Seizures and Epilepsy

Question 1

Classification of epileptic seizures?

Answer 1

1. partial
2. generalised
3. unclassified

Question 2

Partial seizures?

Answer 2

involve part of one cerebral hemisphere
1. ‘simple’, - consciousness not impaired
2. ‘complex’ - consciousness is impaired

Question 3

Generalized seizures?

Answer 3

involve both cerebral hemispheres
- may or may not be convulsive

Question 4

Unclassified seizure?

Answer 4

which do not fit in the other groups

Question 5

General history questions to ask in epilepsy?
(Describe seizure episode?)

Answer 5

1. The classification of the seizure (e.g generalized tonic-clonic, absence).
2. Any prodromal symptoms (e.g irritability, pallor).
3. Any aura (e.g a specific sensory symptom, rare in children)
4. Initial cry or scream
5. Initial localising sign (e.g. twitching of one hand)
6. Description of all the manifestations (motor and autonomic) of the seizure (e.g. eyes ‘rolling back’, cyanosis, jerking movements of limbs, urinary and/faecal incontinence).

Question 6

History questions to ask about the seizure in epilepsy?
(What happens during the seizure?)

Answer 6

1. The duration of the seizures – the range and the usual time
2. The frequency of the seizures – range and the ‘usual’
3. Time of occurrence of the seizures (e.g. on waking, or on going to sleep)
4. The date and time of the last seizure
5. Any precipitating factors, e.g. tiredness, lack of sleep, fever, infectious illness, change of dosage or type of anticonvulsant, intake of other substances (in adolescents), falls or blows to the head, sensory stimuli such as flashing lights, television, computer games, sounds, startling by sudden noises or touch
6. Postictal events (e.g. sleeping, confusion, headache, vomiting, Todd’s paralysis)

Question 7

Past history of seizures?

Answer 7

1. Number of hospitalizations
2. Previous anticonvulsants used and why they were changed
3. Previous complications of seizures or their treatment
4. Whether febrile convulsions occurred at a younger age
5. Family history of seizure disorder or other neurological problems
6. Current anticonvulsants therapy: dose, recent dosage changes, and any current side effects

Question 8

History questions specifically for the parents?

Answer 8

1. How the parents manage when the child is having a seizure
2. What contingency plan exists for a prolonged seizure
3. Criteria for seeking hospital treatment
4. How long it takes to get to hospital in an emergency
5. What restrictions are placed on the child because of the seizures (e.g climbing trees)
6. Evaluate parent’s understanding of seizures, e.g. in terms of prognosis, chances of remission, complications
7. Take a full social history: impact of the disease on the child, schooling, parents and siblings

Question 9

Inspection in PE in epilepsy?

Answer 9

1. dysmorphic features
2. diagnostic rashes (e,g neurocutaneous syndromes)
3. Asymmetry (long-standing hemiplegia)

Question 10

Blood pressure in epilepsy?

Answer 10

hypertension may be the cause

Question 11

Head and neck physical exam in epilepsy?

Answer 11

1. Microcephaly: CP syndrome
2. Macrocephaly: hydrocephalus, intracranial tumors
3. Eyes: raised intracranial pressure (ICP)
4. Hearing: impairment with CP, congenital rubella
5. Cranial nerves

Question 12

How to look for long tract signs in epilepsy?

Answer 12

gait exam

Question 13

Investigations in epilepsy?

Answer 13

1. Electroencephalogram (EEG)
   may help to confirm the diagnosis
   normal EEG does not exclude the diagnosis
2. Biochemical evaluation
   - sodium, calcium, magnesium
3. blood glucose level
4. Brain imaging (CT scan) indications:
   - Abnormal neurological findings (particularly focal signs)
   - Developmental delay/regression
   - Seizures that are difficult to control

Question 14

Common Management Issues in Epilepsy

Answer 14

1. Increasing frequency of seizures and intractable epilepsy
2. Seizure worsening in duration or frequency
3. Seizures changing in nature (appearance different type of seizure)
   Note: reconsider overall management

Question 15

Name conditions that can mimic epilepsy?

Answer 15

1. Syncope
2. Breath-holding attacks
3. Undiagnosed structural causes (e.g brain tumor)

Question 16

Medication management issues in epilepsy?

Answer 16

1. Wrong dose
   - non-compliance, ‘outgrowing’
2. Wrong drug
   e.g carbamazepine can ‘unmask’ absence seizure
3. Adverse drug interactions

Question 17

What are intercurrent problems in epilepsy?

Answer 17

1. Electrolyte imbalances consequent on drug side effects
   e.g. hyponatremia with carbamazepine, via SIADH)
2. Intercurrent infections (e.g UTI)

Question 18

What are potential unrecognised precipitating factors in epilepsy?

Answer 18

Television, video games, open fires

Question 19

Is there a form of epilepsy which is commonly a treatment problem?

Answer 19

Lennox-Gastaut and infantile spasms

Question 20

What is Lennox-Gastaut?

