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Finals Neurology > Epilepsy > Flashcards

Epilepsy Flashcards

1
Q

Define epilepsy

Define status epilepticus

A

**Epilepsy: **Recurrent tendency (minimum 2 episodes) to spontanous, intermittent, abnormal electrical activity in part of the brain, manifesting as seizures

Status epilepticus: State of seizure activity lasting for 30 min with no return to consciousness

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2
Q

Define convulsions

A

Motor signs of electrical discharges

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3
Q

Outline a typical seizure

A
  1. Prodrome - hours/ days previous a ‘change’ is noticed
    • Aura - patient notices change
      • Strange feeling in the gut, deja vu, strange smells, flashing lights
      • Implies focal seizure from temporal lobe (normally)
  2. Seizure occurs
  3. Post-ictally
    • Headache, confusion, myalgia, sore tongue
    • Todd’s palsy - motor cortex seizure causing temp. weakness
    • Expressive dysphasia (frontal)/ Receptive aphasia (temporal)
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4
Q

Outline the different seizure classifications

A

Partial seizures - focal onset

  • Simple - awareness unimpaired, no post-ictal symptoms
  • Complex - awareness impaired, aura & post-ictal symptoms common
  • 2ndary generalization - starts focal & spreads causing 2ndary generalised seizure

**Generalized seizure **- throughout cortex, no localising features

  • Absence (petit mal)- brief (<30s) pauses, then continues
  • Tonic-clonic (grand mal)- loss of consciousness, limbs stiffen (tonic), then jerk (clonic), post-ictal confusion
  • Myoclonic - sudden jerk of limb, face or trunk
  • Atonic (akinetic) - sudden loss of muscle tone (no LOC)
  • Infantile spasms
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5
Q

What are the causes of epilepsy & seizures?

What are precipitating factors?

A
  • Idiopathic (2/3, familial)
  • **Structural **(1/3)
    • CVA
    • Space-occypying lesion
    • Head injury (particularly when LOC >30min + structural findings)

Others causes of seizures;

  • Alcohol/ benzodiazepine **withdrawal **(& binging)
  • Meningitis/ Encephalitis
  • Drugs: phenothiazines, isoniazid, tricyclic antiDs
  • Metabolic:
    • Hypoxia - O2 sats
    • ↑↓Na+- electrolytes
    • ​↑↓**Glucose **- blood glucose
    • ↓Ca2+ - blood calcium
    • Ureaemia - urine biochemistry
    • Liver/ kidney disease - LFTs/ U&Es

Precipitating factors;

  • Sleep deprivation, alcohol & medications lower threshold
  • Peak during ovulation/ 2nd half of cycle
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6
Q

How do you investigate & diagnose epilepsy?

A
  • Electroencephalograph (EEG)
    • When Hx suggests seizure is epileptic in origin
  • Neuroimaging: MRI > CT
    • ​Structural abnormalities
      • Focal? Medication failure?
  • Bloods
    • Hypoxia - O2 sats
    • ↑↓Na+ - electrolytes
    • ​↑↓Glucose - blood glucose
    • ↓Ca2+ - blood calcium
    • Ureaemia - urine biochemistry
    • Liver/ kidney disease - LFTs/ U&Es
  • 12-lead ECG
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7
Q

How would you localise a partial (focal) seizure?

A
  • Temporal - bizzare
    • Automatisms - complex motor phenomena
    • Emotion - hippocampal areas
    • Smell/ tast - uncal areas
    • Receptive aphasia - Wernicke’s area
    • Delusional behaviour
  • Frontal
    • Motor
    • ​Jasksonian march [distal limb to ipsilateral face]
    • Expressive Dysphasia - Broca’s area
    • Post-ictal Todd’s palsy
  • Parietal
    • ​Sensory
  • Occipital
    • ​Visual
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8
Q

Outline the long term management of epilepsy?

A

Anti-Epileptic Drugs (AED)

  • Absence - Sodium valproate (SV) (or Ethosuximide ⇒Lamotrigine)
  • Generalized tonic-clinic - SV (⇒Lamotrigine)
  • Myoclonic - SV (⇒Levetiracetam)
  • Atonic - **SV **(⇒ Lamotrigine)
  • Partial - Carbamazepine (⇒ sodium valproate or lamotrigine)
  • Drug resistant: Levetiracetam, topiramate, zonisamide

+ supplementary Psychological interventions

Surgery…

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9
Q

Outline the mechanism of action of Sodium Valproate

A

Anticonvulsant;

  1. Blocks Na+ channels (weakly)
  2. Inhibits GABA deactivators
  3. Promotes GABA synthesis?
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10
Q

Outline the mechanism of action of Lorazepam

A

Benzodiazepine

  1. Increases GABA effect’s by binding to allosteric site of GABA receptor
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11
Q

Outline the acute management of an epileptic seizure & status epilepticus

A
  • 0-5min
    • Airway - protect, insert airway if possible
    • Breathing - high flow mask 10L/min
    • Circulation - IV access, 02 stats
      • Bloods
      • Lorazepam 4mg IV bolus (diluted 1:1 with sodium chloride/ water) (⇒ Diazepam 10mg IV/ 2min) - monitor O2 sats
    • Poor nutrition/ alcoholism
      • Parenteral thiamine as Pabrinex IV 100mL/ 30min/ 8hrly
  • 5-10min
    • Repeat Lorazepam [max. 8mg]/ Diazepam [max. 30mg]
  • 10-40min
    • Phenytoin IV with cardiac monitoring
    • Contact Neurology Registrar
  • >40min
    • Contact consultant
    • MIU/ critical care
  • Arrange other investigations (ie EEG)
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12
Q

What are the differential diagnoses for seizures?

