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PR3136 > Treatment of Epilepsy l > Flashcards

Treatment of Epilepsy l Flashcards

1
Q

Epilepsy related mortality risks (4)

A
  1. Sudden Unexplained Death in Epilepsy (SUDEP)
  2. Status epilepticus
  3. Unintentional injuries
    eg drowning, head injuries & burns
  4. Suicide
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2
Q

Risk factors for SUDEP (3)

A
  1. Presence & frequency of tonic-clonic seizures
  2. Nocturnal seizures
  3. Lack of seizure freedom
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3
Q

Seizure definition

A
  • a transient occurrence of signs & symptoms due to abnormal excessive or synchronous neuronal activity in brain
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4
Q

Epilepsy definition (3)

A
  1. At least 2 unprovoked seizures occurring >24h apart
  2. 1 unprovoked seizure & probability of further seizures similar to the general recurrence risk after 2 unprovoked seizures, occurring over the next 10 years (60%)
  3. Diagnosis of epilepsy syndrome
  • it is a brain disorder characterised by an enduring predisposition to generate epileptic seizures
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5
Q

Provoked seizures risk factors (5)

A
  1. Metabolic
  2. Toxic
    eg illicit drug use, TCA, alcohol, benzodiazepines withdrawal)
  3. Infections
  4. Inflammations
  5. Structural
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6
Q

Pathophysiology (2)

A
  1. Hyperexcitability
    - enhanced predisposition of a neuron to depolarise
  2. Hypersynchronisation
    - intrinsic re-organisation of local circuits
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7
Q

Epilepsy risk factors (6)

A
  1. Genetic
  2. Structural
    - traumatic brain injury, tumours
  3. Metabolic
  4. Infections
  5. Immune
  6. Unknown
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8
Q

ILAE classification based on 3 key features

A
  1. Site seizures begin in
    - focal vs generalised
  2. Level of awareness during the seizures
    - aware vs impaired
  3. Other factors
    - motor or non-motor onset
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9
Q

Simple partial seizures

A

Focal onset seizures without dyscognitive featues

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10
Q

Complex partial seizures

A

Focal onset seizures with dyscognitive features

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11
Q

Epileptic syndromes

A
  • epileptic disorder characterised by a cluster of signs & symptoms
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12
Q

Focal onset seizures unique feature

A
  • dejavu (aura)
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13
Q

Generalised onset unique feature (Tonic Clonic)

A

Tonic - rigidity

Clonic - jerking

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14
Q

Generalised onset unique features (Absence/Petit Mal)

A
  • basic lapse in awareness that begins and ends abruptly
  • persistant staring
  • mistaken for complex partial seizures
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15
Q

Absence/Petit Mal seizures vs Complex Partial Seizures (4)

A
  1. Not preceded by aura
  2. Last seconds rather than minutes
  3. Begin frequently & end abruptly
  4. Produce characteristic EEG patten (3Hz spike waves)
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16
Q

Generalised onset unique features (Atonic)

A
  • classic drop attack (astatic seizures)
  • sudden lost in postural tone
  • collapse to ground like a rag doll
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17
Q

Diagnosis of epilepsy (6)

A
  1. Thorough history taking
    - description of seizures
    - any aura, preservation of consciousness & post-ictal state
  2. Neurologic examination
  3. Concomitant medical conditions
  4. Electroencephalography (EEG)
  5. MRI with gadolinium
  6. Biochemistry/toxicology
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18
Q

Differential diagnosis (4)

A
  1. Syncope (fainting)
  2. Transient ischemic attacks
  3. Migraine
  4. Psychogenic non-epileptic seizures
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19
Q

Electroencephalography (EEG)

A
  • diagnosis of seizures or epilepsy is considered if there are epileptiform discharges on EEG
  • a normal EEG DOES NOT exclude possibility of epilepsy
20
Q

Electroencephalography (EEG) limitations

A
  1. Not all epileptic patients have abnormal EEG
    - 50% chance of showing epileptiform activity in a first awake EEG
    - 80-90% sensitivity with repeated awake-sleep EEG
  2. EEG can be abnormal in normal persons
21
Q

Situations when MRI with gadolinium is done (2)

A
  • adult patients who present with 1st seizure

- patients with focal neurological deficits/suggestions of focal onset seizures

22
Q

Biochemistry/toxicology

A
  • helps to rule out electrolyte abnormalities (eg hyponatremia, hypomagnesemia)
  • serum prolactin (not routinely used)
  • creatine kinase (raised after GTC)
23
Q

Risk of seizure occurrence

A 
Risk of second occurrence
- 30% within next 5 years, higher in first 2 years
- higher in the presence of :
   ~ epileptiform EEG
   ~ prior brain insult
   ~ structural abnomality
   ~ nocturnal seizures
24
Q

