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Year 4 - Neurology + Special Senses ANNA > Neuro - Epilepsy > Flashcards

Neuro - Epilepsy Flashcards

1
Q

What epilepsy questions might you have for a patient in A&E presenting with collapse with TLOC?

A
  • Previously well / any illness before event?
    • illness can trigger seizures in those with epilepsy e.g. infection, dehydration, sleep deprivation, drug use
  • What was happening at the time of the TLOC?
    • Precipitant? standing / istting / lying / on standing upright
    • TLOC triggered by postural change is likely vasovagal
  • Any warnings prior to event?
    • Pre-syncope symptoms = light-headedness, nausea, sweating and ‘greying’ out of vision
    • Epileptic seizure = unexplained smell, deja-vu, focal muscle jerking/twitching
  • First memory on waking up?
    • Syncopal blackout = pt regains awareness / memory quickly
    • Epileptic seizure = foggy or no memory before paramedics turn up / arriving in hospital
  • Any injuries, tongue biting, urinary / faecal incontinence?
    • If yes to above –> more likely an epileptic seizure
    • Beware! urinary incontinence can occur in syncope (especially women)
  • Any previous similar episodes?
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2
Q

What epilepsy questions might you have for an observer of a patient in A&E presenting with collapse with TLOC?

A
  • Any warning signs beforehand?
    • focal onset seizure = focal twitching, a forced head turn, eye deviation or blank ‘staring’
    • syncope = look pale, sweaty, complain of nausea / light-headedness
  • Did they fall stiffly or floppily?
    • floppy = likely syncope
    • stiffly = generlaised seizure (tonic phase)
  • Did they shake + what did it look like?
    • generalised seizure = rigid (tonic) phase + rhythmic clonic jerks afterwards, ↓ in amplitude + frequency
    • syncope = a few brief myoclonic jerks, low amplitude + less rythmic
  • Cyanosis?
    • generalised seizure = blue lips (tonic-clonic involuntary muscle contraction prevents normal breathing)
  • Duration of LOC?
    • syncope = < 1 min
    • generalised seizure = 1-5 mins
  • Duration of shaking?
    • generalised seizures = < 5 mins
    • prolonged shaking = status epilepticus or NEAD
  • How long did it take to recover afterwards?
    • syncope = speedy (few mins)
    • seizure = drowsy for 15 mins
    • prolonged unresponsiveness can be ‘pseudosleep’ of NEAD
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3
Q

How is a seizure managed actuely?

A
  • Airway: check + maintain airway - apply O2 if appropriate
  • Position: recovery position
  • Medication: benzodiazepines (if seizure is prolonged)
    • Rectal diazepam 10-20 mg for adult (repeat once after 10-15 mins if needed)
    • Midazolam oromucosal solution 10mg adult
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4
Q

What investigations would you do after an acute seizure?

A

Beside:

  • Full neurological exam
  • Cardiac exam
  • Vital obs:
    • Temp, HR, BP, SpO2

Blood:

  • Blood glucose
  • FBC - infection
  • U+Es - hyponatraemia, hypocalcaemia

Other:

  • ECG
  • CT - if abnormal neurological findings or prolonged ↓ conciousness
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5
Q

A pt has a focal seizure of one of their temporal lobes - what symptoms might they experience?

A

HEAD mneumonic:

  • Hallucination (auditory/gustatory/olfactory)
  • Epigastric rising sensation / Emotional (e.g. fear)
  • Automatisms (see below)
  • Deja vu (memory disturbance) / Dysphasia post-ictal

Other symptoms:

  • Fear
  • Bizarre psychotic phenomena e.g. derealisation and depersonalisation or elation
  • Automatisms (absent mindedly doing a simple action) e.g. plucking at clothes, lip-smacking, repetitive mumbling, repetition of a stereotypical phrase
  • Impaired awareness - during/after in the case of ‘complex’ partial seizure
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6
Q

Besides the PC / HPC - what other specific

questions are useful in a seizure history?

A
  • Significant head injuries
  • Hx of CNS infection - meningitis, encephalitis, cerebral abscess
  • FHx of epilepsy
  • Birth history:
    • prematurity, difficulty delivery e.g. forceps, postnatal issues e.g. hypoxia or jaundice
    • seizures in childhood / infancy
  • Medications - some can lower seizure threshold e.g. antipsychotics (worse with atypicals), quinolone Abx (ciprofloxacin or levofloxacin), antidepressants e.g. amitriptyline and some painkillers e.g. tramadol
  • Illicit drug use / alcohol use
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7
Q

What are febrile convulsions?

