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PAN- Neurology > Epilepsy > Flashcards

Epilepsy Flashcards

1
Q

What is a seizure?

A

A seizure is the clinical manifestation of an abnormal and excessive excitation of a population of cortical neurones.

An abnormal, synchronous, paroxysmal neuronal discharge in the brain causing abnormal function.

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2
Q

What is epilepsy?

A

A tendency to spontaneous, intermittent, abnormal electrical activity in part of the brain, manifesting as seizures.

Or simply a tendency to have recurrent seizures

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3
Q

What is meant by an aura?

A

Seizures may be preceded by a sensory experience- this is an aura.

This could be a rising epigastric sensation, gustatory/olfactory hallucinations, visual changes/flashing lights, headaches, paresthesia, de ja vu

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4
Q

What is a symptomatic seizure?

A 
Provoked seizures that have a cause, such as:
Drugs
Severe sleep deprivation
CV Disease
Stroke/TIA
Hypoglycaemia
Electrolyte imbalance
Head injury (can cause scaring and seizures years after onset)
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5
Q

What is idiopathic epilepsy?

A

This is epilepsy for which a cause cannot be found (not symptomatic seizures)

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6
Q

What is the difference between a partial and a generalised seizure?

A

Partial- only affecting part of the brain within a single hemisphere
Generalised- Synchronous activity that involves both hemispheres with widespread cortical involvement

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7
Q

What seizure features can help to differentiate between a between a partial/focal seizure and a generalised seizure?

A

Focal seizures have localising features depending on the area involved

Generalised seizures do not have features that would enable them to be localised to one area of the brain, there are several distinct subtypes including absence, atonic, tonic, and tonic-clonic.

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8
Q

How can partial seizures be further classified?

A

With or without impairment of consciousness

Without Impairment of consciousness (previously called simple)- Awareness is not impaired and there are focal features. No post-ictal symptoms.

With Impairment of consciousness - awareness is impaired. Most commonly arise from the temporal lobe and post-ictal confusion is a feature.

Evolving to a bilateral convulsive seizure (used to be described as secondary generalised)- electrical disturbance initially starts focally, spreads widely and then causes a generalised seizure. Note- if it begins with focal features it is a partial seizure regardless of how quickly it generalises.

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9
Q

What are post-ictal features?

A

These are features that are present after a seizure. These may be headache, confusion, myalgia or temporary weakness (Todd’s Palsy seen after a focal seizure in motor cortex)

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10
Q

What proportion of epilepsy is idiopathic?

A

Around 2/3

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11
Q

What is an absence seizure? When does it typically present?

A

A type of generalised seizure where there is typically loss of awareness for around 10 seconds. Often presents in childhood.

Examples may be a brief pause in speech.

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12
Q

What is the unique feature of absence seizures on an EEG?

A

3Hz Spike and Wave Oscillations

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13
Q

What is a tonic-clonic seizure?

A

A type of generalised seizure where limbs stiffen (tonic phase) and then there are jerking movements (clonic phase).

Often followed by post-ictal confusion and drowsiness.

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14
Q

What is a myoclonic seizure?

A

Sudden jerking movements of a limb, face or trunk. Can cause the patient to be suddenly thrown to the ground.

They’re a type of generalised seizure

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15
Q

What are atonic seizures?

A

Sudden loss of muscle tone which can cause a fall. There is no loss of consciousness.

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16
Q

What is a pseudo-seizure?

A

Seizures that are due to a psychological problem such as severe stress, anxiety or PTSD.

Suspect if seizures have a gradual onset, prolonged duration and abrupt termination and are accompanied by closed eyes +/- resistance to eye opening, rapid breathing, fluctuating motor activity and episodes of motionless unresponsiveness. CNS exam, CT, MRI and EEG are all normal.

