1
Q
In how many main ways can electrical discharges start in epilepsy?
A
Two ways.
2
Q
What are the two ways electrical discharges can start in epilepsy?
A
- Bilateral, synchronous, symmetrical (both hemispheres involved simultaneously → Generalised)
- In one hemisphere only (→ Focal)
3
Q
What type of seizure occurs when both hemispheres are involved simultaneously?
A
Generalised seizure
4
Q
What type of seizure occurs when electrical discharge starts in one hemisphere only?
A
Focal seizure
5
Q
Are all clinical events due to epilepsy electrical in origin?
A
No, not all clinical events have an electrical origin.
6
Q
Is typical loss of function common in epilepsy?
A
No, typical loss of function is less common in epilepsy
7
Q
What are the two main categories of transient symptoms?
A
- Loss of consciousness or awareness
- Focal neurological dysfunction (cortical or non-cortical)
8
Q
What are common causes of transient loss of consciousness or awareness?
A
Concussion, syncope, cardiac causes, TIA, hypoglycaemia, hyponatremia, liver failure, psychiatric.
9
Q
What are key features of syncope?
A
Typical syncopal symptoms, no sense of impending loss of consciousness, may have associated tonic-clonic activity, incontinence, and a post-ictal phase.
10
Q
What are causes of focal neurological dysfunction (cortical or non-cortical)?
A
Trauma, migraine, BPPV, TIA, hypoglycaemia, GIT symptoms, multiple sclerosis, psychiatric.
11
Q
What are the key clinical features of focal neurological dysfunction?
A
Stereotypic description, only one type of event, followed by B and/or C, classical types, and absence of features suggestive of differential diagnoses.
12
Q
Can any person have a seizure?
A
Yes, due to the electrical nature of the brain, anyone can have a seizure.
13
Q
Give examples of seizures that are unlikely to recur.
A
Seizures caused by alcohol withdrawal or an electrical shock.
14
Q
When is a patient considered to have epilepsy?
A
When they have spontaneous seizures with a risk of recurrence.
15
Q
What is the inter-ictal period?
A
The period between seizures.
16
Q
What is the typical state of most patients during the inter-ictal period?
A
Most patients are normal in the inter-ictal period.
17
Q
What is the origin of a generalised seizure?
A
It originates simultaneously in the cortex, thalami, and reticular formation.
18
Q
What are common types of generalised seizures?
A
Absence seizures and generalised tonic-clonic seizures (GTCS).
19
Q
Will an aura occur in a seizure that is generalised from onset?
A
No, there will be no aura.
20
Q
Where does a focal seizure begin?
A
It begins in a specific area (e.g., area A) and can spread to adjacent areas.
21
Q
How does a focal seizure impair consciousness?
A
It spreads from the initial focus to other regions (e.g., area B), which can impair consciousness.
22
Q
Can a focal seizure evolve into a generalised seizure?
A
Yes, it can spread deeper, reach the reticular formation, and then bounce back to the cortex, causing bilateral synchronous seizure activity.
23
Q
Is an aura associated with focal or generalised seizures?
A
An aura occurs in focal onset seizures.
24
Q
What is the old term “petit mal” used for?
A
It refers to absence seizures (a type of generalised seizure).
25
What is the old term “grand mal” used for?
It refers to generalised tonic-clonic seizures (GTCS)
26
How are seizures classified in modern terminology?
They are classified as either focal onset or generalised onset.
27
What does a focal onset seizure mean?
The seizure starts in a specific, localised area of the brain.
28
What does a generalised onset seizure mean?
The seizure begins simultaneously in both hemispheres, involving cortex, thalami, and reticular formation.
29
What key aspects should be included in the history of a seizure patient?
Symptoms and signs, patient’s description, videos of the event, witness accounts, and associated neurological and/or medical findings.
30
What is the difference between seizures and epilepsy?
• Seizures: Manifestations of abnormal hypersynchronous discharges of cortical neurons.
• Epilepsy: A condition characterized by recurrent, unprovoked seizures.
31
What determines the clinical signs and symptoms of a seizure?
The location of the epileptic discharges in the cortex and the extent and pattern of their spread in the brain.
32
Why can patients often not describe whether seizures are generalised or focal at onset?
Because they lose awareness and cannot recall whether the seizure started focally or with bilateral tonic-clonic features.
33
What are generalised seizures mostly caused by?
They are mostly idiopathic, familial, or genetic.
