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FRCS Part 1 > Ch 26 & 27 Seizures > Flashcards

Ch 26 & 27 Seizures Flashcards

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1
Q

How are seizures classified?

A

The ILAE 2017 operational classification of seizures is Focal, Generalised and Unknown. Focal seizures are divided into motor and non-motor and also into aware or impaired awareness. Generalised seizures are Motor or non-motor (absence). Unknown seizures are motor, non-motor or unclassified.

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2
Q

What are the different types of motor seizures?

A

Automatisms Atonic Tonic Clonic Myoclonic Epileptic spasms Hyperkinetic

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3
Q

What is the definition of a generalised seizure?

A

Bilateral hemispheric symmetrical and synchronous onset with loss of consciousness from the start (40% of all seizures)

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4
Q

What are clonic seizures?

A

Bilateral synchronous semirhythmic jerking with elbow flexion and knee extension

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5
Q

What are tonic seizures?

A

Sustained increase in tone. Characteristic cry or grunt.

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6
Q

What are absence seizures?

A

Impaired consciousness with no motor involvement and no post-ictal confusion. EEG shows 3 Hz spike and wave.

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7
Q

What are myoclonic seizures?

A

Shock-like body jerks with generalised EEG changes.

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8
Q

What are atonic seizures?

A

Sudden loss of tone that causes falls.

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9
Q

What are psychomotor seizures?

A

Alteration of awareness with automatisms and aura (usually epigastric rising sensation)

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10
Q

What is the characteristic feature of a seizure arising in the uncus?

A

Olfactory hallucinations - cacosmia = perception of a bad odour

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11
Q

What is the role of the hippocampus?

A

Spatial memory (dom), verbal memory (non-dom) and learning concepts

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12
Q

What are the common semiological features of a mesial temporal lobe seizure?

A

Behavioural arrest, staring, oral automatisms, posturing of the contralateral arm. Seizures last a few minutes and post-ictal confusion, amnesia and aphasia (if dominant side)

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13
Q

What are the characteristic EEG features in mesial temporal lobe epilepsy?

A

Rhythmic theta maximal in basal temporal electrodes

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14
Q

What is a wada test?

A

Intracarotid sodium amytal injection

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15
Q

What the features of juvenile myoclonic epilepsy?

A

Idiopathic generalised epilepsy syndrome characterised by myoclonic jerks after waking, generalised tonic-clonic seizures or absence. EEG shows polyspike discharges with the jerks. Strong family history. Responsive to valproate.

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16
Q

What is West syndrome?

A

Infantile spasms. Occurs in the first year of life with flexion and then extension of the trunk and limbs AKA salaam seizures. Seizures resolve by 5 years. Some may develop Lennox-Gastaut syndrome. HYPSARRHYTHMIA. Responds to ACTH or steroids.

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17
Q

What is HYPSARRHYTHMIA?

A

High amplitude spike and wave

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18
Q

What is Lennox-Gastaut syndrome?

A

Atonic seizures resulting in drop attacks

Medically refractory

Valproate reduces seizure frequency by 50%

Corpus callosotomy is treatment of choice

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19
Q

What factors lower seizure threshold?

A

Sleep deprivation

Hyperventilation

Photic stimulation

Infectins / Drugs / Metabolic disturbances

Trauma / Stroke

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20
Q

What is Todd’s paresis?

A

Post-ictal weakness due to involvement of the motor cortex in the functional deficit zone

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21
Q

What are the classes of antiepileptic medications?

A

Barbiturates - phenobarbital

Benzodiazepines - lorazepam / diazepam

GABA analogues - gabapentin

Voltage gated sodium channel blockage - phenytoin

Synaptic vesicle protein (SV2A) blockage - levetiracetam

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22
Q

Which antiepileptic drugs interfere with platelet function?

A

Valproate and Phenytoin

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23
Q

What is the drug of choice for GTCS?

Study These Flashcards
A

Valproate

Phenytoin

24
Q

What is the drug of choice for absence seizures?

