Seizures

Question 1

What is a seizure?

Answer 1

A seizure is defined as “a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain”

Question 2

What is a focal seizure and its 2 types?

Answer 2

Focal (or partial) seizures refer to the electrical and clinical manifestations of seizures that arise from one portion of the brain.

• Simple focal (aka focal aware) seizures are those in which consciousness is preserved.
• Complex focal seizures (focal impaired awareness) include memory loss for the clinical event and impaired responsiveness at the time of the event.

Question 3

What are febrile seizures?

Answer 3

Seizures in infancy or childhood, usually occurring between 3 months and 5 years of age, associated with high fever but without evidence of intracranial infection or defined cause.

Diagnosis is clinical, with lumbar puncture performed to exclude meningitis or encephalitis if clinical suspicion exists.

Question 4

Seizure vs Syncope

Answer 4

Twitching and jerking are often seen with vasovagal or cardiac syncope, which can be differentiated from rhythmic jerking of all the limbs in tonic-clonic seizures. Postictal confusion is one of the key differentiating factors for seizures.
Syncope Prodrome = hot, dizzy, blurred vision, cold sweat, pallor.
May have motor, ocular and vocal features
May have incontinence

Question 5

What are generalised seizures?

Answer 5

Generalised seizures affect your whole brain. During most of these seizures the person
blacks out (loses consciousness).

Question 6

What are the 6 types of generalised seizures?

Answer 6

• absence
• tonic
• atonic
• clonic
• myoclonic
• tonic-clonic

Question 7

What is an absence seizure?

Answer 7

Absence (petit mal): often children, abrupt cessation of activity and responsiveness, stare into space, subtle movements eg lip smacking, blinking. No aura/postictal state, and lasting 5 to 10 seconds, several times per day.
May have decline in school performance. May be precipitated by hyperventilation and photic stimulation.

Question 8

What is a tonic seizure?

Answer 8

Tonic seizure: the tone is greatly increased: the body, arms, or legs become suddenly stiff or tense. A person may be aware or have only a small change in awareness during a tonic seizure. They usually happen during sleep

Question 9

What is an atonic seizure?

Answer 9

Atonic (drop) seizure: loss of muscle control, suddenly collapse. brief (only about 15 s)

Question 10

What is a clonic seizure?

Answer 10

Clonic: repeated or rhythmic jerking muscle movements, usually affect neck, face and arms.

Question 11

What is a myoclonic seizure?

Answer 11

Myoclonic: Brief shock-like jerks of a muscle or group of muscles in arms or legs. During a myoclonic seizure, the person is usually awake and able to think clearly.

Question 12

What is a tonic-clonic seizure?

Answer 12

A generalised tonic-clonic seizure (grand mal) classically involves loss of consciousness and a phasic tonic stiffening of the limbs (either symmetrically or asymmetrically), followed by repetitive clonic jerking. Most severe type. Loss of bladder control, tongue biting.

Question 13

What is epilepsy?

Answer 13

Disease of the brain defined by any of the following conditions:

1. At least 2 unprovoked (or reflex) seizures occurring more than 24 hours apart
2. One unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after 2 unprovoked seizures, occurring over the next 10 years
3. Diagnosis of an epilepsy syndrome.

Question 14

Risk factors for generalised seizures

Answer 14

family history
previous central nervous system (CNS) infection
head trauma
prior seizure events or suspected seizure events
history of substance use
premature birth
multiple or complicated febrile seizures

Question 15

Clinical features of generalised seizures

Answer 15

focal neurological deficits
premonitory sensation or experience (fear, epigastric sensation, déjà vu, jamais vu)
tongue biting
bladder and bowel involvement
temporary hemiparesis
temporary aphasia
fever, nuchal rigidity, altered mental status
stereotypical aura (always the same signs)

Question 16

What is Todd’s paresis?

Answer 16

Todd’s paresis (postictal paralysis) is temporary weakness of part of the body after a seizure. Typically lasts from one hour to thirty-six hours. Weakness on one side of the body is suggestive of focal-onset epilepsy, and generally indicates that the seizure focus is contralateral to the side of the deficit.
Attributed to the affected cortex being ‘exhausted’ or silenced due to increased inhibition

Question 17

Epilepsy - investigations

Answer 17

electroencephalogram (EEG) (spikes or sharp waves in one temporal lobe)
blood glucose (extreme hypoglycaemia or hyperglycaemia can cause seizures)
FBC (exclude infection)
electrolyte panel (Mg, Na, Ca)
toxicology screen
head CT (focal neuro deficit)
serum prolactin (2x baseline indicates GTCS)
serum creatine kinase (CK) (high in epilepsy, normal in non-epileptic events like syncope)
lumbar puncture (exclude infection)
MRI brain

Question 18

Managing an epileptic seizure

Answer 18

• Cushion their head with your hands or soft material.
• Removing harmful objects from nearby
• Do not restrain them or put anything in their mouth.
• When the seizure stops, check their airway and place them in the recovery position.
• Arrange emergency admission if it is their first seizure.

Question 19

Acute seizure management (epileptic seizure > 5 min or > 3 seizures in an hour)

Answer 19

• buccal midazolam OR rectal diazepam
  OR IV lorazepam if IV access established
• 2nd line: phenytoin
• supportive care (ABC): secure airway, deliver 100% oxygen by mask or nasal cannula, IV access, and correct hypotension, hyperthermia, glucose and electrolyte abnormalities, and potential thiamine deficiency

Question 20

Status Epilepticus

Answer 20

A life-threatening neurological condition defined as 5 or more minutes of either continuous seizure activity or repetitive seizures without regaining consciousness.

Question 21

Status Epilepticus - management

Answer 21

- as for acute management 
> 5 min, having given first dose of benzo
- repeat dose of IV lorazepam 
- adjunct IV phenytoin (+ cardiac monitor)
- thiamine if alcohol abuse suspected
if still not resolved 
- general anaesthetic
- ITU

Question 22

Rx for generalised tonic clonic seizures

Answer 22

1st line - sodium valproate

2nd line - lamotrigine

Question 23

What are psychogenic non-epileptic seizures (non-epileptic attack)?

Answer 23

• previously termed pseudoseizures, epileptic-like seizures but do not have characteristic electrical discharges
  patients may have a history of mental health problems or a personality disorder

Question 24

Epilepsy vs Non-epileptic attack

Answer 24

Epilepsy: synchronous, stiff/shaking, eyes can be opened, may have cyanosis, tongue biting, sterotypical aura, bladder + bowel, 2-3 min duration. Drowsy and sleepy after
(raised serum prolactin favours epilepsy)

Non-epileptic attack: asynchronous, contorted (back arching, pelvic thrusting), eyes resist being opened, tongue biting less likely, longer duration, fluctuates (slows down and increases). Can be tearful/stressed after

Question 25

Rx for partial seizures

Answer 25

1. Carbamazepine

2. lamotrigine

Question 26

What are the 3 P’s which influence entitlement to drive?

Answer 26

Uncomplicated faints: no alternative diagnosis and presence of 3 P’s

• provoking factors (such as pain or a medical procedure)
• prodrome (dizziness, blurring vision, sweating etc)
• postural limitation

Seizures and driving: generally patients cannot drive for 6 months following a seizure. For patients with established epilepsy they must be fit free for 12 months before being able to drive

Question 27

Rx for absence seizures

Answer 27

first line - ethosuximide or sodium valproate

Question 28

Neonatal seizures - Rx

Answer 28

1st line - Phenobarbitone
2nd line - Phenytoin, clonazepam

(lecture slides only mention phenytoin so for exam purpose maybe choose that?)

vigabatrin for infantile spasms