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NEUROLOGY > SEIZURES > Flashcards

SEIZURES Flashcards

1
Q

Common causes of blackouts?

A

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

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2
Q

What is syncope?

A

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

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3
Q

Most common cause of syncope?

A

Vasovagal syncope

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4
Q

Functions of vagus nerve?

A

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

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5
Q

Pathophysiology of Vasovagal syncope

A

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

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6
Q

Typical triggers of Vasovagal syncope?

A

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

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7
Q

Symptoms of Vasovagal syncope?

A

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

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8
Q

Who does orthostatic syncope occur in?

A

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

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9
Q

Characteristics of orthostatic syncope?

A

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

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10
Q

Characteristics of carotid sinus syncope?

A

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

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11
Q

What are reflex anoxic attacks?

A

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

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12
Q

Characteristics of cardiac syncope?

A

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

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13
Q

Causes of cardiac syncope?

A

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

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14
Q

Causes of respiratory syncope?

A

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

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15
Q

Primary CNS causes of syncope?

A

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

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16
Q

What are non-epileptic attack disorders?

A

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!

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17
Q

Characteristics of non-epileptic attack disorder?

A

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)

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18
Q

What is transient global amnesia?

A

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

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19
Q

What is POTS syndrome?

A

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!!

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20
Q

Seizure vs syncope features?

A

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

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21
Q

What is epilepsy?

A

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%)

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22
Q

Epidemiology of epilepsy?

A

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

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23
Q

Classification of seizures?

A

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)

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24
Q

Frontal lobe epilepsy symptoms?

A

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

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25
Q

Temporal lobe epilepsy symptoms?

A

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

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26
Q

Occipital lobe epilepsy symptoms?

A

Distortion of vision - floaters and flashers

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27
Q

Parietal lobe epilepsy symptoms?

A

Alteration of sensual sensation e.g. paraesthesia, pain

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28
Q

Types of motor generalised onset seizures?

A

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

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29
Q

Types of non-motor generalised onset seizures?

A

Typical
Atypical
Myoclonic
Eyelid myoclonia

(These are all types of absence seizures)

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30
Q

Epilepsy syndromes?

A

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

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31
Q

Juvenile myoclonic epilepsy?

A

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

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32
Q

Aetiology of epilepsy?

A

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

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33
Q

Channelopathies and genetic examples

A

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

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34
Q

Investigtaions for epilepsy?

A

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

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35
Q

Types of EEGs?

A

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

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36
Q

Triggers for seizures?

A

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

37
Q

Prn use of benzodiazepines

A

E.g. using short course around time of period

38
Q

AED for generalised tonic-clonic seizures?

A

Males - Sodium valproate
Females - lamotrigine or levetiracetam

39
Q

AED for absence seizures?

A

Ethosuximide

40
Q

AED for focal seizures?

A

Levetiracetam or lamotrigine

41
Q

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

A

Phenytoin, lamotrigine, carbamazepine

42
Q

Treatment options for epilepsy?

A

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

43
Q

What is SUDEP?

A

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

44
Q

What is convulsive status epilepticus?

A

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

45
Q

Risk factors for epilepsy?

A

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

46
Q

Complications of epilepsy?

A

SUDEP
Injuries
Depression and anxiety
Absence from school and work

47
Q

Prognosis of epilepsy?

A

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

48
Q

What are predictive factors for epilepsy?

A

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

49
Q

History for seizures?

A

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

50
Q

Physical exam for seizures?

A

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

51
Q

Investigtaions following a seizure?

A

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

52
Q

What are focal seizures?

A

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

53
Q

What are generalised seizures?

A

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

54
Q

What are focal to bilateral seizures?

A

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

55
Q

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

A

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

56
Q

What usually causes infantile spasms?

A

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

57
Q

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

A

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

58
Q

Prognosis of absence seizures?

A

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

59
Q

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

A

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

60
Q

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

A

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

61
Q

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

A

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

62
Q

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

A

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

63
Q

When do alcohol withdrawal seizures tend to occur?

A

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

64
Q

Pathophysiology of alcohol withdrawal seizures?

A

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

65
Q

AED choice for myoclonic seizures?

A

Males - sodium valproate
Females - levetiracetam

66
Q

AED choice for tonic or Atonic seizures?

A

Males - sodium valproate
Females - lamotrigine

67
Q

Which AED can exacerbate absence seizures?

A

Carabamazapine

68
Q

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

A

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

69
Q

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

A

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

70
Q

Moa of sodium valproate?

A

Increases the activity of GABA which increases the inhibitory activity

71
Q

Notable side effects of sodium valproate?

A

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

72
Q

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

A

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

73
Q

Best AEDs for pregnancy?

A

Lamotrigine
Leveteracetam

74
Q

DVLA rules for driving after first unprovoked seizure?

A

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

75
Q

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

A

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

76
Q

DVLA rules on driving during withdrawal of epilepsy medication?

A

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

77
Q

AED in breast feeding?

A

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

78
Q

Drugs that lower the seizure threshold?

A

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

79
Q

Management of status epilepticus?

A

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

80
Q

What is Todd’s paresis?

A

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

81
Q

Psychosocial impact of epilepsy?

A

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

82
Q

MOA of carbamazepine?

A

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

83
Q

MOA of phenytoin?

A

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

84
Q

MOA of lamotrigine?

A

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

85
Q

MOA of Ethosuximide?

A

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

86
Q

MOA of benzodiazepines?

A

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

87
Q

What blood test can distinguish between seizures and pseudo seizures?

A

Prolactin - raised after a true seizure

88
Q

Common adverse effects of phenytoin?

A

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

89
Q

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

A

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

NEUROLOGY (16 decks)

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