Seizures Flashcards
Differentiating NES from status epilepticus
Eyes and mouth closed and resistant to opening
Status - convulsions last < 90 seconds with a limp and unresponsive interval between episodes
Vasovagal syncope - how can attacks be prevented when warning signs are felt?
Ways of increasing venous return:
- Sit down
- Valsalva manouevres
- Cross legs
- Up on toes
- Lie down and raise legs (if more severe)
Drug prophylaxis: beta-blockers, fluoxetine, midodrine
TLE on investigations
a) Interictal EEG
b) Video EEG
c) MRI (gross)
d) Diffusion-weighted MRI (T2 signal)
e) PET-FDG
f) Histology (e.g. after temporal lobe resection)
a) Abnormalities in anterior temporal regions (focal slow or sharp wave activity, or spikes)
b) Typical automatisms etc.
c) Hippocampal atrophy
d) Increase in T2 weighted signal intensity in hippocampal region
e) Reduced glucose metabolism
f) Histologically - hippocampal sclerosis
Typical epileptic seizure history
a) Triggers
b) Prodrome
c) Witness account
d) Duration
e) Post-ictal
f) Other phenomena/clinical features
g) PMHx
h) FHx
i) DHx
j) SHx
a) Triggers
- often none
- sleep deprivation
- not taking AED
- drugs that lower seizure threshold (eg. TCA, tramadol)
- alcohol, substance misuse
- stress, head injury, infection, other inter-current illness
b) Prodrome: May have an aura
c) Witness account: Stiffening, jerking of limbs, vocalization or grunting, cyanosis, eyes wide open
d) Duration: 1-2 minutes
e) Post-ictal phase:
- Profound confusion for about 20 minutes, ‘I came round with ambulance crew around me’, Agitated, non-verbal, no recognition of family
f) Other phenomena:
- Lateral tongue bite,
- Urinary incontinence,
- Injury (posterior dislocation of shoulder or head injury)
g) PMHx (Risk factors for seizures):
- Febrile sz, head injury, learning difficulties, autism
h) FHx: epilepsy/ seizures
i) DHx: Tramadol
j) SHx: Alcohol XS or recreational drug us
Syncope: typical history
a) Triggers
b) Prodrome
c) Witness account
d) Duration
e) Post-ictal
f) Other phenomena/clinical features
g) PMHx
h) FHx
i) DHx
j) SHx
a) Triggers: Situational / Postural (vasovagal/ postural)
Exertion, or no trigger (cardiac syncope)
b) Prodrome: Typical fainting prodrome
c) Witness: May have jerks especially if maintained upright posture, Pallor
d) Duration: Brief
e) Post ictal phase: Rapid recovery, ‘I came round on the floor with my mum shaking me’
f) Other events: Previous syncopal events
g) PMHx: Cardiac history, autonomic
h) DHx: Hypotensive medications
i) SHx: usually none
j) FHx: Family history of sudden cardiac death
NES: typical history
a) Triggers
b) Prodrome
c) Witness account
d) Duration
e) Post-ictal
f) Other phenomena/clinical features
g) PMHx
h) FHx
i) DHx
j) SHx
a) Circumstances: May be situational
b) Prodrome: Subjective seizure symptoms are often discussed sparingly or by negation: ‘I don’t feel anything’
c) Witness: Eyes and mouth often closed, may be partially responsive, Often wax and wane, May be emotional, continuous shaking (longer than 90 seconds)
d) Duration: Often very prolonged (Think of PNES in cases of apparent status epilepticus)
e) Post-ictal phase: Variable, but almost always tired / washed out
f) Often variable non-stereotyped events
g) PMHx: Psychological comorbidity, Other functional illness (headaches, IBS, CFS)
h) FHx: Evidence of psychosocial deprivation, family trauma, family history of psychological morbidity
i) DHx: Antidepressants, other psychotropic medications
j) SHx: Psychosocial deprivation, domestic abuse, asylum seekers, ex-soldiers, early childhood trauma
Generalised vs focal seizures.
a) Causes
b) Epidemiology
c) Clinical features
d) Investigations/findings
e) Management
a) Focal.
