, on contraception, menopause Alcohol Recreational drugs Stimulants e.g. caffeiene

Question 37

Prn use of benzodiazepines

Answer 37

E.g. using short course around time of period

Question 38

AED for generalised tonic-clonic seizures?

Answer 38

Males - Sodium valproate Females - lamotrigine or levetiracetam

Question 39

AED for absence seizures?

Answer 39

Ethosuximide

Question 40

AED for focal seizures?

Answer 40

Levetiracetam or lamotrigine

Question 41

Which AEDs can give rise to an allergic rash and Steven’s Johnson syndrome?

Answer 41

Phenytoin, lamotrigine, carbamazepine

Question 42

Treatment options for epilepsy?

Answer 42

Drugs Vagal nerve stimulation Surgery - lobectomy, lesion surgery, gamma knife surgery, hemispherectomy, corpus callosotomy (very rarely done but can be done in children to prevent the generalisation of seizures??) Deep brain stimulation Ketogenic diet may be used in children to reduce the number of seizures

Question 43

What is SUDEP?

Answer 43

Sudden Unexplained Death in Epilepsy When a person with epilepsy dies suddenly without an identifiable cause Most common cause of epilepsy-related death in young adults with uncontrolled epilepsy Risk is reduced in people with optimised seizure control

Question 44

What is convulsive status epilepticus?

Answer 44

A prolonged convulsive seizure lasting for 5 minuets or longer, or recurrent seizures 1 after the other without recovery in between

Question 45

Risk factors for epilepsy?

Answer 45

Premature birth Cerebral palsy Complicated febrile seizures Genetic conditions e.g. tuberous sclerosis or neurofibromatosis or mitochondrial diseases Brain development malformations FHx of epilepsy or neurologic illness Head trauma Infections e.g. meningitis or encephalitis Brain tumours Comorbid conditions e.g. CVD, strokes Dementia and neurodegenerative disorders

Question 46

Complications of epilepsy?

Answer 46

SUDEP Injuries Depression and anxiety Absence from school and work

Question 47

Prognosis of epilepsy?

Answer 47

In children and adults with epilepsy, 70% will be in remission but 30% will have ongoing seizures. Risk of recurrent seizures is highest in the first 12 months In some people who remain seizure-free for >2 years, medication can be slowly withdrawn

Question 48

What are predictive factors for epilepsy?

Answer 48

Frequency of seizures in the 6 months after first presentation Response to AED treatment The type of epilepsy syndrome - e.g. 80% of children with absence epilepsy will be in remission by adulthood

Question 49

History for seizures?

Answer 49

Triggers - sleep deprivation, stress, light sensitivity, alcohol use Aura - During - muscle stiffening, jerking, urinary incontinence, tongue biting, behavioural arrest, loss of muscle tone, shock-like movements, LOC Post-octal - drowsiness, headaches, amnesia, confusion

Question 50

Physical exam for seizures?

Answer 50

Cardiac, neurological, mental state, developmental assessment Assess oral mucosa to identify lateral tongue bites Identify any injuries sustained

Question 51

Investigtaions following a seizure?

Answer 51

12-lead ECG Bloods - FBC, U&Es, LFTs, glucose, Ca2+ Toxicology screen EEG Head CT or MRI

Question 52

What are focal seizures?

Answer 52

Previously termed partial seizures They start in a specific area on 1 side of the brain and the level of awareness can vary; can be focal awareness, focal impaired awareness and awareness unknown They are classified as motor, non-motor or having other features e.g. aura

Question 53

What are generalised seizures?

Answer 53

Seizures that engage both sides of the brain at onset Consciousness is lost immediately Can be motor and non-motor

Question 54

What are focal to bilateral seizures?

Answer 54

Previously termed secondary generalised seizures When they start on 1 side of the brain in a specific area before spreading to both lobes

Question 55

What are infantile spasms aka? When do they begin? What do they look like?

