Week 5- epilepsy and non-epileptic attacks Flashcards
Diagnosing epilepsy is largely based on the history. What are the key points to cover when someone has had a suspected epileptic fit?
Onset- what were they doing? Any light headedness or symptoms suggestive of syncope? What did they look like- pallor, breathing, posture of limbs, head turning.
Event itself- type of movement- tonic clonic seizure or carpopedal spasms (when the body blows off too much CO2- the hands and feet go into flexion). Responsiveness and awareness throughout
Afterwards- speed of recovery, sleepiness/disorientation, deficits.
Cases: A 16-year-old female presents following a collapse. She was in the lunch queue at school when became sweaty and light-headed. She describes her vision ‘going dark and closing in’ and the next thing she was aware of friends were standing over her as she lay on the floor. Her friends describe that she became pale, collapsed and lost consciousness for 10 seconds. When she came round she was not confused. Clinical examination was normal.
This is a classic example of syncope. Her vision ‘closing in’ and sweatiness/light headedness are common symptoms. She wasn’t confused and recalled the events. She also recovered almost immediately.
Cases: Paramedics bring a 63-year-old man to A+E at 3am. His wife describes being suddenly awoken by her husband groaning loudly. She turned on the light and found him unresponsive. She describes his body as being rigid with extended arms and legs and his head turned to the right side for about 30 seconds. Following this there was jerking of all 4 limbs lasting 3 minutes. His colour was red and his eyes were open throughout. He had bitten the lateral aspect of his tongue and passed urine. He regained consciousness after 10 minutes but was disorientated for a further 30 minutes. On assessment in A+E he was drowsy, but neurological examination was otherwise normal.
This is a seizure.
However tongue biting and incontinence are not specific to epilepsy. These can also be seen in syncope.
Name some risk factors for developing epilepsy?
Premature birth Previous seizures Head injury Family history Drugs Alcohol
Would you examine a patient with suspected syncope?
Unlikely to in seizure clinic due to it showing little benefit. The history is much more important.
If a patient has been diagnosed with syncope, which examinations would be important?
Cardiovascular examination
Lying and standing BP.
Which drugs can exacerbate epilepsy?
Most/if not all drugs can exacerbate epilepsy.
However antibiotics are particularly bad e.g. penicillins, cephalosporins and quinone.
Tramadol also is very bad.
Anti-emetics
If an epileptic person was being treated for depression with antidepressants, however there epilepsy was getting worse, would you cease treatment?
No- depression is often the thing that kills epileptic patients not the epilepsy. So don’t hold off treatment for that in fear that you will make the epilepsy worse.
What is the one key test that should be done on a fallen patient (with suspected seizure)?
ECG.
What other investigations may be useful in suspected epilepsy?
MRI- best brain quality however some hospitals will do a CT acutely.
When should a patient get a CT scan when they are in A and E?
Clinical or radiological skull fracture Deteriorating GCS Focal signs Head injury with seizure Failure to achieve 15/15 GCS 4 hours after arrival Suggestion of other pathology.
When does an EEG become important?
It helps to classify epilepsy.
What are the likely differential diagnosis’s of epilepsy?
Syncope
Non-epileptic attack disorder
Panic attacks/hyperventilation attacks
Sleep phenomena
(also could be TIA/stroke, migraine, hypoglycaemia, parasomnias, paroxysmal movement disorders, cataplexy, periodic paralysis)
What are the laws on driving in epilepsy?
1st seizure- can’t drive for 6months after that. If you are a HGV driver- 5 years.
If epilepsy- can’t drive a car for 1 year.
What does SUDEP stand for?
Sudden unexplained death in epilepsy.
What are the risk factors for SUDEP?
The risk factors for this are poor drug compliance, drugs and alcohol, predominantly nocturnal seizures without a bed partner.
What actually is epilepsy?
A tendency to have recurrent, usually spontaneous, epileptic seizures.
What are epileptic seizures?
An abnormal discharge of neuronal (electrical) activity in the brain, interrupting normal brain activity.
If it happens in the part of the brain that controls motor- you get motor symptoms. Same for sensory.
How long does an epileptic seizure last?
Usually seconds to minutes.
What causes this abnormal discharge of electricity in the brain?
Unsure- could be due to an imbalance of cell numbers. Could be due to neurones not binding well together. Could be down to an imbalance between excitation and inhibition.
What is focalised epilepsy?
Something is structurally wrong in a specific area in the brain. As a consequence of that, the neurone in the area are sensitive and it can lead to seizures.
What is generalised epilepsy?
If the focal epilepsy hits a cortical network- it will propagate around the brain and give you a generalised seizure. This is whole brain involvement.
