Epilepsy Flashcards
1
Q
What is key in the diagnosis of a seizure?
A
EYE - WITNESS
2
Q
What should you find out about the seizure?
A
Before, during and after
3
Q
What should you find out about the onset of a seizure?
A
What were they doing?
Environment?
4
Q
What is an important CVS question to ask?
A
Did they experience any syncopal symptoms or light headedness?
5
Q
What sort of things do you want to know when asking what they looked like?
A
- Pallor
- Breathing
- Posture of limbs
- Head turning
6
Q
What should you find out about the event itself?
A
- Types of movement
- Tonic phase, clonic movements
- Carpopedal spasms, rigor
7
Q
What is a ‘general tonic-clonic seizure’?
A
Tonic component
- all muscles in the body are rigid
- if the respiratory muscles are involved, person may become blue due to hypoxia.
Clonic component
- jerky movements due to discharge of electrical activity
- clonic component becomes of greater amplitude as discharge rate decreases
8
Q
What is a ‘general tonic-clonic seizure’?
A
Tonic component
- all muscles in the body are rigid
- if the respiratory muscles are involved, person may become blue due to hypoxia
Clonic component
- jerky movements due to discharge of electrical activity
- clonic component becomes of greater amplitude as discharge rate decreases
9
Q
Why may a person become blue during a seizure?
A
If the seizure is tonic, the respiratory muscles may be involved and will be rigid and the person will become hypoxic
10
Q
What do carpopedal spasms suggest?
A
Hyperventillation
11
Q
In a tonic-clonic seizure, will the person be aware of their surroundings?
A
NO
12
Q
What do you want to know about what happened after the seizure?
A
- Speed of recovery
- Sleepiness/disorientation
- Deficits
13
Q
Post - epileptic attack, what do patients feel like?
A
Sleepy and disorientated
14
Q
Give examples of epilepsy risk factors.
A
Birth (ie. premature). Development. Seizures in past (inc. febrile fits). Head injury (inc. LOC). Family hx. Drugs. (BENZOS!!!) Alcohol.
15
Q
What should you reassure a patient with epilepsy of in terms of their occupation?
A
Reassure pt that they can’t be sacked because of this dx since epilepsy is classed as a disability.
16
Q
Is an exam carried out in 1st seizure appointment?
A
NO - history is most important
17
Q
What exams should be carried out if a diagnosis of syncope is made?
A
Cardiovascular examination
Lying and standing BP important
18
Q
What should you never forget to ask about in a history of someone with seizures?
A
Drugs
19
Q
What drugs/drug classes are particularly bad for worsening epilepsy?
A
Aminophylline/Theophylline. Analgesics ie. tramadol. Antibiotics ie. penicillins, cephalosporins, quinolones. Anti-emetics ie. prochlorperazine. Opioids ie. diamorphine, pethidine
20
Q
What is the biggest cause of death in patents with epilepsy?
A
Suicide :(
21
Q
What investigation MUST you always do in a patient who has had a seizure?
A
ECG
22
Q
Why should an ECG always be done?
A
To find out if it was a hypoxic seizure
e.g from prolonged QT
23
Q
What is prolonged QT a common cause of?
A
- Seizures
* Cardiac arrest
24
Q
You don’t need to (+ shouldn’t) CT every person who presents having had a seizure. Who, however, should get a CT scan acutely?
A
Clinical or radiological skull fracture Deteriorating GCS Focal signs Head injury with seizure Failure to be GCS 15/15 4 hours after arrival Suggestion of other pathology – eg SAH
25
Who should always get a CT?
Those who you think will need neurological help in the next few days
26
For what 4 reasons should an EEG be used?
Classification of epilepsy
Confirmation of non-epileptic attacks
Surgical evaluation
Confirmation of non-convulsive status
27
EEG's are shite
Pie them off
28
When should EEG's absolutely not be used?
To investigate the cause of an 'attack'
29
What 4 conditions are commonly confused with epilepsy?
* Syncope
* Non-epileptic attack disorder (pseudopseizures, psychogenic non-epileptic attacks)
* Panic attacks/Hyperventilation attacks
* Sleep phenomena
30
Seizures doesn't always mean epilepsy
TRUE
31
How can risk of recurrence of seizures be decreased?
