Epilepsy: what I need to know

Nik Sanyal FY2

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.

Aims

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?

Definition

Subtypes

Epilepsy

Focal (Partial)Generalised

Secondary

generalised

Temporal lobeJacksonian

Simple motor

AbsenceMyoclonic

TonicClonic

Tonic-clonic

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

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?

Key things from history

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.

Investigations

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

Management

Medications

Focal Generalised

First line: CarbamazepineFirst line: Sodium

valproateAbsence: Ethosuxomide

PCBRAS + OADEVICES

Side effectsDrug Side effect

Sodium valproate N+VWeight gainInhibits CYP450

Lamotrigine SJS + TEN, aggression, dizziness, tremors

Carbamazapine Dry mouth, swollen tongueInduces CYP450

Phenytoin Gum-hypertrophyCerebellar signsInduces CYP450

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?

Pregnancy + epilepsy

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.

Advice re driving

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.

Conclusions

Thank you

Good sites = www.patient.co.uk + epilepsy society.

Questions + resources