1. Epilepsy
Kate McGraw-Allen

2. 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

3. 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%

4. Aetiology Triggers- Stress Lack of sleep Alcohol
Drugs (medications and illicit)
Flashing lights
Menstruation
Hyperventilation
Illness

5. 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)

6. Signs and symptoms- Simple partial seizures
Frontal lobe- Motor function (and personality)
Parietal lobe- Sensation
Temporal lobe- long- term memory, processes sensory output and emotional memory
Occipital lobe- Sight

7. Signs and symptoms- Simple partial seizures
Parietal lobe:
-Burning/ tingling/ numbness
Frontal lobe:
-Motor signs such as twitching or stiffness
Occipital lobe:
-Visual disturbances/ hallucinations
Temporal lobe:
-Déjà vu/ jamais vu
-Unusual taste/ smell
-Feeling of fear
SIMPLE PARTIAL SEIZURES HAVE NO EFFECTS ON CONSCIOUSNESS

8. Signs and symptoms- Complex partial seizures
Parietal lobe and occipital lobe are rare
Frontal lobe:
-Motor signs such as repetitive movements (automatisms), loud cry/ scream, cycling and kicking
POST-ICTAL PHASE- Confusion, memory loss, tiredness
COMPLEX SEIZURES- REMAIN CONSCIOUS, MAY BE CONFUSED/ RESPOND STRANGELY
Temporal lobe:
-Chewing, lip-smacking
-Muttering non-sensical words

9. Signs and Symptoms-Generalised seizures
Activity across brain, person is unconscious
Can come on after a simple seizure- secondary generalised seizure
Absences

10. Signs and symptoms- Generalised seizures
Tonic Clonic
Tonic phase:
Unconscious
Become stiff and fall backwards
Often cry out
Often bite tongue/ cheek
Clonic phase:
Jerk and shake as muscles relax and contract
Breathing becomes difficult
Blue skin
Urination
Post-ictal phase:
Tired
Confused
Headache

11. Signs and symptoms- Generalised 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

12. Investigations History Driving and Job!
Warning symptoms- visual, olfactory, sweating, lightheadedness, nausea
Loss of consciousness?
Time periods
Recovery- post ictal phase? Period of amnesia? Combatative?
Medications? Drugs? Alcohol?
Other health issues
Driving and Job!

13. Seizure diary and video if possible
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

14. Complications Status epilepticus Injuries during fit Todd’s paralysis
Depression/ anxiety

15. Alternative diagnosis
Vasovagal syncope
Hypo/ hyperglycaemia
Electrolyte imbalance (Na+, K+, Ca+)
Space occupying lesion
Cardiac arrhythmias
Postural hypotension
Toxins (eg alcohol, drugs)
Dissociative seizures

16. Additional Investigations
Blood glucose
Bloods- FBC, U+Es
Drug screen
ECG and further cardiac testing

17. 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

18. Management Medical Carbamazepine Sodium Valproate 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

19. Management Medical Lamotrigine Phenytoin Sodium channel blocker
Partial and generalised seizures
S/E- rash leading to Steven Johnson’s syndrome, sedation
Phenytoin
Therapeutic monitoring needed
S/E- rash, sedation, diplopia,

20. Management Surgical- only in drug resistant Resection of focus
Interruption of spread
Callostomy
Alter seizure threshold
Vagus nerve stimulation

21. 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

22. Management 1st stage (0-10 mins) 2nd stage (0-30 mins)
ABC, IV access
2nd stage (0-30 mins)
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

23. Prognosis Controlled in 75% of cases Some confined to childhood
Poor prognosis if:
Long duration
Poor seizure control
Mixed seizure type
Frequent seizure type

24. 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?

25. Questions?