Syncope vs Cardiac vs Epilepsy

Question 1

What is the difference between epilepsy and seizures

Answer 1

Seizures - individual occurences of abnormal electrical activity in the brain
-many possible causes

Epilepsy - neurological disorder that causes repeated seizure activity

Having 1 seizure increases your risk of getting further seizures

Question 2

Pathophysiology and presentation of seizures

Answer 2

Net increase in excitatory activity (decreased inhibitory)

Question 3

Causes of syncope

Answer 3

Syncope - results from brain hypoperfusion

Reflex

• vasovagal
• cough/straining
• carotid sinus syndrome

Orthostatic positional - volume depletion
-diuretics, BP meds, autonomic neuropathy

Cardiac

• structural conditions affecting cardiac output
• arrythmias

Question 4

Seizure markers

Answer 4

Before

• dejavu, jamaisvu
• olfactory aura

Lasts for minutes

• May lose consciousness
• Bitten tongue
• Head turning to one side
• Abnormal posturing
• Eyes open in epilepsy
• Urinary incontinence
• myoclonic jerks, tonic clonic mv

Post ictal confusion
Amnesia of seizure

Increased EEG activity
Low short term mortality

Question 5

Syncope markers

Answer 5

Before

• positional - prolonged standing, from supine to upright
• reflex - situational
• cardiac symptoms and SNS activation arise due to resulting brain hypoperfusion (palpitations, sweating, chest pain, SOB, lightheaded)

Lasts for U1min

• pallor, sweating
• some myoclonic jerks after LOC

Rapid recovery, no confusion

Reduced EEG waves
High short term mortality
AED ineffective

Question 6

Possible seizure mimics

Answer 6

Peripheral neuropathy
Dementia, PD
Stroke
MS
Non organic

Within 7 days of acute brain insult
-stroke, hemorrhage, TBI, encephalitis => AED can be used short term

Question 7

Investigations, diagnosis and management

Answer 7

Bloods - FBC, LFT, RFT, U&E, Blood glucose

• heavy alcohol use
• hypoglycemia

Imaging
-CT and MRI brain - structural abnormalities (malignancy, infection, other causes)

Electrophysiology

• EEG within 6wks of seizure (20mins recording)
• ECG monitoring

Diagnosis - made by specialist based on clinical reasoning
-epilepsy - 2+ with 24hrs+ between episodes

Management - depends on individual circumstances
-Address underlying cause if there is one - most common being sleep deprivation
-Consider impacts of seizure on work, driving
Generalised - valproate
Focal - lamotrigine or carbemazepine

Question 8

When would you be considered seizure free

Answer 8

No seizures for 10years

No AEDs for 5+ years

Question 9

Things to consider with AEDs

Answer 9

Allergies to AEDs are common
Cross reactivity also v common

Severe skin reactions - SJS, TEN, EM
AED hypersensitivity syndrome => multiorgan failure and skin rash

Stop drug = go to A&E

OD - Ataxia, double vision, confusion, sleepy, N+V
May be due to 
-accidental OD
-drug interaction
-changed formulations

Question 10

Driving rules and epilepsy

Answer 10

Inform DVLA about a medical condition that affects your driving - risk a $1000 fine

After 1 epileptic attack - major/minor/auras

• stop driving for 6 months
• stop driving for 1 year if there is a causative factor that increases future risk

After this period => apply for 3 year license
Seizure free for 5 years => apply for prolonged license

Medication changes => stop driving for 6 months

Question 11

Safety at home

Answer 11

Avoid baths where possible => showers
-ensure someone is around if this is not possible, don’t lock the bathroom door

Take care around open flames, ladders

Question 12

AEDs and

• contraception
• pregnancy
• breastfeeding

Answer 12

AEDs reduce COCP efficacy
Progesterone only pill => Progresterone injectable
IUDs are effective

AVOID VALPROATE WHERE POSSIBLE
High dose folate (5mg) => reduce neural tube defects, spontaneous abortion

IMPORTANT NOT TO STOP AEDs in GENERALISED => high risk of sudden death

Breastfeeding is safe with AEDs - including valproate

Question 13

Surgical management of epilepsy refractory to medication

Answer 13

Resective surgery - removal of lesion/lobe
Functional neurosurgery - aim to change brain function to improve epilepsy
-hemispherotomy - disconnect 2 hemispheres
-callosotomy - disconnect corpus callosum
-vagal nerve stimulation - adjust electrical activity within brain
-DBS

Question 14

Status epilepticus

-management of generalised SE

Answer 14

SE - no termination of seizure after 5mins
-can lead to neuronal death

A-E assessment
-Pabrinex before IV glucose if alcohol use suspected
1st line - BZ
2nd line - phenytoin/leviteracetam/valproate
3rd line - anaesthetist intubation

Question 15

Non epileptic attack disorder symptoms and management

Answer 15

No abnormal EEG changes, AEDs not effective
Eyes often closed
No tongue biting
Gradual onset
Can last for many minutes
Fluctuating evolution of seizure

Referral to neuropsych
-CBT, psych assessment