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17
Q

If a patient comes in describing seizures what kind of things would you want to ask>

A

Were there any witnesses who can describe what happened.
Loss of consciousness
Any potential triggers
Strange feelings beforehand (auras?)
Tongue biting
Behavioural changes- e.g. confusion, disorientated

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18
Q

For anyone presenting with seizures what must be done before a diagnosis of epilepsy can be made?

A

Must rule out provoking causes- i.e. are these symptomatic seizures that are due to a cause and are not idiopathic.

All patients with a seizure must be referred for specialist investigation and scanning within 2 weeks.

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19
Q

What investigations would be requested for someone presenting following complaints fo seizures?

A

Standard EEG- If Hx suggests that seizures are due to epilepsy. Methods may be used to trigger a seizure.
Sleep EEG- If standard EEG does not reveal an abnormal activity do a sleep EEG.

Imaging-
MRI Head- to identify structural abnormalities and is the gold standard investigation for this.
CT- If MRI not available or in the acute setting.

ECG-
To identify potential cardiac abnormalities/arthymia/ reflex anoxic seizures for example. RAS is due to a neuronal reflex that reduces HR- triggers may be something unpleasant such as pain, crying, scares…

Bloods (If appropriate)-
Electrolyte abnormalities
Calcium
Glucose
Raised WCC (Infection could be cause- meningitis, encephalitis. Note check the temperature too- febrile seizures)
CRP + ESR
Endocrine function (e.g. TFTs if suspected)
LFTS- Hepatic Encephalopathy
Renal Function- Uraemia leading to seizures?)

Drug screen- using urine.

Lumbar Puncture- If suspecting infection such as meningitis, encephalitis.

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20
Q

How long must a patient be seizure free till they can drive again?

A

At least 1 year

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21
Q

What are some causes of seizure?

A 
Brain tumour
Cerebral abscess
Cerebral infarction
Cerebral venous thrombosis
AVM
Drugs, Alcohol
Toxins
Head injury
Meningitis and encephalitis
Neurodegenerative disease
Biochemical imbalance
Febrile seizures
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22
Q

What is the difference between partial and generalised seizures?

A

Partial seizures involve only a localised part of one hemisphere

General seizures involve both hemispheres

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23
Q

What is secondary generalisation?

A

This is when partial seizures spread to involve both hemispheres of the brain becoming generalised seizures

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24
Q

What determines the features seen in partial onset seizures?

A

The area of the brain involved determines what the features will be.

