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Epilepsy Flashcards

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1
Q

what are common causes of loss of conciousness?

A

Vasovagal 20%

Reflex syncope 14%

Cardiogenic syncope 18%

Epilepsy 8%

Other (provoked seizure) 2%

Metabolic 4%

Unknown (including non-epileptic) 34%

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2
Q

what questions do you ask a patient who had passed out prior in their history?

A

What exactly were they doing at the time?
Prolonged standing, postural change, pain, vomiting, passing urine, coughing, exercising

What had they been doing in the previous 24 hours?
Sleep deprivation, excess alcohol, illicit drug use

Any warning symptoms?
Light-headed, nauseated, hot, sweating/cold sweat, loss of hearing, tinnitus, loss of vision
Rising feeling from abdomen, odd taste or smell, deja vu, sudden feeling of anxiety/panic
Palpitations/ cardiac symptoms

Also ask whether they have had previous episodes and how similar these were

Any awareness during event?
How they felt on recovery
First recollection
?bitten tongue ? incontinence
? prolonged confusion vs brief puzzlement
? Subsequent muscle pain, petechiae, shoulder dislocation

Detailed description of patient’s behaviour before, during and after the event
Duration
Level of responsiveness,
Colour
Motor phenomena
Breathing pattern
Vocalisation, salivation, blood in saliva
Incontinence,
Pulse
Rate of recovery and level of confusion

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3
Q

what warning symptoms may a patient have experienced prior to loss of conciousness?

A

Light-headed, nauseated, hot, sweating/cold sweat, loss of hearing, tinnitus, loss of vision

Rising feeling from abdomen, odd taste or smell, deja vu, sudden feeling of anxiety/panic

Palpitations/ cardiac symptoms

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4
Q

how may a patient feel on rec0very after loss of conciousness?

A

First recollection
?bitten tongue ? incontinence
? prolonged confusion vs brief puzzlement
? Subsequent muscle pain, petechiae, shoulder dislocation

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5
Q

what must be included in a detailed description of a patients behaviour before during and after loss of conciousness?

A

Duration
Level of responsiveness,
Colour
Motor phenomena
Breathing pattern
Vocalisation, salivation, blood in saliva
Incontinence,
Pulse
Rate of recovery and level of confusion

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6
Q

what are the three categories of syncope?

A

Reflex (neuro-cardiogenic)

Orthostatic - most common

Cardiogenic

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7
Q

what may cause reflex syncope?

A

Taking blood/medical situations

Cough, Micturation

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8
Q

what may cause orthostatic syncope?

A

Dehydration, medication related (anti-hypertensive)

Endocrine, autonomic nervous system

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9
Q

what may cause cardiogenic syncope?

A

Arrhythmia, aortic stenosis

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10
Q

what is useful to always try and get in relation to a patient history of syncope?

A

Witness account

for example
Looked a bit pale
Suddenly went floppy
Looked pale
There may have been a few brief jerks
Brief LOC
Rapid recovery
If more prolonged was the patient propped up

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11
Q

which examinations do you do to assess syncope?

A

Heart sounds, pulse
Postural BPs

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12
Q

what would you look for in an ECG for syncope?

A

Look for heart block
QT ratio

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13
Q

when would a patient need a 24H ECG?

A

May need to see cardiology if recurrent (5 day recordings, reveal devices)
Consider Tilt table

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14
Q

give an example of a patient history with cardiogenic syncope?

History preceding events:
History of event itself:
Afterwards:

A

History preceding events
On exertion

History of event itself
Chest pain, palpitations, SOB

Afterwards
Chest pain, palpitations, SOB
Came round fairly quickly
Recovery may be longer
Clammy/sweaty

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15
Q

give an example of patient history with syncope?

History preceding events:
History of event itself:
Afterwards:

A

History preceding events
Stimulus- blood being taken, defecation
Context- only in bathroom, only when standing

History of event itself
Warning- felt lightheaded/clammy/vision blacking out

Afterwards
Very brief LOC
Came round as I hit the ground, Friend standing over them
Fully orientated quickly
Clammy/sweaty
Urinary incontinence

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16
Q

give an example of a patient history with non-epilecptic attack/pseudoseizure?

History preceding events:
History of event itself:
Afterwards:

A

History preceding events
Events may occur at times of stress or while at rest
Will often give lots of detail of others reaction and little of events themselves

History of event itself
May recall what people said during episode
May be prolonged episode, waxing and waining
May describe dissociation

Afterwards
Others reactions

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17
Q

what may a witness acount of a pseudoseizure include?

