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59 Cards in this Set
- Front
- Back
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What are convulsions? |
Motor signs of electrical discharges |
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Elements of a seizure |
Prodrome - (hours to dayse) notice a change in mood or behaviour Aura - part of seizure patient is aware. strange feeling, deja vu, stange smells or flashing lights - implies a partial (focal seizureS) Post-ictally - headache, confusion, myalgia and a sore tongue or temporary weakness after a focal seiaure in motor cortex (todd's palsy) or dysphasia following seizure intemporal lobe |
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What is todd's palsy? |
Paresis after a seziure. Face, arm, or leg weakness, aphasia or gaze palsy lasting from 30mins to 36 hours. |
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% that are idiopathic? |
2/3 |
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Strucutral causes of epilepsy? |
Cortical scarring (Head injury) Developmental (dysgenesis) space-occupying lesion stroke hippocampal sclerosis (eg after a febrile convulsion) vascular malformation |
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Other causes of epilepsy? |
Tuberous Sclerosis sarcoidosis SLA PAN |
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Non-epileptic causes of seziures: |
trauma stroke Haemorrhage ICP alcohol or benzodiazepine withdrawal |
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Metabolic disturbance causes of epilepsy |
(hypoxia, NA+, CA2+, glucose uraemia) liver disease infection (meningitis, encephalitis, custicercosis, HIV), Temperature Drugs (tricyclocs, cocaine, tramadol, theophylline, pseudoseizures |
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Three wuestions to consider in a diagnosis? |
Are these really seizures? what type of seizure is it? Any triggers? |
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What is very suggestive of a seizure? |
Tongue-biting and a slow recovery |
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what else twitches byt isnt epilepsy? |
reflex anoxic convulsions due to syncope |
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In assesing the first seizure what should you consider? |
Is it really the first? Was the seizure provoked? - provoked less likely to reoccur |
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What prompt investigation of first ever seizure is required? |
admission for 24h for bloods drugs screen LP (if safe) EEG CT/MRi + enhancement( or infective caues may be missed) |
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Indications for EEG? What asseses risk of recurrence? |
Cannot exclude or refute epliepsy context of diagnosis (often false +ve) 1st unprovoked fits, unequivocol epileptiform activity on EEG assess risk of recurrence |
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What are Partial seziures and their classifications |
Focal onset - referable to par of one hemisphere (common with strucural disease) Simple partial seizure Complex partial seizures Partial seizure with secondary generalisation |
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what are simple partial seizures? |
Awareness is unimpaired focal motor, sensory (olfactory, cvisual ) autonomic pr psychic symptoms no post-ictal symptoms |
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What are complex partial seizures? |
Awareness is impaired May have a simple partiral onset (aura) or impaired awareness at onset |
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Complex partial seizures commonly arise from? |
The temporal lobe |
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What is common with seizures arising from the temporal lobe? |
Post-ctal confusion whereas recovery is rapid after seizures in the frontal lobe |
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Presenation of Partial seizure with secondary generisation? |
2/3 of patients with partial seizures - electrical disturbance starts focally, spreads widely with is usuall convulsive |
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Clasiification of primary generalised seizures? |
electrical discharge throughout cortex, no localizing features Absence seizures Tonic-clonic seizures Myoclonic seizures Atonic (akinetic) seizures Infaintile spasms |
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What are absence seizues? |
Brief <10s pauses, childhood eg, stop talking mid-sentence |
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What are tonic-clonic seziures? |
Loss of conscsiousness Limbs stiffen (tonic) then jerk (clonic) can just be one post-icatal confusion and drowsiness |
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What are myoclonic seizures? |
Suddern jerk of a limb, face or trunk |
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Atonic (akinetic) seizures |
Sudden loss of mucscle tone causing a fall, no LOC. |
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What are infantile spasms associted with |
Tuberous scerosis |
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Features localised to the temporal lobe? |
Automatisms Abdominal rising sensation or pain (=- ictal vomiting, episodiv fevers, DV) Dysphasia (ictal or post-ctal) Meomry phenomena - Deja Vy, jamais cy hippocampal involvement Uncal involvement Delusional behavious |
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What are automatisms? |
complex motor phenomena with impaired awareness and no recolleion afterwoards can be primtive ora (lip smacking, chewing, swallowing)l, manual (fumbling, fiddling, grabbing), complex (singing, kissing, driving a car) |
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Consequences of hippocampal involvement? |
