Epilepsy

Question 1

what is the differential diagnosis for blackout?

Answer 1

> syncope
> first seizure
> hypoxic seizure
> concussive seizure
> cardiac arrhythmia
> non-epileptic attack

Question 2

what do you need to get from the history from the patient?

Answer 2

> what were they doing
> any warning signs
> what were they doing the night before
> how did the feel afterwards
> injury or incontinence?

Question 3

what information do you need from witnesses?

Answer 3

detailed observations before and during the attacks: 
> responsiveness
> colour
> breathing
> vocalisation
> behaviour following the attacks

Question 4

what information is relevant or important in the history?

Answer 4

> age
> sex
> head injury, birth trauma and febrile convulsions
> past psychiatric history
> alcohol and drug abuse
> family history

Question 5

what is the most common cause of syncope?

Answer 5

vasovagal syncope

Question 6

what prodromes syncope?

Answer 6

> light headed
> nausea
> hot/sweating
> tinnitus
> tunnel vision

Question 7

what are the trigger warnings for vasovagal syncope?

Answer 7

> prolonged standing
> standing up quickly
> trauma
> venepuncture
> watching medical procedures
> micturition
> coughing

Question 8

what features of syncope differ from seizures?

Answer 8

> happens in upright posture
> pallor is uncommon
> there is gradual onset
> injury is rare
> incontinence is rare
> rapid recovery
> precipitants common

Question 9

how do seizures differ from syncope?

Answer 9

> any posture
> pallor uncommon
> sudden onset
> injury is quite common
> incontinence common
> slow recovery
> precipitants rare

Question 10

when do hypoxic seizures occur?

Answer 10

when individuals are kept upright in a faint, there may be a succession of collapses then seizure like activity may occur

Question 11

when do concussive seizure occur?

Answer 11

after a blow to the head

Question 12

can seizures cause cardiac arrhythmias?

Answer 12

yes

Question 13

what should you consider in a family history of sudden death and when collapse occurs during exercise?

Answer 13

> functional cardiac problems (long QT syndrome)

Question 14

describe non-epileptic attacks

Answer 14

> commoner in women
> may be frequent
> prolonged
> superficially resemble generalised tonic-clonic seizure
> may resemble a swoon
> involves bizarre alternating movements

Question 15

what might be found in the history of a patient with non-epileptic attacks?

Answer 15

> history of other unexplained symptoms

> may have a history of abuse

Question 16

what investigations would you carry out for a possible first seizure?

Answer 16

> blood sugar
ECG
consider drugs and alcohol
CT head (criteria)

Question 17

what advice should be given to the patient with a first seizure?

Answer 17

> safety information
employment (they may need to inform them)
potentially dangerous leisure activities
driving regulations

Question 18

after their first seizure how long until a patient can drive again if their investigations are normal and they have no further events?

Answer 18

6 months

Question 19

when can a patient drive a HGV or PSV after their first seizure?

Answer 19

after 5 years if their investigations are normal, they have no further events and the are not on any anti-epileptic medication

Question 20

when is epilepsy normally diagnosed?

Answer 20

after a second unprovoked attack (sometimes on taking the history after a first seizure if it is clear they have undiagnosed epilepsy)

Question 21

in epilepsy what might occur in the morning?

Answer 21

myoclonic jerks

Question 22

what features in a history would be suggestive of primary generalised epilepsy?

Answer 22

> myoclonic jerks

> absences/feeling strange with flickering lights

Question 23

what features of a history is suggestive of focal onset epilepsy?

Answer 23

> deja vu sensation from the abdomen

> episodes of blank look with fiddling

Question 24

what is epilepsy?

Answer 24

a condition in which seizures recur, usually spontaneously

Question 25

what is an epileptic seizure?

Answer 25

an intermittent stereotyped disturbance of consciousness, behaviour, emotion, motor function or sensation which, on clinical grounds is believed to result from abnormal neural discharges

Question 26

what is the incidence of epilepsy?

Answer 26

50-120 per 100000 per year

Question 27

what shaped curve is seen in epilepsy?

Answer 27

j shaped

Question 28

what is the prevalence of epilepsy?

