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C3 CLINICAL > Clinical presentation, Epidemiology and Treatment of Epilepsy > Flashcards

Clinical presentation, Epidemiology and Treatment of Epilepsy Flashcards

1
Q

What is the definition of epileptic seizures?

A

Epileptic seizures are synchronous and excessive discharge in the cerebral cortex that lead to a clinically discernible event

  • many different seizure types depending in which area of the cerebral cortex the discharges originate
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2
Q

Why is it important to classify seizures?

A
  1. Categorisation
  2. Standardisation
  3. Communication
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3
Q

How to classify epilepsy?

A
  1. Seizure type
  2. Underlying aetiology or risk factor
  3. Syndrome
    - age at onset
    - topographic location of discharge
    - EEG findings
    - response to treatment
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4
Q

What are the classification of epilepsies?

A
  1. Seizure classification, ILAE 1981
  2. Epilepsy and Epilepsy Syndromes Classification, ILAE 1989
    - no imaging
    - no genetics
  3. Current Proposal, Epilepsia 2010
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5
Q

What are different types of classification of seizures, ILAE 1981?

A
  1. Generalised:
    - Generalised tonic-comic
    - Absences
    - Myoclonic
    - Atonic
    - Tonic
  2. Partial
    - simple partial
    - complex partial
    - secondarily generalised
  3. Unclassifiable
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6
Q

What are types of classification of seizures?

A
  1. Generalised

2. Focal

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7
Q

What are generalised seizures?

A

Originate at some point within, and rapidly engage, bilaterally distributed networks

Bilateral networks can include cortical and subcortical structures, not necessarily the entire cortex

Individual seizure onset’s can appear localised, the location and lateralisation are not consistent

Generalised seizures can be asymmetric

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8
Q

What are focal epileptic seizures?

A

Originate within networks limited to one hemisphere, which may be discretely localised or more widely distributed

For each seizure type, ictal onset is consistent with preferential propagation patterns

In some cases there is more than 1 epileptogenic network, and more than 1 seizure type

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9
Q

What is absence seizure?

A
  1. Blank stare
  2. Loss of consciousness
  3. Cessation of motor activity
  4. Blinking, eye-rolling, minor tone change
  5. Sudden onset, rapid recovery
  6. Brief, many attacks per day
  7. Usually in idiopathic generalised epilepsy (IGE)
  8. Generalised spike and wave discharge
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10
Q

What is Generalised tonic-clonic?

A
  1. Loss of consciousness and awareness
  2. Vocalisation - ‘epileptic cry’
  3. Fall (injury)
  4. Tonic phase then clonic jerking
  5. Tongue biting, incontinence, cyanosis
  6. Sudden onset, gradual recovery
  7. Post-ictal confusion, sleep, headache, myalgia
  8. Aura/partial features of secondarily generalised
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11
Q

What is Myoclonic jerks?

A
  1. Brief jerk, single or cluster
  2. One muscle —> generalised jerks
  3. Intensity: slight tremor —> large amplitude jerks
  4. Consciousness probably preserved
  5. IGE (diurnal pattern) - JME
  6. Symptomatic epilepsies - deficit, seizures ++
  7. Generalised spike and poly spike wave
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12
Q

What is focal seizures without impairment of consciousness (IOC) ?

A
  1. No alteration in consciousness
  2. No amnesia
  3. Sudden onset and cessation
  4. Focal symptoms or signs reflect seizure focus
  5. Due to focal cortical pathology
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13
Q

What are types of focal seizures (focal seizure without LoC)?

A
  1. Temporal: epigastric-rising, deja-vu, fear, auditory, olfactory
  2. Frontal: less clear, motor, sensory, odd
  3. Parietal: sensory, vertigo
  4. Occipital:visual
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14
Q

What are focal seizures with impairment of consciousness?

A
  1. Temporal: 2-4 minutes

2. Frontal: 15-30 seconds

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15
Q

What are funny turns?

A

48 year old electrician

  1. Deja-by, odd smells from childhood
  2. Looked blank during a conversation with boss
  3. Fiddled with fingers, blew a kiss
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16
Q

What is temporal lobe seizure?

