Epilepsy

Question 1

What is epilepsy?

Answer 1

. Recurrent seizures
. Need to have had more than 2 seizures (>24hrs apart) for a diagnosis of epilepsy

Question 2

Define a seizure

Answer 2

excessive activity of cortical neurons resulting in transient neurological symptoms

Question 3

What are the causes of epilepsy

Answer 3

Primary epilepsy is idiopathic
secondary causes:
. Tumour
. Meningitis
. Vasculitis
. Alcohol withdrawal
. Haemorrhage
. Metabolic

Question 4

What are some of the conditions that have association with epilepsy

Answer 4

cerebral palsy
tuberous sclerosis
mitochondrial disease

Question 5

What is cerebral palsy?

Answer 5

group of neurological disorders that affect a person’s ability to move, maintain balance, and control posture.
It results from damage to the developing brain, usually before birth, during birth, or shortly after. E.G. lack of oxygen during birth, infections during pregnancy, premature births, brain bleeding in infant, genetic factors

Question 6

What is tuberous sclerosis

Answer 6

genetic disorder that cause benign tumours to grow in different parts of the body esp brain, skin, kidneys, heart, lungs and eyes

Question 7

Mitochondrial disease?

Answer 7

group of disorders caused by problems in the mitochondria which can affect any organ but most often the brain, muscles, heart, liver and kidneys

Question 8

What types of seizures are there?

Answer 8

Focal seizure
generalised seizure
status epilepticus

Question 9

focal seizure?

Answer 9

seizure localised to specific cortical regions
may be complex (consciousness affected) or non-complex (consciousness not affected)

Question 10

Generalised seizure

Answer 10

Affects the whole brain and consciousness is lost immediately

Question 11

What are the types of generalised seizure?

Answer 11

Absence (brief loss of awareness)
Tonic (sudden stiffening of muscles)
Atonic (sudden loss of muscle tone causing person to collapse or drop object)
Tonic-clonic (t: sudden loss of consciousness c: rhythmic jerking)
Myoclonic (sudden brief jerking of a muscle or group of muscles)

Question 12

Status epilepticus?

Answer 12

seizure lasting longer than 5 mins or (2 or more seizures) within a 5 min period without the person returning to normal between them

Question 13

How to rule out status epilepticus?

Answer 13

Hypoxia and hypoglycaemia (by blood glucose measurement)

Question 14

How do we treat status epilepticus?

Answer 14

IV lorazepam (benzodiazepine) or PR diazepam (benzodiazepine)

Question 15

Clinical features of focal seizures of the frontal lobe

Answer 15

Motor convulsions
. May show post- ictal flaccid weakness (post-ictal meaning just after seizure ends)
. Jacksonian march (clonic movements starting in 1 extremity and moving proximally through body)- usually starts as twitching/ tingling of area like little toe or finger

Question 16

Clinical features of focal seizures of the temporal lobe

Answer 16

Aura involving weird smells, involuntary movements, deja vu, abdo pain
. lip smacking, plucking, grabbing (automatisms)
. post ictal dysphasia
. hallucinations

Question 17

frontal love complex seizure features? impaired awareness

Answer 17

. loss of consciousness
. involuntary actions
. rapid recovery

Question 18

occipital lobe seizure features?

Answer 18

visual disturbances (flashers and floaters)

Question 19

parietal lobe seizure features?

Answer 19

sensory issues (paraestheria- tingling, numbing)

Question 20

generalised seizures: tonic-clonic seizure features

Answer 20

. vague symptoms before attack e.g. irritability
. tonic phase- generalised muscle spasm- goes stiff and falls to floor
. clonic phase- repetitive synchronous jerks- jerking limbs or loss of bladder control

. urinary incontinence
. tongue biting
Post-ictal phase

Question 21

what is the post ictal phase for tonic-clonic seizure features

Answer 21

impaired consciousness
lethargy
confusion

Question 22

Absence seizure features

Answer 22

onset in childhood

. loss of consciousness but maintained posture (don’t fall down)
. no post-ictal phase
. often begins abruptly without warning and ends abruptly
. patient has no recollection of episode
. stares blankly into space

Question 23

What would you see in absence seizure?