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25
What is the major excitatory neurotransmitter in the brain?
Glutamate
26
What is the major inhibitory neurotransmitter in the brain?
GABA
27
What motor symptoms may be seen in partial onset seizures?
Rhythmic twitching or jerking of one part of the body May spread to other parts of the body/limbs leading to Jacksonian March
28
What sensory symptoms might be experienced in a partial onset seizure?
Tingling or numbness Affecting as single part of the body Flashing lights
29
What higher cortical symptoms might be experienced in partial onset epilepsy?
Disturbance of memory- deja vu Confusion states Dream like states Fear, anger, irritability
30
How can partial onset seizures be subclassified?
Complex or Simple
31
What defines a complex partial onset seizure?
Features of a partial onset seizure with impaired consciousness
32
What defines a simple partial onset seizure?
Features of a partial onset seizure with no loss of consciousness
33
What three components do complex partial-onset seizures have?
Aura- features from simple partial onset seizure where consciousness is in tact Automatism- Coordinated motor activity that occurred either during or after the seizure Impaired Consciousness- Asence of motor arrest, patient may appear vacant or glazed
34
What are the three components of complex partial onset seizure?
Aura Automatism/Motor Activity Impaired consciousness
35
What is the most common type of partial onset seizure?
Temporal lobe epilepsy
36
How does temporal lobe epilepsy usually present?
Epigastric sensation that rises up to the throat | Higher cortical manifestations, deja vu, aura, altered consciousness, automatism
37
How does frontal lobe epilepsy usually present?
Partial onset seizures Usually present with deviation of the head and eyes to one side associated with jerking of the arm on the same side May be followed by paralysis of the arm- Todd's Paralysis
38
How do parietal lobe seizures usually present?
Sensory abnromalities
39
How do optical seizures usually present?
Visual symptoms such as visual hallucinations with impairment in sensations of colours, shapes and patterns
40
What are the three main type of generalised seizures?
Tonic-clonic Absence Myoclonic
41
What are some features of a tonic clonic features?
Tonic phase- Increased tone of the muscles with rigid jaw clenching, breath holding and frothing from the mouth Clonic phase- rhymitc clonic jerking of the limbs, neck and back followed by tongue biting and urinary incontinence.
42
What often follows a tonic-clonic seizure?
Post ictal stage- confused, drowsy, irritable, headache, may go to sleep
43
What is seen in a tonic seizure?
Sudden muscle contraction, jaw rigidity, can often cause the patient to fall backwards
44
What is seen in a atonic seizure?
Sudden loss of muscle tone causing the patient to fall
45
What is seen in a clonic seizure?
Rhythmic jerking of the limbs | Convulsions
46
What are the most common generalised seizures?
Tonic-Clonic
47
What happens in an absence seizure?
Loss of awareness and the patient becomes absent
48
How are absence seizures often seen in?
Children
49
What is seen in myoclonic seizures?
Sudden brief jerking movements that affect the upper limb and can be accompanied by loss of consciousness
50
What is status epilepticus?
Prolonged seizure lasting more than 5 minutes without interruption It's a medical emergency- often given benzodiazepines
51
What are some differential diagnosis for seizure?
``` Syncope Pseudoseizure Panic attacks TIA Hypoglycaemic episodes Migraine Movement disorders- e.g. Tics and Chorea ```
52
What causes syncope?
Reduced blood flow to the brain causing loss of consciousness
53
What features are typically also seen with syncope?
``` Dizziness Lightheadedness Nausea Tinnitus Patient appears pale and sweaty ``` Urinary incontinence is uncommon, tongue biting is uncommon
54
What features might help to suggest a seizure over syncope?
``` Jerking movements Preceding aura Tongue biting Urinary incontinence Post ictal confusion ``` Perfusion to the brain is likely to be more reduced when the patient is standing, which wouldn't be a feature of epilepsy Syncope may occur during exercise (e.g. AS or CVD)
55
What is the cause of a pseudo-seizure?
Psychological distress- this will be managed by the neuropsychiatrists
56
What test can be done to help distinguish between syncope and seizure?
ECG Testing- ECHO is also helpful for assessing valvular function.
57
What questions should you ask about before the attack happened?
What were they doing? Is this the first time this has happened? Were they lying or standing? How have they been in the period before the most recent attack- stress, physical illness? Were there any warning signs?- Confusion, flashing lights, colours
58
What is really helpful to have in patient's presenting with seizure?
A collateral history from someone who say this incident.
59
What would you want to ask someone who witnessed the seizure?