A

Description
May recognise stress as a trigger (even if patient doesn’t)
May report signs of patient retaining awareness

Tracking eye movements, still some verbalisation during episodes
Movements not typical of seizures
Pelvic thrusting
Asynchronous movements, tremor
Episodes waxing and waining

Ideally we try and capture a typical episode on EEG
-Important to make diagnosis to avoid iatrogenic harm

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18
Q

why may a seizure be provoked?

A

(Febrile convulsions in childhood)
Alcohol withdrawal
Drug withdrawal
Within few days after a head injury
Within 24hrs of stroke
Within 24hrs of neurosurgery
With severe electrolyte disturbance
Eclampsia

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19
Q

what is epilepsy?

A

the tendency to recurrent seizures

we use the term Epilepsy if patients have more than one unprovoked seizure

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20
Q

how do seizures occur?

A

Our neurones have background electrical activity. If this is disrupted it can lead to a seizure

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21
Q

what causes synchronous discharges in cortical neurons?

A

too much excitation

damaged neurons

too little inhibition

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22
Q

what causes too little inhibition?

A

GABA receptors

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23
Q

what causes damage to neurons?

A

stroke, tumour, trauma, developmental causes

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24
Q

what causes too much excitation?

A

glutamate receptors

ion channels (Na/Ca2+)

