Epilepsy and Blackouts

Question 1

What is a seizure?

Answer 1

Sudden Synchronous Discharge of Cerebral Neurones that is apparent either to the patient
only (e.g. Simple Partial Seizure) or to an observer (e.g. Generalised Seizure); Definition
excludes Migraine Aura (more gradual onset, more prolonged, on EEG correlation)

Question 2

What is epilepsy?

Answer 2

Ongoing liability to recurrent epileptic seizures; Common (0.7-0.8%, more common
in developed countries); Highest incidence at young/elderly; Often goes into remission

Question 3

Generalised onset

Answer 3

Discharge arises from both hemispheres

o Includes Absence, Myoclonic, Tonic, Tonic-Clonic, Atonic; Combination or Sequential

Question 4

Focal Onset

Answer 4

Arises from one or part of one hemisphere; LOC may be retained, lost or evolve
into secondary GTCS

Question 5

Frontal Lobe Seizures

Answer 5

Motor or Premotor Cortex; Clonic movements which may travel proximally (Jacksonian march) or Tonic seizure (e.g. both upper limbs raised high for several seconds)

Question 6

Temporal Lobe Seizures

Answer 6

Strange warning feelings, or Aura with Smell/Taste
abnormalities, Distortion of Sound and Shape etc
▪ Automatisms – Lip-smacking, Plucking, Walking in Non-purposeful manner;
due to spread to Pre-motor Cortex
▪ Consciousness can be impaired, usually longer than absence seizures

Question 7

Occipital Lobe Seizures

Answer 7

Stereotyped Visual Hallucinations

Question 8

Parietal Lobe Seizures

Answer 8

Contralateral dysaesthesia or distorted body image

Question 9

ILAE 2017

Answer 9

– Focal (Awareness/Impaired, Motor/Non-motor, Focal to Bilateral Tonic-
Clonic), Generalised (Motor or Non-motor), or Unknown (Motor or Non-motor)

Question 10

Epilepsy syndromes by age groups

Answer 10

In Adolescents, Genetic, Perinatal and Congenital Disorders predominate; In Younger Adults, Trauma, Drugs, Alcohol are common while in the Elderly, Cerebrovascular Disease and Mass Lesions (e.g. Brain Tumours) are commoner

Question 11

Primary Generalised Epilepsies

Answer 11

Presents in Childhood and Early Adult life; Accounts for up to 20% of all patients with
Epilepsy; Polygenic with complex inheritance
Structurally normal brain but abnormal Ion Channels which lead to abnormal Neuronal,
Neurotransmitter and Synaptic Functioning

Question 12

Juvenile Myoclonic Epilepsy

Answer 12

10% of all Epilepsy patients; Myoclonic Seizures start in teenage years; Followed by GTCS; 1/3 of patients also have Absence Seizures
o Often occur in the morning after waking; Lack of sleep, Alcohol, Strobe lighting are
triggers; Responds well to treatment
o Usually associated with EEG abnormalities and requires life-long therapy

Question 13

Hippocampal Sclerosis

Answer 13

Major cause of Epilepsy; Damage leading to
Scarring and Atrophy of the Hippocampus (usually
visible on MRI) leading to Temporal Lobe Epilepsy,
leading cause of LRE
• Childhood Febrile Convulsions are the main Risk Factor; One of the commoner causes of Refractory Epilepsy; Surgical Resection of damaged Temporal Lobe might be useful

Question 14

Causes of Epilepsy: TBI

Answer 14

Might cause Epilepsy, even years after; Risk is not increased for minor injury (LOC/Amnesia <30 mins); Depressed Skull Fracture, Penetrating Injury and ICH increases risk significantly

Question 15

Causes of Epilepsy: Perinatal Brain Injury and Cerebral Palsy

Answer 15

Periventricular Leukomalacia and ICH associated

with Prematurity and Foetal Hypoxia can cause Early Onset Epilepsy; 1/3 of Cerebral Palsy patients have Epilepsy

Question 16

Causes of Epilepsy: Brain neurosurgery

Answer 16

Seizures in up to 17% of cases; Prophylactic Anticonvulsant use
Postoperatively is not recommended (Risk of Altered Mental Consciousness>Benefits)

Question 17

Causes of Epilepsy: Genetic Disorders

Answer 17

Genetic Disorders (>200 types) can cause Epilepsy; Only counts for 2% of Epilepsy causes;
Developmental Disorders E.g. Neuronal Migration detects during Brain development,
Dysplastic Cerebral Cortex and Hamartomas also contribute to Seizures

Question 18

Causes of Epilepsy: Vascular Disorders

Answer 18

Stroke and Small Vessel Cerebrovascular Disease is the commonest cause of Epilepsy after 60yrs; AVMs including Cavernous Haemangiomas

Question 19

Causes of Epilepsy: Neurodegenerative Disorders

Answer 19

Involvement of the Cerebral Cortex e.g. Alzheimer’s Disease is associated with increased risk for Epilepsy

