epilepsy

Question 1

management of generalised tonic-clonic seizures

Answer 1

males - sodium valporate

females - lamotrigine or levetiracetam

(girls under 10 + unlikely to need treatment when they are older may be offered sod val)

Question 2

management of focal seizures

Answer 2

1st - lamotrigine or levetiracetam

2nd - cabamazepine, oxcarbazepine

Question 3

absence seizure management

Answer 3

1st = ethosuximide

2nd
male - sodium valporate
female - lamotrigine or levtiracetam

(carbamazepine may exacerbate)

Question 4

myoclonic seizures management

Answer 4

male - sodium valporate

female - levetiracetam

Question 5

management of tonic or atonic seizures

Answer 5

male - sodium valporate

females - lamotrigine

Question 6

generalised tonic-clonic seizure

Answer 6

loss of consciousness
tonic (muscle tensing) - comes first
clonic (muscle jerking)

may be assoc tongue biting, incontinence, groaning

after seizure - post ictal period, confused, drowsy

Question 7

focal seizures

Answer 7

start in temporal lobes
affect hearing, speech, memory + emotions
- halluconations, memory flashbacks
- deja vu, doing strange things on autopilot

Question 8

atonic seizures

Answer 8

drop attacks - brief lapses in muscle tone
dont usually last more than 3min
typically begin in childhood

Question 9

myoclonic seizure

Answer 9

sudden brief muscle contractions - jump
patient usually awake
typically in kids as part of juvenile myoclonic epilepsy

Question 10

general MoA of antiepileptic drugs (AEDs)

Answer 10

raising threshold + reducing liklihood of patient having a seizure

Question 11

sodium valporate

Answer 11

increases activity of GABA, relaxing effect

SE -
- teratogenic
- liver damage, hepatitis
- hair loss, weight gain
- tremor
- enzyme inhibitor

Question 12

carbamazepine SE

Answer 12

agranulocytosis
aplastic anaemia
indices P450 system so there are many drug interactions

Question 13

phenytoin SE

Answer 13

acute management ONLY

folate + vit D deficiency
megoblastic anaemia - folate deficiency
osteomalacia - vit D deficiency

Question 14

ethosuximide SE

Answer 14

night terrors
rashes

Question 15

lamotrigine SE

Answer 15

stevens-johns syndrome
leukopenia

Question 16

status epilepticus

Answer 16

seizure lasting more than 5 min or 2 or more seizures without regaining consciousness

Question 17

status epilepticus management

Answer 17

secure airway, high conc O2, assess cardiac/resp function, check blood glucose

IV lorazepam

10mg after 10mins, wait 5 mins then another 10mg, no more than 2 doses

if continuing after 20mins with reatment -> phenytoin
if persists induce general anaesthesia (propofol, thiopentone)

Question 18

status epilepticus management community

Answer 18

buccal midazolam
rectal diazepam

10mg after 10mins, wait 5 mins then another 10mg, no more than 2 doses

if continuing after 20mins with reatment -> phenytoin

Question 19

anticonvulsants

Answer 19

phenytoin - acute only
sodium valporate
lamotrigine
levetiracetam
topiramate

gabapentin, pregabalin

Question 20

levetiracetam

Answer 20

very popular
few interactions with other meds
causes mood swings - avoid in depression

Question 21

topiramate

Answer 21

SE = weight loss, sedation, dyphasia, psychosis

very affective in those with learning difficulties

Question 22

ladies and anticonvulsants

Answer 22

some anticonvulsants can induce hepatic enzymes
- carbamazepine, oxcarbazepine, phenobarbitol, phenytoin, primidone, topiramate

can alter efficacy of COCP
shouldnt use POP - depot progesterone needs more frequent dosing, progesterone implants not effective

Question 23

morning after pill in epilepsy

Answer 23

not adequate if taking enzyme inducing AEDs - dose should be increased

Question 24

women + sodium valporate

Answer 24

If women of childbearing age – shouldn’t take sodium valproate even if on contraception

• Balance risk of uncontrolled seizures vs teratogenicity
  o Sodium val taken later in pregnancy can cause autism
• Folic acid + vit K

Question 25

primary generalised epilepsy

Answer 25

Abnormal discharge across cortical network - Most have genetic predisposition - Often present childhood or teens - Present in childhood + adolescence, generalized spike-wave abnormalities on EEG tonic clonic, myoclonic, atonic, absence

Question 26

management of primary generalised epilepsy

Answer 26

men - sodium valporate women - lamotrigine

Question 27

generalised tonic-clonic seizures

Answer 27

loss of consciousness + tonic (muslce tensing) + clonic (muscle jerking episodes

Question 28

juvenile myoclonic epilepsy

Answer 28

typical onset in teenage years, commoner in girls infrequent generalised seizures, often in morning/following sleep deprivation daytime absences risk factors - sleep deprivation, flashing lights MX = sodium valporate

Question 29

how can antiepileptics medications interfere with other medications?

Answer 29

can induce/inhibit the P450 system resulting in varied metabolism of other medications - eg warfarin

Question 30

how can a focal seizure become generalised?

Answer 30

if focal seizure hits cortical pathways -> spread in brain + secondary generalised seizure

Question 31

tonic vs clonic

Answer 31

Tonic = lose consciousness, body stiff, may fall. Clonic = limb jerk, bladder/bowel control loss, tongue bite.

Question 32

epilepsy and driving

Answer 32

1st seizure - car = 6months - HGV = 5yrs epilepsy - car = seizure free for 1yr (3if during sleep) with/without meds - HGV = 10yrs off medication

Question 33

focal seizure in temporal lobe presentation

Answer 33

motor -> Autonomic movements: chewing, repetitive body movement (jerking, posturing etc). sensory -> Olfactory sensation, rising feeling in stomach, auditory psychic -> Memories, déjà vu, jamais vue (staring blankly)

Question 34

focal seizure in frontal lobe presentation

Answer 34

Head/eye deviation, urinary incontinence, vocalisation, bizzare behaviour Head/leg movements, posturing, post-ictal weakness, Jacksonian march

Question 35

focal seizure in parietal lobe presentation

Answer 35

altered somatoensation, Paraesthesia -> sensory modalities that are associated with touch, proprioception, and interoception. These modalities include pressure, vibration, light touch, tickle, itch, temperature, pain, proprioception, and kinesthesia.

Question 35

focal seizure in occipital lobe presentation

Answer 35

visual symptoms - flashers/floaters

Question 36

risks of status epilepticus

Answer 36

hypoxia rhabdomyolysis hyperthermia (->hypotension->hypoperfusion to heart) aspiration, brain damage long term cerebral effects -> break down of blood brain barrier causes fluid shift -> cerebral oedema

Question 37

types of status epilepticus

Answer 37

Generalized convulsive status epilepticus Non convulsive status  Conscious but altered state epilepsia partialis continua  Continual focal seizures, conscious preserved

Question 38

precipitants of status epilepticus

Answer 38

- Abrupt withdrawal of anti-convulsant - Treating absence seizures with CBZ - Severe metabolic disorders – hyponatremia, pyridoxine deficiency - Infection - Head trauma - Sub arachnoid haemorrhage