Avoid alcohol, drugs and lack of sleep
32
What are the rules with regard to driving a i) car ii) HGV/PCV after the 1st seizure?
i) Can’t drive car for 6 months
| ii) Can’t drive for 5 years
33
What are the rules with regard to driving a i) car ii) HGV/PCV after a diagnosis of epilepsy?
i) Must be seizure free for 1 year
| ii) Can drive if had no seizures, and been OFF MEDICATION for 10 years
34
What is SUDEP?
Sudden Unexpected Death in Epilepsy
35
What are the risk factors for SUDEP?
Non-compliance with meds.
Drinking/Drugs.
Nocturnal seizures, and don’t have a bed partner
36
If someone presents with a seizure, what should you assume until proven otherwise?
That the cause of the seizure is a brain tumour
37
What is epilepsy?
A tendency to recurrent, usually spontaneous, epileptic seizures.
38
At what age does epilepsy occur?
At any age, but is most common in INFANCY and OLD age
39
Describe 'focal' seizures.
There is a focal abnormality which is a bit more sensitive than other areas of the brain. If the seizure starts there, it usually stays there.
40
What can focal seizures become?
If it ‘hits’ one of the cortical networks, it can spread more widely, causing a secondary generalized seizure
41
Describe generalised seizures.
KEY: a generalized seizure can start from a focal point, then propagate around a tract in the brain ie. corticothalamic circuitry
42
Who is most likely to develop focal epileptic seizures?
Older people 50/60+ because, as people get older, the brain is more likely to be injured
43
Who is more likely to develop generalised epileptic seizures?
Children - due to genetics
44
What is a seizure?
An abnormal discharge of electrical activity in the brain
45
Focal seizures can be either ______ or ______?
Simple OR Complex
46
Describe simple focal seizures.
Seizure WITHOUT impaired consciousness
47
Describe complex focal seizures.
Seizure WITH impaired consciousness
48
List the different types of generalised seizures.
```
Absence.
Myoclonic.
Atonic.
Tonic.
Tonic clonic
```
49
What do most people with generalised epilepsy have?
A genetic predisposition
50
What motor features are focal seizures associated with?
```
Rhythmic jerking.
Posturing.
Head and eye deviation.
Other movements (ie. cycling).
Automatisms (ie. plucking).
Vocalisation.
```
51
What sensory features are focal seizures associated with?
```
Somatosensory.
Olfactory.
Gustatory.
Visual.
Auditory.
```
52
What psychic features are focal seizures associated with?
```
Memories.
Déjà vu.
Jamais vu.
Depersonalisation.
Aphasia.
Complex visual hallucinations
```
53
What is the characteristic appearance of generalised epilepsy on an EEG?
Spike - wave abnormalities
54
An ‘aura’ before a seizure is the focal seizure which then spreads to become a generalized seizure
TRUE
55
What is the treatment of choice for CHILDREN with GENERALISED epilepsy?
Sodium valproate
56
What is the biggest side effect of using sodium valproate?
It is teratogenic
57
What is the treatment of choice for ADULTS with GENERALISED epilepsy?
Lamotrigine
58
What is the most common type of primary generalised epilepsy?
Juvenile Myoclonic Epilepsy
59
How does Juvenile Myoclonic Epilepsy usually manifest?
As early morning jerks.
| Generalized seizures
60
What are the risk factors for JME?
Sleep deprivation
| Flashing lights
61
In focal epilepsy, there is an underlying _____ cause?
STRUCTURAL
62
What drugs are used in the treatment of focal epilepsy?
Carbamazepine (Tegretol).
or
Lamotrigine
63
Why is sodium valproate not the first drug of choice in focal epilepsy?
It has too many side effects
64
What is the effect of Na+ influx on a cell?
It increases excitability and drives action potentials
65
What AED's inhibit Na+ influx into a cell?
Carbamazepine, lamotrigine, oxcarbazepine, phenytoin, eslicarbazepine, rufinamide
66
What is the effect of K+ efflux from a cell?
Reduces neuronal excitability
67
What AED acts on K+ efflux from a cell? What is the effect of this?