Question 20

Causes of Epilepsy: Inflammatory Conditions

Answer 20

Encephalitis, Cerebral Abscess, Tuberculomas; Also occurs in Chronic TB Meningitis and rarely Acute Bacterial Meningitis; Parasitic infections commoner in
less developed countries

Question 21

Causes of Epilepsy: Chronic Alcohol Use

Answer 21

Common cause; Occur while heavy drinking or during withdrawal; Induced Hypoglycaemia and Head Injury also can cause seizures

Question 22

Causes of Epilepsy: Drugs

Answer 22

Antipsychotics, TCAs, SSRIs, Lithium, Class Ib Anti-Arrhythmics (Lidocaine), Ciclosporin and Mefloquine; Stimulants e.g. Cocaine

Question 23

Causes of Epilepsy: Metabolic

Answer 23

Hypocalcaemia, Hypoglycaemia, Hyponatraemia, Acute Hypoxia, Uraemia
and Hepatic Encephalopathy, Porphyria

Question 24

Management of First Fit

Answer 24

Clinical diagnosis based on History taking; Majority of patients referred to First Fit
clinic have not had a seizure; Most commonly misdiagnosed Syncope
If not doubt, do not diagnose Epilepsy
• Bloods (FBC, U/Es, Serum Calcium), ECG
• EEG – Most useful to categorise Epilepsy rather than confirm diagnosis; High False Negative Rate and low False Positive Rate
o Focal Cortical Spikes (e.g. Temporal Lobe Epilepsy) or Generalised Spike-and-Wave Activity (e.g. in PGE); Continuous in Status
Epilepticus

• MRI Brain indicated in most patients after
first Seizure; Especially for Partial Onset or
Elderly (Greater risk of Focal Brain Lesions);
Not essential if <30yrs with definite EEG/Clinical Diagnosis of PGE

Question 25

Distinguishing Syncope from Seizure

Answer 25

Distinguishing from Syncope – Seizures have prolonged recovery period, tongue may be bitten, colour change (Cyanosis occurs in Seizure, Pallor in Syncope)

Question 26

Advice for First Seizure

Answer 26

Avoid precipitants, Advice on safety, stop driving and ask patients to inform DVLA • Recurrence after first fit in 70-80% of people; Risk highest 6 months after initial seizure; Risk is significantly increased by features of PGE on EEG, Partial Seizures and Structural Brain Lesion

Question 27

Management of Continuous Seizure

Answer 27

Seizure >5mins or repeated Seizure treated with Rectal Diazepam, IV Lorazepam or Buccal Midazolam; O2 and monitor Airway

Question 28

Status Epilepticus

Answer 28

Continuous Seizures for >30mins; Mortality 10-15%; Longer duration of status increases risk of Permanent Cerebral Damage; Rhabdomyolysis leads to AKI in convulsive Status Epilepticus

Question 29

What kind of form can SE take

Answer 29

Status can be Convulsive, Absence or Focal; Epilepsia Partialis Continua is continuous Seizure activity in one part of the limb without loss of Consciousness; Often due to Cortical Neoplasm or Cortical Infarct (especially in the Elderly)

Question 30

How are antiepileptic drugs given?

Answer 30

Indicated if firm clinical diagnosis of Epilepsy and Substantial Risk of Recurrent Seizures; Introduced at low dose and titrated upwards until Seizures controlled or SE intolerable • 70% of patients only require monotherapy • If seizures not controlled with first drug, introduce second agent and withdraw first drug; if not seizure free, combination therapy required • Non-Generic prescribing to ensure consistent drug levels • Routine monitoring not required; For assessing compliance and toxicity

Question 31

SE of AEDs?

Answer 31

Unsteadiness, Nystagmus, Drowsiness; Skin rashes in Lamotrigine, Carbamazepine and Phenytoin; Variety of Idiosyncratic drug reactions

Question 32

AEDs and pregnancy?

Answer 32

Increased risk of Birth Defects; Recommend switching to Monotherapy at low-dose; Folate and Vitamin K supplementation; Risk of Birth Defect < Risk of Seizures to Foetus

Question 33

AEDs and oral contraception?

Answer 33

Phenytoin, Carbamazepine, Phenobarbital are liver inducers; Oral contraception affected

Question 34

AED withdrawal

Answer 34

Withdrawal after at least 2-3yrs seizure free; 50% Recurrence Rate after withdrawal

Question 35

Management of GTCS

Answer 35

``` 1st Line: Valporate, Carbamazepine, Lamotrigine 2nd Line Clobazam, Levetiracetam, Topiramate ```

Question 36

Management of Generalised Absence

Answer 36

``` 1st Line Valporate, Ethosuximide, Lamotrigine 2nd Line Clobazam, Levetiracetam, Topiramate ```

Question 37

Management of Generalised Myoclonic

Answer 37

``` 1st Line Valporate, Levetiracetam, Topiramate 2nd Line Clobazam, Piracetam ```

Question 38

Management of Focal Seizures

Answer 38

``` 1st Line Carbamazepine, Valporate, Levetiracetam, Lamotrigine 2nd Line Clobazam, Topiramate, Gabapentin, Tiagabine ```