34
What types of seizures fall under generalised seizures?
Absence seizures, other types (e.g., myoclonic, tonic, atonic), and generalised tonic-clonic seizures.
35
What are focal seizures mostly caused by?
They are mostly due to another disease (structural, metabolic, or acquired brain abnormality)
36
What is the typical sequence of focal seizure progression?
Aura → Blank (impaired awareness/blank stare) → Bilateral tonic-clonic seizure.
37
What does the “blank” phase in focal seizures indicate?
It indicates the patient is not aware of the seizure or has a blank stare.
38
At what age do generalised tonic-clonic seizures (GTCS) usually start compared to focal onset with bilateral spread?
GTCS: onset younger; Focal with bilateral spread: any age, especially older onset.
39
Do GTCS have an aura or warning?
No, GTCS have no aura or warning. Focal seizures may have a preceding aura or blank stare.
40
What does the interictal EEG show in GTCS vs focal onset with bilateral spread?
GTCS: generalised interictal pattern;
Focal: focal spikes
41
What does the ictal EEG show in GTCS vs focal onset with bilateral spread?
GTCS: generalised pattern; Focal: focal discharges that spread bilaterally.
42
What are the imaging findings in GTCS vs focal onset with bilateral spread?
GTCS: usually no lesions on imaging;
Focal: may reveal a focal lesion.
43
At what age do absence seizures usually occur?
Typically in children aged 5–15 years
44
How long do absence seizures last compared to focal seizures with impaired awareness?
Absence: very short (seconds);
Focal impaired awareness: may last minutes.
45
What types of automatisms are seen in absence vs focal seizures?
Absence: simple automatisms;
Focal: may have complex automatisms.
46
Are postictal effects present in absence seizures vs focal seizures with impaired awareness?
Absence: no postictal effects;
Focal: postictal confusion or headache may occur.
47
What does the EEG show in absence vs focal seizures with impaired awareness?
Absence: generalised pattern;
Focal: focal discharges.
48
How does drug responsiveness differ in absence vs focal seizures?
Absence: controlled with some specific drugs;
Focal: may require many drugs.
49
What is the definition of epilepsy?
Epilepsy is a disease of the brain defined by:
• At least 2 unprovoked seizures occurring more than 24 hours apart, OR
• 1 unprovoked seizure with >60% probability of further seizures over the next 10 years.
50
Is epilepsy diagnosed as a single event or a syndrome?
Epilepsy is diagnosed as a syndrome
51
What are the main categories of seizure classification?
Generalised and focal.
52
What seizure syndromes fall under generalised epilepsy?
• Childhood absence epilepsy
• Juvenile myoclonic epilepsy
• Generalised tonic-clonic alone
• Other generalised epilepsies
53
What are the subtypes of focal epilepsy?
• Unifocal
• Multifocal
• Hemispheric
54
What are the structural causes of epilepsy, and what seizure type do they usually produce?
Causes: tumour, trauma, stroke, AVM, scars → Usually focal seizures.
55
What are the genetic causes of epilepsy, and what seizure type do they usually produce?
Causes: hereditary or new mutations → Usually generalised seizures.
56
What are infectious causes of epilepsy, and what seizure type do they usually produce?
Causes: meningitis, encephalitis, abscess, cysticercosis → Usually focal seizures.
57
What are metabolic causes of epilepsy, and what seizure type do they usually produce?
Causes: porphyria, MERRF (Myoclonic Epilepsy with Ragged Red Fibers) → Usually generalised seizures.
58
What are immune causes of epilepsy, and what seizure types do they usually produce?
Cause: autoimmune encephalitis → Can cause generalised or focal seizures.
59
What does “unknown cause” mean in epilepsy classification?
It means the underlying cause is not identified.
60
How can a person “grow out” of epilepsy?
• If they have a recognised syndrome that is self-limited (age-dependent).
• If their seizures have stopped and not recurred.
61
When is epilepsy considered to be resolved?
Epilepsy is resolved when:
• The individual had an age-dependent self-limited epilepsy syndrome and is now past that age, OR
• The person has been seizure-free for 10 years, with no seizure medication for the last 5 years.
62
What does “self-limited epilepsy syndrome” mean?
It refers to epilepsy syndromes that only occur within a certain age range and stop spontaneously as the child grows older.
63
What is the definition of status epilepticus?