Answer 20

Lennox-Gastautsyndrome is a severe form of epilepsy
- Seizures begin in early childhood, usually before the age of 4 years
- Children, adolescents, and adults withLennox-Gastautsyndrome have multiple types of seizures that vary among individuals.

Question 21

What are infantile spasms?

Answer 21

Infantile spasms (IS) is a seizure disorder in babies
- Theseizures(or spasms) make muscles in the arms and legs stiff and bend the baby’s head forward
- They look very much like a startle.
- Babies also might have slowed development or loss of skills (like babbling, sitting, or crawling)
- Although the spasms usually go away by the time a child is 4 years old, many babies with IS will have other kinds ofepilepsylater in life.

Question 22

Advice to give parents and teachers on taking care of a child with epilepsy?

Answer 22

1. management during a seizure
2. safety considerations
3. avoid known precipitants
   - Photosensitive epilepsy, avoid sitting close to open fires, television and changing TV channels

Question 23

Management during a seizure?

Answer 23

1. Lie the child on the side
2. Do not put things in the mouth
3. Move away nearby objects to avoid 4. child hurting himself or herself
4. Have a time plan (For example, if a seizure lasts more than 15 minutes, seek medical attention)

Question 24

Safety considerations for a child with epilepsy?

Answer 24

1. No climbing on a height e.g. trees, ladders
2. No swimming
3. No bathing alone in younger children
4. No riding bicycles in busy roads
5. Use helmets when riding on less busy roads

Question 25

What to communicate with parents on treatment for epilepsy?

Answer 25

1. Rationale for treatment 2. Explain to parents reasons for recommending treatment 3. benefits and possible side effects of chosen drug 4. Probable duration of treatment - All parents will wish to know about this 5. Stop if seizures free for between 2 and 4 years

Question 26

How to administer anticonvulsant medications?

Answer 26

Monotherapy is the goal 1. Start at a low dosage, and gradually increased until the appropriate dosage is reached 2. If one drug given at the correct dosage, is unsuccessful in controlling the seizure, then commence the next most appropriate agent 3. Only once the second drug’s dosage has been optimized should the first drug be withdrawn

Question 27

Generalized tonic-clonic seizure anticonvulsants?

Answer 27

1. carbamazepine 2. phenobarbitone 3. valproate 4. phenytoin

Question 28

Abscence seizure anticonvulsant medication?

Answer 28

1. ethosuximide 2. valproate 3. clonazepam

Question 29

Simple partial seizure anticonvulsants?

Answer 29

1. carbamazepine 2. valproate 3. phenytoin

Question 30

Complex partial seizures anticonvulsants?

Answer 30

1. capamazepin 2. valproate 3. phenytoin

Question 31

Infantile spasms anticonvulsant?

Answer 31

prednisolone

Question 32

What are the Likely Side Effects of Anticonvulsants?

Answer 32

1. Acute toxicities e.g. nystagmus and ataxia with carbamazepine and phenytoin 2. Acute idiosyncratic reactions e.g. skin manifestations such as Stevens-Johnson syndrome 3. Chronic toxicities e.g various effects on haematological system, bones, connective tissue, cosmetic effects and teratogenicity effects 4. Drug interactions between anticonvulsants e.g carbamazepine lowering phenytoin levels, valproate increasing phenobarbitone levels 5. Drug interactions with other drugs e.g erythromycin increasing carbamazepine levels

Question 33

What are idiosyncratic drug reactions?

Answer 33

adverse effects that cannot be explained by the known mechanisms of action of the offending agent, do not occur at any dose in most patients, and develop mostly unpredictably in susceptible individuals only

Question 34

The chance of further seizure recurring after a single seizure, at 5 years of age is?

Answer 34

1. normal neurodevelopmental status, EEG, and MRI: 20% - treatment is usually not started 2. neurodevelopmentally normal: 40% 3. mild neurological problems: 70% 4. severe neurological problems (e.g. CP): 90% Note: If the patient has abnormal EEG, MRI, development, and/or neurologic exam, and/or a positive family history of epilepsy, then the risk is higher and often treatment is started.

Question 35

What are febrile sezures?

Answer 35

- Febrile seizures occur between the ages of 6 and 60 mo (peak 12-18 mo) - There is usually a temperature of 38°C (100.4°F) or higher - Not a result of CNS infection or any metabolic imbalance - No prior history of afebrile seizures

Question 36

What are clinical features of simple febrile seizures?

Answer 36

1. A primary generalized 2. Usually tonic-clonic 3. Associated with fever >38 degree celsius 4. Lasting for a maximum of 15 min 5. Not recurrent within a 24-hr period

Question 37

What is a complex febrile seizure?

Answer 37

1. A complex febrile seizure is more prolonged (>15 min) and/or 2. Focal and/or 3. Recurs within 24 hr

Question 38

What is febrile status epilepticus?

Answer 38

Febrile status epilepticus is a febrile seizure lasting longer than 30 min