1. By Laura Parker

2.  Define an epileptic seizure, epilepsy and status epilepticus  Name common causes and factors that may predispose an individual to epileptic seizures  Recognise the symptoms a patient may present with who has epilepsy  Know the acute management of status epilepticus  Recognise the impact a diagnosis of epilepsy may have on the patient as a whole (driving, occupation, contraception, pregnancy)  Understand the role of AEDs in the management of epilepsy

3. “An epileptic seizure is the transient occurrence of signs or symptoms due to abnormal electrical activity in the brain, leading to a disturbance of consciousness, behaviour, emotion, motor function or sensation” NICE 2009

4.  Epilepsy is a common neurological disorder characterised by recurrent seizures  Status Epilepticus is a state of continued seizure (or recurrent seizures with failure to regain conciousness) lasting > 30 minutes

5.  ILAE (2006 revision of 1981 classification)  Focal Onset ◦ Begins in a focal area of the cerebral cortex ◦ Symptoms will vary dependent on area of cortex affected  Generalized Onset ◦ onset recorded simultaneously in both cerebral hemispheres

6.  Simple (3%) ◦ Preservation of consciousness ◦ Experienced as an aura alone ◦ >30 minutes = simple status epilepticus  Complex (20%) ◦ Loss of consciousness, but usually w/o loss of postural control

8.  Primary generalized tonic-clonic seizures (60%)  Absence seizures  Myoclonic seizures  Clonic seizures  Tonic seizures  Atonic seizures

9.  3-5% population have 1 or 2 seizures  0.5% population have epilepsy  2 incidence peaks ◦ Childhood / adolescence ◦ Middle Age

11. No apparent cause in >50% cases ◦ Genetic ◦ Congenital brain malformations ◦ Febrile convulsion ◦ Cranial Infection ◦ Trauma ◦ SOL ◦ CVA ◦ Alzheimer's ◦ Metabolic disturbance ◦ Drugs, Alcohol Withdrawal

12.  Missed medication  New medication  Photosensitivity  Sleep deprivation

13.  Motor ◦ Sudden Falls ◦ Jerky movements  Cognitive ◦ Blank spells ◦ Disorientated ◦ Déjà vu ◦ Dissociation ◦ Loss of language skills  Perception ◦ Hallucinations  Mood ◦ Elation / depression ◦ Fear  Misc ◦ Loss of continence ◦ Epigastric fullness

14. Key Questions ◦ Any warning? ◦ Precipitants? ◦ What happens and how long does it last? ◦ LOC / loss of awareness? ◦ Post-ictal? ◦ Frequency of episodes? ◦ Any response to treatment?

15.  Dilated pupils, hypertension, tachycardia, extensor plantar response are suggestive of seizure  May find evidence of stigmata to diagnose cause / syndrome / associated condition

16.  Migraine  Syncope  Pseudo-seizure  TIA  Hypoglycaemia  Sleep disorders

17.  Bedside ◦ Obs ◦ BMs ◦ ECG  Bloods ◦ FBC, U&Es, LFTs, CRP, Ca, Mg, PO4, Glucose, Prolactin

18.  Imaging ◦ CT head ◦ MRI  Special tests ◦ EEG ◦ LP

20. AA BB CC DD EE MEDICAL EMERGENCY MORTALITY RATE 10-15% CALL FOR HELP ASAP

21. No Access  PR Diazepam 10-20mg Access  IV Lorazepam 4mg bolus ◦ rpt after 10 minutes

22.  Phenytoin infusion 15-18mg/kg @ 50mg / minute  GA ◦ Propofol ◦ Midazolam ◦ Thiopentone

23.  Avoid Triggers  Swimming  Driving  AEDs

24.  Phenytoin  Phenobarbitone  Topiramate  Sodium Valporate  Carbamazepine  Lamotrigine

25.  Acute toxicity  Idiosyncratic toxicity  Chronic toxicity

26.  The risk of recurrence in the 2 years after a first unprovoked seizure is 15-70% ◦ Abnormal EEG ◦ Abnormal brain imaging ◦ Focal onset  > 1 unprovoked seizure  2/3s people with active epilepsy have epilepsy controlled with AEDs

27. ◦ Psychological Interventions ◦ Ketogenic diet ◦ Vagal nerve stimulators ◦ Resective Surgery

28.  Contraception ◦ AEDs are liver enzyme inducers  Pregnancy ◦ Risk of anti-epilepsy drugs in pregnancy  Cleft lip/palate, CV malformations  Neural tube defects ◦ Risk of fits during pregnancy

29.  Life expectancy is reduced by up to 10 years for people with symptomatic epilepsy and up to 2 years for idiopathic epilepsy  In the UK 1,150 people died of epilepsy related causes in 2009  SUDEP accounts for ~ half of ALL epilepsy related deaths

31. A 62 year old man presents to A&E after his wife called an ambulance when he woke her up having “a fit”. He was shaking and jerking all over his body, would not respond to her and had soiled himself. He was brought to A&E and despite the paramedics giving 10mg of PR diazepam, he is still fitting….

33. His seizures terminate. He is drowsy and postictal. You obtain history from his wife that he has been complaining of a headache for the last few weeks and the last 2 days has had some blurred vision. He went to bed early last night after he vomited. His wife tells you he seemed more confused yesterday and she was worried but he refused to see his GP. Normally fit and well. No regular mediations and no allergies. Examination when he is more alert is mostly unremarkable except for an element of subtle left sided weakness and poor co- ordination

34.  What are your differentials?  How would you investigate this man?  What would your long term management plan be for him?  What is the classification system for epilepsy?  What is the current DVLA advice on driving with epilepsy?

35.  Define an epileptic seizure, epilepsy and status epilepticus  Name common causes and factors that may predispose an individual to epileptic seizures  Recognise the symptoms a patient may present with who has epilepsy  Know the acute management of status epilepticus  Recognise the impact a diagnosis of epilepsy may have on the patient as a whole (driving, occupation, contraception, pregnancy)  Understand the role of AEDs in the management of epilepsy

36. Are There Any Questions

37. GROUP 1GROUP 2  1 st Unprovoked seizure ◦ 6 months from date of seizure ◦ Risk of recurrence >20% 12 months  Diagnosis of epilepsy ◦ 12 months seizure free ◦ 6 months if “permitted seizure”  Following withdrawal meds ◦ 6 months seizure free ◦ 12 months following seizure  1 st unprovoked seizure ◦ 5 years seizure free on no anticonvulsants  Diagnosis Epilepsy ◦ 10 years seizure free on no anticonvulsants

39. 1. NICE guidance epilepsy http://guidance.nice.org.uk/CG137 2. Berg et al, Revised terminology and concepts for organization of seizures and epilepsies: Report of the ILAE Commission on Classification and Terminology, 2005–2009, Epilepsia, 51(4):676–685, 2010 3. Moran et al, Epilepsy in the United Kingdom: seizure frequency and severity……, Seizure, 6, 425-433, 2004 4. Crash course neurology 3 rd edition Turner 5. Brown et al, Epilepsy needs revisited; a revised epilepsy needs document for the UK, Seizure 1998 6. DVLA guidance https://www.gov.uk/current-medical- guidelines-dvla-guidance-for-professionals-conditions