A

Seizures provoked by fever in otherwise normal children

  • Typical onset = 6 months - 5 years
  • Seen in 3-5% of children
  • Features:
    • Viral infection causing pyrexia
    • Seizure is brief ( < 5 mins) - if > 5 mins phone an abulence (15-30 mins = complex febrile convulsion)
    • Commonly tonic-clonic seizure
    • Typically no recurrence within 24hrs
    • Recover in < 1 hour
    • Boys > girls
  • Prognosis:
    • 1 in 3 have further febrile convulsions (depends on seizure risk factors)
    • If further febrile convulsions –> teach parents how to use rectal diazepam or buccal midazolam
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8
Q

What is the link between febrile convulsions and epilepsy?

A

Majority of children who have febrile convulsions have no future issues, but a small proportion can develop epilepsy in later life!

  • Risk factors for developing epilepsy:
    1. FHx of epilepsy
    2. Complex febrile convulsions
      • i.e. > 15 mins, focal not generalised, repeat episodes in < 24hrs)
    3. Background of neurodevelopmental disorder
  • 0 risk factors = 2.5% risk of epilepsy
  • all 3 risk factors = ~ 50% risk of epilepsy

If pt goes on to develop epilepsy it tend to …

  • originate from one of the temporal lobes
  • associated with atrophy + scarring (gliosis) - seen on MRI –> called ‘mesial temporal sclerosis’ (MTS) - seen in attached image (high signal in R hippocampus + R atrophy = MTS)
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9
Q

What is sodium valproate?

A

Sodium valproate = anti-epileptic drug (AED), used in management of epilepsy and is 1st-line therapy for generalised seizures

  • MoA: voltage-gated Na+ channel blocker + ↑ GABA activity in brain (main mechanisms of action)
  • Women of childbearing age = AVOID!!
  • Other AED are often better for seizure control
  • Adverse effects:
    • P450 inhibitor = ↓ drug breakdown, thus ↑ drug efficacy
    • Nausea
    • ↑ appetite + weight gain
    • Alopecia
    • Neuro: ataxia, tremor
    • Organs: hepatotoxicity, pancreatitis, encephalopathy
    • Thrombocytopaenia
    • Hyponatraemia
    • Teratogenic
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10
Q

What monitoring is required for sodium valproate?

A

Normally NONE!!

Poor clinical correlation between levels of serum valproate and efficacy (exception = phenytoin) –> thus blood tests aren’t done, except special circumstances

Special circumstances for valproate monitoring:

  • Concerns about drug toxicity / OD
  • Concordance or poor absorption (if these are concerns they could cause poor seizure control on valproate)
  • Drug interactions e.g. P450
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11
Q

What concerns are there when swapping a pt from one AED to another?

A
  1. Breakthrough seizures - as dose of original AED is lowered and the other AED increased the combination may not effecitvely prevent seizures
    • Pt should be advised to avoid any dangerous activity during transition e.g. working at height, cycling in traffic, work with machinery, taking baths
  2. Tolerability of new AED - will pt have bad side effect profile from new AED / combo of AEDs during transition
  3. Interactions:
    • Between AEDs
    • Between new AED + other current medication e.g. P450 enzyme inducing impacting on COOP = ↓ contraceptive effect
  4. Driving - if pt has breakthrough seizure = no liscence for 6 months (minimum)
    • DVLA recommends (but doesn’t legally enforce) that during transition to new AED the pt stop driving during the transition + for 6 months thereafter
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12
Q

What is Lamotrigine and it’s side effects?

A

Lamotrigine = AED, 2nd-line for various generalised and partial seizures

  • MoA: sodium (Na+) channel blocker
  • Side effects:
    • Common: sedation, dizziness, nausea and insomnia
    • Rare: Stevens-Johnson syndrome (SJS = flu like symptoms progress to blistering red / purple rash) and toxic epidermal necrolysis (TEN) - type of severe skin reaction in which skin blisters leaving raw areas
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13
Q

How is pregnancy planned in patients taking AED for epilepsy?

A
  1. ↓ teratogenic risk - change AED e.g. sodium valproate (no AED is completely safe + risks for each AED are unknown)
  2. Establish lowest therapeutic dose of AED
  3. Prophylactic folic acid 5mg daily as soon as contraception is stopped (continue through 1st trimester)
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14
Q

Name factors which can ↑ an epileptic pt’s liklihood of having a seizure.

