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epilepsy Flashcards

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1
Q

What is epilepsy?

A

Epileptic seizures occur when ordinary brain activity is disrupted spontaneously and recurrently

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2
Q

Definition of a Seizure

A

a transient paroxysm of uncontrolled discharges, beginning at the epileptic focus, causing an event which is discernible by the person experiencing the seizure and/or an observer

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3
Q

What are the main causes of epilepsy

A

Most common defined causes:
cerebrovascular disease,
cerebrovascular tumours,
genetic, congenital, or hereditary conditions,
alcohol,
drugs and toxic causes,
head trauma (including neurosurgery),
post-infective causes (encephalitis/meningitis)

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4
Q

Risk Factors for Seizures

A

Disturbed levels of water/electrolytes
Disturbed levels of blood glucose
Altered blood gasses
Raised body temperature
Altered sleep patterns
Hormonal disturbance
Toxicity
Heredity
Tumours

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5
Q

how to diagnsose epilepsy

A

use EEG, MRI and/or CT but they are not conclusive alone

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6
Q

what does EEG recors and what are its limitations

A

EEG records abnormal electric discharges
limitations:
5% of people without epilepsy have abnormal discharges
40% of people with epilepsy have normal discharges in between attacks

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7
Q

does epilepsy have highly synchronus discharges?

A

yes

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8
Q

what is epilepsy a disorder of?

A

cerebral cortex

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9
Q

In EEG whats the frequency and amplitude show?

A

frequency - have fast neurones are firing (depolarisation)
amplitude - number of neurones in synchrony

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10
Q

what are the two main types of seizures?

A
  1. generalised
  2. focal
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11
Q

What are the subgroups of the generalised seizure type?

A
  1. Absence
  2. Tonic clonic
  3. myoclonic
  4. clonic
  5. tonic
  6. Atonic
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12
Q

What is the most common generalised seizure and its properties?

A

Tonic-clonic Convulsions (Grand Mal)
Most common form
Patient stiffens, falls and convulses
Laboured breathing, hyper-salivation
Cyanosis, tongue biting and incontinence
Lasts a few minutes
Followed by headache and drowsiness

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13
Q

symptoms of tonic seizures

A

stiffening of body – head, trunk +/- limbs
typically when falling asleep/on waking

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14
Q

Symptoms of clonic seizures

A

rhythmic, motor, jerking movements
+/- impairment of consciousness
simultaneous involvement of arms and legs

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15
Q

What are the symptoms of absence attacks (generalised seizure)

A

Rarer; almost exclusively in childhood and early adolescence
Goes blank, stares, eyelids flutter, head flops
Last a few seconds
Child may not be aware of it

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16
Q

What are the symptoms of Myoclonic seizures (generalised seizure)

A

Abrupt, brief, involuntary, shock-like jerks
Involve head, limbs or whole body
Recovery immediate
Not always epilepsy

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17
Q

What are the symptoms of Atonic seizures (generalised seizure)

A

Sudden loss of muscle tone
quick recovery
very rare

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18
Q

what are two subgroups of focal seizures (somtimes called partial seizures)

A
  1. simple focal/ focal aware seizures
  2. complex focal/ focal altered-awareness seizures
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19
Q

symptoms of complex focal

A

‘automatic’ behaviours
confusion
apparent drunkness

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20
Q

What are secondary generalised seizures

A

Can be simple or complex focal seizures
then spread to the whole brain which leads to tonic clonic attack

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21
Q

What is Status epilepticus?

A

Serious uncontrolled seizure
Convulsive (tonic-clonic) status epilepticus

A tonic-clonic seizure lasts for 5 minutes or more, or
One tonic-clonic seizure follows another without the person regaining consciousness in between

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22
Q

Where do seizures arise?

A

Anywhere
subcortical rare (thalamus: absence)
mostly cortical:
frontal, parietal, occipital, temporal
Temporal most prevalent - 30-40%
Hippocampus, entorhinal cortex, amygdala
Most common seizures that are drug refractory
Surgical resection

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23
Q

How do seizures arise?

A

Cortical activity - dynamic balance between inhibition and excitation

Two levels of control
Intrinsic or level of individual cell: determined by ion channels (in neurons)
At a Network level- controlled by synaptic transmission

Disturbed balance - excessive synchrony and epilepsy
(up) excitation, normal inhibition
(down) inhibition, normal excitation
(down) inhibition,
(up) excitation

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24
Q

How do excitory and inibitory neurones work together to keep balance?

Study These Flashcards
A

Excitatory neurones (glutamte) recurrently excite each other
Excitatory recurrently excite inhibitory neurones (GABA)
Inhibitory neurones recurrently control excitation
Loss of inhibition can lead to epilepsy