A single seizure lasting more than 5 minutes, or two or more seizures within a 5-minute period without the person returning to normal between them.
64
Can status epilepticus be generalised or focal?
Yes, it can be either generalised or focal
65
What are the two main clinical forms of status epilepticus?
Convulsive status epilepticus and non-convulsive status epilepticus.
66
Clinical Case 1
A 60-year-old woman complains of uncontrolled deviation of her head to one side, eyes facing in the same direction, rapid blinking. She remains aware during these episodes. Each lasts about a minute, is distressing, and has recurred several times. No past medical history, no constitutional symptoms, HIV negative.
⸻
Q1. Is this a seizure? Or what else should be considered? The following may be considered, EXCEPT:
• a) Myoclonus
• b) Dystonia
• c) Functional disorder
• d) Chorea
Answer: a) Myoclonus
Explanation:
• The described event (sustained head/eye deviation + blinking + preserved awareness) is more consistent with focal seizure or a movement disorder.
• Differentials include dystonia (sustained muscle contractions), functional (psychogenic) disorder, or chorea (irregular, jerky movements).
• Myoclonus involves brief, shock-like jerks — this does not fit the sustained and patterned movements described.
67
Clinical Case 1
A 60-year-old woman complains of uncontrolled deviation of her head to one side, eyes facing in the same direction, rapid blinking. She remains aware during these episodes. Each lasts about a minute, is distressing, and has recurred several times. No past medical history, no constitutional symptoms, HIV negative.
Q2. Is this a seizure? How would you support your clinical proposal?
• a) CT brain
• b) MRI brain scan
• c) EEG
• d) SPECT (isotope scan)
Answer: c) EEG
Explanation:
• An EEG is the best test to confirm epileptic activity by recording abnormal electrical discharges.
• MRI or CT may be needed later to look for structural lesions, but they do not directly prove seizure activity.
• SPECT may show changes during seizures but is not first-line.
68
Clinical Case 1
A 60-year-old woman complains of uncontrolled deviation of her head to one side, eyes facing in the same direction, rapid blinking. She remains aware during these episodes. Each lasts about a minute, is distressing, and has recurred several times. No past medical history, no constitutional symptoms, HIV negative.
Q3. If you have support that this is a seizure, what would be your next step?
• a) CT brain with contrast
• b) MRI brain scan without contrast
• c) Reassure the patient that this is benign
• d) Give IV benzodiazepine immediately
Answer: b) MRI brain scan without contrast
Explanation:
• In a new-onset focal seizure in an older patient, structural causes must be excluded → MRI brain (preferred over CT for better resolution).
• Reassurance is inappropriate because the episodes are not benign.
• IV benzodiazepines are only indicated in acute prolonged seizures/status epilepticus, not in brief recurrent episodes.
69
Clinical case 2
- A 3o yo woman presents with odd behavioural episodes.
- She has no knowledge of these events; just knows that there are times when she's found she's wet
herself and is a bit confused what has happened
- Her mother describes that she doesn't respond to any communication and just rocks her body (see
video)
- There was one occasion where this event was followed by bilateral tonic and then clonic jerking
Which features in this case support a diagnosis of seizure?
Features supporting a seizure diagnosis include:
• Stereotyped episodes (each attack is almost the same)
• Post-event confusion (observed by mother)
• Incontinence of urine during the episode
• Rarely, premonitory sensations like epigastric rising (auras)
These features are typical of epileptic seizures, especially focal seizures with impaired awareness
70
Clinical case 2
- A 3o yo woman presents with odd behavioural episodes.
- She has no knowledge of these events; just knows that there are times when she's found she's wet
herself and is a bit confused what has happened
- Her mother describes that she doesn't respond to any communication and just rocks her body (see
video)
- There was one occasion where this event was followed by bilateral tonic and then clonic jerking
Which feature is NOT reliable in supporting a seizure diagnosis in this patient?
The patient sometimes complains of a strange epigastric sensation. Because it occurs inconsistently (“only sometimes”), it is less useful diagnostically compared to stereotypy, post-ictal confusion, or incontinence, which are more robust indicators of seizure activity.
71
Clinical case 2
- A 3o yo woman presents with odd behavioural episodes.
