Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

PR3153 > CA Seizure and Epilepsy Clinicals > Flashcards

CA Seizure and Epilepsy Clinicals Flashcards

1
Q

Define seizures

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Define epilepsy

A

Any of the following
1. At least two unprovoked seizures occurring >24 h apart
2. One unprovoked seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years
3. Diagnosis of an epilepsy syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Patient suffered a stroke attack 10 days ago, admitted today for new onset seizure, is the seizure considered as acute or remote?

A

Remote

REMOTE: seizures that occur longer than 1 week following a disorder that is known to increase the risk of developing epilepsy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Distinguish between Acute/Remote/Unprovoked seizures

A

ACUTE: result from some immediately recognizable stimulus or cause

REMOTE: seizure ≥ 1 week after a disorder likely to cause seizure

UNPROVOKED: absence of potentially responsible clinical condition or beyond the time estimated for recurrent seizures from stimulus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

State some examples of etiology behind acute symptomatic seizures
* Metabolic
* Toxic substances/drugs
* Structural
* Infection/inflammation

A

Metabolic:
* Low sodium, calcium, magnesium, sugar
* High urea

Toxic subst/drugs:
* Illicit drugs (e.g. cocaine, amphetamines)
* Drugs (e.g. Tricyclic antidepressants, carbapenems, baclofen)
* Abrupt discontinuation of drugs
* Alcohol (withdrawl/ intoxication)
* Benzodiazepine withdrawal

Structural
* Stroke
* Traumatic Brain Injury

Infection/Inflammation
* CNS Infection
* Febrile illness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Define non-epileptic seizures. What are the 2 types of non-epileptic seizures?

A

Resemble epileptic seizures, but are not related to abnormal epileptiform discharges.

  1. Psychogenic (stressful/ psychological experiences/ trauma)
  2. Physiological (symptoms of paroxysmal systemic disorder)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is the pathphysiology of seizures? (hyperexcitability and hypersynchronisation)

A

Basic physiology: instability in a single neuronal cell membrane/ grp of cells around it
Characterised by synchronised paroxysmal discharges occurring in a large population of neurons within cortex

Hyperexcitability - enhanced predisposition of a neuron to depolarise
* Voltage/ ligand-gated K+, Na+, Ca2+, Cl- ion channels
* Abnormalities in intra & extracellular substances (e.g. K+, Na+, O2, glucose, etc)
* Excessive excitatory neurotransmitters (e.g. glutamine, acetylcholine, histamine, cytokines, etc)
* Insufficient inhibitory neurotransmitters (e.g. GABA, dopamine)

Hypersynchronisation (hippocampal sclerosis)
* Intrinsic reorganisation of local circuits - hippocampus, neocortex, thalamus
* Contribute to synchronisation & promote generation of epileptiform activity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are the 3 key features of ILAE Classification?
1. ________ of onset
2. ________ of consciousness
3. ________ components

A
  1. Mode of onset
  2. Impairment of consciousness
  3. Motor/ non-motor components (tonic/ atonic/ clonic/ myoclonic/ epileptic spasms, etc.)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is status epilepticus?

A

Seizure that lasts longer than 5mins, or having more than one seizure within a 5 min period, without returning to a normal level of consciousness between episodes

Medical emergency!!! Contact emergency services immediately

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is a focal seizure? State its signs and symptoms
* Motor
* Sensory
* Autonomic symptoms
* Somatosensory symptoms

A

Motor:
* Clonic movements (twitching/ jerking)
* Speech arrest (dysarthria)

Sensory:
* Numbness, tingling
* Visual disturbances (flashing lights)

Autonomic Symptoms:
* Sweating, salivation, pallor
* BP/HR

Somatosensory Symptoms:
* Flashbacks
* Hallucinations (visual, auditory, gustatory, olfactory)
* Affective symptoms (e.g. fear, depression, anger, irritability

Type and specific area of symptoms depends on which area of the cortex is affected, on the opposite side

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is a tonic clonic seizure? State its signs and symptoms

A
  • Begins with tonic phase, then clonic phase
  • During tonic phase, breathing might stop → cyanosis of nail beds, lips and face
  • Clonic phase lasts for 1 min, after which brain is hyperpolarised and insensitive to stimuli
  • Incontinence may occur, along with biting of the tongue or inside of the mouth; noisy & laboured breathing
  • Patient may have a headache after the seizure and appear lethargic, confused or sleepy
  • Full recovery in several minutes to hours
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is a tonic seizure? State its signs and symptoms

A

Sudden loss of consciousness & rigid posture of entire body (10-20 secs)
Occur to all ages for patients with diffuse cerebral damage & learning disability

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What is a clonic seizure? State its signs and symptoms

