Epilepsy

Question 1

What is this describing?

A recurrent tendency to spontaneous, intermittent, abnormal electrical activity in part of the brain.

Answer 1

Epilepsy

Question 2

How does epilepsy manifest?

Answer 2

As seizures that are unprovoked

Question 3

What are the key elements of an epileptic seizure?

Answer 3

1. Preceding prodrome - change in mood/behaviour
2. Aura implies focal seizure (often temporal)
3. Post-ictal state - headache, confusion, myalgia, weakness (Todd’s paralysis)

Question 4

What are the causes of epilepsy?

Answer 4

1. 2/3 are idiopathic
2. Space-occupying lesion, stroke, structural brain causes
3. Infection and autoimmune disease

Question 5

What are the risk factors for epilepsy?

Answer 5

1. Young patient/congenital (family history)

2. Febrile convulsions in childhood, motor/developmental delay

Question 6

What provoking causes of seizures should be ruled out before diagnosing epilepsy?

Answer 6

Trauma, stroke, tumour, haemorrhage, raised ICP, alcohol withdrawal, BZD withdrawal, hypoxia, electrolyte disturbances, metabolic disturbances, liver disease, meningitis, encephalitis, febrile seizure, TCA, cocaine.

Question 7

What investigations should be done for suspected epilepsy?

Answer 7

1. Glucose, FBC, U&Es, bone profile, serum drug levels of AED, urine drug screen.
2. ECG
3. Consider EEG - spike and wave discharges
4. Consider CT/MRI
5. Home video may help diagnosis

Question 8

What does the DVLA say about driving ban with one isolated seizure vs epileptic seizures?

Answer 8

1. 1 seizure - 6 months car, 5 years lorry

2. Diagnosed epilepsy - 12 months car, 10 years lorry

Question 9

What advise must you give to patients about dangers with epilepsy?

Answer 9

Swimming, driving, baths, heights.

Question 10

What important counselling should you give for a new epilepsy diagnosis?

Answer 10

Employment, sport, insurance, conception, sudden unexpected death in epilepsy (very low risk, only generalised tonic-clonic seizures)

Question 11

What advise should be given about contraception to someone with a new epilepsy diagnosis?

Answer 11

1. Enzyme-inducing AEDs make POP unreliable
2. Oestrogen containing medications lower lamotrigine levels, higher doses required to control seizures.
3. No problem with IM Depo Provera and progesterone IUS.

Question 12

What is the criteria for starting someone on an anti-epileptic drug?

Answer 12

Must have confirmed diagnosis:

Two or more seizures occurring 24 or more hours apart. Or one seizure with high risk of recurrence.

Question 13

What medication is used for focal (partial) seizures?

Answer 13

Carbamazepine or lamotrigine

Question 14

What medication is used for tonic-clonic seizures?

Answer 14

Sodium valproate or lamotrigine or levetiracetam

Question 15

What medication is used for absence and myoclonic seizures?

Answer 15

Sodium valproate or lamotrigine

Question 16

What are the common side effects of anti-epileptic drugs?

Answer 16

CNS sedation, unsteadiness, diplopia, weight changes, nausea, diarrhoea, memory and cognitive issues.

Question 17

What should you do if someone develops depression whilst on an antiepileptic drug?

Answer 17

Treat if indicated, SSRIs NOT contraindicated.

Question 18

What should you consider when putting someone one an anti-epileptic drugs?

Answer 18

1. Bone health - calcium and vitamin D

2. Slowly build up dose until good control, only withdraw one drug when established on the second of swapping.

Question 19

What is there a risk of in pregnancy if on anti-epileptic drugs?

Answer 19

5% risk of foetal abnormalities (take folic acid)

Question 20

Which anti-epileptic drugs should be avoided in pregnancy and which are preferred?

Answer 20

1. Avoid sodium valproate and polytherapy

2. Lamotrigine preferred (also not harmful to infants in breastmilk)

Question 21

When should you immediately stop an anti-epileptic drug and why?

Answer 21

1. If a rash develops

2. Potentially Stevens-Johnson Syndrome