- She has no knowledge of these events; just knows that there are times when she's found she's wet
herself and is a bit confused what has happened
- Her mother describes that she doesn't respond to any communication and just rocks her body (see
video)
- There was one occasion where this event was followed by bilateral tonic and then clonic jerking
How does the EEG help in this case? The EEG is normal
The EEG is normal, which does not rule out seizures. EEGs can be normal between seizures (interictally), especially in focal epilepsy. Diagnosis is mainly clinical, supported by history and eyewitness accounts
72
Clinical case 2
- A 3o yo woman presents with odd behavioural episodes.
- She has no knowledge of these events; just knows that there are times when she's found she's wet
herself and is a bit confused what has happened
- Her mother describes that she doesn't respond to any communication and just rocks her body (see
video)
- There was one occasion where this event was followed by bilateral tonic and then clonic jerking
Given the clinical picture and EEG, what is the correct diagnosis/management?
This is a seizure disorder (epilepsy). Features like stereotypy, post-event confusion, and occasional progression to bilateral tonic-clonic activity confirm seizure activity. Normal EEG does not exclude epilepsy. Management should focus on neurology referral for seizure management, not urology.
73
Clinical case 2
- A 3o yo woman presents with odd behavioural episodes.
- She has no knowledge of these events; just knows that there are times when she's found she's wet
herself and is a bit confused what has happened
- Her mother describes that she doesn't respond to any communication and just rocks her body (see
video)
- There was one occasion where this event was followed by bilateral tonic and then clonic jerking
Why is referral to urology not appropriate in this case?
Incontinence occurs during the seizure as part of the ictal event, not due to a primary urinary problem. Treating her for incontinence alone would miss the underlying epileptic disorder, which requires neurological evaluation and possible anti-seizure medication.
74
Clinical case 2
- A 3o yo woman presents with odd behavioural episodes.
- She has no knowledge of these events; just knows that there are times when she's found she's wet
herself and is a bit confused what has happened
- Her mother describes that she doesn't respond to any communication and just rocks her body (see
video)
- There was one occasion where this event was followed by bilateral tonic and then clonic jerking
What type of seizure is suggested by this case?
The episodes suggest focal impaired awareness seizures (previously called complex partial seizures), sometimes with secondary generalization (the single tonic-clonic episode). Features like unresponsiveness, rocking movements, and amnesia support this classification.
75
Clinical case 3
- This young man has no knowledge of his events.
- His family are worried as he suffered a severe traumatic episode as a child
- He has multiple events, especially when stressed
- After the event he does not appear confused and carries on with what he was doing
- He has never had a bilateral tonic-clinic event.
Which features support a functional (PNES) diagnosis in this patient?
Features supporting PNES include:
• Bizarre or unusual movements during episodes
• Multiple episodes triggered by stress
• History of post-traumatic stress or prior trauma
• Lack of response to antiepileptic drugs
These are consistent with psychogenic origin rather than epileptic activity.
76
Clinical case 3
- This young man has no knowledge of his events.
- His family are worried as he suffered a severe traumatic episode as a child
- He has multiple events, especially when stressed
- After the event he does not appear confused and carries on with what he was doing
- He has never had a bilateral tonic-clinic event.
Which feature does not support PNES?
“Each attack is almost the same (stereotypic)” does not support PNES. Stereotypy—episodes being nearly identical—is a hallmark of epileptic seizures, not functional events, which tend to vary in presentation.
77
Clinical case 3
- This young man has no knowledge of his events.
- His family are worried as he suffered a severe traumatic episode as a child
- He has multiple events, especially when stressed
- After the event he does not appear confused and carries on with what he was doing
- He has never had a bilateral tonic-clinic event.
Which features support a seizure diagnosis in general?
Features supporting seizures include:
• Stereotypic episodes (almost identical each time)
• Patients may have amnesia for events even if they appear aware
• Focal seizures may occur without ever progressing to bilateral tonic-clonic seizures
These point toward a neurological origin (epilepsy) rather than a psychogenic cause.
78
Clinical case 3
- This young man has no knowledge of his events.
- His family are worried as he suffered a severe traumatic episode as a child
- He has multiple events, especially when stressed
- After the event he does not appear confused and carries on with what he was doing
- He has never had a bilateral tonic-clinic event.
Which feature does not support a seizure diagnosis in this case?
“No postictal confusion excludes seizures” is incorrect. Many seizures, especially focal seizures without secondary generalization, may not cause noticeable postictal confusion. Lack of postictal confusion does not rule out epilepsy.
79
What key historical factors help differentiate PNES from epilepsy in this patient?