``` What happened Did they go stiff Did they go floppy Did they describe anything before the seizure happened Were they conscious Did they change colour How long did it last Was there any trauma during the attack? ```
60
What would you want to ask the person about after the seizure?
``` Had they bitten their tongue? Was it bleeding? Did they lose control of their bladder? Were they confused? Did they have a headache? Any muscle aches and pains Did they want to go to sleep? ```
61
What test is commonly used in clinical practice to investigate epilepsy?
EEG Should be used to support a clinical diagnosis of epilepsy
62
Does a normal EEG exclude a diagnosis of epilepsy?
No as they may not experience a seizure whilst being monitored with EEG
63
What does a routine EEG involve?
Attempts to trigger a seizure with overbreathing and light stimulation
64
What unique feature is seen on absence seizures on EEG?
3Hz spike and wave pattern
65
Why might you request a brain MRI in someone with seizures?
If they have any symptoms of raised ICP, focal neurological signs or high fever Structural lesions can cause epilepsy
66
What structural lesion is associated with temporal lobe epilepsy?
Hippocampal sclerosis
67
What investigations might you request in someone with seizures?
Bloods- FBC, U&Es, Calcium, Glucose, LFTs, B12 and Folate (Alcohol) Urgent CT- If suspecting any bleeds Brain MRI- If suspecting any structural lesions ECG- If it may be syncope EEG- to investigate for synchronous activity Drug screen on urine Lumbar puncture- if any consideration of infection, can also check opening pressure for raised ICP
68
Do patients need to tell the DVLA after a single seizure
Yes
69
How long must patients not drive for after a first/unprovoked seizure?
6 months if there are no relevant structural abnormalities or EEG changes 12 months if there are
70
How long must patient be seizure free for before they can qualify for a driving licence?
12 months
71
If the decision is made to withdraw anti-epileptic medications, how long should patient's wait before driving?
6 months after the last dose
72
What are the main treatments of epilepsy?
Anticonvulsant drugs
73
When are patients normally started on anti-epileptic medications?
Usually after two or more seizures
74
What is first line for partial seizures?
Carbamazepine or lamotrigine
75
What is second line for partial seizures?
Levetiracetam, Sodium Valproate, Oxcarbazepine
76
What is first line for generalised tonic-clonic seizures?
Sodium valproate | Lamotrigine
77
What is second line for generalised tonic-clonic seizures?
Carbamazepine Clobazam Topiramate (this is also used for migraine prevention)
78
What is first line for absence seizures?
Sodium valproate | Ethosuximide
79
What is second line for absence seizures?
Lamotrigine
80
What is first line for myoclonic seizures?
Sodium valproate
81
What is second line for myoclonic seizures?
Levetiracetam | Topiramate
82
What should be avoided in myoclonic seizures?
Carbamazepine- may worsen seizures
83
What is first line for tonic or atonic seizures?
Lamotrigine | sodium valproate
84
What is a general rule of thumb for first line anti-convulsants?
Lamotrigine can be used in most except as first line treatment
85
When is carbamazepine used first line?
Partialised seizures Should be avoided in absence and myoclonic seizures
86
What are some side effects of carbamazepine?
``` Nausea and vomiting Headaches Diplopia Dizziness Blurred vision ```
87
What are some side effects of sodium valproate?
It should never be used in pregnant women or women of childbearing age as it is teratogenic ``` Nausea Weight gain Amenorrhoea PCOS Hepatotoxicity Thrombocytopenia Pancreatitis ```
88
When might surgical intervention be considered for epilepsy?
If a single focus is identified | OR is due to structural changes that could be corrected with an operation
89
Summarise the antiepileptics used for seizure type
Partial- Carbamazepine/ Lamotrigine/ Sodium Valproate Generalised- Lamotrigine/Sodium Valproate/ Topiramate Absence- Ethosuximide Avoid carbamazepine in myoclonic seizures
90
What is a dermatological side effect of lamotrigine and carbamazepine?
Skin rash can occur as a side effect in patients taking lamotrigine or carbamazepine
91
When might stopping antiepileptics be considered?
If seizure free for 2 years- but most patients choose to carry on with anti-epileptic drugs
92
What is status epilepticus?
Prolonged tonic-clonic seizures persisting for more than 5 minutes
93
What is the management of status epilepticus
``` Medical emergency so ABC approach Protect the airway Establish IV access Take bloods for emergency investigation- FBC, Glucose, eGFR, creatinine, U&Es, LFTs, Calcium, Anti-epileptic drug level (if considering compliance issues) Lorazepam IV Bolus ``` If failure to resolve escalate and transfer to ITU. If IV access difficult rectal diazepam or IM midazolam
94
Can women on antiepileptic drugs breastfeed?
Yes only a small amount enters the breast milk
95
How long must patients be seizure free for if they want to drive HGVs or busses?
10 years without taking AEDs

PAN- Neurology (10 decks)

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