232 - Epilepsy Flashcards by Lucy Knox

What is an epileptic seizure?

A transient event experienced due to synchronous and excessive discharge or cerebral neurones

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Why do people get epilepsy?

Idiopathic - ? genetic link
Symptomatic - as a symptom of a cause eg. tumour
Cryptogenic - suggestive of a cause buy can’t find one

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What are some differentials for epilepsy?

Syncope
Non-epileptic attack disorder
Panic attacks
Sleep disorders
Migrane
TIAs
Hypoglucaemia

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What are the 3 Ps related to syncope?

Prodrome
Posture
Provocation

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What are some signs that point to a seizure?

Stereotyped
cyanosis
unprovoked
lateral tongue biting
shoulder dislocation
post-ictal confusion

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What are the 2 main categories of epileptic seizures? What are the subtypes seen in each?

Generalised - starts in both hemispheres, sudden onset
- tonic clonic, absence, myoclonic

Partial/focal - Starts in 1 place then spreads
- simple (aware). complex (unaware)

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What are the characteristics of a generalised tonic-clonic seizure? GTCS

Sudden onset, sterotyped
Tonic stiffening - then syncrhonised clonic movements
Cyanosis, stertorous breathing, tongue biting, incontinance, injuries, post-ictal confusion.

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What are the characteristics of idiopathic generalised epilepsy?

Mixture of seizures - tonic clonic, absences and myoclonic
Starts in childhood/teens/young adults
EEG abnormal - generalised spike-wive
Triggers - eg. sleep deprivation and alcohol excess

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What are the characteristics of JME - Juvenile myoclonic epilepsy?

A form of generalised epilepsy
Onset 8-18
FH common
Upper limb jerks, GTCS, absences. 
Seizures on waking, triggers: alcohol, sleep deprivation, photosensitivity
MRI ok, EEG abnormal
Good treatment response

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What are the characteristics of Temporal lobe complex partial epilepsy?

3As

Aura - olfactory, gustatory, psychic, limbic…
Arrest - motor and speech
Automatism - manual or oro-facial movements

Lasts 2-10 minutes, gets post ictial confusion

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Descirbe NEAD: Non epileptic attack disorder

Psychologically mediated, altered consciousness + behaviour

Markers:

awareness maintained
Gradual onset, prolonged seizure
Frequant
No drug response
Autonomic arousal preceeds it
Asynchronous movements
Eyes closed
Back arching
Carpet burns
normal colour
Tip of tongue bitten

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What is catamenial epilepsy?

Seizures around menstruation

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What drugs are available for epilepsy?

Sodium valproate (epilim)

Carbamazepine (tegretol)

Lamotrigine (lamictal)

Levetiracetam (keppra)

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Sodium valporate

Generalised epilepsy

Na channels / GABA

S/e: weight gain, tremor, teratogenic

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Carbamazepine

Partial/focal epilepsy

Na channels

S/e: Rash, ataxia, double vision, interacts with enzyme inducers eg. warfarin and OCP

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Lamotrigine

1st line in partial/focal
2nd line for generalised

Na channels

s/e: rash

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Levetiracetam

1st line in partial/focal
2nd line for generalised, add in as 2nd line in partical/focal
SV2A protein

s/e: psychiatric issues

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What is SUDEP?

Sudden unexpected death in epilepsy

a non-traumatic, unwitnessed death
Normal post mortem
1/1000 a year risk
Why? cardiac arrhythmias?

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What is status epilepticus?

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Seizures lasting 30minutes or more without regaining consciousness inbetween

20% mortality - treat after 5 min of seizure, don’t wait for 30!

What can cause status epilepticus?

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50% new cause - encephilitis, trauma…

50% known epilepsy - missed medication

Why is status epilepticus so dangerous?

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associated with severe psychological and metabolic compromise + neuronal damage

How do you treat status epilepticus?

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1st: IV lorazepam or buccal midazolam

If established: IV phenytoin or AEDs

Then if refractory - ITU, sedation, ventillation

What is a coma?

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A state of unrousable unconsciousness
No meaningful interaction
Unaware of external stimulus - eye opening to pain at best

What is arousal? Where in brain is it based?

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Level or consciousness / alertness

Reticular activating system in Pons/midbrain + thalamus

What is awareness? Where in brain is responsible?

Content of consciousness - awareness of self + environment Cortical areas

What are 4 key categories of causes of coma?