Important differentiators include:
• Stress-related triggers
• Variable or bizarre movements
• Lack of postictal confusion
• History of trauma or PTSD
• Poor response to antiepileptic therapy
In contrast, epilepsy typically has stereotyped events, postictal confusion, and predictable progression.
80
What is the main management approach for PNES?
Management focuses on:
• Psychological interventions (cognitive-behavioral therapy, trauma-focused therapy)
• Education of patient and family about PNES
• Avoiding unnecessary antiepileptic medications
Neurology involvement is helpful to confirm the diagnosis and exclude coexisting epilepsy.
81
Clinical case 4
- This man has had 5 seizures like this (video) during the past 2 hours. Each seizure lasts 3 minutes.
- He is currently a bit confused.
- He is not known with epilepsy but drinks a bit
- He had a head injury many years ago.
- The following are reasonable, EXCEPT:
o this should be treated as status epilepticus
o he should be anesthetised and intubated immediately
o an urgent search for underlying brain pathology should be looked for (brain lesions or
meningitis)
o IV benzodiazepines should be followed by an antiepileptic agent
This is considered status epilepticus, defined as continuous seizure activity lasting ≥5 minutes or recurrent seizures without full recovery between them. The patient’s multiple seizures over 2 hours with confusion in between meet the criteria.
Initial management includes:
• Immediate IV benzodiazepines (e.g., lorazepam) to stop seizures
• Followed by loading with a long-acting antiepileptic drug (e.g., levetiracetam, phenytoin)
• Supportive care: airway, oxygen, monitoring vital signs
• Search for underlying cause (brain lesions, infection, metabolic disturbances, alcohol withdrawal)
“He should be anesthetised and intubated immediately” is not required at this stage. Intubation and anesthesia are reserved for:
• Refractory status epilepticus (seizures continue despite benzodiazepines and antiepileptics)
• Compromised airway or breathing
Since he is currently maintaining airway and only slightly confused, first-line treatment with IV benzodiazepines is appropriate.
82
Epilepsy due to structural causes typically presents with what seizure type?
Options:
A. Combined generalized and focal
B. Focal
C. Impaired awareness
D. Generalized
Focal
Explanation: Structural brain lesions (stroke, tumor, trauma, infection) typically produce focal seizures originating from the affected area. Depending on spread, these can remain focal or secondarily generalize. Generalized seizures without focal onset are less likely caused by structural lesions.
83
A 25-year-old female with well-controlled epilepsy on Sodium Valproate tests positive for HIV and will start ART. Which anti-epileptic should you change her to?
Options:
A. Lamotrigine (fewest drug-drug interactions)
B. Phenobarbital
C. Phenytoin
D. Levetiracetam
A. Lamotrigine
Explanation: Many anti-retroviral drugs interact with enzyme-inducing AEDs like Phenytoin or Phenobarbital, reducing ART efficacy. Lamotrigine has minimal drug-drug interactions and is safer in HIV patients. Levetiracetam is also an option but may be less preferred in some resource-limited settings due to cost/availability
84
A 13-year-old boy has hand jerking, attention lapses, and a family history of tonic-clonic seizures. Which thought is NOT appropriate?
Options:
A. These sound like myoclonic jerks.
B. Juvenile Myoclonic Epilepsy is familial.
C. CT brain is preferred to an EEG
D. He may also have absence seizures
C. CT brain is preferred to an EEG
Explanation: Juvenile Myoclonic Epilepsy (JME) is diagnosed clinically and confirmed with EEG (shows generalized 4–6 Hz polyspike-and-wave discharges). CT brain is usually normal and not the first-line investigation for epilepsy without focal neurological signs.
85
Examples of structural cause seizures include the following except:
Options:
A. Stroke
B. Meningitis
C. Tumours
D. Trauma resulting in intracranial haemorrhage
B. Meningitis
Explanation: Structural causes are due to anatomical brain damage (stroke, tumor, trauma). Meningitis causes seizures secondary to infection/inflammation, not primarily structural changes, so it is not considered a typical structural cause.
86
A 23-year-old man with difficult-to-control epilepsy has gained 5 kg after a medication change. Which AED is most associated with weight gain?
Options:
A. Lamotrigine
B. Phenytoin
C. Sodium valproate
D. Levetiracetam
C. Sodium valproate
Explanation: Sodium valproate is well-known to cause weight gain as a side effect. Lamotrigine and levetiracetam are weight-neutral, while phenytoin may rarely cause mild weight changes.