A
  • Syncope!
    • Vasovagal
      • Reflexive anoxic seizures (asystole due to trigger [pain, fear])
      • Carotid sinus hypersensitivity
    • **Cardiac **- arrythmias & mechanical valves
    • Electrolyte abnormalities
      • ↑↓Na+
      • ​↑↓Glucose
      • ↓Ca2+
      • Ureaemia
    • Orthostatic hypotension
  • Hyperventilation
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13
Q

What implications does epilepsy have on driving?
What are the laws regarding it?

A
  • Following a seizure you must stop driving, inform DVLA & motor insurance company
  • Group 1 (car/ motorcycle)
    • Epileptic attack
      • Stop driving for 1 year after attack
      • If attack while sleeping must stop for 1 year also (unless for the past 3 years youve only had an attack while asleep)
      • Must comply with treatment & check-ups
    • First unprovoked seizure
      • 6 months off unless evidence suggests risk
  • Group 2 (large goods)
    • For epileptics
      • 10 years preceeding license issue must have NO epileptic attacks & be on no medication
    • First unprovoked seizure
      • 5 years off driving unless evidence suggests risk
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14
Q

What are complications of epilepsy?

A
  • SUDEP
    • Sudden unexpected death in epilepsy (no identifiable cause)
    • 500 deaths each year
    • Risk increases with inc. freq. & severity of seizures
  • Accidents (obviously)
  • Depression & anxiety more prevalent
  • Women with epilepsy: osteoporosis, osteomalacia, fractures
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15
Q

Outline typical petit mal seizure

  • Presentation
  • Provocation
  • Prognosis
A

Absence seizure;

  • Child stops what they are doing, stares, then continues
  • Provoked by hyperventilation
  • 90% resolve by teens
    • ⇒ Grand mal (tonic-clonic) & Juvenile myoclonic epilepsy
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16
Q

Outline Juvenile myoclonic epilepsy

  • Age
  • Typical presentation
  • Prognosis
  • Aetiology
A

Juvenile myoclonic epilepsy;

  • Teen years
  • Early morning sudden myoclonic jerks, esp. arms & shoulders
    • ⇒ Often later developing generalised tonic-clonic seizures
  • May be inherited as autosomal dominant
17
Q

Outline Benign Rolandic epilepsy with centrotemporal spikes

  • Other names
  • Meaning of Rolandic
  • Age & sex
  • Typical presentation
  • Prognosis
  • EEG findings
A

Benign Rolandic epilepsy with centrotemporal spikes

  • Benign Partial/ Childhood Epilepsy with centrotemporal spikes
  • Seizure starts around Rolandic fissue (aka Central sulcus)
  • 4-10yrs, boys>
  • Nocturnal seizures with facial twitching & aphasia
    • +/- generalised tonic-clonic seizures
  • Infrequent & outgrown.
  • Centrotemporal spikes
    • Inter-ictal EEG characterised by large spikes over Rolandic area **of one hemisphere **(aka Central sulcus)
18
Q

Outline typical infantile spasms

  • Age
  • Typical presentation
A

Infantile spasms;

  • Infants aged 4-8 months
  • Clusters of myoclonic spasms when waking up
19
Q

Outline Dravet’s syndrome

  • Typical presentation (definition)
  • Onset
  • Comorbitities
  • Prognosis
A

Dravet’s syndrome;

  1. Severe myoclonic epilepsy of infancy +
  2. Recurrent a/febrile hemiclonic/generalised seizures, or status epilepticus
  • Onset <15 months
  • Developmental arrest/ regression
  • Motality up to 15% by 20yrs
20
Q

Outline Lennox-Gastaut syndrome

  • Typical presentation & definition
  • Onset age
  • Classifications
A

Lennox-Gestaut syndrome;

  1. Mutliple types of epileptic seizures
    • Most commonly tonic-axial, atonic & absence
    • Drop attacks frequent & most dangerous
    • Often resistant to treatment
  2. Slow spike-and-wave EEG
  3. Psychomotor delay
  4. Behavioural disorders
    • ​​Hyperactivity, aggressiveness, autistic ⇒ psychosis
  • Onset <8yrs (peak 3-5)
    • 20% have infantile spasms with hypsarrhythmia
  • Classification
    • Idiopathic (25%)
      • Normal psychomotor development prior to symptoms
      • No neuro-logical/radiological abnormalities found
    • Symptomatic (75%)
      • Due to diverse cerebral conditions usually generalised involving grey matter
      • ie Encephalitis, meningitis, tuberous sclerosis, malformations, lesions, injury & trauma
21
Q

Outline Panayiotopoulos syndrome

  • Definition & typical presentation
  • Age onset & prevelence
  • EEG findings
  • Common differentials
A

Panayiotopoulos syndrome;

  • Multifocal autonomic childhood epileptic disorder
    • Prolonged seizures with autonomic symptoms & ictal vomiting
  • Onset 3-6yrs, Common.
  • EEG: shifting/ multiple foci + occipital dominance
  • Often confused with occipital epilepsy & acute non-epileptic disorders

Finals Neurology (40 decks)

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