25
How do seizures stop (without intervention?
- K+ channel activation - Na+ channel inactivation - Glutamate receptor desensitization - Glutamate depletion
26
Whats the pharmacological treatment for epilepsy
- Antiepileptic drugs (AEDs)/anti-seizure medicines (ASMs) decrease the frequency and/or severity of seizures in people with epilepsy - Treat the symptoms not the condition - Goal: maximise quality of life by minimising seizures and adverse drug effects
27
Mechanism of action of anti-epileptics
Antiepileptic drugs inhibit the abnormal neuronal discharge in epilepsy but do not resolve the underlying cause (antiepileptic but not antiepileptogenic!)
28
Steps to treat epilepsy
1. Block destabilizing (depolarising) currents * Increase stabilsing currents 2. Reduce synaptic excitation Block glutamate release* Block glutamate receptors 3. Increase synaptic inhibtion Increase GABA release * Potentiate GABA receptors* * - most common approaches
29
Why is it good that many AEDs that block voltage-dependant sodium channels are use-dependant?
This allows the drugs to preferentially block the excitation of cells that are firing repetitively , so can block the high-frequency discharge that occurs in an epileptic fit, without interfering with the low-frequency firing when neurons are in the normal state
30
What are the drugs that block Na-channels?
Phenytoin carbamazepine lamotrigine sodium valproate
31
How does the use-dependant blocking action work?
Depolarisation of a neuron increases the proportion of sodium channels in inactivated state The drugs bind preferentially to the inactivated state of sodium channels, preventing them from returning to the resting state This reduces the number of sodium channels available to generate action potentials
32
What drugs block Ca-channels?
ethosuximide gabapentin phenytoin (?)
33
which drugs increase GABA levels
vigabatrin sodium valproate
34
which drug blocks NMDA receptors
felbamate
35
which drug blocks AMPA/kainate receptors
topiramate
36
which drug activates K-currents
retigabine
37
What are the non-drug treatments for epilepsy?
Resection - removes damaged area of brain multiple subpial transection - seperates damaged area from rest of the brain corpus callosotomy - seperates the two hemispheres of the brain Hmeispherectcomy - removes outer layer of one hemisphere
38
what are the non-pharmacological treatments for epilepsy
Vagus nerve stimulation (VNS) - stimulation with a pacemaker type device, may intercept abnormal brain activity Deep brain stimulation (DBS) - stimulates area of brain where seizures originate
39
Who should you not give valproate to?
Any women or girl able to have children unless there is a pregnancy prevention program (PPP) in place
40
what do the categories 1,2 and 3 mean for antiepileptic drugs?
Category 1 - must maintain the same branded product and cannot be changed Category 2 - use clinical judgement to determine wether its ok to switch to a different manufacturers brand or not category 3 - usually unnecessary to maintain same product
41
What form of epilepsy can sodium valproate be used for?
All forms of epilepsy
42
Common side effects of sodium valproate
Abdominal pain, agitation, anaemia, abnormal behaviour, confusion, deafness, diarrhoea, drowsiness ... Hepatic dysfunction - discontinue immediately if persistent vomiting and abdominal pain occur Pancreatitis - Discontinue treatment if symptoms of pancreatitis develop
43
Monitoring of sodium valproate
- Monitor liver function before and 6 months into therapy - Measure blood count and ensure bleeding before starting a and before surgery
44
What supplement should be given with sodium valproate?
consider vitamin D supplementation in patients that are immobilised for long periods or have inadequate sun light or dietary intake of calcium
45
Which types of seizure can carbamazepine be used for?
- focal and secondary generalised tonic-clonic seizures - primary generalised tonic-clonic seizures - can exacerbate certain other seizures
46
what are the side effects of carbamazepine
Dizziness, drowsiness, dry mouth, eosinophilia, fatigue, fluid imbalance, headache ...
47
What to monitor for carbamazepine?
- Plasma concentration for optimum response 4-12mg/L - Manufacturers recommended blood count and hepatic and renal function tests
48
Special precautions in Carbamazepine
- Presence of HLA-B*1502 allele, mainly in chinese or thai origin have a increased risk of developing Steven-Johnson syndrome - adviced to also take vitamin D
49
What types of seizures can Lamotrigine be used for?
- Monotherapy of focal seizures - Monotherapy of primary and secondary generalised tonic-clonic seizures - Monotherapy of seizures associated with Lennox-Gastaut syndrome
50
Side effects of Lamotrigine
Aggression, agitation, pain, rash, sleep disorder, tremor, vomiting ...
51
Monitoring of Lamotrigine
In preganancy - Plasma-drug conc should be monitored before, during and after pregnancy including shortly after birth (may increase rapidly after birth)
52
What types of seizure can Levetiracetam be used for?
- Monotherapy of focal seizures with or without secondary generalisation - Adjunctive therapy of focal seizures with or without secondary generalisation - Adjunctive therapy of myoclonic seizures and tonic-clonic seizures
53
Side effects of Levetiracetam
Anxiety, appetite decrease, depression, diarrhoea, dizziness, drowsiness, movement disorder, skin reaction, tremor, vomiting ...
54
Monitoring Levetiracetam
In pregnancy - monitor plasma concentration decrease during pregnancy - by up to 60% in the third trimester)
55
Topiramate - what seizures it is used for?
- Monotherapy and adjunctive treatment of generalised tonic-clonic seizures or focal seizures with or without secondary generalisation - Adjunctive treatment for seizures associated with Lennox-Gastaut syndrome
56
What types of seizures can Phenytoin be used for?
- Tonic-clonic seizures - Focal seizures - May exacerbate seizures in patients with absence or myoclonic seizures (including juvenile myoclonic epilepsy) and myoclonic-atonic seizures
57
Special precautions in Phenytoin
- Phenytoin has a narrow therapeutical index - small change (dosage increase or missed doses) can lead to acute toxic side effects - monitor plasma-drug concentration - Overdose - symptoms include nystagmus, diplopia, slurred speech, atexia, confusion and hyperglycaemia
58
What seizures can Gabapentinoids (gabapentin/pregabalin) be used for?
- Gabapentin: Adjunctive treatment of focal seizures with or without secondary generalisation and Monotherapy for focal seizures with or without secondary generalisation - Pregabalin: Adjunctive therapy for focal seizures with or without secondary generalisation - Both may exacerbate certain seizure types

CNS 201 (9 decks)

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