A
  1. Aura (SPS)
  2. Altered consciousness (CPS)
  3. Amnesia
  4. Automatism (oro-alimentary, gestural)
  5. Rapid onset, gradual recovery
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17
Q

What is temporal focal seizure with impairment of consciousness?

A
  1. 2-4 minutes
  2. Behavioural arrest/ motionless state
  3. Contralateral hand posturing & ipsilateral hand automatism
  4. Orofacial automatism
  5. May continue simple tasks
  6. Speech retained or dysphasia during and/or after seizure
  7. May be confused post-Ictally
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18
Q

What is frontal focal seizure with impairment of consciousness?

A
  1. Brief stereotyped seizures, 15-30 seconds
  2. Frequent attack with clustering
  3. Nocturnal
  4. Sudden onset and cessation
  5. Complex bilateral motor automatism
  6. Head rotation and automatism: face, limbs, speech
  7. Secondary generalisation - interictal and ictal EEG variable
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19
Q

What are examples of other extra-temporal focal seizures?

A
  1. Central
  2. Parietal
  3. Occipital
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20
Q

What are examples of central extra-temporal focal seizures?

A
  1. Contralateral jerks (March)
  2. Contralateral sensory
  3. Posturing
  4. EEG often Norma
21
Q

What are examples of parietal extra-temporal focal seizures?

A
  1. Somatosensory
  2. Illusion of change in body size/shape
  3. Vertigo
  4. Gustatory
22
Q

What are examples of occipital extra-temporal focal seizures?

A
  1. Elementary visual hallucinations
  2. Visuo-spatial distortion
  3. Amaurosis
  4. Head turning (usually adversity)
  5. Eye-lid flutter, blinking, nystagmus
23
Q

What are the types of Epilepsy?

A
  1. Idiopathic
  2. Symptomatic
  3. Crypto genie

Range of causes

24
Q

What are epilepsy syndrome defined by?

A
  1. Age at seizure onset
  2. Seizure types
  3. Seizure frequency
  4. Precious medical history
  5. Family history
  6. EEG
  7. Brain imaging
25
Q

What are the classification of Epilepsies and Epilepsy syndromes, ILAE 1989?

A
  1. Localisation related (partial)
    - idiopathic
    - cryptogenic
    - symptomatic
  2. Generalised
    - idiopathic
    - cryptogenic
    - symptomatic
  3. Undetermined
    - with both partial and generalised features
    - without unequivocal partial or generalised features
26
Q

What is idiopathic generalised?

A

Childhood absence

27
Q

What is idiopathic partial?

A

Benign Rolandic

28
Q

What is symptomatic generalised?

A

Lennox-Gastuat

29
Q

What is symptomatic partial?

A

TLE with HS

30
Q

What is the Epilepsies: the new terminologies and structure?

A

Recognise epileptic syndromes

  • ongoing research to validate syndromes & discover new ones
  • syndromes can be used but not currently classifiable

Describe syndromes (where known) by aetiology:

  • genetic
  • structural/metabolic
  • unknown

Some syndromes may fit into more than one category

31
Q

What is the genetic of the epilepsy

A
  1. Direct result of a known or presumed genetic defect (a)
  2. Seizures are the core symptom of the disorder
    e. g. BFNS, Dravet, Childhood absence epilepsy

Is the term justified? What are the boundaries?

32
Q

What are the structural/metabolic of the epilepsy?

A

Distinct other condition is associated with a substantially increased risk of developing epilepsy e.g. trauma, tumour but also some inherited condition, TS

33
Q

What is the classification and syndromes: the future?

A
  1. Work in progress!
  2. Need for the epilepsy community to take this one
  3. Clear difficulties to use this in field work
  4. Revision for Epidemiological guidelines needed
34
Q

What is epilepsy?

