Epilepsy: what I need to know Nik Sanyal FY2

Aims Be able to define what a seizure is and what epilepsy is Be able to define different types of epilepsy Be able to establish a management plan involving investigations and medications. Be able to explain to a patient the implications of epilepsy on their life If time – discuss the special case of epilepsy in pregnancy.

Definition A seizure is an episode of uncontrollable electrical activity in the brain. Epilepsy is defined as a condition that causes a pre-disposition to seziures – must have had 2+. It is important to remember that we can all have a seizure as we all have a seizure threshold. Can you think of anything that lowers the seizure threshold?

Secondary generalised Subtypes Epilepsy Focal (Partial) Generalised They can also be simple or complex depending on whether consciousness is lost Secondary generalised Absence Myoclonic Tonic Clonic Tonic-clonic Temporal lobe Jacksonian Simple motor

http://youtu.be/obbg1BFt26Q - absence http://youtu.be/Nds2U4CzvC4 - tonic clonic

Key things from history Is this the first time? Was the “seizure” witnessed? Does the person remember what happened before, during and after? Did they lose continence or bite their tongue? Which part of the tongue is bitten? What happened after the seizure? On any medication/relevant PMHx/social hx etc?

Investigations Bedside: BMs, sats, obs, ECG Bloods: FBC, U+Es, bone profile (LFTs + γGT - alcoholic), septic screen. Can any blood test distinguish a pseudoseizure from a seizure? Imaging: CXR (if think seizure related to infection), CT/MRI MRI if <2 or focal neurology Special tests: EEG? How easy is one to get done? Useful to look for specific patterns Normal in some with epilepsy, abnormal in some without it.

Management Initial – ABCDE – give oxygen + control seizures Review status epilepticus BMs!!! Alcohol withdrawal? – chlordiazopoxide + pabrinex Septic screen if appropriate Long-term management: Lifestyle advice Start low and go slow with medication Control with lowest dose of fewest drugs

Medications Focal Generalised First line: Sodium valproate First line: Carbamazepine First line: Sodium valproate Absence: Ethosuxomide

Side effects PCBRAS + OADEVICES Drug Side effect Sodium valproate N+V Weight gain Inhibits CYP450 Lamotrigine SJS + TEN, aggression, dizziness, tremors Carbamazapine Dry mouth, swollen tongue Induces CYP450 Phenytoin Gum-hypertrophy Cerebellar signs PCBRAS + OADEVICES PCBRAS: phenytoin, carbamazepine, barbiturates, rifampicin, alcohol (chronic), sulphonylureas ODEVICES: omeprazole, Allopurinol disulfiram, erythromycin, valproate, isoniazid, cipro, ethanol (acute) + sulphonamides

Pregnancy + epilepsy Ideal world – a woman with epilepsy will be planning a pregnancy in advance – clearly not always the case. Risks of epilepsy in pregnancy – to mother and child Drugs are all teratogenic but some are less teratogenic than others – best in pregnancy was lamotrigine – convert to this. Risk of seizure worse than teratogenicity Take folic acid – dose?

Advice re driving Have to establish if Group 1 or 2 licence (1 is normal cars, 2 is lorries/buses/taxis Group 1: can drive again if an isolated seizure after 6 months or free of seizure for 1 year if recurrent. Unless having seizures only when asleep. Group 2: 5 years free if isolated or 10 years if they are recurrent.

Conclusions Clinical dx therefore the history is vital! Think carefully of investigations – always ask “why am I ordering this?” Start low and go slow Advise advance planning in young women of child-bearing age. Counsel re impact on life – driving rules, avoiding triggers if appropriate, don’t go swimming alone. Prognosis: 1st seizure = 10% recur if provoked, 50% if not.

Questions + resources Thank you Good sites = www.patient.co.uk + epilepsy society.