Question 39

Which drugs should be avoided in absence, myoclonic and JME

Answer 39

Avoid Carbamazepine, Gabapentin and Tiagabine

Question 40

SE Valproate

Answer 40

Weight gain, Hair loss, Teratogenic, Rare Idiosyncratic Liver Failure

Question 41

SE Carbamazepine

Answer 41

Rash, Hyponatraemia, Ataxia, Liver Enzyme Induction, Interference with other medications including Oral Contraception

Question 42

Management of Refractory Epilepsy

Answer 42

* Re-evaluate Diagnosis, Consider drug concordance, Combination therapy to maximum tolerable dose, Referral for Epileptic Surgery (e.g. Temporal Lobectomy, Cure in 50-70%) * Vagal Nerve Stimulation, Ketogenic Low Carbohydrate Diet might be useful

Question 43

Vasovagal syncope

Answer 43

Simple faint due to sudden reflex tachycardia with vasodilation of peripheral and splanchnic vasculature Precipitated by Prolonged Standing,Fear, Venesection or Pain o Brief Prodrome of Dizziness, Nausea, Sweating, Heart and Visual Grey-out o Blackout may be accompanied with jerking/twitching movements; Pallor o Rapid recovery (usually seconds) by followed by a feeling of general fatigue

Question 44

Cardiac Syncope (Stokes-Adams Attacks)

Answer 44

Cardiac Arrhythmias E.g. Heart Block, LVOT | Obstruction; Syncope during exercise is cardiac in origin

Question 45

Micturition Syncope

Answer 45

More common in men, particularly at night

Question 46

Cough Syncope

Answer 46

Venous Return to the heart obstructed by coughing; Also, laughter

Question 47

Postural Hypotension

Answer 47

Occurs in the Elderly, patients with Autonomic Neuropathy, or drugs e.g. Antihypertensives especially β-Blockers

Question 48

Carotid Sinus Syncope

Answer 48

Vagal response to pressure on Carotid Sinus Baroreceptors

Question 49

Convulsive Syncope

Answer 49

Collapsing in a propped-up position results in delayed restoration of Cerebral Blood Flow; Secondary Anoxic Seizure following Syncope

Question 50

Management of Syncope

Answer 50

• 12-lead ECG – Identify Heart Block, Pre-Excitation, Long QT syndrome • Cardiac ECG Holter Monitoring and Echo if Cardiac Syncope suspected; alternatively, Implantable Loop Recorder for infrequent events • Tilt table testing sometimes diagnostic but low sensitivity

Question 51

Non-Epileptic Attack Disorder (Pseudoseizures)

Answer 51

Presents similarly to Grand Mal Seizures; Bizarre thrashing, non-synchronous Limb Movements; No rise in Prolactin (No rise also seen in Partial Seizures) and no EEG changes even during attack

Question 52

Panic Attacks

Answer 52

Sudden Sympathetic Activation; Often Hyperventilation leading to Respiratory Alkalosis; Dizziness, Chest Pain/Tightness, Feeling or Choking, SOB, Facial Tingling and Extremities, Trembling, Feeling of dissociation o Consciousness is usually preserved, attacks easily recognised

Question 53

Hypoglycaemia

Answer 53

Confusion followed by LOC, Convulsion, Dysphasia, Hemiparesis; Often warning with Hunger, Malaise, Shaking and Sweating; Prompt recovery with IV/PO Glucose o Prolonged Hypoglycaemia can cause widespread Cerebral Damage; Usually related to underlying Diabetes

Question 54

Vertigo

Answer 54

Acute Vertigo might be severe enough to cause prostration

Question 55

Migraine

Answer 55

Severe Basilar Migraine and Familial Hemiplegic Migraine may cause LOC

Question 56

Drop Attacks

Answer 56

Instant, Unexpected episodes of LL Weakness with Falling; Due to sudden drop in LL Tone? Brainstem origin; More common in 60+ Women; Also occurs in Hydrocephalus

Question 57

Narcolepsy

Answer 57

Abnormalities of orexin, unusually low, autoimmune hypothalamic damage Tetrad of excessive daytime sleepiness, cataplexy (sudden loss of tone), dream like hallucinations peri sleep often frightening and sleep paralysis

Question 58

Management of Narcolepsy

Answer 58

• Multiple Sleep Latency Testing – Demonstrate rapid transition from Wakefulness to Sleep, Short time to onset from REM sleep • HLA testing for HLA-DR2 and HLA-DQBI*0602 Antigens (Strong Association) • Good sleep hygiene advice; CNS Stimulants like Modafinil (? Dopamine Reuptake Inhibitor) and Methylphenidate (Dopamine-Noradrenaline Reuptake Inhibitor) for treatment although often only partial response • TCAs (especially Clomipramine) or SSRIs to improve Cataplexy; Sodium Oxybate also used

Question 59

Parasomnias

Answer 59

Disruptive Motor/Verbal Behaviours – REM and non-REM parasomnia depending on what stage of sleep it occurs in • Includes Sleepwalking, Night Terrors, Confusional Arousals and REM Sleep Behaviour Disorder o REM Sleep Behaviour Disorder might be early feature of Parkinson’s Disease