Epilepsy

Question 1

Brief spasms beginning in first few months of life
1. Flexion of head, trunk, limbs → extension of arms (Salaam attack); last 1-2 secs, repeat up to 50 times
2. Progressive mental handicap
3. EEG: hypsarrhythmia
usually 2nd to serious neurological abnormality (e.g. TS, encephalitis, birth asphyxia) or may be cryptogenic
poor prognosis

Answer 1

Infantile spasms (West’s syndrome)

Question 2

May be extension of infantile spasms (50% have hx)
onset 1-5 yrs
atypical absences, falls, jerks
90% moderate-severe mental handicap
EEG: slow spike
ketogenic diet may help

Answer 2

Lennox-Gastaut syndrome

Question 3

paraesthesia (e.g. unilateral face), seizures characteristically occur at night

Answer 3

Benign rolandic epilepsy

Question 4

Typical onset in the teens, more common in girls
1. Infrequent generalized seizures, often in morning
2. Daytime absences
3. Sudden, shock-like myoclonic seizure
usually good response to sodium valproate

Answer 4

Juvenile myoclonic epilepsy (Janz syndrome)

Question 5

Other features to ask

Answer 5

Tonge-biting
Incontinence
Post-ictal

Question 6

Investigations of epilepsy

Answer 6

EEG
MRI

Question 7

How long can patients not drive for after seizure

Answer 7

6 months fit free
If established epilepsy, 12 months

Question 8

Important cosiderations in seizures

Answer 8

Driving
Other medication e.g. warfarin
Pregnancy
Oral contraceptives

Question 9

Sodium valproate
1. How does it work
2. What used for
3. Adverse effects

Answer 9

1. Increases GABA activity
2. generalised seizures in males
3. increased appetite and weight gain, alopecia, P450 enzyme inhibitor, teratogenic

Question 10

Carbamazepine
1. How does it work
2. What used for
3. Adverse effects

Answer 10

1. Binds to sodium channels increasing their refractory period
2. second-line for focal seizures
3. P450 enzyme inducer, dizziness and ataxia, drowsiness, SIADH

Question 11

Lamotrigine
1. How does it work
2. What used for
3. Adverse effects

Answer 11

1. Sodium channel blocker
2. Different types
3. Stevens-Johnson syndrome

Question 12

Phenytoin
1. How does it work
2. What used for
3. Adverse effects

Answer 12

1. Binds to sodium channels increasing their refractory period
2. No longer 1st line
3. P450 enzyme inducer, gingival hyperplasia, hirsutism, coarsening of facial features, megaloblastic anaemia, osteomalacia

Question 13

UKMEC for lamotrigine and COCP

Answer 13

3

Question 14

Pseudoseizures vs seizures

Answer 14

Pseudoseizures pelvic thrusting and gradual onset

Prolactin is raised in seizures + tonge biting and incontinece (not in psudoseizures)

Use video telemetry

Question 15

Management of absence seizures

Answer 15

sodium valproate, ethosuximide

Question 16

Valproate and pregancny

Answer 16

Teratogenic - neural tube defects

Question 17

phenytoin and pregnancy

Answer 17

cleft palate

Question 18

Is breastfeeding safe on antiepileptics?

Answer 18

Yes

Question 19

rising epigastric sensation
psychic or experiential phenomena, such as déjà vu, jamais vu
less commonly hallucinations (auditory/gustatory/olfactory)

Seizures typically last around one minute
automatisms (e.g. lip smacking/grabbing/plucking) are commo

Answer 19

Temporal lobe seizure

Question 20

Head/leg movements, posturing, post-ictal weakness, Jacksonian march

Answer 20

Frontal lobe (motor)

Question 21

Paraesthesia

Answer 21

Parietal (sensory)

Question 22

Floaters/flashes

Answer 22

Occipital (visual)

Question 23

When are antiepileptics started
What is the exception

Answer 23

After 2nd seizure
If
neurological deficit
brain imaging shows a structural abnormality
the EEG shows unequivocal epileptic activity
the patient or their family or carers consider the risk of having a further seizure unacceptable

Question 24

Generalised tonic-clonic seizures Mx

Answer 24

males: sodium valproate
females: lamotrigine or levetiracetam

Question 25

Women with generalised tonic-clonic seizures who are unable to have children mx

Answer 25

Sodium valproate

Question 26

Focal seizures mx

Answer 26

first line: lamotrigine or levetiracetam

second line: carbamazepine, oxcarbazepine or zonisamide

Question 27

Absence seizures (Petit mal) mx

Answer 27

Ethosuximide

2nd line same as generalised tonic clonic

Question 28

What antiepileptic will make absence seizures worse

Answer 28

Carbamazepine

Question 29

Myoclonic seizures mx

Answer 29

males: sodium valproate
females: levetiracetam

Question 30

Tonic or atonic seizures

Answer 30

males: sodium valproate
females: lamotrigine