Retigabine – increases channel activity, opening the channels, stabilising the neuron and reducing excitability
68
What does Ca2+ influx into a cell do?
Drives neurotransmitter release
69
What AED's act on the Ca2+ channel of cells? What is the effect of this?
Pregabalin + Gabapentin (also ethosuximide)
| These inhibit this channel
70
What AED enhances GABA synthesis?
Sodium valproate
71
What does a GABA transporter do?
Removes GABA from the synapse
72
What AED acts on the GABA transporter? What is the effect of this?
Tigabine – inhibits the GABA transporter to elevate GABA levels
73
What does GABA transaminase do?
Degrades GABA
74
What AED acts on GABA transaminase? What is the effect of this?
Vigabatrin – inhibits GABA transaminase to elevate GABA levels
75
What drugs are used in the initial treatment of focal seizures?
* **Carbamazepine
| * ** Lamotrigine
76
What drugs are used to treat ABSENCE seizures?
Sodium valproate.
Ethosuximide.
(topiramte, levetiracetam)
77
What drugs are used to treat MYOCLONIC seizures?
Sodium valproate.
Levetiracetam.
Clonazepam.
(lamotrigine, topiramate)
78
What drugs are used to treat ATONIC / TONIC / GENERALISED TONIC CLONIC seizures?
***Sodium valproate.
Levetiracetam
Topiramate
Lamotrigine
79
List some side effects of sodium valproate.
Weight gain.
Teratogenicity.
Hair loss.
Fatigue
80
What does Carbamazepine make worse?
Primary generalized epilepsies
81
What is the advantage of using lamotrigdine?
It is well tolerated in general and focal seizures
82
What are the disadvantages of using lamotrigdine?
Takes a long time to titrate up.
| Can cause a severe skin rash - can cause Stevens Johnson Syndrome
83
What drug causes mood swings?
Levitiracetam
| think 'lev me alone'
84
What are the side effects of topiramate?
Sedation
Dysphasia
Weight loss
85
What is pregabalin and gabapentin used for?
Neuropathic pain
86
When do we give drugs?
- If the patient has epilepsy
- If the patient had a single seizure but was at a high risk of recurrence
- Only if the patient wants the drug
(Need to balance benefits and side effects)
87
What can some anti-convulsants induce?
Hepatic enzymes
88
Give examples of drugs that induce hepatic enzymes.
Carbamazepine, oxcarbazepine, phenobarbitol, phenytoin, primidone
89
Drugs that alter hepatic enzymes also....
Alter the efficacy of the COMBINED ORAL CONTRACEPTIVE PILL
90
What should not be used in women who take anti-convulsants that induce hepatic enzymes?
The progesterone only pill
91
What is not effective when on an enzyme inducer?
Progesterone implants
92
What are the implications on the morning after pill when a pt is taking enzyme-inducing AEDs?
The usual morning after pill is not adequate, so the dose should be increased
93
Women must be taking _________ 3 months prior to pregnancy
FOLIC ACID
94
What is status epilepticus?
Recurrent epileptic seizures without full recovery of consciousness.
Continuous seizure activity, lasting more than 30 minutes
95
What are the 3 types of status epilepticus?
* Generalized convulsive status epilepticus.
* Non-convulsive status conscious, but in ‘altered state.’
* Epilepsia partialis continua continual focal seizures, consciousness preserved
96
List some precipitants to status epilepticus.
* Severe metabolic disorders (e.g hyponatraemia)
* Infection
* Head trauma
* SAH
* Abrupt withdrawal of anti-convulstants
* Treating absence seizures with CBZ
97
What is convulsive status?
Generalised convulsions without cessation
98
What causes lasting damage in convulsive status?
Excess cerebral energy demand and poor substrate delivery
99
What can convulsive status cause?
* Respiratory insufficiency and hypoxia
* Hypotension
* Hyperthermia
* Rhabdomyolysis
100
How is status epilepticus managed?
1. ABCDE - to stabilise pt as this is an emergency
2. Find cause
3. Emergency bloods +/- CT
4. Anti-convulsants
5. Benzodiazepine (NEVER more than 2 doses of 10mg)
