Transcript Epilepsy - Wsimg.com

Epilepsy
Kate McGraw-Allen
Definition
 Seizure- Spontaneous, intermittent electrical activity in
the brain resulting in temporary signs and symptoms
 Epilepsy- The recurrent tendency for seizures
 2 or more seizures separated by 24 hours without a clear
cause
Aetiology
 Common, affects 6 to 10 per 1000
 Risk factors M=F
 Idiopathic- family history
 Symptomatic- CVD, difficult birth,
congenital abnormalities, head injury,
meningitis, encephalitis, developmental
problems, stroke, tumour
 Cryptogenic- cause has not been
found
Idiopathic (70%)
CVD
13%
Aetiology
 Triggers
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Stress
Lack of sleep
Alcohol
Drugs (medications and illicit)
Flashing lights
Menstruation
Hyperventilation
Illness
Pathophysiology
 Electric, sudden, synchronous
discharge from nerve cells, often
recurrent.
 Depolarisation spreads out in
waves known as depolarising shift.
 Triggers interfere with
neurotransmitters in the brain,
lowering the seizure threshold.
 Increased excitatory
neurotransmission (glutamate)
 Decreased inhibitory
neurotransmission (GABA)
Signs and symptoms- Simple
partial seizures
Frontal
lobe- Motor
function (and
personality)
Temporal lobe- longterm memory,
processes sensory
output and emotional
memory
Parietal lobeSensation
Occipital
lobe- Sight
Signs and symptoms- Simple
partial seizures
Frontal
lobe:
-Motor signs
such as
twitching or
stiffness
Temporal lobe:
-Déjà vu/ jamais vu
-Unusual taste/ smell
-Feeling of fear
Parietal lobe:
-Burning/ tingling/
numbness
Occipital lobe:
-Visual
disturbances/
hallucinations
SIMPLE PARTIAL SEIZURES HAVE NO
EFFECTS ON CONSCIOUSNESS
Signs and symptomsComplex partial seizures
Frontal lobe:
-Motor signs
such as
repetitive
movements
(automatisms),
loud cry/
scream, cycling
and kicking
Temporal lobe:
-Chewing, lip-smacking
-Muttering non-sensical
words
Parietal lobe
and occipital
lobe are rare
POST-ICTAL
PHASEConfusion,
memory loss,
tiredness
COMPLEX SEIZURES- REMAIN
CONSCIOUS, MAY BE CONFUSED/
RESPOND STRANGELY
Signs and SymptomsGeneralised seizures
 Activity across brain, person is unconscious
 Can come on after a simple seizure- secondary
generalised seizure
 Absences
 https://www.youtube.com/watch?v=H3iLQi6wt94
Signs and symptomsGeneralised seizures
Tonic Clonic
 Tonic phase:
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Unconscious
Become stiff and fall backwards
Often cry out
Often bite tongue/ cheek
https://www.youtube.com/wa
tch?v=Nds2U4CzvC4
 Clonic phase:
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Jerk and shake as muscles relax and contract
Breathing becomes difficult
Blue skin
Urination
 Post-ictal phase:
 Tired
 Confused
 Headache
Signs and symptomsGeneralised seizures
 Tonic
 Stiff muscles
 Fall backwards
 Atonic
 Muscles relax and go floppy
 Fall forwards
 Clonic
 Similar to clonic phase in tonic-clonic seizure
 Myoclonic
 Muscle jerks
 Often in morning- juvenile myoclonic epilepsy
 Consciousness not affected
Investigations
 History
 Warning symptoms- visual, olfactory, sweating,
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lightheadedness, nausea
Loss of consciousness?
Time periods
Recovery- post ictal phase? Period of amnesia?
Combatative?
Medications? Drugs? Alcohol?
Other health issues
 Driving and Job!
 Collateral history
 Description of movement,
appearance, recovery etc
 Seizure diary and video if
possible
 EEG
 Hyperventilation can bring
on a seizure
 Absence seizures have 3
peaks and waves per sec
 MRI- if structural cause is
suspected
Complications
 Status epilepticus
 Injuries during fit
 Todd’s paralysis
 Depression/ anxiety
Alternative diagnosis
 Vasovagal syncope
 Hypo/ hyperglycaemia
 Electrolyte imbalance (Na+, K+, Ca+)
 Space occupying lesion
 Cardiac arrhythmias
 Postural hypotension
 Toxins (eg alcohol, drugs)
 Dissociative seizures
Additional Investigations
 Blood glucose
 Bloods- FBC, U+Es
 Drug screen
 ECG and further cardiac testing
Management
 Conservative
 Education
 Avoid triggers
 Notify DVLA
 Seizure free for 1 year before being able to drive again.
 Seizure free for 10 years without taking medication before
driving HGV
 Medical alert bracelet
 Psychiatric help if struggling
Management
 Medical
 Carbamazepine
 Partial seizures
 Stabilises sodium channels and potentiate GABA receptors
 Therapeutic monitoring needed
 S/E- rash, sedation, dizziness, neutropenia
 Sodium Valproate
 Sodium channel blocker and inhibits enzymes breaking down
GABA
 Generalised seizures
 S/E- weight gain, sedation, platelet dysfunction
 Teratogenicity
Management
 Medical
 Lamotrigine
 Sodium channel blocker
 Partial and generalised seizures
 S/E- rash leading to Steven Johnson’s syndrome, sedation
 Phenytoin
 Sodium channel blocker
 Partial and generalised seizures
 Therapeutic monitoring needed
 S/E- rash, sedation, diplopia,
Management
 Surgical- only in drug resistant
 Resection of focus
 Interruption of spread
 Callostomy
 Alter seizure threshold
 Vagus nerve stimulation
Status epilepticus
 Seizures normally last a set amount of time
 If it lasts >30 mins without regaining consciousness it is
classed as status epilepticus
 This is a MEDICAL EMERGENCY
Management
 1st stage (0-10 mins)
 ABC, IV access
 2nd stage (0-30 mins)
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Monitor
Rectal diazepam if out of hospital
IV lorezapam in hospital
Glucose and thiamine if any suggestion of alcohol
 3rd stage (0-60 mins)
 Establish cause
 Alert anaesthetist and ICU
 4th stage (30-90 mins)
 Establish intensive care
 Phenytoin infusion
Prognosis
 Controlled in 75% of cases
 Some confined to childhood
 Poor prognosis if:
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Long duration
Poor seizure control
Mixed seizure type
Frequent seizure type
 What percentage of people are affected?
 What is the most common risk factor?
 Name 3 triggers.
 Which neurotransmitter is increased? What effect does this have?
 What kind of symptoms would you get in a simple partial seizure of
the parietal lobe?
 What is the difference between simple partial and complex partial
seizures?
 Name 3 types of generalised seizure.
 What pattern is seen on the EEG in an absence seizure?
 What is the main mechanism of action for anticonvulsant drugs?
 In which drug would we worry about a woman becoming pregnant?
 What percentage of patients remain seizure free?
Questions?