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Neurology > Epilepsy > Flashcards

Flashcards in Epilepsy Deck (35):
1

What is epilepsy?

A paroxysmal disorder in which cerebral cortical neuronal discharges result in intermittent, stereotyped attacks of altered consciousness, motor or sensory function, behaviour or emotion.
-recurrent tendency to siezures

2

what is the pathogenesis of epilepsy?

abnormal cortical neuronal communication

due to:
-increased connectivity (too many connections)
-increase in excitatory transmission (too many excitatory signals – glutamate)
-failure of inhibitory mechanism (GABA)

3

What are the causes of epilepsy

Primary (idiopathic): over 50%

Secondary: e.g. vascular/infection/neoplasia/drugs... etc

4

How are epileptic siezures classified?

-focal (partial)
-generalised (tonic clonic)

5

What is a partial seizure?
-simple
-complex

This is a seizure which begins focally, in a particular area giving specific s/s

Simple partial seizures:
Where consciousness is retained throughout the attack

Complex partial seizures:
Consciousness is impaired at any stage

They may become secondarily generalised where the patient loses consciousness with clinical evidence of spread across cerebral cortex e.g. bilateral convulsive movements

-Starts focally then loss of consciousness and have tonic-clonic seizures.

6

Generalised seizure - what is a:
-tonic-clonic
-tonic
-myoclonic
-absence
-atonic

Both cerebral hemispheres are involved from the start of the seizure

Tonic-clonic - grand mal

Tonic – increase stiffness and rigidity

Myoclonic – sporadic jerks

Absence – petit mal (blank stare and no post-ictal confusion)

Atonic – drop attacks: complete loss of tone

7

Primary generalised epilepsy:
-when does this onset?
-what kind of seizures?

Onset childhood

Tonic-clonic seizure

8

Describe the nature of the tonic clonic seizures in primary generalised epilepsy:
-what happens before the attack
-what happens during the attack
-what happens after the attack

tonic-clonic seizures (grand-mal)

before an attack vague symptoms of dizziness/irritability

convulsion may begin with an epileptic cry – loss of consciousness and collapse

tonic phase – generalised muscle spasms occur

clonic phase – sharp repetitive muscle jerks

tongue biting, incontinence of urine and salivation may occur

when jerking stops patient is left unconscious for approx.. 30mins

confusion and drowsiness then occur for several hours

on recovery usually headache and stiffness or injury from the fall

muscular spasms can cause vertebral fractures

9

What is the treatment for primary generalised tonic-clonic seizures?

Sodium valproate

second line: Lamotrigine/carbamazepine

10

Absence seizures:
-when does this occur
-is it commoner in males or females

-always begin in childhood (4-8years)

-commoner in girls

11

Absence seizures:
-describe the attacks
-what is seen on EEG?

attacks occur without warning

child stares blankly into space and stops talking

eyes may flutter or roll up under lids

recovery occurs within seconds and there may be many daily attacks

absences are associated with characteristic EEG abnormalities (3-HZz generalised, symmetrical, spiked wave complexes)

12

What is the risk of seizures after absence seizures

Risk of seizures as an adult following this is 10%

13

What is treatment of absence seizures

sodium valproate or ethosuximide
sodium valproate particularly effective if co-existent tonic-clonic seizures in primary generalised epilepsy

Carbamazepine might make these worse

14

Describe the nature of temporal lobe epilepsy?

This is a complex partial seizure

aura of attack: fear or sensation déjà vu, hallucinations or rising sensation in epigastrium

patients may become confused/anxious and exhibit organised stereotyped movements – automatism

chewing

lip smacking

can be more complex and sometimes aggressive/violent

15

Jacksonian epilepsy:
-where do these begin?
-what are these assoc. with?
-what happens after the attack?
-what is epilepsia partialis continua?

focal motor attacks that typically begin in corner of mouth, thumb, index finger or the great toe

movements spread across face or ascend up limb (jacksonian march)

generally associated with underlying organic brain disease

tumour in motor cortex

after attack the affected limb(s) may remain temporarily weak

epilepsia partialis continua is a rare form where the attack persists for days, weeks or even months

16

What are the treatment of partial seizures?

carbamazepine or lamotrigine

second line: sodium valproate

17

When should an MRI scan be used to investigate seizure?

-Clearly focal onset
-those that begin after 25yrs

18

When is prophylactic treatment considered for epilepsy?

Prophylactic treatment is mostly only considered after a second attack

19

What is the treatment for myoclonic seizures?

sodium valproate

second line: clonazepam, lamotrigine

20

Carbamazepine:
-what are the s/e?

-SIADH
-Hyponatraemia
-rashes
-leucopenia

21

Sodium valproate:
-what are the side effect?

-Teratogenic
-hepatitis
-leucopenia

22

Phenytoin:
-what are the side effects?

-hirsutism

23

Lamotrigine:
-what are the side effects?

stevens-johnson syndrome

24

in pregnancy - what is sodium valproate assoc. with?

neural tube defects

25

in pregnancy which antiepileptics is considered the least teratogenic?

carbamazepine

26

What is phenytoin assoc. with in pregnancy?

cleft palate
-It is advised that pregnant women taking phenytoin are given vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn

27

What may need to change with the dose of lamotrigine in pregnancy?

studies to date suggest the rate of congenital malformations may be low. The dose of lamotrigine may need to be increased in pregnancy

28

Is breast feeding safe with antiepileptics?

Breast feeding is generally considered safe for mothers taking antiepileptics with the possible exception of the barbiturates

29

What is the general advice for contraception for women taking anti-epileptics?

consistent use of condoms, in addition to other forms of contraception.

30

For women taking:
phenytoin,carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine: which contraceptive is:
UKMEC 1
UKMEC 2
UKMEC 3

UKMEC 3: the COCP and POP
UKMEC 2: implant
UKMEC 1: Depo-Provera, IUD, IUS

31

For women taking lamotrigine which contraceptive is:
UKMEC 1
UKMEC 3

UKMEC 3: the COCP
UKMEC 1: POP, implant, Depo-Provera, IUD, IUS

32

Describe the acute management of a seizure

ABCDE
If have IV access:
Give midazolam 0.05-0.1mg/kg up to 10mg IV
Or
Diazepam 0.-0.2mg/kg up to 20mg IV

If don’t have IV access:
Midazolam 5-10mg intranasally/buccally
Or
Diazepam 10-30mg per rectum

Reassess and wait for seizure to cease

If continuing Gain IV access and repeat dose

If it continues – status epilepticus

Start phenytoin infusion – 18mg per kg IV

Monitor heart – bradycardia and hypotensive

Intubate and ICU if still fitting

33

What is status epilepticus, what is the treatment?

Status epilepticus – if they have been having a seizure for more than 5mins treat
pre-hospital: diazepam 10-20mg PR or midazolam 10mg buccally

first line in hospital: lorazepam (or diazepam) IV

if benzo unsuccessful: phenytoin infusion 15-18mg/kg at a rate of 50mg/minute 

officially status if more than 30mins or 3 seizure without regaining consciousness

34

Describe the driving rules for seizures and epilepsy

first seizure: 6 months off driving*.

For patients with established epilepsy they must be fit free for 12 months before being able to drive

If sleep-related, have to have an established pattern of seizures occurring only in relation to sleep during the previous 3 years
More stringent for heavy goods vehicles and passenger-carrying vehicles

35

When should you consider the stopping of AEDs? How long does this happen over?

Can be considered if seizure free for > 2 years, with AEDs being stopped over 2-3 months