A

Clonic jerking (asymmetrical & irregular)
Frequent in neonates, infants or young

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is a myoclonic seizure? State its signs and symptoms

A

Involves rapid, brief contractions of bodily muscles, usually occurring on both sides of the body concurrently.
Occasionally involve just one arm/foot

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is a atonic seizure? State its signs and symptoms

A
  • Classic drop attack; all postural tone is suddenly lost, collapsing onto the ground
  • Short episode, then immediate recovery
  • Occur to all ages for patients with diffuse cerebral damage & learning disability
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Tonic and atonic seizures are common in:

A

Lennox-Gastaut syndrome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is an absence seizure? State its signs and symptoms

A
  • Manifests as basic lapse of awareness that begins and ends abruptly
  • Lasts a few seconds, no warning, no after-effects
  • More common in children than adults
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

The difference of absence seizures from complex partial seizures is that absence seizures:
* Not preceded by ________
* Lasts ________
* Begin ________, end ________
* Produce ________ on EEG

A
  • Not preceded by auras
  • Lasts seconds (not minutes)
  • Begin freqeuntly, end abruptly
  • Produce 3Hz spike waves on EEG
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What are the first line treatments for tonic clonic seizures?

A
  • Carbamazepine
  • Lamotrigine
  • Sodium Valproate
  • If only tonic: Sodium Valproate
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are the first line treatments for absence seizures?

A
  • Lamotrigine
  • Sodium Valproate
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What are the first line treatments for myoclonic seizures?

A
  • Levetiracetam
  • Sodium Valproate
  • Topiramate
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What are the first line treatments for atonic seizures?

A
  • Levetiracetam
  • Sodium Valproate
  • Topiramate
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What are the first line treatments for focal seizures?

A
  • Carbamazepine
  • Lamotrigine
  • Levetiracetam
  • Sodium Valproate
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What is the difference between focal (partial) and generalised seizures

A
  • Focal: begin in only one hemisphere
  • Generalised: begin in both hemispheres

Secondary generalised: first begins as focal, then spreads to the contralateral hemisphere such that in the end, both hemispheres are affected

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What are some differential diagnosis of seizures?

A
  • Syncope vs seizure
  • TIA
  • Migraine
  • Psychogenic nonepileptic seizures
26
Q

State some classes of drugs known to lower seizure threshold

A
  • Antimicrobials (high dose β-lactams) - Carbapenems
  • Analgesics (opioids)
  • Antineoplastics (anti-cancer)
  • Antipsychotics (overdose)
  • Phenothiazines
  • Immunosuppressants
  • Theophylline
27
Q

List some triggers of seizures

A
  • Physical and emotional stress
  • Photo/ sensory stimulation
  • Sleep deprivation
  • Alcohol
  • Hyperventilation
  • Infection
28
Q

What are the 3 lab tests and investigations used for seizures? What are their functions?

A
  1. Scap electroencephalography (EEG): epileptiform discharged
  2. MRI with Gadolinium: identify any focal lesions (sclerosis, injury, tumor, etc.)
  3. Biochemical/ toxicology: rule out electrolyte abnormalities (renal panel)
29
Q

True or false?

A symptomatic epileptic patient with a normal EEG has epilepsy.

A

False
But a normal EEG does not rule out epilepsy, but doesn’t rule in as well

30
Q

True or false?

A perfectly normal patient (with no epilepsy symptoms) with an abnormal EEG has does not have epilepsy.

A

True
EEG can be abnormal in normal persons

31
Q

Video EEG used if routine EEG insufficient, can be ________ and ________

A

Video EEG used if routine EEG insufficient, can be expensive and labour-intensive

32
Q

What type of patients is MRI with gadolinium recommended for?

A

For adult patients with first seizure, patients with focal neurologic deficits, and potential focal onset seizure

33
Q

First Aid for Seizures
* Ease the person to ________
* ________ the person gently ________. This will help the person ________
* ________ the area around the person of anything ________. This can prevent ________
* Put something ________, like a folded jacket, under his or her ________
* Remove ________
* ________ ties or anything around the neck that may make it hard to ________
* ________ the seizure. Call 911 if the seizure lasts longer than ________

A
  • Ease the person to the floor
  • Turn the person gently onto one side. This will help the person breathe
  • Clear the area around the person of anything hard or sharp. This can prevent injury
  • Put something soft or flat, like a folded jacket, under his or her head
  • Remove eyeglasses
  • Loosen ties or anything around the neck that may make it hard to breathe
  • Time the seizure. Call 911 if the seizure lasts longer than 5 minutes
34
Q

True or false?