Significant structural injury to cerebral hemispheres Brainstem dysfunction Diffuse physiological brain disfunction Metabolic + endocrine causes

What can cause diffuse physiological brain dysfunction leading to coma?

Hypothermia sudden hypertension Status epilepticus Drugs/toxins

What metabolic/endocrine disterbances can lead to coma?

Hypothyroid -> high or low Na Addisons -> high Ca Pan-hypopituitarism -> High or low glucose Renal or hepatic failure

What clues should you look for to try find cause of coma?

Temperature Breath Skin - rash, needle tracts, head injury RR - low: opiates? high: hyperuricemia, pneumonia Pulse - high:drugs + infection, low:hypertyroid BP- Low: trauma, shock, cardiac failure, high: CVAm SAH, RICP, drugs

What 4 things mean you can't reliably interpret somones coma + signs?

Hypothermia Metabolically deranged Sedated Endocrine disterbances - must correct before final judgement

What signs do you look for in coma?

Papilloedema - raised ICP UMN signs - unilateral? Meningism - meningitis or SAH Pupil responses + eye movements

What do different pupil responses mean in a coma?

Pinhole - opioids or pontine lesion Large - MDMA, cocaine Unilateral large - Raised ICP (about to cone), CNIII damage

What do eye movement signs show in coma?

Roving - intact brainstem Corneal reflex - intact brainstem Horizontal deviation - siezure, frontal lobe damage, pontine damage Oculocephalic response - dolls eyes - abnormal if low brainstem damaged

How do you asses brainstem function?

Pupils, corneal reflex, gaf reflex, response to hypercapnia, vestibuloocular reflex

What are the possible outcomes of coma?

Death Regions consciousness - good, dependant, minimally conscious Persistant vegetative state

What is persistent vegetative state?

Recovery of arousal but not awareness - no awareness, language or comprehension - have roving eye movements, brainstem reflexes are ok. - Maintains resp + circulatory independence, and sleep-wake cycle - due to diffuse cortical/subcortical damage

When is persistent vegetative state considered permanent?

>6 months if non-traumatic | >12 months if traumatic

What is minimally conscious state?

May make eye contact Turn head when spoken to Grasp objects, moths words, tracks objects Very severely disabled

What is locked-in syndrome?

De-efferenated motor tracts - no motor output below CNIII Blinking and vertical eye movements possible Awareness and arousal retained why? Pontine infarction, eg. basilar artery issue.

What us a psychogenic coma?

Psychologically generated coma - no organic cause Must exclude other causes Reflexes preserved Tuning fork in nose!

Case: 77 year old lady, medical ward, progressively more drowsy and disorientated, now unable to rouse. HAs roving eye movements, pupils are midsized and reactive, opens eyes in response to pain, makes grunts, reflexes symetrical and brisk. What are her possible causes of coma and what investigations are needed?

Metabolic - do BM Stroke - CT head Tumour - CT Head Post-MI - ECG Accidental OD - look at chart Meningitis/encephalitis - Temp, FBC

23 year old girl brought into A+E in coma. Shallow resp, hypoxic, small pupils, absent corneal reflex, absent oculo-vestibular reflexes, flaccid limbs, no response to pain, refleces absent. BP was 80/50. GCS 3. What possible causes? What history needed? What action?

? Opiate OD ? Basilar artery thrombosis, Trauma? - Drug history, self harm? onset, what happened before? - ABCDE, naloxone, BM, blood toxicity, MRI or MRA

What is an example of an autosomal dominant neuogenetic disease?

TS - tuberous sclerosis complex

What features are seen in tuberous sclerosis?

``` Ashleaf macules Cafe au lait spots Dermal neurofibromas Optic nerve glioma Astrocytic harmatoma (lesion on eye) Periungal fibromas (nails) Facial angiofibromas (liek acne) Rhabdomyoma (polps on heart) Angiomyolipoma (fatty tumour on kidney) ```

What is an example of an autosomal recessive neurogenetical disorder?

Tay Sachs - course features, neuro-degeneration secondary to lipofuscin deposition in brain. Cherry red spot on retina

What are some X linked genetic disorders?

Duchenne muscular dystrophy Becher Muscular dystrophy Fragile X Heamophillia

What are some mitochondirally inherited genetic disorders?

Leber's herediatary optic neuropathy Kearn's sayre Pearsons syndrome MELAs

232 - Epilepsy Flashcards

(47 cards)