Strokes and seizures

Question 1

Is norman neurological activity synchronous or asynchronus?

Answer 1

asynchronus

Question 2

what do the symptoms of a seizure depend on?

Answer 2

where it takes place within the brain (what area of the brain is affected)

Question 3

broca’s and wernikes ? what are they responsible for?

Answer 3

production and understanding of speech respectively

Question 4

what are the 2 categories of seizures

Answer 4

focal or generalised (part of the brain - pt will be aware of the seizure

or all of the brain - pt will be unaware of their surroundings)

Question 5

Symptoms of tonic seizure

Answer 5

muscles become stiff and rigid

Question 6

symptoms of atonic seizure

Answer 6

lack of tone to muscles can make you collapse to the floor

Question 7

myoclonic

Answer 7

can make you jerk

Question 8

tonic-clonic

Answer 8

classic seizures

Question 9

what are the phases of a seizure

Answer 9

prodrome (can last for hours or days) - pt may feel light headed or irritable
- pt has a feeling seizure is on its way

Question 10

what is aura ?

Answer 10

just before the seizure - headaches or changes in vision/sound

Question 11

what is the ictal phase?

Answer 11

seizure phase -
motor changes and changes in awareness
some patients might not have aural phase at all

Question 12

what is the post ictal phase

Answer 12

pt is sleepy, confused, headache
phase of cognital depression

Question 13

are seizures always due to epilepsy?

Answer 13

NO! Not all seizures are due to epilepsy

Question 14

what is the definition of epilepsy

Answer 14

2 or more unprovoked seizures

Question 15

what is a provoked seizure?

Answer 15

hypoxia/hypoglycaemia, drugs/drug withdrawal can change neurone excitability, infection of the brain, structural change (trauma/tumour), vascular eg: stroke

Question 16

what are some of the causes of epilepsy (chronic background causes)

Answer 16

structural, genetic, metabolic, autoimmune
idopathic (no underlying cause - unexplained)

Question 17

what kinds of tests are done for a person with a seizure?

Answer 17

clinical (blood test or metabolic causes)
brain imaging + EEG
anti-epileptic medications
surgery (eg for structural epilepsy)

Question 18

what are some examples of medications for epilepsy?

Answer 18

carbamazepine
levetiracetam
phenytoin (causes gingival overgrowth)
pregablin

Question 19

what kinds of questions would you ask a patient with MH of epiepsy?

Answer 19

1. what type of seizure do they have?
   - ask them describe what happens to them (might need a friend or relative to describe it/ might have it in a care plan
2. how often do they have the seizures?
   - are they still having frequent seizures? when was their last one?
   - are they well controlled with medications? (are they in remission- not having seizures as often)
3. how long do the seizures usually last?
   - few minutes
   - prolonged >5mins
4. how are their seizures usually managed
   - care plans? medications to take if they feel a seizure coming on
   - some patients will have medication to take to terminate a seizure? do they need some one to give this to them? or do you need to understand it
5. how long do their post-ictal phase usually last?
   - what symptoms do they have in that time
   - what is their typical recovery time

Question 20

how do you manage a tonic - clonic seizure?
- pt will go very stiff (tonic phase)
- pt will breathe out with a very large groan
- pt will have symmetrical rhymical muscle contractions throughout their for body for a few mins (bite tongue, drool, potentially incontenence)

Answer 20

STOP!
Safety - lower the dental chair BUT don’t hold them down, try and protect their airway but do not try put fingers in their mouth, encourage a head tilt chin left to help open the airway but don’t brace the pt as will hurt their neck
Time - start the stopwatch - a seizure becomes prolonged at 5mins - at this point 80% of prolonged seizure will become status epilepticus (last around 30mins)
- IF PT HAS PROLONGED SEIZURE WHICH IS NOT KNOW TO HAVE PROLONGED THEN CALL AMBULANCE!!
Oxygen - Pt stops breathing in tonic phase - so they will become hypoxic (blue/cyanosed) and will struggle to keep pulse oximeter on them
- SO ADMINISTER 15/L of oxygen via a non-rebreather face mask
Plan- does pt have a care plan - if so follow it! if pt does not have history of epilepsy call an ambulance! if something outside of their normal - CALL AMBULANCE

Question 21

how long should you monitor a patient for after a seizure?

Answer 21

1 hour to rule out serial seizures (3 or more in an hour)

Question 22

what should you do for the post-ictal phase?

Answer 22

Recovery postition
ABCDE
Wean oxygen slowly
Discharge

Question 23

what is a stroke?

Answer 23

acute - the blood supply to the brain is interrupted and the brain tissue dies

Question 24

what are the 2 categories of stroke?

Answer 24

ischaemic (caused by some blockage to blood flow) - usually 85% are ischaemic and typically caused a blood clot or thrombosis

and hemorrhagic (bleed in the artery that supplied the brain)

Question 25

what is a TIA?

Answer 25

transient ischaemic attack
- temporary (called a mini stroke)
- the symptoms are the same as a stroke but last for 24 hrs
- same risk factors of a stroke

Question 26

what are symptoms of a subarachnoid haemorrhage?

Answer 26

thundering headache
stiff neck
patients can feel quite sick
not tolerating bright lights

Question 27

what should you do if you suspect a subarachnoide haemorrhage?

Answer 27

CALL 999

Question 28

what are the risk factors for a stroke?

Answer 28

similar to that of CVD
- hypertension
- high cholesterol
- atherosclerosis
- diabetes
- smoking and drinking
- arterial fibrillation
- Patent foramen ovale - hole in the heart between left and right atrium

Question 29

what is FAST?

Answer 29

Face - is it drooping? can they smile? is one eye drooping?
Arm - is there loss of sensation in one arm? can they raise both arms?
speech - is there speech affected? is there disarthria (difficulting in enuciating words) are they repeating a particular word? do they understand the instructions given?
Time - critical - call 999

while waiting for ambulance do ABCDE and manage

Question 30

what is the diagnosis and management of stroke?

Answer 30

Neurology exam -
CT head - brain imaging for evidence of ischaemic or haemorrhagic
Thrombolysis (clot dissolving drugs)/ thrombectomy (surgically removing the clot) = NEED TO BE DONE WITHIN 4 HRS of the symptoms starting !!!
lumbar puncture (take a small sample of fluid from spinal fluid and detect for red blood cells)/angiogram
neurosurgery (fill an aneurysm with coils to fill it up)

Question 31

What is the aftermath of a stroke?

Answer 31

1. Investigate the reason why the stroke took place - assess pt blood pressure, cholesterol, ECG (to check for atrial fibrillation), image the carotid artery to look for stenosis
2. Pharmacological level - antiplatelets or anticoagulants/ statin/anti-hypertensive
3. Rehabilitation - multidisciplinary team (physiotherapy to regain strength), occupational therapy, speech and language therapy, nutrition, psychology

Question 32

What are the dental considerations for a patient who has had a stroke?

Answer 32

1. Defer tx for 6m
2. Accessibility to dental practice (wheelchair? / travelling?) given info more slowly to process info
3. Difficulty swallowing/chewing - increased risk of aspiration , OHI is v important + may be struggling to
4. Risk of aspiration
5. Drug interactions + side effects
6. Potential sensitivity to sedatives/ opioids
7. Limit LA + avoid adrenaline in gingival retraction