A patient is newly diagnosed with tonic epilepsy. He has seizure episodes around 10 times per month, with it lasting less than 5 minutes each time. He has complained of it affecting his daily life. He should be started on medications immediately,

A

True
Before starting treatment, consider:
* Recurrence Risk - cause, epileptic syndrome, EEG findings
* Potential seizure morbidity - seizure type
* Risk of treatment - tolerability
* Personal Circumstances - Work, need driving licence, desire to bear children

Since it has affected his quality of life significantly, should start treatment

35
Q

A patient is newly diagnosed with focal epilepsy. He has seizure episodes about once month, with it lasting less than 2 minutes each time. He states that his seizures have not significantly impacted his daily life, and expressed hesitancy to starting medications. Regardless, he should be started on medications immediately,

A

False
Studies have shown early treatment of seizure does not improve long term prognosis or lowered risk of death / injuries/ status epilepticus

∴ can actually watch and wait, no need start treatment

Germ: lemme know if yall accept this reasoning or not haha, the main point was to reinforce that don’t need to always start meds straight away, it all depends on the patient and their preference

36
Q

When do we monitor TDM for ASM patients?
1. To establish patient’s ____________
2. To assess ____________ (…..)
3. To assess ____________ (…..)
4. To assess potential ____________ (…..)

A

1. To establish patient’s effective therapeutic range
2. To assess lack of efficacy (Fast metabolizers? Adherence issues?)
3. To assess loss of efficacy (Changes in physiology, pathology, formulation, DDIs)
4. To assess potential toxicity (Changing physiology? Slow metabolizers? Changes in disease/drugs? Concentration-dependent A/Es)

37
Q

When can ASMs be discontinued?

A

After a minimum of 2 years without a seizure

Decision to stop medication involves a balance of the risks of continuation (chronic toxicity, teratogenicity) with the implications of relapse (injury, SUDEP, employment)

38
Q

When is epilepsy considered to be resolved for individuals who had an age-dependent epilepsy syndrome?

A

Are now past the age/seizure-free for last 10 years, and without ASMs for last 5 years

39
Q

How many medications should a newly diagnosed epileptic patient be given initially?

A

One ASM

Choose meds based on seizure classification, comorbidities, and SEs

40
Q

A patient has been on 1 ASM for the past 3 months. He has not achieved seizure freedom yet, and complains of intolerable SEs from the medication. What should you do?
A. DIscontinue ASM
B. Decrease dose of ASM
C. Increase dose of ASM
D. Add second ASM

A

B and D (decrease dose first, then add on second med)

41
Q

A patient has been on 1 ASM for the past 3 months. He has achieved seizure freedom, but complains of intolerable SEs from the medication (dizziness, fatigue). What should you do?
A. DIscontinue ASM
B. Decrease dose of ASM
C. Increase dose of ASM
D. Add second ASM

A

B

42
Q

A patient diagnosed with focal epilepsy is initially on carbamazepine, and was seizure-free 40% of each month. The doctor then added on lamotrigine, and became 100% seizure-free 2 months ago. He does not complain of any intolerable side effects. What should you do?
A. Discontinue carbmazepine
B. Discontinue lamotrigine
C. Decrease dose of carbamazepine
D. Continue current treatment

A

A
Can consider removing first ASM, which is carbamazepine

Could also be because carbamazepine is less effective than lamotrigine (40% vs 60%), thus you would discontinue carbamazepine first

43
Q
A
44
Q

When do you consider the use of ketogenic diet for seizure patients? Explain how does ketogenic diet help to reduce seizure frequency.

A

For patients who cannot tolerate / unresponsive to ASM

Rationale: Induction of ketosis → anaerobic metabolism → slows energy availability → ↓ seizure likelihood

45
Q

A patient on carbamazepine has achieved seizure freedom 25 months ago. He does not complain of any intolerable side effects. What should you do?
A. Can discontinue carbamazepine immediately
B. Slowly taper down dose of carbamazepine
C. Add on lamotrigine
D. Continue current treatment

A

B
Can consider withdrawal of ASM after being seizure free for 2 years.
But (as with all CNS drugs), cannot just immediately discontinue the drug, need to slowly taper down the dose

46
Q

When is Vagus Nerve Stimulation indicated?

A

Indicated in intractable focal seizures

Intractable = unresponsive

47
Q

When is Responsive Neurostimulator system indicated in seizure patients?

A
  • Indicated in patients with localised ≤ 2 epileptogenic foci (diagnostically tested)
  • Indicated in patients refractory to ≥2 ASMs
  • Indicated in patients with frequent, disabling symptoms
48
Q

Briefly recall some psychosocial issues that seizure patients might face.