Risk of recurrent seizures after 2 unprovoked seizures

A

70% at 4 years

25
Q

Benefit of initiating treatment after 1st episode of seizures

A

Reduce the risk of 2nd seizures

26
Q

Limitations of initiating treatment after 1st episode of seizures (2)

A
  1. No effect on long-term prognosis

2. No evidence of higher risk of death, injuries or status epilepticus in patients with deferred treatment

27
Q

Factors to consider when initiating treatment (4)

A
  1. Recurrence risk
    - 30% after 1 episode
    - 70% after 2 episodes
  2. Potential seizure morbidity
  3. Risk of treatment
    eg ADR
  4. Personal circumstances
    eg compliance to medication
28
Q

Treatment goals for epilepsy (3)

A
  1. Absence of epileptic seizures (symptoms)
  2. Absence of anti-epileptic drug SE
  3. Attainment of optimal quality of life

2/3 of patients are able to achieve seizure-freedom

29
Q

Types of treatments for epilepsy

A
  1. Pharmacological ASM (mainstay)
    - monotherapy preferred
  2. Non-pharmacological
    - Keto diet
    - Vagus Nerve Stimulation
    - Responsive Neurostimulator System (RNS)
    - Epilepsy surgery
    - Seizure diary
30
Q

Factors influencing ASM choice (6)

A
  1. Seizure type
  2. Epilepsy syndrome
  3. Co-medication
  4. Co-morbidity
  5. Patient’s preference
  6. National/Institutional
    - costs
    - guidelines
31
Q

Rapid titration required

A

Cannot use lamotrigine & topiramate (req slow titration)

32
Q

Epilepsy with migraine

A

Use topiramate

33
Q

Epilepsy with depression/anxiety

A

Caution when using levetiracetam

34
Q

Women with child bearing potential

A

Avoid valproate

Consider levetiracetam & lamotrigine

35
Q

Monotherapy ASM treatment benefits (6)

A
  1. Lower incidence of ADR
  2. Absence of DI
  3. Reduced risk of birth defects
  4. Lower cost
  5. Easier to correlate response & ADR
  6. Better adherence
36
Q

Dosing features of ASM initiation (1st line)

A
  1. Start low
  2. If seizure continue but no SE
    - increase dose of ASM
  3. If seizures continue despite max tolerated dose or intolerable to SE at low doses
    - review diagnosis & drug appropriateness
    - check adherence
    - change ASM
  4. If patient tolerates 1st and 2nd line agent but with suboptimal responses
    - combination ASM therapy
37
Q

Drug resistant epilepsy

A
  • failure of adequate trials of 2 tolerated ASM

- regardless monotherapy or in combination

38
Q

Keto diet

A
  • for patients that cannot tolerate or have not responded well to ASM treatment
  • comprises of low carb high fat diet to induce ketosis
  • used mainly in children to prevent seizures
  • challenging to adhere long term
39
Q

Epilepsy surgery

A
  • not usually advocated early

- advocated early therapy for specific epileptic syndromes

40
Q

Patient education for epilepsy (4)

A
  • avoid preventable seizure triggers
  • counsel on ADR & potential DDI
  • activities (unintentional injuries from seizures)
    eg swimming
  • community resources available to support them
41
Q

Seizures triggers (9)

A
  1. Hyperventilation
  2. Photostimulation
  3. Physical & emotional stress
  4. Sleep deprivation
  5. Electrolyte imbalance
  6. Sensory stimuli
  7. Infection
  8. Hormonal changes
    eg pregnancy, menses, puberty
  9. Drugs
    eg TCA, anticholinergics, bupropion
42
Q

First aid for seizures (7)

A
  1. Ease the person to the floor
  2. Turn the person gently to 1 side to help breathing
  3. Clear the area around the person to prevent injury
  4. Put something soft/flat under heard
  5. Remove eyeglasses
  6. Loosen ties or anything around the neck
  7. Time the seizures (if >5min call 995)
43
Q

Things not to do on patients with seizures (4)

A
  1. Do not hold the person down
  2. Do not put anything in the person’s mouth
  3. Do not try to give mouth-mouth breathing
    - even if look pale (hypoxia after tonic)
  4. Do not offer food/water until patient is fully alert
44
Q

Focal onset

A

1 hemisphere affected

45
Q

Generalised onset

A

Both hemispheres affected

46
Q

Ion channels (4)

A

Depolarise :

  1. Na+
    - influx
  2. Ca2+

Hyperpolarise :

  1. K+
    - efflux
  2. Cl-

PR3136 (19 decks)

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