Epilepsy Flashcards

1
Q

Define epilepsy

A

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

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2
Q

Define seizure

A

Excessive, abnormal and synchronised electrical activity that leads to external manifestations. Can be provoked or unprovoked

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3
Q

What defines a prolonged and pseudo-seizure

A

Prolonged seizure = seizure activity ≥5 minutes
Pseudo-seizure= The patient believes to be having a seizure

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4
Q

What is the cause of epilepsy

A

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

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5
Q

What are the childhood epileptic syndromes

A

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

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6
Q

What is the difference between generalised and focal epilepsy and which types of epilepsy fall in each group

A

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

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7
Q

What is the classification of epilepsy according to the International League Against Epilepsy 2017

A
  1. Where they begin: focal, unknown, generalised, focal to bilateral
  2. Level of awareness: focal aware, focal impaired, awareness unknown, generalised
  3. 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)
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8
Q

What is the aetiology and risk factors of epilepsy

A

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

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9
Q

What is the epidemiology of epilepsy

A

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

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10
Q

What are the signs and symptoms that suggest a generalised seizure

A

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

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11
Q

Describe absence seizures

A

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

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12
Q

Describe myoclonic seizures

A

Brief, repetitive, jerking movements of the limbs, neck or trunk
Includes benign rolandic epilepsy and juvenile myoclonic epilepsy

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13
Q

Describe tonic epileptic seizures

A

Generalised increase in tone

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14
Q

Describe tonic-clonic seizures

A
  1. Tonic phase - children may fall to the ground, sometimes injuring themselves
    - May not breathe → cyanosis
  2. 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
  3. Post-ictal phase:
    - followed by unconsciousness or deep sleep for up to several hours
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15
Q

Describe atonic seizures

A

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

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16
Q

Describe frontal focal epileptic seizures

A

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

17
Q

Describe temporal focal epileptic seizures

A

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)

18
Q

Describe parietal focal epileptic seizures

A

Sensory disturbances: tingling, numbness
Motor symptoms: abnormal movements, rhythmic muscle contractions

19
Q

Describe occipital focal epileptic seizures

A

Visual phenomena: spots, lines, flashes

20
Q

What investigations should be done for epilepsy

A

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

21
Q

What is the long term management for epilepsy

A

Advice and safety netting
MDT management (paeds, neuro, school nurse, epilepsy nurse, GP)
Anti-epileptic monotherapy (usually valproate)
Rescue therapy (seizures >5mins): Buccal midazolam

22
Q

What anti-epileptics are indicated in tonic-clonic seizures

A

First line: sodium valproate, carbamazepine
Second line: clozabam, levetiracetam, Topiramate

23
Q

What anti-epileptics are indicated in myoclonic seizures

A

First line: sodium valproate, levetiracetam
Second line: clozabam, clonazepam

24
Q

What anti-epileptics are indicated in absence seizures

A

First line: valproate, ethosuximide
Second line: clozabam, lecetiracetam, topiramate

25
Q

What anti-epileptics are indicated in focal seizures

A

First line: carbamazepine, valproate, levetiracetam, lamotrigine
Second line: clozabam, topiramate, gabapentin

26
Q

What are the treatment options for intractable epilepsy

A

Ketogenic (low-carb, fat-based) diets
Vagus nerve stimulation or responsive neurostimulation system
- delivered using externally programmable stimulation of a wire implanted around the afferent (left) vagus nerve
Resective epilepsy surgery (lobectomy, hemispherotomy
- For epilepsy has a well-localised structural cause or epileptogenic zone
- Demonstrated by good concordance between ictal EEG, MRI, functional imaging findings

27
Q

What advice should be given for epilepsy

A

How to recognise a seizure
Video record future seizure
Avoid dangerous activities (i.e. swimming or deep baths) unsupervised
Ensure school/workplace is informed
Support: epilepsy action
Driving: 1 year free of seizures is safe to drive,
May interact with contraception, affects pregnancy outcomes
Avoid alcohol, drugs, poor sleep

28
Q

Define status epilepticus

A

Continuous seizure activity ≥ 30 minutes or repetitive seizures with no intervening recovery of consciousness

29
Q

What is the management for status epilepticus

A

0mins:
- A-E
- High flow oxygen if available
- Check BM and confirm it is epileptic seizure

5mins:
- Buccal midazolam / rectal diazepam
- IV established: IV lorazepam

15mins:
- IV lorazepam
- Call senior
- Re-assess, confirm epilepsy

25mins:
- IV phenytoin/IV phenobarbitone (if already on phenytoin)
- Call anaesthetics and inform ICU

45mins: Rapid sequence induction of anaesthesia with thiopental, PICU transfer

30
Q

What are the complications of epilepsy

A

Falls and injuries → Fractures
Aspiration
Status epilepticus - respiratory arrest
SUDEP - sudden death in epilepsy (1 in 1000 chance of death)
Depression and anxiety disorders
Absence from school, learning difficulties

31
Q

What are the side effects of anti-epileptics

A

Valproate: weight gain, hair loss, rare idiosyncratic liver failure, teratogenic (DO NOT give to female children/adolescents, women of childbearing potential or pregnant women

Carbamazepine: rash, neutropenia, hyponatraemia (SIADH), ataxia, inducer

Lamotrigine: severe skin rash (SJS)

Levetiracetam: sedation (rare)

32
Q

What is the prognosis for epilepsy

A

50% remission at 1 year
Mortality 2 in 100,000/year
Related to seizure or secondary to injury
Children with epilepsy do less well educationally, with social outcomes and future employment compared to others with chronic conditions e.g. diabetes
2/3 of children go to mainstream school but some may need educational help for associated learning difficulties.
1/3 go to special schools but often have multiple disabilities and their epilepsy is part of a severe brain disorder.
Few children require residential schooling