A

Social Stigma (Marriage, starting a family)

Employment
Epileptic people require more time away from work for medical follow ups
Higher costs borne by employer

Prohibited from driving, depending on country
SG is prohibited completely

Caregiver burden (childhood epilepsy)

Comorbidities
Poorer health outcomes, ↑ health care needs, ↓ QoL, ↑ social exclusion, intellectual disability

49
Q

Which ASMs are associated with congenital malformations in pregnancy?

A

Carbamazepine, phenobarbital, phenytoin, topiramate

Mostly Gen 1 + topiramate

50
Q

A patient diagnosed with focal epilepsy is initially on carbamazepine, and was seizure-free 40% of each month. The doctor then added on lamotrigine, which has only helped him be seizure-free 60% of each month. He does not complain of any intolerable side effects. What should you do?
A. Discontinue carbmazepine
B. Discontinue lamotrigine
C. Increase dose of carbamazepine
D. Increase dose of lamotrigine
E. Continue current treatment

A

D, Increase dose of second ASM

Good to also check for interactions and compliance

51
Q

Which ASMs are associated with increassed neurodevelopment risk when used during pregnancy?

A

Valproate, Phenobarbital, phenytoin, topiramate

Mostly Gen 1 + topiramate

52
Q

Which ASMs are safer in pregnancy / women of childbearing age?

A

Levetiracetam & Lamotrigine

(Valproate should not be used UNLESS RLLY CMI)

53
Q

What is the minimum discontinuation period for a Man on Valproate if he wishes to have a child?

A

3 months. Cannot donate sperms also

54
Q

A patient diagnosed with focal epilepsy is initially on carbamazepine, and was seizure-free 40% of each month. The doctor then added on lamotrigine, which has only helped him be seizure-free 60% of each month. He complains of debilitating headaches and drowsiness, which is affecting his QoL. What should you do?
A. Discontinue carbmazepine
B. Discontinue lamotrigine
C. Increase dose of carbamazepine
D. Increase dose of lamotrigine
E. Continue current treatment

A

B
Remove least effective ASM (lamotrigine only helped by 20% VS carbamazepine with 40%), and add another ASM in place of lamotrigine

55
Q

What are 2 potential causes of status epilepticus?

A
  • Failure of mechanisms for seizure termination
  • Initiation of mechanisms leading to abnormally prolonged seizures
56
Q

Can a woman on ASM breastfeed?

A

YES!

WPS say the child borne by breastfeeding woman taking Valproate (under no choice circumstance) during pregnancy has higher IQ than that of a woman who discontinued Valproate during pregnancy!

TLDR: Can.

57
Q

What are the potential long term consequences of status epilepticus?

A

Neuronal death / injury, alteration of neuronal networks

58
Q

What are the important steps taken during the stabilisation phase of a patient with status epiliepticus?

A

Stabilise patient, time the seizure, check glucose.

Stabilise Patient (airway, breathing, circulation, disability)

Time Seizure (from onset)

If glucose < 60 mg/dL,
Adults: 100mg thiamine IV then 50mL D50W IV
Children ≥ 2y: 2ml/kg D25W IV
Children < 2y: 4ml/kg D12.5W IV

59
Q

For status epilepticus caused by tonic-clonic seizures:
* Prolonged seizure: ____ minutes
* Onset of long term consequences: ____ minutes

A

5 and 30 minutes respectively

60
Q

What should be administered as first line for patients with status epilepticus? During the inital therapy phase.

A

BENZODIAZEPIENS
(then wait 20mins to see if seizure stops)

IM Midazolam
(10 mg for > 40kg,
5mg for 13-40kg,
single dose)

IV Lorazepam (0.1mg/kg/dose,
max 4 mg/dose,
may repeat dose once)

IV Diazepam
(0.15-0.2mg/kg/dose,
Max 10mg/dose,
may repeat dose once)

61
Q

True or false?

If a patient with status epilepticus treated with IV Lorazepam continues seizuring after 20 mins, add on IV Fosphenytoin (20 mg PE/kg, single dose)

A

FALSE!
Not add on, switch to any second therapy phase treatment.

IV Fosphenytoin
(20 mg PE/kg, single dose)

IV Valproic acid
(40 mg/kg, max 3000mg/dose,
single dose)

IV Levetiracetam
(60 mg/kg,
max 4500mg/dose,
single dose)

62
Q

Select all that apply.

Patient with status epilepticus unresponsive to all treatments even after 40 mins. What should you do?
1. Adminster IV Diazepam a a higher dose.
2. Administer IM Midazolam at a anaesthetic dose.
3. Administer IV Fosphenytoin single dose.
4. Conduct EEG monitoring.

A

2, 3, 4.

Repeat second line therapy or anaesthetic doses of either thiopental, midazolam, pentobarbital, propofol (with EEG monitoring)

PR3153 (10 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions