Epilepsy Flashcards by Eilidh Middleton

Define epilepsy

Epilepsy is a chronic neurological disorder characterised by recurrent seizures

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Define a seizure

Symptom not a condition

Seizures are transient episodes of abnormal synchronous, hyperexcited neuronal activity in the brain

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Epilepsy most commonly occurs in isolation although certain conditions have an association with epilepsy.

Name a condition that is associated with epilepsy?

Cerebral palsy

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Define a primary seizure

Unprovoked seizure

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Define a secondary seizure

Clear precipitate leading to the seizures e.g. stroke, head injury, alcohol, severe infection, medication

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GABAergic characteristically:

a) Inhibitory
b) Excitatory

a) Inhibitory

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GABAergic signals are characterised by which type of receptors

Gamma-aminobutyric acid (GABA)

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Glutamatergic characteristically:

a) Inhibitory
b) Excitatory

b) Excitatory

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Glutamatergic signals are characterised by which type of receptors

Glutamate receptors

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GABA is the main ____ neurotransmitter

a) Inhibitory
b) Excitatory

GABA is the main Inhibitory neurotransmitter

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What type of receptors are GABA receptors and what ion does it influence?

Ligand-gated ion channel that allows flow of chloride ions.

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Glutamate is the main ____ neurotransmitter

a) Inhibitory
b) Excitatory

b) Excitatory

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What type of receptors are glutamate receptors?

Multiple types e.g. G coupled receptors, ion channels etc

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What happens during the tonic phase of seizure

Prolonged depolarisation with action potential

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What happens during the clonic phase of seizure

Period of depolarisation followed by hyperpolarisation

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There are four stages of a seizure.

Name these stages

Prodromal
Early-ictal
Ictal
Post-ictal

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Describe the prodromal phase of a seizure

Describes a period of subjective feeling or sensation a set of non-specific symptoms that occurs before the onset of a seizure

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Describe the early ictal phase of a seizure

This phase is characterised by aura

An aura is a sensory disturbance e.g. visual, olfactory etc, that precede an attack, usually just by a few minutes.

Not all patients will experience an aura – it is more suggestive of focal seizures

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Describe the ictal phase of a seizure

Refers to the seizure

Highly variable depending on seizure type.

It may be associated with urinary incontinence and tongue biting, and normally lasts 1-2 minutes

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Describe the post-ictal phase of a seizure

This is the recovery period, when the seizure has abated
During the period of recovery there may be altered consciousness, confusion, memory loss, drowsiness, general malaise, feeling irritable and/or depressed
This period may last hours
It typically does not occur if they retained consciousness during the ictal phase

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What are the two key clinical features of a seizure which is able to distinguish it from other differential diagnosis?

Tongue biting
Experience incontinence of urine during the seizure

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Seizure can be classified based on 3 key features.

Name these three features

The area where the seizures begin in the brain
Level of awareness they have during a seizure
Features e.g., motor features, non-motor features

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What are the characteristics of a focal seizure

Seizures which arise from a specific area, on one hemisphere – typically the temporal lobe
Level of awareness varies
They may experience either motor or non-motor features

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In focal seizures the level of awareness varies depending on what type of focal seizure it is.

What is the name given to the two types of level of awareness

Primary focal aware

Primary focal impaired awareness

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Define the term "primary focal aware"

**Primary focal aware** refers to when they are aware that the seizure is happening

Define the term "primary focal impaired awareness"

**Primary focal impaired awareness** refers to when they are **not** aware the seizure is occurring. These types of seizures are most commonly originating at the temporal lobe

Name some of the motor features associated with a focal seizure

Jacksonian march, lip-smacking, blinking

Name some of the non-motor features associated with a focal seizure

déjà vu Hallucination Doing things on autopilot

What is a focal to bilateral convulsive seizure

A focal seizure that has spread to affect a wider network of neurons involving both hemispheres and thus eveolves to a generalised seizure, which is typically tonic-clonic

What is the first line antiepileptic pharmaceutical therapy in managing focal seizures

Carbamazepine or lamotrigine

What is the second line antiepileptic pharmaceutical therapy in managing focal seizures

Sodium valproate or levetiracetam

What are the characteristics of a generalised seizure

* Involve networks on both hemispheres * Generalised seizures will always occur with no awareness as all loss consciousness

What is the first line antiepileptic pharmaceutical therapy in managing generalised seizures

Sodium valproate

What is the second line antiepileptic pharmaceutical therapy in managing generalised seizures

Lamotrigine or Carbamazepine

Name some of the types of generalised seizures

* **Tonic-Clonic**: Stiffening and shaking * **Tonic**: Generalised muscle stiffening * **Clonic**: Rhythmic muscle jerking * **Atonic**: drop seizure * **Myotonic**: brief, shock-like jerking * **Absence**: staring blankly into space and returns back to normal after 10-20 secs

What are the key characteristics of a generalised tonic clonic seizure

* Characterised by a loss of consciousness and tonic (muscle tensing/stiffening) and clonic (muscle jerking) – typically in that order * May be associated with tongue biting, incontinence, groaning and irregular breathing * Prolonged post-ictal phase

What is the first line antiepileptic pharmaceutical therapy in managing generalised tonic clonic seizures

Sodium Valproate

What is the second line antiepileptic pharmaceutical therapy in managing generalised tonic clonic seizures

Lamotrigine or Carbamazepine

What are the key characteristics of a generalised atonic seizure

* Characterised by brief lapses in muscle tone * Lasting \< 3 mins * Typically begin in childhood

Atonic seizures may be indicative of what syndrome

Lennox-Gastaut syndrome

Name the three types of generalised seizures that typically occur in childhood

Atonic seizure Myoclonic seizure Absence seizure

What is the **first** line antiepileptic pharmaceutical therapy in managing **generalised** **atonic** seizures

Sodium Valproate

What is the **second** line antiepileptic pharmaceutical therapy in managing **generalised** **atonic** seizures

Lamotrigine

What are the key characteristics of a generalised myoclonic seizure

* Characterised by sudden brief muscle contractions – almost like a sudden “jump” * These contractions can be of a limb, trunk or face * Patient usually remains conscious during these seizures

Myoclonic seizures typically happen in children as part of what syndrome

Juvenile myoclonic epilepsy

What is the **first** line antiepileptic pharmaceutical therapy in managing **generalised myoclonic** seizures

Sodium valproate

What is the **second** line antiepileptic pharmaceutical therapy in managing **generalised** **myoclonic** seizures

Lamotrigine, levetiracetam or topiramate

What drug should **not** be used in the managing of myoclonic seizures as it can worsen the seizures

Carbamazepine

What are the key characteristics of a generalised absence seizure

* Patients, often children, becomes blank, stares into space briefly, \< 10 seconds, and then abruptly returns to normal * During the episode they are unaware of their surroundings and won’t respond

What is the **first** line antiepileptic pharmaceutical therapy in managing **generalised absence** seizures

Sodium valproate or ethosuximide

What drug should **not** be used in the managing of absence seizures as it can worsen the seizures

Carbamazepine

What are the two key investigations that help support a diagnosis of epilepsy (as it is a clinical diagnosis)

Neuroimaging (usually MRI) Electroencephalogram (EEG)

What does an electroencephalogram (EEG) assess?

A non-invasive method of assessing and recording the electrical activity of the brain It is not used as a sole diagnostic tool and cannot be used to exclude epilepsy, particularly if the clinical presentation supports a diagnosis of epilepsy.

If MRI is not available or suitable what is the second line neuroimaging technique for assessing epilepsy

Following a single seizure, patients are typically referred to a “first fit” clinic for further assessment. What are the assessments involved in this visit

The clinic involves formal assessment (history and examination) and organisation of relevant investigations (e.g. MRI, EEG) to determine whether the seizure is likely to represent epilepsy.

What is the aim of anti-epileptic drug treatment?

The aim of treatment is to be seizure free on the minimum anti-epileptic medications Ideally they should be on monotherapy with a single anti-epileptic drug

As a general rule sodium valproate is used first-line for patients with what kind of seizures A) Generalised B) Focal

A) Generalised

As a general rule carbamazepine is used first-line for patients with what kind of seizures A) Generalised B) Focal

B) Focal

Ethosuximide is the 1st line therapy drug of choice for what kind of seizures

Absence seizures

Carbamazepine may worsen what kind of seizures.

Myoclonic and absence

In what patient group should sodium valproate use be avoided (or use should be carefully monitored)

Women of wearing bearing age as it is highly teratogenic

What is the mechanism of action of sodium valproate

Increases GABA activity

Name some of the adverse effects associated with sodium valproate

Highly teratogenic Increase in appetite and weight gain Alopecia: causes hair loss and when regrown it is curly Drug induced hepatitis Pancreatitis Thrombocytopenia i.e. low platelet count

What is the mechanism of action of carbamazepine

Sodium channel antagonist – binds to sodium channels, preventing sodium influx. Leading to an increase in their refractory period

Name some of the adverse effects of carbamazepine

Agranulocytosis - increased risk of infections Syndrome of inappropriate ADH secretion (SIADH) p450 enzyme inducer – commonly causes drug interactions

What is the mechanism of action of lamotrigine

Sodium channel blocker – preventing sodium influx in the presynaptic terminal

Name some of the adverse effects of lamotrigine

Stevens-Johnson syndrome Leukopenia - low WCC

What is the mechanism of action of levetiracetam

Acts by binding to SV2A, interfering with synaptic vesicles and inhibiting neurotransmitter release

What is levetiracetam used (in regards to epilepsy control)

Used second-line drug choice in myotonic seizures

Name some of the adverse effects of levetiracetam

? teratogenic CNS disturbance Neuropsychiatric disturbance

What is the mechanism of action of phenytoin

Sodium channel antagonist – binds to sodium channels increasing their refractory period

When is phenytoin used (in the control of epilepsy)

No longer used first-line due to side-effect profile However does give excellent seizure control in difficult cases (only used under the guidance of specialists)

Name some of the adverse effects of phenytoin

P450 enzyme inducer Folate and vit D deficiency Megaloblastic anaemia (folate deficiency) Osteomalacia (vitamin D deficiency) Gum hypertrophy Cerebellar atrophy

What is the mechanism of action of ethosuximide

Calcium channel blocker – inhibits the T-type calcium channels in the presynaptic terminal. Calcium influx drives neurotransmitter release

When is ethosuximide used (in epilepsy control)

Used first line in absence seizures

Name some of the adverse effects of ethosuximide

Night terrors Rashes

Generally patients cannot drive for how long following a seizure

6 months

For patients with established epilepsy they must be fit free for how long before being able to drive

12 months

Name some of the complications of epilepsy

* Status epilepticus * Depression * Suicide * Sudden unexpected death in epilepsy (SUDEP) - thought to be due to excessive electrical activity causing a cardiac arrhythmia and death.

Define Status epilepticus

* Defined as continuous seizure activity, which has failed to self-terminate. * Medical emergency

Name the two criteria which can be used to diagnosis status epilepticus

* A single epileptic seizures lasting \> 30 minutes * A run of epileptic seizures (≥2) without regaining consciousness between episodes

What is the 1st line therapy for status epilepticus

Benzodiazepine

In what form is the Benzodiazepine given in status epilepticus

* IV lorazepam 4mg * Rectal diazepam 10mg\* * Buccal midazolam 10mg\* \* if you do not have access

If the seizures are still ongoing (in status epilepticus) despite the initial dose of Benzodiazepine. What is the 2nd line treatment

2nd dose of Benzodiazepine

If the seizures are still ongoing (in status epilepticus) despite the 1st and 2nd dose of Benzodiazepine. What is the 3rd line treatment

IV loading of anti-epileptic medication e.g. phenytoin (alternatives are sodium valproate or levetiracetam) ***NOTE****: When giving phenytoin ensure ECG monitoring as it can lead to significant arrhythmias*

Epilepsy Flashcards

(85 cards)