A
  1. Illness e.g. LRTI or UTI
  2. Poor concordance with AED medication
  3. New medication interaction - some can lower seizure threshold e.g.
    • antipsychotics (worse with atypicals)
    • quinolone Abx (ciprofloxacin or levofloxacin)
    • antidepressants e.g. amitriptyline
    • some painkillers e.g. tramadol
  4. Alcohol excess
  5. Metabolic disturbances e.g. hypo-/hyper-natraemia, hypoglycaemia, hypocalcaemia (↓ Ca)
  6. Disturbed sleep, jetlag, fatigue
  7. GI disturbances which cause poor AED absorption
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15
Q

What is medically refractory epilepsy and how can it be managed?

A

Medically refractory epilepsy = epilepsy that has failed to be controlled by at least 2 AEDs (occurs in 20-30% of epilepsy)

Management:

  • Further AEDs - tends to show ‘law of diminishing returns’ with each new AED being less likely to help
  • 2 simultaneous AEDs - works for minority of pts (↑ risk of side effects)
  • In some cases epilepsy surgery can be an option e.g. mesial temporal sclerosis
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16
Q

A 23 year old female presents with a blackout. Which one of the following clinical pointers strongly suggests an epileptic seizure as the cause of an episode of TLOC?

  • Witness history of ‘eyes rolled back in head’ during event
  • Attack occurred in bathroom during the night
  • History of bilateral tongue biting
  • Witness history of shaking during event
  • Incontinence of urine
A

History of bilateral tongue biting

  • Bilateral tongue bites, affecting the sides of the tongue are uncommon in syncope or NEAD
17
Q

A 42 year old man is seen in clinic due to TLOC. Following assessment this was felt to be due to an epileptic seizure. Choose the most appropriate driving advice.

  • The patient must inform the DVLA and be seizure free for 6 months before driving again
  • The patient must inform the DVLA and be seizure free for 12 months before driving again
  • The patient can drive if commenced on anti-epileptic medication
  • The patient can drive if an MRI brain scan is normal
  • The patient can drive if an EEG is normal
A

The patient must inform the DVLA and be seizure free for 6 months before driving again

18
Q

A 23 year old woman is seen in clinic with a new diagnosis of focal epilepsy due to cerebral venous sinus thrombosis. She is anticoagulated with Warfarin and takes the combined oral contraceptive pill.

Choose the most appropriate antiepileptic drug in this situation.

  • Clobazam
  • Levetiracetam
  • No antiepiletic drug
  • Phenytoin
  • Sodium Valproate
A

Levetriacetam = good 1st-line drug that doesn’t interact with warfarin

  • Clobazam = a short term adjunctive AED so is not appropriate
  • No antiepiletic drug - pt has high risk of short term seizure recurrence
  • Phenytoin - older AED, no longer 1st line (but still used in status epilepticus) + interacts with warfarin
  • Sodium Valproate - not 1st line in adult seizures, teratogenic, interacts with warfarin
19
Q

A patient with treatment resistant epilepsy is admitted to the emergency department following a series of generalised tonic clonic seizures. Despite the administration of buccal midazolam twice in the department the patient has 2 more attacks consistent with generalised seizures. In between episodes the patient remains drowsy and is hypotensive. Status epilepticus is diagnosed.

Choose the next most appropriate management step:

  1. IV Lorazepam
  2. IV midazolam infusion
  3. IV phenytoin
  4. IV sodium valproate
  5. Oral levetiracetam
A

IV sodium valproate

  • IV Lorazepam - 1st line for status epilepticus IV lorazepam or buccal midazolam. However, this patient has already had that given
  • IV midazolam infusion - can be used to treat refractory status but require intensive care monitoring, and often respiratory support, due to sedation and respiratory depression with the drug
  • IV phenytoin - is 2nd line along with sodium valproate but has worse side effects e.g. hypotension + bradycardia
20
Q

What are the 5 Ps and Cs to remember questions in a syncope / seizure history?

A

5 P’s:

  • Precipitant - vasovagal trigger, infection, seizure trigger
  • Prodrome
  • Position (orthostatic)
  • Palpitations (cardiogenic)
  • Post-event phenomena (confusion/disorientation is more common after epileptic seizures)

5 C’s:

  • Colour (blue is more likely transient loss of respiratory muscle action in a tonic seizure, pale more likely systemic hypoperfusion ie syncope)
  • Convulsions (happens in both syncope and seizures but tonic phase is characteristic)
  • Continence (incontinence is more likely in seizures)
  • Cardiac problems (points to cardiogenic syncope)
  • Cardiac death family history (cardiogenic syncope)
21
Q

What are the 3 types of reflex (neurally mediated) syncope?