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A

Ethosuximide and valproate

25
What is the drug of choice for focal seizures?
Carbamazepine Phenytoin Levetiracetam (Valproate is second line)
26
What is the action of sodium valproate?
Voltage gated sodium channel blocker Calcium channel 'T current' blocker
27
What are the pharmacokinectics of phenytoin?
1st order (eliminiation proportional to concentration) then zero-order (elimination at constant rate i.e. eliminiation saturated). Half-life 24 hours. Aim for therapeutic levels 10-20 mcg/ml. Serum binding is affected by urea and albumin levels i.e. the active phenytoin level is higher than expected (because 90% is protein bound).
28
How does NG feed affect phenytoin levels?
Absorption is decreased by 70% when given with NG feeds. The feed should be held for 2 hours before and 1 hour after.
29
What are the cardiac effects of phenytoin?
Hypotension Arrhythmias (Should be given as slow IV with cardiac monitoring and BP check at a max rate of 50 mg / min). Note the loading dose is 18 mg / kg and maintenance is 300-500 mg per day i.e. 100 mg TDS.
30
What are the advantages of fosphentoin?
Fosphenytoin is a prodrug that is converted to phenytoin Less venous irritation Can be given IM Less arrythmias and can be given 2x as fast as phenytoin therefore.
31
What are the side effects of phenytoin?
Cognitive slowing SLE-like syndrome Megaloblastic anaemia Cerebellar degeneration Gingival hypertrophy Neonatal haemorrhage TEN / Steven-Johnsons Osteoporosis / rickets Teratogenic
32
What factors require phenytoin dose adjustment?
Albumin and Ureamia (Renal failure without uraemia does not need adjustment)
33
How do you prescribe Carbamazepine?
Start at 200 mg PO /day and increase dose weekly and checking levels. Normal adult dose is 600mg - 2000 mg /day. Aim for therapeutic levels of 6-12 mcg/ml
34
What effect does carbemazepine have on hepatic enzymes?
Auto-induction - induces the hepatic enzymes to increase metabolism of itself and other drugs
35
What are the common signs of carbamazepine toxicity?
Leucocytopenia Diplopia Ataxia Marrow suppression SIADH Steven-Johnsons syndrome
36
What is the benefit of oxcarbazepine over carbamazepine?
No need for monitoring No Cytochrome P450 induction so minimal drug interactions BD dosing Linear kinetics
37
What is the main concern with valproate in women of child bearing age?
Causes neural tube defects
38
What is the drug of choice for absence seizures?
Ethosuximide
39
How do you manage an adult with a new onset seizure?
History / examination Bloods to rule out infectious or metabolic causes EEG +/- sleep deprivation EEG MRI
40
What is the incidence of seizures within the first 7 days of a severe head injury?
30%
41
What is the risk of post-traumatic seizures following a penetrating head injury?
50%
42
What is the role of seizure prophylaxis follwing head injury?
In severe head injury phenytoin reduces risk of seizures by 73% for the first week but does not affect long term seizure rates. (Ref Temkin et al NEJM 1990 Double blinded RCT)
43
What features are suggestive of non-epileptic seizures?
Arching of the back Asychronous movements Forced eye closure Bilateral shaking with preserved awareness Weeping
44
What is the definition of status epilepticus?
Sz\>5 minutes or persistent sz activity after 1st and 2nd line AEDs
45
What % of seizures that persist \>5 mins will continue \>1 hour?
60%
46
What is the management of status epilepticus?
ABCs Bloods incl glucose, electrolytes & AED levels Lorzepam / midazolam / diazepam \> phenytoin / levetiracetam / valproate \> I&V midazolam or propofol \> If continues to sz despite above then phenobarbital CT head \*\* If low glucose give thiamine first to prevent wernicke's encephalopathy
47
What is the treatment for myoclonic status?
Valproate
48
What is the management of absence status?
Diazepam
49
How does Carbamazepine work?
Blocks voltage-gated Na channels. Risk of marrow suppression, stevens johns syndrome and hepatitis
50
How does Valproate work?
Voltage gated Na channels GABA action T-type Ca channels Side effects are teratogenicity, thrombocytopaenia, hepatotoxicity and high ammonia
51
How does Gabapentin work?
Voltage gated Ca channel blockade GABA-B receptor blockade
52
How does ethosuxamide work?
T-type Ca currents in the thalamus. Used for absence seizures!
53
How does perampanel work?
AMPA antagonist
54
How does phenytoin work?
Voltage-gated Na channel blockade
55
Which AED causes weight loss?
Topiramate

FRCS Part 1 (85 decks)

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