A

Commonest serious neurological condition

  • affects >50 million people worldwide
  • globally distributing knowing more racial or geographic barriers
  1. Hugely stigmatised
  2. Heavy burden to society
35
Q

What are differing aspects of epilepsy

A
  1. Seizures - not there most of the time!
    - frequency and severity, unpredictability, safety
  2. Physical
    - impairment of function, mobility, morbidity, co-morbidity
  3. Emotional and behavioural
    - depression, anxiety, adjustment to circumstances
  4. Social and family functioning
    - relationships, dependence, family, leisure
  5. Cognitive and academic
    - schooling, employment, aspirations, expectations
36
Q

What is Epidemiology?

A

The study of the dynamics of a condition in a population
- therefore the “patient” is the community and not an individual

A sine qua non is that data must be derived or collected from an unselected population
- it must be community or general population based

Accurate diagnosis and case ascertainment methods are prerequisite
- a major problem in epilepsy

37
Q

What is the methodological problems II?

A
  1. Diagnostic accuracy
    - epilepsy can only be diagnosed by taking a history of the index event or by chance observation of a seizure
  2. Diagnosis is a discretionary judgement depending on skill and experience and quality of witness information available
  3. 10-20% of “chronic” cases referred to tertiary centres do not have epilepsy
  4. > 50% of cases suspected or diagnosed in primary care do not have epilepsy
38
Q

What is the methodological problems III?

A

The heterogeneity of the Epilepsies

  1. Erroneous to regard epilepsy as one diagnosis
  2. Parallels would be to regard cancer or anaemia as a single condition
  3. Most epidemiological studies oversimplify classifying only by seizure type or broad aetiological categories
  4. Death of data on epileptic syndromes
39
Q

What are incidence of new cases of epilepsy?

A
  1. Developed world: 40-80/100,000/year
    - 50/100,000/ year
  2. Resource-poor counties: 80-190/100,000/year
    - 120/100,000/year
    - few studies only (chile, Ecuador, Tanzania)
  3. Incidence of single seizures:
    - 20-30/100,000/ year
40
Q

What is the prevalence of epilepsy?

A

Plethora of studies (from > 30 countries)

  • wide variations
  • 2.5-57/1,000

Number of people with active epilepsy (independent of location)

  • 5-10/1,000
  • usually higher in rural areas
  • reports that more people have epilepsy in resource-poor counties in selected or isolated populations
41
Q

What are the incidence and prevalence in the UK?

A
  1. About 30,000 new cases a year
  2. Up to 350,000 of active cases
  3. Up to 80,000 cases of severe epilepsy
42
Q

What are rational prescribing?

A

Different mechanisms of action may be complementary

Optimal seizure control might be achieved by combining certain drugs

Sodium valproate and Iamotrigine

Other combinations:
Pharmacogenomics

43
Q

What are non-drug treatment of epilepsy?

A
  1. Vagal nerve stimulations
  2. Trigeminal nerve stimulation
  3. Deep brain stimulations
  4. Epilepsy surgery
44
Q

What is epilepsy surgery?

A
  1. Most evidence to support use
  2. Up to 70% seizure freedom rates
  3. High complication risk m
  4. Under provision worldwide
45
Q

What is vagal nerve stimulation?

A
  1. Peripheral implantation onto vague nerve
  2. Retrograde stimulation of deep Brian structures
  3. Reduction in seizure frequency up to 70%
  4. Sustained efficacy up to 10 years
  5. Hoarseness, throat discomfort
46
Q

What is deep brain stimulation?

A
  1. Sub-thalamus nucleus
  2. Limited evidence of efficacy
  3. Intracranial implantation
  4. Potential for seizure detection and early termination
  5. Watch this space
47
Q

What is Trigeminal Nerve Stimulation?

A
  1. Peripheral per-cutaneous stimulation
  2. Local side effects - irritations, pain, twitching
  3. ~50% seizure reduction rate
48
Q

What is drug development?

A

Suppressing excitation
Enhancing endogenous inhibition
Multiple potential students identified chemically
High throughput screening of thousands of compounds (e.g. Topiramate)
Modification of existing compounds (e.g. Eslicarbazepine)
Strategic design largely unsuccessful (e.g. Gabapentin)
Tested in animal models

C3 CLINICAL (27 decks)

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