Epilepsy

Question 1

What is the definition of epilepsy?

Answer 1

A tendency to recurrent, usually spontaneous, epileptic seizures.

Question 2

Who does epilepsy most commonly affect?

Answer 2

Any age but most common in infancy and old age
Generalised epilepsy presents in childhood and adolescence and most have genetic predisposition

Question 3

What are some risk factors for epilepsy?

Answer 3

Genetic
Acquired brain injury
Metabolic
Toxic
Environmental

Question 4

What is the pathophysiology of epilepsy?

Answer 4

Epileptic seizure is abnormal synchronisation of neuronal activity (usually excitatory with high frequency action potentials but sometimes predominantly inhibitory)
Interruption of normal brain activity
Usually brief (secs-mins)

Question 5

What is primary generalised epilepsy?

Answer 5

Often presents in childhood/teens
Early morning jerks
Risk factors - sleep deprivation, flashing lights

Question 6

What is focal onset epilepsy?

Answer 6

Underlying structural cause
Onset at any age
Hippocampal sclerosis can occur

Question 7

What are the types of generalised seizures?

Answer 7

Tonic-clonic
Absence
Atonic (‘drop attacks’)
Myoclonic

Question 8

What are the types of focal seizures?

Answer 8

Temporal lobe
Frontal lobe
Parietal lobe
Occipital lobe

Question 9

What is a tonic-clonic seizure?

Answer 9

Loss of consciousness and tonic (muscle tensing) and clonic (muscle jerking) episodes
May have tongue biting, incontinence, groaning and irregular breathing
Prolonged post-ictal period where person is confused, drowsy, feels irritable/depressed

Question 10

What is an absence seizure?

Answer 10

Typically in children and stop as get older
Patient becomes blank, stares into space and then abruptly returns to normal
Unaware of surrounding during episode and won’t respond
Lasts 10-20 seconds

Question 11

What is an atonic ‘drop attack’ seizure?

Answer 11

Brief lapses in muscle tone, causing patient to fall
Don’t usually last more than 3 minutes
Consciousness retained

Question 12

What is a myoclonic seizure?

Answer 12

Sudden brief muscle jerks of a limb, trunk, face

Question 13

What is temporal lobe epilepsy?

Answer 13

Aura occurring in most patients:
- Rising epigastric sensation
- Psychic or experiential phenomena (eg deja vu)
- Hallucinations less common (eg auditory, gustatory, olfactory)

Seizures lasting around 1 min
- Automatisms (lip smacking, grabbing, plucking)

With or without impaired awareness/consciousness

Question 14

What is frontal lobe epilepsy (motor)?

Answer 14

Head/leg movements
Posturing
Post-ictal weakness
Jacksonian march

Question 15

What is parietal lobe epilepsy (sensory)?

Answer 15

Paraesthesia

Question 16

What is occipital lobe epilepsy (visual)?

Answer 16

Floaters/flashes

Question 17

What are some investigations for epilepsy?

Answer 17

ECG (rule out prolonged QT syndrome)
Imaging (MRIb)
EEG (generalised epilepsy shows generalised spike-wave abnormalities)

Question 18

What are the principles for starting anti-epileptics?

Answer 18

Drug therapy only started after minimum two fits
Only use one drug at a time, begin with small dose and gradually increase until control is achieved, toxic affects occur, or max dose is reached

Question 19

What are the first and second line drugs for generalised seizures in men?

Answer 19

1) Sodium valproate
2) Lamotrigine/levetiracetam

Question 20

What are the first line drugs for generalised seizures in women of childbearing age?

Answer 20

Lamotrigine/levetiracetam

Question 21

What are the first and second line drugs for focal seizures?

Answer 21

1) Lamotrigine/levetiracetam
2) Carbamazepine

Question 22

What is the first and second line treatment for absence seizures?

Answer 22

1) Ethosuximide
2) Sodium valproate
3) Lamotrigine/levetiracetam

Question 23

What anti-seizure drugs can exacerbate absence and myoclonic seizures?

Answer 23

Carbamazepine
Gabapentin
Phenytoin
Pregabalin
Lamotrigine (for myoclonic only)

Question 24

What is the first and second line drugs for myoclonic seizures?

Answer 24

1) Sodium valproate
2) Levetiracetam

Question 25

What is the driving advice for epilepsy?

Answer 25

If driver has seizure of any type, must immediately stop driving and inform the DVLA
First unprovoked epileptic seizure/single isolates seizure = 6 months no driving
Established epilepsy must be seizure free for at least 1 year

Question 26

What is the definition of status epilepticus?

Answer 26

A seizure lasting >5 mins, or multiple seizures over 5 minutes with incomplete resolution

Question 27

What are some precipitants of status epilepticus?

Answer 27

Severe metabolic disorders
Infection
Heady trauma
Sub-arachnoid haemorrhage
Abrupt withdrawal of anti-convulsants
Treating absence seizures with CBZ

Question 28

What can status epilepticus cause?

Answer 28

Respiratory insufficiency and hypoxia
Hypotension
Hypothermia
Rhabdomyolysis

Question 29

What are some investigations for status epilepticus?

Answer 29

Identify cause after stabilising patient
- Emergency blood tests +/- CT

Question 30

How is status epilepticus treated?

Answer 30

1) 2x doses benzodiazepines
- Diazepam 10-20mg rectally
- Midazolam 10mg buccally
- Lorazepam 4mg IV

2) IV phenytoin/levitiracetam/sodium valproate

3) General anaesthesia with propofol/midazolam/thiopental sodium
- Continued for 12-24 hours after last seizure then dose tapered

Generally:
Give high concentration oxygen
Give glucose if hypoglycaemic
Give IV thiamine is suggestion of alcoholism/impaired nutritional status
Assess cardiac and respiratory function