- More common in older age group (onset > 30)
- Causes: stroke, head injury, tumour, dementia, infection
- Features: aura (eg. odd sensation, nausea, abnormal taste or smell, déjà vu), automatisms (eg. lip smacking, picking at clothes), focal motor activity during seizure (note: focal seizures may have secondary generalisation)
- Ix: CT head (?structural lesion)
- Rx: carbamazepine, lamotrigine
b) Generalised.
- More common in childhood/adolescence (onset < 30)
- Causes: IDIOPATHIC, syndromes, learning disability, family history
- Features: GTC/absence/myoclonic, early-morning seizures, triggered by lack of sleep/alcohol, tongue biting, incontinence, no focal signs, less commonly have aura
- Ix: EEG - 3Hz spike and wave pattern
- Management: valproate*, lamotrigine
*beware in young women = teratogen!
Physical signs that may indicate cause of epilepsy
- Café-au-lait spots (neurofibromatosis)
- Port-wine stain (Sturge-Weber syndrome)
- Adenoma sebaceum (tuberous sclerosis)
SUDEP - define
Sudden, unexpected, unwitnessed, non-traumatic, non-drowning death of a person with epilepsy
- +/- seizure (excluding status)
- in whom post-mortem examination does not reveal a structural or toxicological cause of death
Investigations for suspected epilepsy.
a) Types
b) When should an EEG be performed?
c) If standard EEG non-conclusive, consider…?
d) Can also request that family do what?
Bedside
- Urine - toxicology
- ECG - very important! - exclude cardiac cause (eg. syncope, arrhythmias)*
- May also require 24-hour ECG or implantable loop recorders to detect any arrhythmias
Bloods.
- FBC, CRP, U+Es, LFTs, TFTs, calcium, glucose
Imaging.
- CT/MRI - ?focal - suspect structural cause
EEG.
- After 2nd seizure usually (occasionally after 1st)
- Only if suspected epilepsy from history
- Use photic stimulation/ hyperventilation as required
- If non-conclusive, consider sleep EEG, ambulatory EEG or long-term video EEG
Hand-held video recording.
- Request that family record the seizure if diagnosis is uncertain
- Must obtain patient consent first
Epilepsy management: non-drug
MDT.
- GP review every 3 - 12 months (annual review minimum)
- Epilepsy specialist nurses
- PT/ OT
- Social worker
- Psychologist
Education and self-management
- DVLA - seizure free for 12 months generally
- Importance of compliance
- Avoid triggers (eg. alcohol, sleep deprivation)
Epilepsy management: AEDs
a) Mono/combination therapy?
b) Initiation of therapy
c) Continuation/ monitoring
d) Withdrawal
a) Monotherapy preferred; if fail on one drug, consider switching to another
- Combination therapy considered for resistant epilepsy
b) - By a specialist
- Generally after 2nd unprovoked seizure (earlier if structural abnormality, neurological deficit or deemed high risk of recurrent seizure)
c) - Blood tests not routinely indicated (only if worried about complications, or adjusting dose)
- Pregnancy testing in young women - ensure on contraception
d) - Only consider if seizure free for > 2 years
- Gradually reduce
- Beware risk of withdrawal seizures (especially if withdrawing benzos)
Choosing AED.
a) 1st line in GTC (alternatives); 2nd line drugs
b) 1st line in absences (2 options)
c) JME - 1st line? (which drugs can worsen JME?)
d) 1st line in focal epilepsy; 2nd line
a) - 1st line: Valproate; lamotrigine or carbamazepine
- 2nd line: levetiracetam, topiramate, clobazam
b) Valproate or ethosuximide
c) Valproate (lamotrigine/carbamazepine may worsen JME)
d) 1st line: carbamazepine or lamotrigine.
- 2nd line: levetiracetam, oxcarbazepine, valproate
Drug-resistant epilepsy.
a) Define
b) Reasons
c) Management
a) Failure to become seizure-free after trials of two tolerated and appropriate AEDs
b) - Misdiagnosis (may have NEAD)
c) - Referral to specialist
- Consider alternative AEDs
- Consider vagal nerve stimulation or deep-brain stimulation
- Consider surgery:
e. g. anteromedial temporal resection (for TLE), corpus callosotomy (for GTC)