A
  1. Vasovagal
    • also called ‘simple faint’
    • commonest type of syncope
    • common in young people
    • often after an emotional response
      • fear, anxiety or disgust
    • may also happen due to prolonged standing
  2. Situational
    • syncope occurs consistently after a specific trigger​ e.g:
      • Post-micturition (the most common)
      • Post-cough
      • Post-swallow
      • Post-defecation
      • Post-prandial (after a meal)
      • Post-exercise (if syncope occurs during exercise = more alarming + suggests cardiac cause)
  3. Carotid sinus
    • syncope after mechanical manipulation of the carotid sinus
    • can happen accidentally whilst shaving, wearing a tight shirt collar or even head movement
22
Q

What is 1st-line AED for epilepsy in a woman of childbearing age?

A

Lamotrigine

23
Q

An absence of prodromal symptoms makes you more likely to consider what cause of TLOC?

A

cardiogenic syncope

24
Q

Which AEDs are tetrogenic?

A
  1. Sodium valproate
  2. Topiramate
  3. Carbamazepine
25
Q

What are the DVLA guidelines regarding epilepsy / seizures?

A
  • 1st unprovoked seizure = 6 months (without episode)
  • Epileptic seizure = 12 months (without episode)
  • Seizure due to doctor changing / reducing medication:
    • 6 months (without episode) and
    • 6 months on previous AED medication
26
Q

What are the MoAs for the following AEDs.

  • Phenytoin
  • Carbamazepine
  • Lamotrigine
  • Sodium valproate
  • Pregabalin
  • Gabapentin
  • Benzodiazepines e.g. diazepam or lorazepam
  • Topiramate
  • Levetiracetam
A
27
Q

What are the potential adverse effects of AEDs?

A
  • Rare and serious:
    • Rash (Steven-Johnson Syndrome = flu like symptoms progress to blistering red / purple rash)
      • Lamotrigine carbemazepine, phenytoin
    • Bone marrow suppression
      • Carbemazepine
    • Hepatic toxicity
      • Valproate
  • Neurotoxic side effects (common)
    • dizziness
    • diplopia
    • ataxia / incoordination
    • drowsiness
    • cognitive slowing
  • Metabolic side effects:
    • Weight gain - valproate
    • Weight loss - topiramate
  • Reproductive
    • Teratogenic
    • Polycystic ovarian syndrome - valproate
    • Erectile dysfunction
28
Q

Which of the following AEDs doesn’t interact with the COOP?

  • Phenytoin
  • Carbamazepine
  • Phenobarbitone
  • Sodium valproate
  • Topiramate
A

Sodium valproate

29
Q

Generalised seizures can be divided into 2 catagories - what are they?

What the the key features of a generalised seizure?

A

Types of generalised seizure:

  1. motor (e.g. tonic-clonic,
  2. non-motor (e.g. absence)

Features of generalised seizures:

  • Loss of conciousness / awareness
  • Postictal confusion / drowsiness (~15 mins) - not specific to generalsied seizures
  • Fall stiffly (tonic phase of tonic-clonic)
  • Shaking - rigid (tonic) phase + rhythmic clonic jerks afterwards, ↓ in amplitude + frequency
  • Blue lips (in tonic-clonic due to ↓ respiratory ability)
  • Tongue biting
  • Incontinence of urine (non-specific as can occur in syncope)
30
Q

Generally, which AED is 1st line for generalised seizures?

A

Sodium valproate

2nd line = lamotrigine or carbamazepine

31
Q

Generally, which AED is 1st line for focal seizures?

A

Carbamazepine or Lamotrigine

2nd line = levetiracetam, oxcarbazepine or sodium valproate

32
Q

Why are AED prescribed by brand?

A

Due to risk of slightly different bioavailability - which can result in a ↓ seizure threshold (due to ↓ bioavailability of a drug)

33
Q

What is Carbamazepine and it’s side effects?

A

Carbamazepine = 1st-line AED for focal seizures

  • MoA = sodium (Na+) channel blocker
  • Side effects:
    • P450 inducer –> ↑ breakdown of drugs, thus ↓ drug efficacy
    • diplopia
    • dizziness / ataxia
    • drowsiness
    • Rare / dangerous: agranulocytosis, leucopenia and SIADH
34
Q

What is status epilepticus?

How is it managed?

A

Status epilepticus = life-threatening disorder of acute, prolonged seizures. Seizure > 5 mins or repeptive seizures without regaining consciousness

Management:

  • 1st line - benzodiazepines e.g. diazepam or lorazepam (rectally, intranasally or under tongue) - should work within 10 mins –> if not move to 2nd-line
  • 2nd line:
    • sodium valproate
    • phenytoin
    • levetiracetam
    • phenobarbital
  • If no response within 30 mins from onset –> general anaesthesia

Year 4 - Neurology + Special Senses ANNA (12 decks)

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