Epilepsy and Seizure

Question 1

Statistics about epilepsy

Prevalence

Duration

Answer 1

Epilepsy is a chronic non-communicable disease of the brain that affects people of all ages.

One of the oldest recognised conditions c 4000 BC

1/200 people have epilepsy - 1/100

250 million people world

5 million people are diagnosed with epilepsy each year

500,000 in UK have epilepsy diagnosis

4-10 / 1000 - active epilspsy with seizures or in need of treatment

The most common serious brain disorder in the world with no age, class, ethnic, geographic boundaries

Seizures are the most common child / maternal neurological condition

Over 50% cases begin in childhood or adolescence.

0.5% global burden of disease

70% of those living with epilepsy could be seizure free if well treated

Question 2

Relevance (stats - 3-4 lines)

Specific to MH?

Answer 2

More prevalent in LD - 1/3 have epilepsy

3 x risk of premature death than general pop - 1000 deaths per year in England

70% of those living with epilepsy could be seizure free if well treated

Question 3

Definition

Seizure vs Epilepsy

Answer 3

Epilepsy is a disease characterised by recurrent, unprovoked seizures (ILAE)

associated with abnormal electrical activity in the brain

Question 4

Classification of Seizures:

How are they grouped?

Who introduced this?

Answer 4

Grouped depending on:

• Onset location?
• Awareness affected?
• Other symptoms? e.g. movement

In 2017 the International League Against Epilepsy (ILAE) introduced new method to group.

Question 5

Myoclonus

Answer 5

Jerking arrhythmically

Question 6

Clonus

Answer 6

Jerking rhythmically

Question 7

Atonic

Answer 7

Limp

Question 8

Tonic

Answer 8

extension or flexion postures

Question 9

Spasm

Answer 9

Trunk flexion

Question 10

Hyperkinetic

Answer 10

thrashing / pedalling

Question 11

Word Changes! (due to 2017 ILAE)

Partial
Simple Partial
Complex partial
Dyscognitive

Answer 11

Partial-> Focal
Simple Partial-> Focal aware
Complex partial-> focal impaired awareness
Dyscognitive -> focal impaired awareness

Question 12

Onset types ?

Answer 12

Focal onset
Generalised onset
Unknown onset - idiopathic

Question 13

Focal Seizures - what are they?

What is another type of focal seizure?

Answer 13

Originate within networks limited to one hemisphere

May be discretely localised or more widely distributed.

Can spread to both sides of the brain (called a focal to bilateral tonic-clonic seizure - the focal seizure is then a warning, sometimes called an ‘aura’ that another seizure will happen)

Question 14

Generalised Seizures - what are they?

Where is affected?

Answer 14

Originate at some point within and rapidly engaged bilaterally distributed networks

Can include cortical and sub-cortical structures but not necessarily entire brain complex

Question 15

Aetiology of seizures:

Answer 15

Structural - brain injury, genetic abnormality,

Brain dysfunction due to infection
Metabolic issues, e.g. problems with glucose, sodium or potassium,

• Structure
• Genetic
• Infection
• Metabolic
• Immune
• Unknown

Question 16

Name some Common Co-morbities

% of children with epilepsy who also have MH problems?

Answer 16

ADHD
LD
ASD

59% of children with epilepsy also have MH problems

Question 17

Tuberous Sclerosis - what is it?

Answer 17

Complex, rare genetic condition that causes mainly benign tumours to develop - structural, metabolic, genetic.

Question 18

Focal Aware Seizure

• Previously named?
• Clinical presentation?

Answer 18

AKA Partial seizure

In FAS the person is conscious (aware and alert), will usually know that something is happening ‘feel strange’ and will remember the seizure afterwards.

Question 19

Focal Impaired Awareness Seizure (FIAS)

• Previously named?
• Clinical presentation?
• Particular location?

Answer 19

Previously Complex partial seizure

Affect a bigger part of one hemisphere

May be confused and difficult to communicate with. Afterwards they may be confused for a while, tired or not able to remember.

esp. temporal lobes

Question 20

Focal seizures - examples of motor symptoms?

Answer 20

Lip-smacking
Atonic
Stiffness of limbs
Jerking
Screaming 
Crying

Question 21

Focal seizures - examples of non-motor symptoms?

Answer 21

deja vu
Unusual sensations
Intense emotions
Hallucinations

Question 22

Focal to bilateral tonic clonic

• Previously named?
• Clinical presentation?

Answer 22

AKA secondary generalised seizure

tonic-clonic - convulsive or shaking seizure

If this happens quickly, they may not be aware that it began as focal

Question 23

Generalised onset seizures

• Clinical presentation?
• Location?

Answer 23

Both hemispheres

Unconscious except myoclonic seizures

Won’t remember

Question 24

Tonic-clonic

Clinical presentation:

• Pre
• During
• Post

Answer 24

Pre:

Unsconscious
Stiffness
Fall down
Cry
Bite tongue

During:

Jerk and Shake
Breathing difficulties,
Cyanosis
Incontinence

After:

Tired, confused, headache, want to sleep

Question 25

Clonic Seizures - Clinical presentation? - Location?

