Epilepsy

Question 1

What is an epileptic seizure

Answer 1

Paroxysmal and transient event in which changes of neuro processes are caused by excessive, hypersynchronous neuronal discharges in the brain

Question 2

What is the clinical definition of epilepsy (criteria)

Answer 2

Any of the following:
* >2 unprovoked seizures occurring >24h apart
* one unprovoked seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years

Question 3

What is a focal seizure

Answer 3

Refer to the electrical and clinical manifestations of seizures that arise from one portion of the brain

Question 4

What is the most frequently recognised focal epilepsy

Answer 4

Temporal lobe origin

Question 5

What are focal aware seizures

Answer 5

Remain conscious and typically recall the event

Question 6

Characteristics of a focal impaired awareness seizures

Answer 6

• Loss of consciousness
• Memory loss of event
• Impaired responsiveness at tie of event

Question 7

Characteristics of a focal seizures affecting the temporal lobe

Answer 7

• Aura - deja vu, fear, strange smells
• Dysphasia
• Automatisms: Picking at clothes, Lip smacking
• Epigastric sensation

Question 8

Characteristics of a focal seizure affecting the frontal lobe

Answer 8

• Jacksonian march - jerking starts in a specific muscle and spreads to surrounding groups
• Todd’s paralysis - unilateral paralysis of arms/legs

Question 9

Characteristics of a focal seizure affecting the parietal lobe

Answer 9

• Paraesthesia
• Pain
• warmth

Question 10

Characteristics of a focal seizure affecting the occipital lobe

Answer 10

Visual disturbances:
* Flashes/ floaters
* Change in colour vision

Question 11

Give 5 RFs for focal seizures

Answer 11

• Febrile seizures
• Traumatic brain injury
• CNS infection
• Dementia
• Stroke
• tumour

Question 12

What is the name for when focal seizures spread outside of one region

Answer 12

Bilateral tonic-clonic seizures

Question 13

4 investigations for suspected epilepsy

Answer 13

• Blood glucose - exclude hypo/hyperglycaemia
• MRI brain - lobe abnormalities
• Electroencephalogram
• Serum electrolytes
• CT head - urgent if focal neuro deficits

Question 14

What is the treatment for acute repetitive seizures

Answer 14

• Benzodiazepines - rectal/ IV diazepam or midazolam (community vs hospital)

Question 15

How are focal seizures treated

Answer 15

• 1st line Anticonvulsant monotherapy
  1) Lamotrigine or levetiracetam
  2) Oxcarbazepine, Zonisamide or carbamazepine
• 3rd line Anticonvulsant dual therapy

Question 16

What are generalised seizures

Answer 16

• Both hemispheres of the brain are affected
• characterised by LOC and widespread motor manifestation

Question 17

Describe a tonic seizure

Answer 17

• Sudden onset increased muscle tone - Stiff and flexed muscles
• Usually fall backwards
• LOC

Question 18

Describe an atonic seizure

Answer 18

Referred to as ‘drop attacks’
* Sudden loss of muscle tone
* Often results in a fall
* Usually aware during episodes

Question 19

Describe an absence seizure

Answer 19

• Blank, stares into space then abruptly returns to normal
• Unaware of surrounding and unresponsive during episodes
• Eyelids may flutter
• Usually seen in children

Question 20

Describe a myoclonic seizure

Answer 20

• Sudden, brief muscle contractions - abrupt jump/ jolt
• Usually conscious

Question 21

Describe a tonic-clonic seizure

Answer 21

• complete LOC
• Tonic (muscle rigidity) then clonic (muscle jerking)
• Tongue biting, incontinence, irregular breathing
• Prolonged post-ictal period

Question 22

Describe the 4 phases of a seizure

Answer 22

• Prodromal: Mood changes days before a seizure - confusion & irritability
• Aura: warning feeling just before - deja vu, strange smells
• Ictal phase: the seizure
• Post-ictal: brain recovers from seizure - behaviour changes, amnesia, agitation, confusion

Question 23

What is the treatment for tonic-clonic seizures

Answer 23

• 1st - Sodium valproate
• 2nd - Lamotrigine or levetiracetam (1st in woman and girls)

Question 24

What is the treatment for myoclonic seizures

Answer 24

• 1st - Na valproate (CI = women/girls)
• 2nd - levetiracetam
• 3rd - lamotrigine

Question 25

What is the treatment for tonic/ atonic seizures

Answer 25

• 1st - Na valproate (CI = women/girls)
• 2nd - Lamotrigine
• 3rd - Topiramate

Question 26

What is the treatment for absence seizures

Answer 26

• Ethosuximide
• Na valproate
• 3rd - Lamotrigine/ levetiracetam

Question 27

How is treatment-resistant epilepsy treated

Answer 27

• Surgical resection
• Vagus nerve stimulation

Question 28

Mechanism of action of sodium valproate

Answer 28

• Increases the activity of GABA which has a calming effect on the brain

Question 29

Why is sodium valproate avoided in females with childbearing potential

Answer 29

Teratogenic
* Causes neural tube defects and developmental delay

Question 30

Apart from teratogenicity, give 3 side effects of sodium valproate

Answer 30

• Liver damage/ hepatitis
• Hair loss
• Reduced fertility

Question 31

Give 3 side effects of carbamazepine

Answer 31

• Agranulocytosis
• Aplastic anaemia
• P450 inducer

Question 32

What is status epilepticus

Answer 32

Medical emergency defined as a seizures that lasts:
* more than 5 mins for gen tonic-clonic
* >10 mins for focal seizures

Question 33

How is status epilepticus treated

Answer 33

• ABC approach
• Supportive care - high [O2], glucose if hypo, thiamine
• Benzodiazepines, repeated after 5-10 mins if seizure continues

Question 34

How is status epilepticus treated if seizures continue despite 2 doses of benzodiazepine

Answer 34

• Levetiracetam
• Phenytoin
• Na valproate

Question 35

What are 3 options of benzodiazepine that are used in the treatment of status epilepticus

Answer 35

• Buccal midazolam
• Rectal diazepam
• IV lorazepam

Question 36

Give 4 features that would indicate a non-epileptic seizure opposed to epilepsy

Answer 36

• Doesn’t occur in sleep
• Eyes tightly closed
• Longer (>3 mins)
• Asynchronous movements

Question 37

Give 5 causes of non-epileptic seizures

Answer 37

• Autoimmune - SLE
• Metabloc - Low glucose/Na/Ca
• Drugs - cocaine
• Alcohol withdrawal
• Infection