Epilepsy

Question 1

Definition

Answer 1

Recurrent spontaneous intermittent excessive electrical activity in part of brain causing seizure.

Question 2

Aetiology

Answer 2

Often idiopathic, possibly due to channelopathies.
Structural- cortical scarring, developmental, SOL, stroke, sclerosis, vascular malformation.
Sarcoidosis, SLE

Question 3

Symptoms

Answer 3

Various types of seizure, see other cards.
Sometimes triggers.
In general distrubed conciousness, behaviour, emotion, motor function, sensation.

Question 4

Management

Answer 4

Drugs
Surgical resection
Acutely may need paralysis and intubation.

Question 5

Partial seizure

Answer 5

One hemisphere, focal onset with site specific features.

• Simple- retain awareness, often precursor to larger seizure (aura). Focal motor, sensory, autonomic or psychic symptoms.
• Complex- lose awareness, odd behaviour eg lip smacking. Commonly temporal lobe= post ictal confusion.
• Secondary generalisation- electrical disturbance starts focal and spreads widely.

General symptoms eg amnesia, los bladder tone. Headache, drowsy.

Question 6

Frontal lobe partial seizure

Answer 6

Abnormal head movement
Swearing and shouting
Unusual posturing
Repeated movements eg rocking

Question 7

Temporal lobe partial seizure

Answer 7

Deja vu
Strange taste or smell
Rising sensation in stomach
Lip smacking, swallowing, chewing

Question 8

Parietal lobe partial seizure

Answer 8

Abnormal sensation
Feeling like body part missing
Hallucinations
Cant understand language or reading

Question 9

Occipital lobe partial seizure

Answer 9

Hallucinations
Disturbed vision
Eye pain
Nystagmus

Question 10

Generalised seizure

Answer 10

Both hemispheres so cross corpus callosum. Simultaneous throughout cortex. Impaired conciousness.

• tonic clonic- LOC, stiffen, jerk, loss bladder control, tongue bite, respiratory arrest. Post ictal confusion and drowsy.
• atonic- sudden loss tone, no LOC.
• myoclonic- sudden jerking limb, face or trunk.
• absence- under 10 seconds. Unresponsive pause. May be blinking or slight jerking. Often in kids.

Question 11

Diagnosis

Answer 11

Often clinical
Seizure characteristics
Triggers? Eg photic and hyperventilation.
EEG supports diagnosis only.
Check bloods, glucose, electrolytes, LFT, UE, ECG.

Question 12

Management

Answer 12

AED depends on type
-VGSC blocker eg carbamazepine, phenytoin, lamotrigine.
-benzodiazepine GABA enhancement.
-valproate decrease GABA breakdown and increase synthesis.
Emergency management if over 5 mins-
buccal midazolam
ABCDE
Blood glucose
IV lorazepam, IV phenytoin.
Look for cause eg drug, withdrawal, electrolytes, infection.
Surgery if very severe.

Question 13

Differentials

Answer 13

Syncope
Arrhythmia
TIA
Migraine
Sleep disorder
Panic attack
-Non epileptic causes-
Trauma
Stroke
Haemorrhage
RICP
Alcohol or benzo withdrawal
Hypoxia, electrolytes, glucose, urea
Liver disease
Infection eg meningitis, syphillis, HIV
Drugs eg TCA, cocaine, tramadol, theophylline. 
Pseudoseizures.

Question 14

AED in pregnancy

Answer 14

Lomotrigine safest, including during breast feeding.

Valproate teratogenic

Question 15

AEDs by seizure type

Answer 15

-generalised tonic clonic- valproate or lamotrigine 1st line. Then carbamazepine.
-absence- valproate, lamotrigine, ethosuximide.
-other generalised eg atomic, myoclonic- same as tonic clinic but NOT carbamazepine.
-partial- carbamazepine 1st line. Then valproate, lamotrigine etc.
Aim for monotherapy. Start low dose.

Question 16

Complications

Answer 16

Status epilepticus convulsions over 5 mins. Tx with IV lorazepam or phenytoin.
Brain dysfunction or damage.

Question 17

Important benzo points

Answer 17

-benzodiazepines-
Lorazepam for status epilepticus
Clonazepam for absence ST
AE- sedation, tolerance, confusion, lack coordination, agression, dependance, withdrawal can trigger seizure.
OD reversed by IV flumazenil but this can trigger seizure or arrhythmia.

Question 18

Important valproate points

Answer 18

Used for all types
Less severe AE eg sedation, ataxia, tremor, weight gain, transaminase increase, nausea.
Inhibited by antiDs and antipsychotics.
Aspirin competes binding.
Monitor plasma level, blood, hepatic and metabolism disorders.

Question 19

Phenytoin important points

Answer 19

Not used for LT control
Not usd for absence
IV acutely as therapeutic level reached fast
AE- gingival hyperplasia, ataxia, dizzy, headache, nystagmus, anxiety, hypersensitivity, tremor, dysarthria, decreased intellect, depression.
Non linear PK, very variable dose responses.
Monitor plasma level.
Compete for binding with valproate, NSAIDs.
OCP decrseas, cimetidine increases.

Question 20

Lamotrigine important points

Answer 20

1st choice in adults NOT paeds as ADRs
Safer in pregnancy. 
Used for all types
Less AE. Occasional rash and hypersensitivity, blurred vision, photosensitvity, tremor, vomiting, agitation, aplastic anaemia. 
No CYP induction
Use with other AEDs
Valproate binding completion. 
OTC decreases plasma level.

Question 21

Carbamazepine important points

Answer 21

Not for absence
Contra indicated in AV conduction problems
AE include BP fluctuation, hypoNa, neutropenia, parasthesia, motor, blurred vision, diplopia, balance.
Induces own CYP metabolism.
Warfarin, phenytoin, OCP and systemic CS all decrease.
AntiD interfere
Monitor effect and adjust dose as levels fall.

Question 22

Explanation

Answer 22

-Epilepsy is when you have seizures due to abnormal excitation in brain. The seizures can range from causing jerking involuntary muscle movements to just being short losses of alertness that can look like daydreaming.
-with treatment it can be well controlled. If not there is slight risk of brain damage with repeated seizures. Also risk of injury if tonic clinic seizure.
-you should carry with you emergency medicine and wear an alert bracelet. Also try to avoid any triggers if possible. Compliance to medication is important.
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