Epilepsy

Question 1

Types of generalised seizures

Answer 1

Tonic-Clonic

Absence

Myoclonic

Atonic

Question 2

Generalised Tonic-Clonic Seizures

Presenting features

Answer 2

FEATURES

• loss of consciousness
• tonic (muscle tensing) and clonic (muscle jerking) episodes: often tonic phase comes before clonic phase
• may be associated tongue biting, incontinence, groaning and irregular breathing.
• prolonged post-ictal period where the person is confused, drowsy and feels irritable or depressed

MANAGEMENT

1. Sodium Valproate (SE: teratogenic, hair loss / grows back curly, tremor)
2. Lamotrigine (SE: rash [Steven johnson], leukopenia)

Question 3

Subtypes of focal seizures

Answer 3

COMPLEX With impairment of consciousness:

• Patients lose consciousness either after an aura, or at seizure onset
• Most commonly originate at the TEMPORAL LOBE
• Post-ictal symptoms are common (eg. confusion in temporal lobe seizures).

SIMPLE Without impairment of consciousness:

• Patients do not lose consciousness, and only experience focal symptoms
• Post-ictal symptoms do not occur.

SECONDARY GENERALISED:

• Evolving to a bilateral, convulsive seizure (‘secondary generalised’)
• Patients experience a focal seizure, which then evolves to a generalised seizure, which is typically tonic-clonic
• This occurs in 2/3 of patients with focal seizures.

Question 4

Features of specific focal seizures in each of the 4 lobes

Answer 4

1) Temporal lobe - Automatisms (eg. lip-smacking); déjà vu or jamais vu, emotional disturbance (eg. sudden terror); olfactory, gustatory, or auditory hallucinations.
2) Frontal lobe - Motor features such as Jacksonian features, dysphasia, or Todd’s palsy.
3) Parietal lobe - Sensory symptoms such as tingling and numbness; motor symptoms - due to spread of electrical activity to the pre-central gyrus in the frontal lobe.
4) Occipital lobe - Visual symptoms such as spots and lines in the visual field.

Question 5

Treatment for focal seizures

Answer 5

First line:

• Carbamazepine (SE: SIADH, agranulocytosis, aplastic anaemia, P450 inducer)
• Lamotrigine (SE: rash (Steven johnson), leukopaenia)

Question 6

Absence Seizures

Features

Management

Answer 6

FEATURES

• typically happen in children
• patient becomes blank, stares into space and then abruptly returns to normal
• typically only lasts 10-20 seconds
• most patients (> 90%) stop having absence seizures as they get older

MANAGEMENT
First line:
- Sodium valproate (SE: teratogenicity, tremor, hair that grows back curly)
- Ethosuximide (SE: night tremors)
Must not use carbamazepine as it worsens the seizures

Question 7

Atonic Seizures

Answer 7

FEATURES
Sudden loss of muscle tone, causing the patient to fall, whilst retaining consciousness

MANAGEMENT
First line:
- Sodium Valproate (SE: teratogenic, tremor, hair loss / hair grows back curly)
- Lamotrigine (SE: rash [Steven-johnson], leukopaenia) is first-line.

Question 8

Myoclonic seizures

Features

Management

Answer 8

FEATURES
Sudden jerk of a limb, trunk, or face

MANAGEMENT
Sodium Valproate is first-line
avoid Carbamazepine as it worsens seizures.

Question 9

Infantile Spasms

Features

Management

Answer 9

West syndrome

It is a rare (1 in 4000) disorder starting in infancy at around 6 months of age

FEATURES
- clusters of full body spasms

There is a poor prognosis: 1/3 die by age 25, however 1/3 are seizure free

MANAGEMENT
Prednisolone
Vigabatrin