87
A young isiXhosa man has a first tonic-clonic seizure. CT shows multiple small round calcified lesions typical of cysticercosis. What is the most appropriate interpretation?
Options:
A. He only had one seizure; no epilepsy
B. He probably had a focal onset seizure
C. Cysticercosis is incidental
D. Idiopathic generalized tonic-clonic epilepsy
B. He probably had a focal onset seizure
Explanation: Cysticercosis lesions act as a structural cause, likely producing focal seizures, which can secondarily generalize to tonic-clonic. One seizure does not rule out epilepsy if structural lesions exist.
88
A 33-year-old woman has short episodes of unresponsiveness with subsequent anxiety. What is most likely?
Options:
A. Focal unaware seizures
B. An epileptic aura
C. Absence epilepsy
D. Panic attacks
A. Focal unaware seizures
Explanation: Brief episodes of unresponsiveness, often with post-event anxiety, without tonic-clonic activity, suggest focal seizures with impaired awareness. Panic attacks usually do not involve staring spells or altered responsiveness.
89
A 24-year-old lady has a whole-body seizure, unable to speak, can make eye contact, no post-ictal confusion, history of PTSD and alcohol overuse. Most likely diagnosis?
Options:
A. Tonic-clonic seizure
B. Psychogenic non-epileptic seizure (PNES)
C. Absence seizure
D. Alcohol withdrawal seizure
B. Psychogenic non-epileptic seizure (PNES)
Explanation: Features suggesting PNES include:
• Preserved awareness (eye contact when called)
• No post-ictal confusion
• History of psychological stressors (PTSD, social stress)
• Variable motor activity (whole-body movements)
Unlike tonic-clonic seizures, PNES is not associated with true epileptic activity on EEG
90
Which statement is TRUE in the diagnosis of epilepsy?
Options:
A. One unprovoked seizure in an elderly patient
B. 2 or more seizures following an alcohol binge
C. 1 seizure with focal lesion on CTB
D. At least 2 unprovoked seizures occurring more than 24 hours apart
D. At least 2 unprovoked seizures occurring more than 24 hours apart
Explanation: The classic definition of epilepsy is two or more unprovoked seizures separated by >24 hours. Single seizures or provoked seizures (e.g., alcohol withdrawal) do not confirm epilepsy
91
A 34-year-old female experiences a dream-like sensation, then lip-smacking with no recollection. Most likely diagnosis?
Options:
A. Absence seizure
B. Generalized seizure
C. Myoclonic seizure
D. Focal impaired awareness seizure
D. Focal impaired awareness seizure
Explanation: Features:
• Aura: dream-like or derealization
• Automatisms: lip-smacking
• Amnesia of the event
These are classic for focal seizures with impaired awareness. Absence seizures are brief staring spells without automatisms
92
What is the global prevalence of epilepsy?
Approximately 5–7.5 per 1,000 people worldwide, which translates to just under 50 million people—more than the number of people living with HIV.
93
What proportion of people with epilepsy receive treatment?
Only about 20% of people with epilepsy receive appropriate treatment, highlighting a significant treatment gap.
94
What are the main epidemiological causes of epilepsy?
Epilepsy arises at the intersection of multiple factors, including:
• Genetic causes (inherited or polygenic risk)
• Secondary causes, such as:
• Infectious diseases (e.g., cysticercosis, meningitis)
• Maternal and child health complications
• Traumatic injuries
• Diseases associated with poverty and poor access to healthcare
95
What proportion of epilepsy is attributed to genetic causes?
About 25% of all epilepsy is linked to genetic factors
96
What is the nature of most genetic causes of epilepsy?
Most are epigenetic or polygenic, where multiple genes contribute small risks, often influenced by environmental exposures and risk scores.
97
How do environmental factors influence genetic epilepsy?
Environmental exposures can interact with polygenic risk, meaning a person may inherit susceptibility genes but only develop epilepsy if exposed to certain triggers or adverse conditions (e.g., infection, trauma, poor maternal health).
98
What is a seizure?
A seizure is the clinical manifestation of abnormal hypersynchronous discharges of cortical neurons. These discharges originate in an irritant zone, spread to an epileptogenic zone, and produce symptoms in the symptomatic zone
99
What determines the clinical signs or symptoms of a seizure?