Answer 55

Aka wests syndrome Brief spasms that begins in the first few months of life Salaam attacks which last 1-2 seconds and repeat up to 50 times (flexion of head/trunk/limbs and extension of arms). May also have progressive mental handicap

Question 56

What usually causes infantile spasms?

Answer 56

usually secondary to serious neurological abnormality (e.g. tuberous sclerosis, encephalitis, birth asphyxia) or may be idiopathic

Question 57

absence seizures What age do they usually occur? What do they look like?

Answer 57

Most commonly 4-8 years Usually a few-30 seconds with no warning the child will seem spaced out and not responsive. They recover quickly. There are often many in a day

Question 58

Prognosis of absence seizures?

Answer 58

good prognosis: 90-95% become seizure free in adolescence

Question 59

What is Lennox-gustaut syndrome? What age is the usual onset? How do they present?

Answer 59

May be an extension of infantile spasms 1-5 years Causes different types of seizures e.g. atypical absences, tonic, Atonic and myoclonic. 90% will have moderate-severe mental handicap

Question 60

Who does benign Rolandic epilepsy usually occur in? How does it present?

Answer 60

In children. More common in males Paraesthesia unilaterally on the face or inside the mouth on waking Twitching can occur - mostly in the face Drooling, hypersalivation, speech arrest

Question 61

When does juvenile myoclonic epilepsy usually occur? How does it present?

Answer 61

Teenage years, more common in girls Causes infrequent generalised seizures in the morning or following sleep deprivation. May have daytime absences. May have sudden shock-like myoclonic seizures

Question 62

Who do febrile convulsions typically occur in? How common are they? What causes them?

Answer 62

Children 6 months - 5 years Around 3% of children will have at least 1 febrile convulsions in their lifetime Usually they occur early in a viral infection as the temperature rises rapidly

Question 63

When do alcohol withdrawal seizures tend to occur?

Answer 63

In pt with a history of alcohol excess who suddenly stop drinking -> 36 hours later

Question 64

Pathophysiology of alcohol withdrawal seizures?

Answer 64

Chronic alcohol consumption enhances GAB-mediated inhibition in the CNS and inhibits NMDA-type glutamate receptors Alcohol withdrawal is the opposite which means the enhanced GABAergic inhibition is suddenly decreased leading to a relative state of hyper excitability. On top of this the inhibition of NMDA receptors is stopped causes increased glutamate activity, an excitatory neurotransmitter This leads to hyperexcitability

Question 65

AED choice for myoclonic seizures?

Answer 65

Males - sodium valproate Females - levetiracetam

Question 66

AED choice for tonic or Atonic seizures?

Answer 66

Males - sodium valproate Females - lamotrigine

Question 67

Which AED can exacerbate absence seizures?

Answer 67

Carabamazapine

Question 68

What should you do to protect a person from injury during a seizure?

Answer 68

Cushioning their head, for example with a pillow. Removing glasses if they are wearing them. Removing harmful objects from nearby, or if this is not possible, moving the person away from immediate danger. Do not restrain them or put anything in their mouth When the seizure stops check their airway and place them in the recovery position Observe them until they have recovered Arrange emergency admission if first seizure

Question 69

How do you treat tonic-clonic seizures lasting >5 minutes or those who have had >3 seizures in an hour?

Answer 69

Buccal midazolam as first-line treatment in the community. Rectal diazepam can be used IV lorazepam if they have IV access already

Question 70

Moa of sodium valproate?

Answer 70

Increases the activity of GABA which increases the inhibitory activity

Question 71

Notable side effects of sodium valproate?

Answer 71

Teratogenic - neural tube defects and developmental delay Liver damage and hepatitis Hair loss Tremor Stomach pain, n&v, diarrhoea Reduce fertility Tremor Hyponatraemia Rare but serious: Suicidal ideation Acute pancreatitis Hepatotoxic Thrombocytopenia Hyperammonemic encephalopathy

Question 72

Risk of congenital defects if a woman doesnt and does take AEDs?

