Epilepsy Flashcards
(34 cards)
Define epilepsy
Recurring tendency to have seizures
- At least 2 unprovoked seizures >24 hours apart
- 1 unprovoked seizure + probability of further seizures similar to general recurrence risk (60%) after 2 unprovoked seizures occurring over the next 10 years
Define seizure
Excessive, abnormal and synchronised electrical activity that leads to external manifestations. Can be provoked or unprovoked
What defines a prolonged and pseudo-seizure
Prolonged seizure = seizure activity ≥5 minutes
Pseudo-seizure= The patient believes to be having a seizure
What is the cause of epilepsy
Most epilepsy (70-80%) is genetic/idiopathic with complex inheritance
Primary epilepsy syndromes e.g. idiopathic generalised, temporal lobe, juvenile myoclonic
Secondary: tumours, CNS infection, vasculitis, electrolyte abnormalities, drugs, haemorrhage/infarction, malignant hypertension, TBI
What are the childhood epileptic syndromes
Infantile spasms (West syndrome)
Lennox-Gastaut
Childhood absence epilepsy
Epilepsy with centro-temporal spikes (Childhood rolandic epilepsy)
Panayiotopoulos syndrome (early-onset benign occipital epilepsy)
Juvenile absence epilepsy
Juvenile myoclonic epilepsy
What is the difference between generalised and focal epilepsy and which types of epilepsy fall in each group
Generalised: Discharge arises from both hemispheres
- Convulsive: tonic, clonic, tonic-clonic, myoclonic
- Non-convulsive: absent, atonic
Focal: Seizures arise from one or part of one hemisphere. Each one will produce different symptoms. Originates in a relatively small group of dysfunctional neurones
- Simple partial: no loss of consciousness
- Complex partial: May have a loss of consciousness
What is the classification of epilepsy according to the International League Against Epilepsy 2017
- Where they begin: focal, unknown, generalised, focal to bilateral
- Level of awareness: focal aware, focal impaired, awareness unknown, generalised
- other features
- Focal: motor onset (twitching, jerking, stiffening, automatisms) or non-motor (cognitive, emotional, sensory)
- Generalised onset: motor (tonic clonic) or non-motor (absence, awareness changes, automatisms)
What is the aetiology and risk factors of epilepsy
Most genetic/idiopathic (70-80%)
Family history
Perinatal asphyxia
Metabolic disorders
Febrile seizure
Head trauma
CNS infection or tumour
Cerebral palsy
Learning disabilities
Down’s syndrome
What is the epidemiology of epilepsy
0.05% incidence (less common during the first year of life) and a prevalence of 0.5%
Peak age of onset in early childhood or in the elderly <20, >60
Males > females
What are the signs and symptoms that suggest a generalised seizure
Before: Epileptic aura, triggers e.g. flashing lights
During: stiffness, jerking, incontinence, tongue-biting, sweating, palpitations, mouth frothing, pallor, cyanosis
After: Muscle ache, post-ictal confusion, drowsiness
Describe absence seizures
Transient loss of consciousness
Abrupt onset and termination
May see flickering of the eyelids and minor alteration in muscle tone, otherwise NO motor phenomena
May be precipitated by hyperventilation
Describe myoclonic seizures
Brief, repetitive, jerking movements of the limbs, neck or trunk
Includes benign rolandic epilepsy and juvenile myoclonic epilepsy
Describe the types of childhood myoclonic epileptic disorders
Benign Rolandic Epilepsy (BRE) (most common childhood epilepsy) / Sylvian seizures
3-12yo
S/S: seizures of face / upper limbs during sleep with hypersalivation & speech arrest
Childhood (age 3-12yo) seizures – outgrown at end of puberty
Juvenile myoclonic epilepsy
12-18yo
Usually involving neck, shoulders, upper arms, most occur after waking up
Begin around puberty
Describe tonic epileptic seizures
Generalised increase in tone
Describe tonic-clonic seizures
- Tonic phase - children may fall to the ground, sometimes injuring themselves
- May not breathe → cyanosis - Clonic phase - Rhythmical contraction of muscle groups → jerking of limbs
- Breathing may be irregular as cyanosis persists and saliva accumulates in the mouth
- May show biting of the tongue and incontinence of urine - Post-ictal phase:
- followed by unconsciousness or deep sleep for up to several hours
Describe atonic seizures
Often combined with myoclonic jerk, followed by a transient loss of muscle tone causing a sudden fall to the floor or drop of the head
Describe frontal focal epileptic seizures
Behavioural changes
Motor: posturing, peddling, motor arrest (dysphasia, speech arrest)
± Jacksonian March: As the seizure increases in size, more of the homunculus becomes affected i.e. hand shaking → elbow shaking → Arms shaking
± Todd’s paralysis: Post-ictal flaccid weakness
Describe temporal focal epileptic seizures
Aura (visceral and psychic symptoms - fear or deja-vu sensation)
Hallucinations (smell, taste)
Emotional disturbance
Depersonalisation
Automatisms e.g. lip-smacking, fumbling, fiddling, chewing, singing, kissing)
Describe parietal focal epileptic seizures
Sensory disturbances: tingling, numbness
Motor symptoms: abnormal movements, rhythmic muscle contractions
Describe occipital focal epileptic seizures
Visual phenomena: spots, lines, flashes
What investigations should be done for epilepsy
Bedside: ECG, urine dip, BM
Bloods: Glucose, U&Es, FBC, genetic testing, toxicology, serum prolactin, CRP/ESR
Other: MRI brain, EEG (inter-ictal, ictal, sleep-deprived), /CT head/PET/SPECT, ± LP
What is the management for a child with a first fit
Urgent referral to hospital for paediatric assessment
Referral to first fit clinic
What is the long term management for epilepsy
Advice and safety netting
MDT management (paeds, neuro, school nurse, epilepsy nurse, GP)
Anti-epileptic monotherapy (usually valproate)
Rescue therapy (seizures >5mins): Buccal midazolam
What anti-epileptics are indicated in tonic-clonic seizures
First line: sodium valproate, carbamazepine
Second line: clozabam, levetiracetam, Topiramate