NOTE- very easy to confuse epilepsy and seizures. Epilepsy is the tendency to have multiple seizures. However focal and generalised seizures are abnormal brain activity coming from a focal or generalised lesion.
:)
what is the old name for focal seizures?
Partial seizures.
How are focal seizures further classified?
Simple or complex
Simple- consciousness sustained
Complex- consciousness lost.
What motor symptoms may you see with seizures?
Rhythmic jerking Head turning Head and eye deviation Posturing Vocalisations Automatisms (excessive tapping, lip smacking, chewing etc)
What sensory modalities may be affected with seizures?
Somatosensory, olfactory, gustatory, visual, auditory.
What sorts of generalised seizures can you get?
Absence Myotonic Tonic Atonic Tonic Clonic
What is the criteria for it being a generalised epilepsy?
Most have a genetic predisposition
Present in childhood (never presents after the age of 30),
Generalised spike wave abnormalities on EEG
What is the treatment of choice for primary generalised epilepsy?
Sodium valproate.
What is the downside of sodium valproate? What is the alternative
Its teratogenic.
Lamotrigine is the alternative.
What is juvenile myoclonic epilepsy? What provokes it?
An example of a primary generalised epilepsy.
Often provoked by sleep deprivation, alcohol and flashing lights. Seen in freshers.
Treatment of focal onset epilepsy?
Carbamazepine or lamotrigine (sodium valproate also works but not first choice due to side effects).
Which channels in the neuron do carbamazepine and lamotrigine inhibit?
The sodium channels. They stop propagation of the AP to the synaptic terminal.
What is sodium valproate role on GABA systems?
Enhances GABA synthesis.
What is a downside of carbamazepine?
It can make generalised seizures worse. Therefore have to make sure its a focal seizure.
What is the downside of lamotrigine?
Takes about 2-3 months before reaching its target dose.
What do some epilepsy drugs do to ladies that you need to be aware of?
They alter the hepatic enzymes meaning the oral contraceptive pill may not be as effective. These include carbamazepine, oxcarbazepine, phenobarbital, phenytoin, primidone, topiramate.
Also morning after pill not as effective.
Which hormone is most effected by the altered hepatic enzymes on some epileptic drugs?
Progesterone. The progesterone only pill won’t work and neither will the implant.
What is status epilepticus?
Recurring epileptic seizures without full recovery of consciousness. Continuous seizure activity lasting more than 30 minutes.
How would you treat status epilepticus?
Treat the cause. Could be due to metabolic disturbances, hyponatraemia, pyridoxine deficiency, infections, head trauma.
Give them ABCDE management and a controlled anticonvulsant. If they don’t respond to two doses of benzodiazepines they won’t respond at all. Try a different anti-convulsant.
What is a functional disorder?
Trauma causes symptoms, it propagates. The medical professionals then treat the symptoms but not the initial trauma. For the patient to improve- you have to tackle the initial trauma.
In functional disorders, does the patient have control over their attacks?
No- patient has no control.
What sorts of trauma can cause functional disorders?
Traumatic events Physical/sexual abuse Other stress Anxiety Depression
How would you diagnose functional disorders?
History
Linguistic analysis
Outpatient EEF and video with provocation
Longterm video EEG monitoring.
What is de ja vu?
Abnormal discharge from the temporal lobe (where memory occurs). Abnormal discharge = an abnormal memory- familiar but not quite right.
What sort of language is an epileptic likely to use?
Vague language because of the abnormal discharge. In non-epileptic attacks- likely to use descriptive terms.
What would happen if you treat someone with non-epileptic attacks with anti-convulsants?
You make the attacks worse.
If the seizure has bilateral involvement, for it to be epilepsy the patient must lose consciousness, t or f?
True.
Give examples of somatosensory auras? where is the issue?
Numbness, tingling, electrical shocks, thermal sensations, pain.
Parietal lobe
Give examples of visual auras? where is the issue?
Simple shapes, static, flashing lights, colour changes.
Occipital lobe, occasionally temporal.
Give examples of auditory auras?
Changes in hearing
Tinnitus etc.
Auditory cortex affected.
where do autonomic auras arise from?
Temporal lobe (insula)
Describe a functional attack?
Attacks with prominent motor activity.
Episodes of collapse with no movement
Abreactive attacks- gasping, hyperventilation, fear
Often prolonged.
How would you treat a functional attack?
Withdrawal of any anti-epileptic drugs and removal of the diagnosis of epilepsy.
Counselling for traumatic events
Treatment of associated anxiety and depression
CBT?
Describe a non-epileptic attack?
Hypermotor
Very prominent, co-ordinated movement
Can also present with sudden loss of tone and power.
Sometimes can present as cataplexy (however cataplexy always also has narcolepsy).