Answer 28

5-8 per 1000

Question 29

name some generalised seizures

Answer 29

``` > tonic-clonic seizures > myoclonic seizures > clonic seizures > tonic seizures > atonic seizures > absence seizures ```

Question 30

describe a tonic-clonic seizure

Answer 30

there is a tonic stage where they can stop breathing then they enter the clonic stage and begin to breath again

Question 31

describe an atonic seizure

Answer 31

the patient can rapidly collapse to the floor, resulting in injury though there is quick recovery

Question 32

describe an absence seizure

Answer 32

children will frequently drift away then come back, they can grow out of it

Question 33

what are focal seizures characterised by?

Answer 33

> aura > motor features > autonomic features > degree of awareness or responsiveness

Question 34

what can focal seizures evolve into?

Answer 34

generalised convulsive seizure

Question 35

describe primary generalised epilepsy

Answer 35

``` > no warning > <25 years > history of absences and myoclonic jerks, and GTCS > generalised abnormality on EEG > family history? ```

Question 36

describe focal/partial epilepsies

Answer 36

``` > aura > any age > cause can be any focal brain abnormality > focal abnormality on the EEG > MRI may show the cause ```

Question 37

what focal epilepsies may become secondarily generalised?

Answer 37

simple partial and complex partial seizures

Question 38

what can you get the patient to do when carrying out an EEG for primary generalised epilepsies?

Answer 38

> hyperventilate > photic stimulation > sleep deprivation

Question 39

when would you carry out a MRI for epilepsy?

Answer 39

patients under the age of 50 with possible focal onset seizures

Question 40

what could you carry out if you were uncertain of the diagnosis?

Answer 40

video telemetry

Question 41

what is the first line treatment for primary generalised epilepsies?

Answer 41

> sodium valproate > lamotrigine > levetiracetam

Question 42

what is the first line treatment for partial and secondary generalised seizures?

Answer 42

> lamotrigine | > carbamazepine

Question 43

what is the first line treatment for absence seizures?

Answer 43

ethosuximide

Question 44

what is the first line treatment for status epilepticus?

Answer 44

> lorazepam | > midazolam

Question 45

what is the second line treatment for status epilepticus?

Answer 45

> valproate | > phenytoin

Question 46

what is the second line treatment for generalised seizures?

Answer 46

> topiramate | > zonisamide

Question 47

what does carbamezapine make worse?

Answer 47

myoclonic jerks

Question 48

what is sodium valproate, topiramate and leviteracetam a second line treatment for?

Answer 48

partial seizures

Question 49

what are the side effects of sodium valproate?

Answer 49

``` > tremor > weight gain > ataxia > nausea > drowsiness > transient hair loss > pancreatitis > hepatitis ```

Question 50

what are the side effects of carbamazepine?

Answer 50

``` > ataxia > drowsiness > nystagmus > blurred vision > low serum sodium levels > skin rash ```

Question 51

what are the side effects of lamotrigine?

Answer 51

> skin rash | > difficulty sleeping

Question 52

what are the side effects of levetiracetam?

Answer 52

> irritability | > depression

Question 53

what are the side effects of topiramate?

Answer 53

> weight loss > word finding problems > tingling of the hands and feet

Question 54

what are the side effects of zonisamide?

Answer 54

> bowel upset | > cognitive problems

Question 55

what is the side effect of lacosamide?

Answer 55

dizziness

Question 56

what is the side effect of pregabilin?

Answer 56

weight gain

Question 57

what are the side effects of vigabatrin?

Answer 57

> behavioural problems | > visual field defects

Question 58

when can patients hold a group one licence after a year?

Answer 58

> if they have been seizure free for a year | > if they have only had seizures arising from sleep for a year

Question 59

when must a patient wait three years before they can drive again?

Answer 59

> if they have ever had a daytime seizure then the pattern becomes nocturnal

Question 60

when can epileptic patients hold a HGV or PSV licence?

Answer 60

if they have been seizure free for 10 years and are not on antiepileptic medication

Question 61

what is status epilepticus?

Answer 61

prolonged or recurrent tonic-clonic seizures persisting for more than 30 minutes with no recovery period between seizures

Question 62

in what patients does status epilepticus normally occur?

Answer 62

in patients with no previous history of epilepsy (stroke, tumour, alcohol)

Question 63

what is the first line treatment for TCSE?

Answer 63

> midazolam: buccal/intranasal repeated after 10 mins if necessary > lorazepam: 4mg bolus repeated once after 10mins > diazepam: 10-20mg IV or rectally repeated after 15mins if necessary

Question 64

what is the second line treatment for TCSE?

Answer 64

> phenytoin | > valproate

Question 65

what is the third line treatment of TCSE?

Answer 65

anaesthesia usually with propofol or thiopentone. this shuts down brain activity, they are loaded with anticonvulsants then woken up in 24 hours

Question 66

in what groups is mortality from TCSE the greatest?

Answer 66

in the very young and old

Question 67

what is reported in 24% percent of children who have an episode of status?

Answer 67

neurological problems