Week 5- overview of Epilepsy

Question 1

what is epilepsy?

Answer 1

-is a neurological condition affecting the brain.

Question 2

what is the definition of epilepsy from ILAE?

Answer 2

as a disease of the brain
• At least 2 unprovoked (or reflex) seizures occurring more than 24hours apart
• One unprovoked (or reflex) seizure and a probability of further seizures
similar to the general recurrence risk after 2 unprovoked seizures (at least
60%) over the next 10years; or
• Diagnosis of epilepsy syndrome”(1)

Question 3

what is a seizure?

Answer 3

the transient occurrence of signs or
symptoms due to abnormal excessive or synchronous neuronal
activity in the brain

Question 4

what is the incidences and prevalence for epilepsy?

Answer 4

• affects over 70 million people worldwide.

- Close to 80% of those with epilepsy live in low- to middle income countries(3,4)

Question 5

what percentage of people with epilepsy aren’t receiving the right treatment~?

Answer 5

75%

Question 6

who can epilepsy affect?

Answer 6

can affect people of all ages, race, and gender
• Highest in infants and people over 50
-People who have learning difficulties also have higher rates of epilepsy in
comparison to the general population

Question 7

what is the mortality for people with epilepsy? what causes deaths??

Answer 7

• There is an increased risk of premature death in patients with epilepsy
-caused by conditon itself=injury, during seisure, The antiepileptic treatment, status epilepticus, co-morbities
- SUDEP – sudden unexpected death in
epilepsy

Question 8

what how does SUDEP occur?

Answer 8

• can occur just after a seizure not all the time
• can be related to charges in heart rhythm
• can occur in their sleep or at night so can go unseen
• risk factors of SUDEP= no treatment, night seizures

Question 9

what is the aetiology of epilespsy?

Answer 9

-not always known
-2/3 of people hae epilespy that has an unknown cause
• Structural= stroke, trauma
• Genetic= mutation
• Infectious= known infection
• Metabolic= metabolic disorder
• Immune= inflammation

Question 10

what are some risk factors of epilepsy?

Answer 10

• Premature birth
• Complicated febrile seizures (seizures brought on by a high temperature)
• Brain development malformation
• A family history of epilepsy or neurological disease
• Head trauma
• Infections (e.g. meningitis and encephalitis)
• Tumours
• Cerebrovascular disease/stroke
• Dementia and neurodegenerative disorders (Alzheimer’s disease)
• Drugs and alcohol withdrawal

Question 11

how is epilepsy diagnosed?

Answer 11

• Referral to a specialist in epilepsy (3)
• Detailed history from the patient and eyewitness of the attack
-investigations
• EEG
• Blood tests
• Neuroimagine (MRI/CT)
• ECG
• U&Es
• Neuropsychological assessment= to help with learn difficulties identification

Question 12

what are the different factors that are used to classify epilepsy’s?

Answer 12

• Seizure type
• Epilepsy type
• Epileptic syndrome

Question 13

what are the main 3 groups seizures that can be classified?

Answer 13

• Focal seizures
• Generalised seizures
• Unknown

Question 14

what are focal seizures?

Answer 14

• Increased neuronal activity originating and remaining in one
hemisphere of the brain.
-they are subdivide into:
• Simple focal seizures (no loss of consiousness)
• Complex or focal dyscognitive seizures (impaired awareness)
-motor symptoms or not

Question 15

what affects the signs and symptoms of a seizure?

Answer 15

the specific area of

the brain involved

Question 16

what are focal to bilateral clonic seizures?

Answer 16

they dont stay in one place in the brain branch off

Question 17

what are generalised seizures?

Answer 17

• Increased neuronal activity that is widespread across both
hemispheres of the brain. These are subdivided into:
• Motor symptoms
• Non-motor symptoms
- NOTE – level of awareness is not looked at as much with this type of
seizure because the majority (not all) of these seizures the patient has
impaired awareness

Question 18

when talking about motor symptoms what does tonic mean?

Answer 18

Sustained increased muscle contraction (tense and rigid muscles)

Question 19

when talking about motor symptoms what does myclonus mean?

Answer 19

Muscle twitching (can involve single or multiple muscle groups)

Question 20

when talking about motor symptoms what does atonic mean?

Answer 20

Muscles becoming limp (opposite to tonic)

Question 21

when talking about motor symptoms what does clonic mean?

Answer 21

Jerking rhythmic twitching movements

Question 22

when talking about motor symptoms what does tonic-clonic mean?