excitatory amino acids

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25
what factors increase seizure risk?
Missed medications (most common) Sleep disturbance, fatigue Hormonal changes, menstrual cycle Drug/alcohol use, drug interactions Stress/Anxiety Photosensitivity in a small group of patients Other rarer reflex epilepsies (visual patterns, music)
26
what are different classes of generalised seizures?
Absence seizures Generalised tonic-clonic seizures Myoclonic seizures Juvenile myoclonic epilepsy Atonic seizures
27
whay are different classes of focal seizures?
Simple partial seizures Complex partial seizures Secondary generalised Or by localisation of onset (temporal lobe, frontal etc)
28
what are primary generalised seizures?
No warning May have history of absences and myoclonic jerks as well as GTCS e.g in juvenile myoclonic epilepsy
29
who do primary generalised seizures most commonly affect?
< 25 years May have family history
30
what will be shown in an EEG in a patient with primary generalised seizures?
Generalised abnormality on EEG
31
what are focal/partial seizures?
May get an “aura” Simple partial and complex partial seizures can become secondarily generalised
32
who do focal/partial seizures commonly affect?
Any age – cause can be any focal brain abnormality
33
what is shown in an EEG or MRI for focal/partial seizures?
Focal abnormality on EEG MRI may show cause
34
what would a patient accounr of a generalised tonic clonic seizure entail? History preceding events: History of event itself Afterwards
History preceding events Unpredictable, tend to cluster PMH- complications at birth, Feb conv, trauma, menigitis, brain injuries History of event itself May have vague warning Irritability before them Afterwards Lateral (severe) Tongue biting, incontinence First recollection in ambulance or hospital Muscle pain
35
what may a witness acount of a generalised tonic clonic seizure entail?
Groaning sound Tonic (rigid phase) Then generalised jerking in all four limbs Eyes open Staring/ roll upwards Foaming at the mouth Jerking for a few minutes and then groggy for 15-30mins May be agitated afterwards May have a cluster of episodes, stopping and starting
36
what is an absence seizure?
May be provoked by hyperventillation/ Photic stimulation (light through trees while in car) Sudden arrest of activity for a few seconds Brief staring May have eye-lid fluttering Re-start what they were doing
37
when is an ebscence seizure stimulated?
May be provoked by hyperventillation/ Photic stimulation (light through trees while in car)
38
who do abscence seizures most commonly affect?
Often in children (unaware of them)
39
what would a patient account of a complex partial seizure (temporal lobe) entail?
History preceding events Rising feeling in stomach, Funny smell/taste De ja vu (familiar experience) History of event itself No recollection Afterwards Disorientated for a spell
40
what would a witness account of a complex partial seizure entail?
Sudden arrest in activity Staring blankly into space Automatisms Lip smacking Repetitive picking at clothes
41
what is a frontal lobe seizure?
Unusual and can be mistaken for non-epileptic attacks because they look so strange “Brief, bizarre and motor” Can be frequent with rapid recovery Pattern of movement is stereotyped because it reflects seizure spread through pre-motor cortex and supplementary motor areas
42
how are seizures clinically assessed?
Refer to first seizure clinic Do an ECG, routine bloods (Glc) A+E will often arrange a CT From Neurology clinic May arrange an MRI for focal lesion May arrange EEG (Usually in <40yrs) Discuss Anti-epileptic drugs Refer to Epilepsy nurse (post diagnostic information) Discuss driving (inform DVLA)
43
what may happen after referral to a neurology clinic?
May arrange an MRI for focal lesion May arrange EEG (Usually in <40yrs) Discuss Anti-epileptic drugs Refer to Epilepsy nurse (post diagnostic information) Discuss driving (inform DVLA)
44
describe the incidence and prevalence of epilepsy?
Incidence: 50 - 120 per 100 000 per year “J-shaped” curve Prevalence: 5 – 8 per 1000 (Aberdeen 0.9%) 22% of patients with LD have Epilepsy 3 - 5% of the population will experience at least one seizure in their lifetime There are over 300 000 people in the UK with active epilepsy
45
what investigations are done for epilepsy?
EEG for primary generalised epilepsies including hyperventilation and photic stimulation: sometimes sleep deprivation MRI for patients under age 50 with possible focal onset seizures: CT usually adequate to exclude serious causes over this age Video-telemetry if uncertainty about diagnos
46
when is an EEG used in seizures?
for primary generalised epilepsies including hyperventilation and photic stimulation: sometimes sleep deprivation
47
when is an MRI used for seizures?
for patients under age 50 with possible focal onset seizures: CT usually adequate to exclude serious causes over this age
48
what is first line treatment for epilepsy?
Sodium Valproate, Lamotrigine, Levetiracetam for primary generalised epilepsies Lamotrigine, Carbamazepine, Levetiracetam for partial and secondary generalised seizures Ethosuximide for absence seizures
49
what is first line treatment for primary generalised epilepsies?
Sodium Valproate, Lamotrigine, Levetiracetam
50
what is second line treatment for partial and secondary epilepsies?
Lamotrigine, Carbamazepine, Levetiracetam
51
what is first line treatment for abscence seizures?
Ethosuximide
52
what is second line treatment for generalised epilepsy?
Topiramate Zonisamide ( generally avoid carbamazepine)
53
what is second line treatment for partial seizures?
Sodium valproate -Topiramate - Brivaracetam -Gabapentin -Pregabilin -Zonisamide -Lacosamide -Perampanel - Clobazam/Clonazepam Vigabatrin
54
what are side effects of Sodium Valproate?
tremor, weight gain, ataxia, nausea, drowsiness, transient hair loss, pancreatitis, hepatitis Avoid if possible in women of childbearing age
55
what are side effects of Carbamazepine?
ataxia, drowsiness, nystagmus, blurred vision, low serum sodium levels, skin rash.
56
what are side effects of Lamotrigine?
skin rash, difficulty sleeping
57
what are side effects of Levetiracetam?
irritability, depression
58
what is status epilepticus?
Generalised convulsive or non-convulsive seizures going on for 5 minutes or more either continuously or repetitively with no intervening recovery
59
what are risk factors for status epilepticus?
Non-adherence to treatment Chronic alcoholism Refractory epilepsy Toxic or metabolic causes Acute brain injury of any cause
60
what is first line treatment of status epilecticus?
Midazolam: 10mg by buccal or intra-nasal route, repeated after 10mins if necessary (our patients with a history of seizures lasting more than 5 minutes have Midazolam careplans) Lorazepam: 0.07mg/kg, usually 4mg bolus repeated once after 10 mins
61
what is second line treatment of status epilecticus?
Valproate – 30mg/kg iv over 10 mins. Max 3000mg (avoid in women of child-bearing age) Levetiracetam 30mg/kg over 10mins. (Other guidelines go up to 60mg/kg). Max is 4500mg Phenytoin - 20mg/kg, at 50mg/min (maximum 2g)
62
what is third line treatment of status epilecticus?
Anaesthesia usually with propofol or thiopentone
63
when can a patient drive following a seizure?
Patients who have had a first seizure and have normal investigations will be permitted to drive group 1 vehicles after 6 months and Group 2 (HGV) vehicles after 5 years
64
what are the rules for group 1 liscences following seizure?
Have been seizure free for one year Have an established pattern of seizures only during sleep for at least a year If any history of awake seizures as well as sleep seizures, established pattern of only sleep seizures for three years before driving permitted Provoked seizures dealt with on individual basis Patients should not drive during medication withdrawal and for 6 months thereafter
65
Professional licences for heavy goods or public service vehicles will not be issued to anyone who has experienced seizures after the age of 5 unless.....
they have been seizure free and on no medication for 10 years
66
DVSA and epilepsy?
The patient is responsible for disclosing their condition to the DVLA The doctor has a legal obligation to inform patients of the regulations If the patient continues to drive the doctor may inform the DVLA and should inform the patients in writing that he/she intends to do so – see GMC advice, Defence associations also helpful

Nervous System (40 decks)

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