The location of epileptic discharges in the cortex and the extent/pattern of their spread determine the seizure’s clinical presentation. For example, motor cortex involvement may cause jerking, while temporal lobe involvement may cause déjà vu or automatisms.
100
How are seizures classified?
Seizures can be:
• Focal (partial) seizures: originate in a specific cortical area; more common
• Generalized seizures: involve both hemispheres from onset; usually genetic in origin
101
What is the definition of epilepsy?
Epilepsy is a disease of the brain, defined by:
• At least 2 unprovoked seizures occurring >24 hours apart in a well patient, OR
• 1 unprovoked seizure with a >60% probability of recurrence in the next 10 years
102
Epilepsy is diagnosed as a syndrome, which can be based on:
• Clinical seizure history
• EEG findings
• Genetic testing (in some syndromes)
Seizures are events; epilepsy is the underlying diagnosis, and an epilepsy syndrome groups similar seizure types with shared etiology.
103
Can a person be diagnosed with an epilepsy syndrome without having had a seizure?
Yes. Some genetic or EEG-defined epilepsy syndromes can be diagnosed before a seizure occurs, based on syndrome-specific patterns and risk profiles
104
What is the key difference between a seizure, epilepsy, and epilepsy syndrome?
• Seizure: a single clinical event caused by abnormal neuronal activity
• Epilepsy: a chronic brain disease characterized by recurrent unprovoked seizures
• Epilepsy syndrome: a group of epilepsies with shared features (genetic, EEG patterns, or clinical)
105
What is a Jacksonian march in focal seizures?
It is when tingling or twitching begins in a small area and spreads to a larger body region, following the somatotopic map of the motor cortex (homunculus). This is a classic progression of motor focal seizures.
106
What are common features of focal seizures involving blank staring and automatisms?
Features include:
• Blank stare or looking away from the lesion
• Ipsilateral automatisms (e.g., lip-smacking, hand movements)
• Posturing like fencing posture, figure-four leg posture, or cycling movements
• Movements reflect evolved pathways of motor behavior in the brain
107
What characterizes mesial temporal lobe epilepsy?
Features include:
• Involvement of hippocampus, parahippocampal gyrus, amygdala
• Aura immediately preceding the seizure
• Most common and treatable focal seizure
• Clinical signs: behavioral arrest, déjà vu, heart palpitations, heavy breathing, funny smells, rising epigastric sensation (insular involvement)
108
What are features of lateral temporal lobe seizures?
Because lateral temporal lobe handles hearing, memory, and language:
• Simple vocalizations
• Auditory hallucinations or sensations
• Can include brief memory or language disruptions
• Postictal aphasia can last ~2 minutes
109
What are characteristics of frontal lobe seizures?
Frontal lobe seizures often involve:
• Complex, learned behaviors or hypermotor activity
• Bilateral movements, screaming, jumping
• Short duration, quick onset and offset
• Frequently occur during sleep, may be multiple times per night
• Can appear bizarre and complex
110
How do occipital and parietal lobe seizures typically present?
They are mostly experiential and subjective, meaning:
• Visual phenomena (occipital) or sensory experiences (parietal)
• Often not observable to bystanders
• Can include flashes, distortions, or unusual sensations
111
How does the progression of focal seizures depend on cortical location?
The manifestation and spread of seizures reflect the function of the cortical area involved:
• Motor cortex → Jacksonian march
• Temporal lobe → automatisms, auras, sensory experiences
• Frontal lobe → hypermotor, complex behaviors
• Occipital/parietal → mostly experiential, non-observable
112
How are generalized seizures categorized?
They are categorized based on:
• Age of onset
• Clinical manifestations (motor vs non-motor, patterns of involvement)
113
What are epileptic spasms?
Occur in infants, often with arm jerks
• Respond to steroids and CBD
• Considered part of infantile epilepsy syndromes
114
What characterizes childhood absence epilepsy?
Onset around 4–6 years
• Brief lapses in awareness, sometimes with automatisms
• Can occur up to 50 times/day
• Hyperventilation can trigger episodes, useful for bedside diagnosis
• Often remits with age
115
What is typical of juvenile primary generalized tonic-clonic seizures?
Begins with tonic phase: limb extension (decorticate posturing) and ictal scream
• Clonic phase: rhythmic relaxation and contraction of muscles
• Seizure wanes spontaneously
• Followed by post-ictal confusion
116
What are the key features of juvenile myoclonic epilepsy?