Answer 25

Repeated rhythmical jerking movements of one side or part or both sides of body, depending where seizure starts Seizures can start in one part of brain (focal motor) or affect both sides of the brain (generalised clonic)

Question 26

Tonic Atonic What happens? Post?

Answer 26

Tonic - stiff, fall backwards, brief seizure Atonic - drop attack - muscles suddenly relax Quick recovery usually unless collapse caused trauma

Question 27

Myclonic seizures What are they?

Answer 27

muscle jerk Not always due to epilepsy, often happen in clusters, close together, shortly after waking Conscious but classified as generalised as likely to have other

Question 28

Absence Seizure - Previously named? - Clinical presentation? Atypical absence - e.g.?

Answer 28

Previously petit mal Unresponsive blank Appears to be daydreaming If walking, may continue Atypical - includes change in muscle tone

Question 29

Types of epilepsy give a few examples

Answer 29

Status Epilepticus Most seizures less than 5 minutes, SE is 30 minutes +, life threatening Others - catamenial or photosensitive epilepsy

Question 30

Pathophysiology

Answer 30

Brains cells need to work in harmony Nerve impulses to one another,muscles and glands - action potentials baby AP's driven by Sodium potassium pump

Question 31

What would you see on an EEG?

Answer 31

Abnormal with spikes of electrical activity

Question 32

Brain - weight / CO % of weight? % of cardiac output? ml per minute required for brain?

Answer 32

2% weight 20% cardiac output Needs 750mls cerebral blood flow per minute, extracts 40% of oxygen from arterial bed

Question 33

Seizures thought to result from...?

Answer 33

Abnormal hyperactive neurons that form an epilogenic focus Abnormal and excessive discharge of AP's These stimulate contractions in skeletal muscle Subside due to a lack of neurotransmitter in the synapse

Question 34

Causes - previously discussed?

Answer 34

``` Structural Infectious Metabolism Immune Unknown ``` ``` Brain damage Stroke Malnutrition - protein, Alcohol - Pre-natal or perinatal causes Pyrexia - high temperature Hyperglycaemia - glucose Hyponatraemia (sodium) Hypocalcaemia - calcium req. for AP Diarrhoea & Vomitting - potassium loss Eclampsia - blood pressure on brain tissue Pregnancy - circulatory volume increases, BP falls ```

Question 35

Seizure threshold - causes:

Answer 35

Genetically determined - parents

Question 36

Why so serious? | 1000 die each year in England

Answer 36

Cerebral oxygen consumption can increase by up to 60% - more ATP seizures cause metabolic requirements to increase, resulting in elevation of cerebral blood flow and cerebral blood volume supply demand abnormality - need more oxygen but get less - > hypoxia Need oxygen - BUT oxygen and glucose consumption by skeletal muscle Apnoea - temporary ceasing of breathing Problems with hypoxemia - low levels of oxygen in the blood hypercapnia - elevated co2 in the blood hypoglycaemia - low blood sugar seizures cause metabolic requirements to increase, resulting in elevation of cerebral blood flow and cerebral blood volume hypoxia -> acidosis lactate 0.5-1:1,3,5,10 blood pH - 6.8= death irreversible neuronal destruction cell death & lyosomal activation

Question 37

Diagnosis & Tests

Answer 37

Family history - type, cause, duration, previous treatments, current status Physical examination - neurological deficits associated with recent or remote lesions ``` Diagnostic tests: - EEG - electrical activity - MRI - small lesions and scars - CT or CAT - structure - Ambulatory EEG (24-48 hours) Video telemetry - video + EEG PET Scan - glucose usage ```

Question 38

EEG Wave types

Answer 38

Alpha - Resting state, here and now Theta - Alpha - Bridge between conscious and subconscious Beta - conscious states, reading thinking calculating Gamma - conscentration complex tasks

Question 39

Assessment

Answer 39

Monitor through ABCDE approach Looking for the cause Prevent additional seizures Provide safe environment ABCDE: Assess for safety, early call for help, PPE Introduce yourself A - Look listen and feel: Airway occlusion, tongue biting or thrusting, excessive saliva, don't touch B - Look listen and feel - respiratory distress, apnoea, cyanosis, high flow oxygen rate depth cough conversation, accessory muscles, cyanosis, gurgling wheezing stridor, equal chest expansion? C - Work way up the arm - capillary refill, cardiovascular instability due to hypoxia, bladder and bowel incontinence, D - glucose and level of consciousness ACVPU - unconscious? GI symptoms, abnormal movements, glucose could go down E - warm, privacy and dignity, fractures rashes or bleeding, after seizures, place in recovery position

Question 40

ACVPU

Answer 40

A V P U