emotional disturbance derealisation (out of body experience) which may manifest as excessive relgiosi |
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Consequences of uncal involvment? |
hallucinations of smell or taste and a dream like state and seizures in auditory cortex may cause complex auditory hallucinations |
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What is aura interruption? |
smelling a pleasant smell if the aura is a certain bad smell may abort emotion-triggered seizures |
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You do not diagnose drugs after one fit unless? |
risk of recurrence is high - structural brain lesion, focal CNS defecit, or unequivocal epileptiform EEG |
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What does drug choice depend on? |
Seizure type epilepsy syndrome other medications co-morbidities plans for pregnancy Patient preferenec |
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Rx Generalised tonic-clonic seizures? |
1st line - Sodium valporate or lamatorigine then carbamazepine or topiramate others - levetiracetam, oxcarbazepine, clobazam |
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Rx Absence seizures? |
Sodium valporate, lamotrigine or ethosuximide |
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Rx Tonic, atonic and myoclonic seizures? What should you avoid? |
same for generalised tonic-clinic seizures Avoid - carbamazepine and oxcarbazepine which may worsen seizures |
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Rx Partial seizures +- secondary generalisation? |
1st line - Carbamazepine then sodium valporate, lamotrigine, then oxcarbazepine or topiramate others - levetiracetam, gabapentin, tigabine, phenytoin, clobazam |
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How to switch drugs? |
introduce new drug and only withdraw 1st drug once established on the 2nd |
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EEG's role in epilepsy? |
cannot exclude or refute forms part of the context for diagnosis |
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If 1st unprovoked fits what on the EEG will help assess risk of recurrence? |
unequivocal epileptiform activity |
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When do you MRI? |
for structural lesions |
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If a single epileptogenic focus can be identified such as hippocampal sclerosis or a small low-grade tumour? |
Neurosurgical resection offers up to 70% |
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An alternative to neurosurgical resection is? |
Vagal nerve stimulation which can reduce frequency and severity in 33% |
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When is SUDEP? |
Sudden unexpected death in epilepsy epilepsy mortality rate 3x that of controls |
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Carbamazepine? Dosage |
Initially 100mg/12h increase by 200mg/d every 2 weeks up to 1000mg/12hr |
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Carbamazepine SE? |
C-CHFA-AtaxiaR-Renal damageB-Blur visionA-AgranulocytosisM-MigraineA-Aplastic anemiaZ- SIADH E-Erythematous skinP-Platelet decreaseI-Increase risk of lupusN-NauseaE-Emesis |
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Lamotrigine? Dosage? |
intially 25mg/d, increase by 50mg/d every 2 weeks up to 100mg/12hrs (max 250mg/12hf) |
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Lamotrigine SE? |
Maculopapular rash 10% typically in 1st 8 weeks esp if on valporate warn patient to see a doctor if rash/flu symps develop hypersensitivity (fever, LFTs and disseminated intrvascular coagulopathy) diplopia, blurred vision, photosensitivity, treor, agitation, vomiting, aplestic anaemia |
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Levitracetam SE? |
psychiatric side-effects : depression, agitation D&V, dyspepsia, drowsiness, diplopia, blood dyscrasias |
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Phenytoin why is it no longer 1st line for generalised or partial epilepsy? |
toxicity - nystagmus, diplopia, tremor, dysarthria, ataxia SEs - intellect, depression coarse facial features, acne, gum hypertrophy, polyneuropathy, blood dyscrasias |
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Sodium valporate dosage? |
Initially 300mg/12h increase by 100mg/12 hr every 3 days up to max 30mg/kg (or 2.5g daily) nausea is very common (take with food) |
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Valporate side effects? |
V Appetite increase, weight gain Liver failure (LFTs during 1st 6/12) Pancreatitis Reversible hair loss Oedema Ataxia Tertogenicity, tremor, thrombocytopenia Encephalopathy due to hyperammonaemia |
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What AEDs are liver inducing? |
Carbamazepine, phenytoin, barbiturates |
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Women of child baring aged should... |
take folic acid 5mg/d valporate should be avoided (use lamatogrine) |
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Which AEDs can be used in breastfeeding? |
Carbamazepine and valporate - not present in breast milk Lamotrigine - is not thougth to be harmful to the infant |
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Which AEDs have no effect on the pill? |
Bib-enzyme inducing AEds |
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Stopping anticonvulsants...when can withdrawal be tried? |
Normal CNS examination normal IQ normal EEG prior to withdrawal Seizure free for >2 yrs and no jvenile myoclonic seizures |
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withdrawal - decrease the dose by 10% every 2-4 weeks with which drugs? |
for carbamazepine, lamotrigine, phenytoin, valporate and vigabatrin |
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withdrawal by 10% every 4-8 weeks for which drugs? |
phenobarbital, benzodiazepines and ethosuzimide |