Onset around 18 years old
• Can present with myoclonic jerks (brief involuntary muscle twitches affecting single or multiple muscles)
• May also have generalized tonic-clonic seizures
• Often genetic, triggered by sleep deprivation or stress
117
How can generalized seizures be recognized clinically?
Recognition depends on:
• Motor involvement (tonic, clonic, myoclonic, spasms)
• Age of onset
• Triggers (e.g., hyperventilation for absence seizures, sleep deprivation for myoclonic jerks)
• Post-ictal signs (confusion, fatigue, automatisms)
118
Which epilepsies may respond to steroids?
Some infantile epilepsies, such as epileptic spasms, respond to steroids as part of treatment.
119
What are examples of broad-spectrum antiseizure medications?
Broad-spectrum AEDs cover multiple seizure types and include:
• Benzodiazepines
• Valproate
• Levetiracetam
• Lamotrigine
120
What are key points about Levetiracetam?
Slowly metabolized, excreted renally
• Safe in pregnancy
• First-line for many seizure types
• Side effects: 10% develop new affective disorders (depression, bipolar, anxiety), 1% may become psychotic
121
What are key points about Lamotrigine?
Safe with HIV treatment and pregnancy
• Start at very low dose to avoid Stevens-Johnson syndrome
• Takes ~3 months to reach therapeutic dose
• Lowest side effect profile once therapeutic dose is reached
122
Which drugs are narrow-spectrum AEDs, and what caution is needed?
Phenytoin and Carbamazepine
• Primarily treat focal seizures
• Can worsen generalized epilepsy
• In South Africa, focal seizures are more common, so narrow-spectrum use is frequent
• They induce liver enzymes, lowering levels of antiretroviral therapy (ART)
123
How are AEDs generally classified?
• Broad-spectrum: effective for multiple seizure types (e.g., Valproate, Levetiracetam, Lamotrigine, Benzos)
• Narrow-spectrum: effective for limited seizure types, mainly focal (e.g., Phenytoin, Carbamazepine)
124
What are important considerations when starting AEDs?
Consider seizure type (broad vs narrow spectrum)
• Drug interactions (especially with ART)
• Pregnancy safety
• Side effect profiles (e.g., Lamotrigine: SJS risk, Levetiracetam: psychiatric effects)
125
How long must a person be seizure-free before being allowed to drive?
2 years seizure-free, unless they only have nocturnal seizures.
126
What is the chance of a repeat seizure if a patient is on an appropriate antiseizure medication?
Around 30%.
127
How is control of epilepsy typically defined?
0 seizures.
128
What is treatment-refractory epilepsy?
Continued seizures after 3–6 months on appropriate medication.
129
What criteria are used for diagnosing treatment-refractory epilepsy?
2 or more seizures despite treatment
• Persistence regardless of agent used
130
When can a patient with focal epilepsy be considered for surgery?
If the epilepsy is treatment-refractory and:
• A cause is identified
• Monitoring (EEG) off medication confirms seizure focus
• A lesion on MRI matches the seizure type
• Neuropsychiatric profile is acceptable
131
What is the chance of being cured of epilepsy after eligible focal epilepsy surgery (e.g., lobectomy)?
About 60%.
Neurology
flashcards
Decks in class (38)
# Cards
-
Headache113
-
Headache cases13
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Weakness59
-
Epilepsy131
-
The Rule of 4 and Brainstem Localisation36
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Epilepsy133
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Into To Neuro51
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Raised ICP102
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Epilepsy CPC31
-
Stroke178
-
Movement Disorders93
-
Stroke39
-
Traunatic Brain Injury90
-
Glascoma Scale13
-
CNS Tumors115
-
Neuroradiology156
-
Neurocascular43
-
Neurosurgery Red Flags93
-
Surgical Stroke38
-
The Spine29
-
Spinal Pathology103
-
Spinal Cord Compression30
-
Spinal Lesion88
-
Spina Bifida83
-
Neuro Exam33
-
Spinal Quiz26
-
Stroke Localisation45
-
Chronic Dizziness62
-
Coma63
-
Denentia125
-
Disorders Of The Spinal Cord132
-
Hyperkinetic Movements154
-
Hypoxic Ischemic Brain Injury20
-
Infections Of The Nervous System77
-
Motor Neuron Disease38
-
Muscle Disease33
-
Peripheral Berve Disease37
-
Spinal Cord Lesions44