Answer 23

3 Hz spike and wave

Question 24

How do you treat absence seizure?

Answer 24

Ethosuximide

Question 25

What is myoclonic seizure features?

Answer 25

. convulsions without the muscle tensing (tonic phase) . sudden jerking of limb, trunk or face with preserved consciousness

Question 26

What is atonic seizure features?

Answer 26

sudden muscle relaxation causing patients to fall to the ground and then may motionless . can result in incontinence . can result in post-ictal confusion

Question 27

What is tonic seizure features?

Answer 27

muscle tensing without convulsions (clonic phase)

Question 28

Investigations for epilepsy- how are they primarily diagnosed?

Answer 28

clinical diagnosis- 2 or more unprovoked seizures 24hrs apart

Question 29

What scans can you do?

Answer 29

electroencephalogram- help confirm diagnosis and classify epilepsy MRI- look for structural space occupying or vascular lesions that may cause midline shift. . could use for non-epileptic patient presenting with seizures

Question 30

what bloods do we take and why?

Answer 30

. capillary blood glucose- exclude hypoglycaemia . electrolytes to look for hypocalcaemia and hyponatraemia . prolactin to tell the difference between seizures and pseudoseizures. Prolactin would be high in seizures and not raised in pseudoseizures

Question 31

What is the general rule in terms of providing medication

Answer 31

Only start anti-convulsant treatment after more than 2 unprovoked seizures

Question 32

What's 1st line for focal seizures

Answer 32

Lamotrigine Levetiracetam

Question 33

What rare effect is there of lamotrigine

Answer 33

Stevens- Johnson syndrome- large blistering rash throughout body

Question 34

What's 2nd line treatment for focal seizures?

Answer 34

Antiepileptics: Carbamazepine Oxcarbazepine Zonisamide

Question 35

What side effects of carbamazepine are there?

Answer 35

SIADH Drowsiness Stevens- Johnson syndrome Neutropenia Osteoporosis

Question 36

What's 1st line for generalised seizure

Answer 36

Levetiracetam Lamotrigine

Question 37

What's 1st line for absence seizures

Answer 37

Ethosuximide- antiepileptic (anticonvulsant). Blocks Ca2+ channels in thalamic neurons

Question 38

What's 2nd line for absence seizures

Answer 38

Lamotrigine Levetiracetam

Question 39

What anti-epileptic can exacerbate absence seizures

Answer 39

Carbamazepine

Question 40

What's first and second line for myoclonic seizures?

Answer 40

Levetiracetam 2nd- lamotrigine

Question 41

What's first and second line for tonic/ atonic seizures

Answer 41

Lamotrigine 2nd- clobazam, rufinamide, topiramate

Question 42

What do we give for status epilepticus in hospital vs community. What do we give if this doesn't work?

Answer 42

H- IV lorazepam C- PR diazepam b) another dose of IV lorazepam, if that doesn't work then IV phenytoin

Question 43

What is the side effects of phenytoin?

Answer 43

Gingival hypertrophy- overgrowth of the gums Peripheral neuropathy- can cause weakness, numbness, pain, or loss of function in the affected areas

Question 44

What is the max dose of IV benzodiazepines that we can give?

Answer 44

max of 2 doses

Question 45

What is benzodiazepines?

Answer 45

CNS depressant drugs that act on brain to produce sedative, anti anxiety, muscle relaxant and anti-convulsant effects Enhances the effect of GABA

Question 46

What does the DVLA do?

Answer 46

DVLA- medical assessment carried out to check if someone is medically fit to hold a driving license . 1st unprovoked seizure- 6 months off driving . if no abnormal brain imaging or EEG then 12 months off driving . No formal diagnosis of epilepsy after 1 seizure

Question 47

Complications of epilepsy?

Answer 47

. Fractures from tonic-clonic seizures . Behavioural problems . Sudden death in epilepsy . Complications to anti-epileptic drugs: Phenytoin: gingival hypertrophy Carbamezapine- neutropenia and osteoporosis Lamotrigine- steven johnson syndrome

Question 48

What is prognosis rate

Answer 48

50% remission at 1 year