Answer 22

Where the seizure starts off in tonic phase (muscle rigidity, loss of consciousness,
respiration stops, involuntary crying) into clonic phase where you have muscle
twitching – relaxing and contracting, with loss of control of bladder and/or
bowels). After the seizure, some people get a post-ictal phase where they have
trouble remembering what has happened, feel tired, and confused.

Question 23

when talking about non motor symptoms what does absence mean?

Answer 23

Vacant staring, movement stops

Question 24

how is the epilepsy type similar to the seizure type?

Answer 24

it mirrors the type of seizure

Question 25

what is epilepsy syndromes?

Answer 25

These are epilepsies with specific signs and symptoms that can be
clustered together. Factors used to help identify a specific epilepsy
syndromes include:
• Age of onset of seizures
• Types of seizures
• Specific EEG patterns and imaging

Question 26

how do you manage a seizure?

Answer 26

• Look for an epilepsy identity card or jewellery.
• Protect them from injury
• Do not restrain them or put anything in their mouth.
• When the seizure stops, check their airway and place them in the recovery position.
• Observe them until they have recovered.
• Examine for, and manage, any injuries.
• Arrange emergency admission (call for an ambulance) if it is their first seizure; a seizure reoccurs shortly after the first one; the person is injured or having trouble breathing after the seizure, or is difficult to wake up.

Question 27

what is convulsive status epilepticus?

Answer 27

• Status epilepticus is defined as a prolonged convulsive seizure lasting
5minutes or longer OR recurrent seizures one after the other without
recovery in between
-its a medical emergency

Question 28

who could have a status epilepticus?

Answer 28

• Patients who have existing epilepsy

* Patients that have never had seizures

Question 29

what can trigger a status epilepticus?

Answer 29

• Triggered by head injury, metabolic disturbance (hypoglycaemia),
cerebrovascular event (stroke) or alcohol withrdrawal

Question 30

how do you deal with Convulsive status epilepticus in

the community?

Answer 30

-should time the seizure
• Airways, respiratory and cardiac function must be secured
• Buccal midazolam (first line) or rectal diazepam can be prescribed for use in the
community in patients that have had previous episodes of prolonged or serial
convulsive seizures.
• This should only be administered by trained personnel or specified by an individually
agreed protocol drawn up by the specialist, family members or carers.
-Depending on response to treatment/pt’s condition/care plan an
ambulance may need to be called if:
• Seizure continues 5mins after emergency medication has been given
• Pt’s history of frequent serial seizures, who has convulsive status epilepticus or this
is the first episode requiring emergency treatment
• Concerns/difficulties monitoring pt’s airways, respiratory and cardiac functions.

Question 31

how to deal with convulsive status epilepticus in

hospital setting in 0-5mins?

Answer 31

• The seizure is timed from onset=to know what treatment can be given
• Establish IV access –
• Airways must be secured and regular monitoring of cardiac
and respiratory functions set up.
• Give high conc of oxygen
• Give high potency of thiamine (if suggestion of alcohol abuse)
e.g Pabrinex
• Give glucose if patient is hypoglycaemic

Question 32

how to deal with convulsive status epilepticus in

hospital setting in 5-20 mins?

Answer 32

• Get a bit more information about the patient
• Start setting up other investigations to help management –
Chest X-ray, CT scan
• Give IV lorazepam (0.1mg/kg – max of 4mg) or IV diazepam if
lorazepam not available. Alternative to this is buccal
midazolam if no IV access. Max of 2 doses to be given
including the pre-hospital dose.

Question 33

how to deal with convulsive status epilepticus in

hospital setting in 20-40 mins?

Answer 33

Alert anesthetist and ICU – if patient is not responding to treatment more
intervention and care is needed and therefore these people need to
become involved
• Give 2nd line IV AED – and this will depend on the hospital protocols in
place. In the NICE guidance they mention use of Phenytoin, Fosphenytoin
sodium and phenobarbitol. However newer AEDs as listed in this diagram
could potentially be used

Question 34

how to deal with convulsive status epilepticus in

hospital setting in 40-60 mins?

Answer 34

Transfer to ICU and general anesthesia would be administered:
• Propofol
• Midazolam (titrated to effect)
• Thiopental sodium
• EEG monitoring needs to set up when giving anaesthetic
• Anasthetic continued for 12-24hours after last clinical/electrographic
seizure the dose tapered.