Answer 72

1-2% of newborns born to non-epileptic mothers have congenital defects This rises to 3-4% if the mother takes AEDs

Question 73

Best AEDs for pregnancy?

Answer 73

Lamotrigine Leveteracetam

Question 74

DVLA rules for driving after first unprovoked seizure?

Answer 74

6 months off if there is no relevant structural abnormalities on brain imaging and no definite epileptiform activity on the EEG 12 months if these conditions are not met

Question 75

DVLA rules for driving for patients with established epilepsy or multiple unprovoked seizures?

Answer 75

12 months off driving After vbeing seizure free for 5 years a ‘til 70 licence is usually restored

Question 76

DVLA rules on driving during withdrawal of epilepsy medication?

Answer 76

Should not drive whilst AEDs are being withdrawn and must wait until 6 months after the last dose

Question 77

AED in breast feeding?

Answer 77

All AEDs are generally considered safe for breast feeding except for barbiturates

Question 78

Drugs that lower the seizure threshold?

Answer 78

Beta lactam antibiotics Isoniazid Antimalarials Opioid analgesics NSAIDs Methylxantines e.g. theophylline Antipsychotics e.g. clozapine Antidepressants - SSRIs, TCAs, MAOIs Bupropion Anaesthetics

Question 79

Management of status epilepticus?

Answer 79

ABC PR diazepam or buccal midazolam if in community IV lorazepam if in hopsital Repeat IV lorazepam if after 5-10 mins If ongoing then start levetiracetam, phenytoin or sodium valproate If refractory status i..e 45 mins from onset, then induce GA or phenobarbital

Question 80

What is Todd’s paresis?

Answer 80

Weakness or paralysis in part of or all of the body after a seizure Common syndrome

Question 81

Psychosocial impact of epilepsy?

Answer 81

Stigma -> social isolation and discrimination Emotional impact e.g. distress, anxiety, concerns about safety educational and occupation challenges e.g. driving restrictions, job restrictions Impacts with ADLs which may impact QoL Family dynamics may change e.g. parents worrying about child’s safety May affect self-esteem and self image

Question 82

MOA of carbamazepine?

Answer 82

Inhibits voltage-sensitive sodium channels, stabilising neuronal membranes and modulating the release of presynaptic excitatory neurotransmitters

Question 83

MOA of phenytoin?

Answer 83

Inhibits voltage-sensitive sodium channels, stabilising neuronal membranes and modulating the release of presynaptic excitatory neurotransmitters

Question 84

MOA of lamotrigine?

Answer 84

Inhibits voltage-sensitive sodium channels, stabilising neuronal membranes and modulating the release of presynaptic excitatory neurotransmitters

Question 85

MOA of Ethosuximide?

Answer 85

Inhibits voltage-sensitive calcium channels, stabilising neuronal membranes and modulating the release of presynaptic excitatory neurotransmitters

Question 86

MOA of benzodiazepines?

Answer 86

Bind to benzodiazepine receptors in post-synaptic GABA chloride channels = increases GABA inhibitory effects = increased flow of Cl- into the cell = hyper polarisation and stabilisation of plasma membrane

Question 87

What blood test can distinguish between seizures and pseudo seizures?

Answer 87

Prolactin - raised after a true seizure

Question 88

Common adverse effects of phenytoin?

Answer 88

Acute: Dizziness, diplopia, nystagmus, slurred speech, ataxia Later - confusion and seizures Chronic: Gingival hyperplasia, coarsening of facial features, drowsiness, Megaloblastic anaemia, peripheral neuropathy, osteomalacia, lymphadenopathy, dyskinesia

Question 89

DVLA rules for bus/coach/lorry drivers after a seizure?

Answer 89

5 years off driving if it was only 1 seizure 10 years off driving if multiple seizures