faints, fits and funny turns
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Faints, fits and funny turns. Dr Dominic Heaney Consultant Neurologist and Honorary Senior Lecturer National Hospital for Neurology and Neurosurgery Queen Square 1 October 2013. Aims of presentation. Faints, fits and funny turns Definitions Epilepsy Epidemiology, morbidity, mortality - PowerPoint PPT PresentationTRANSCRIPT
Faints, fits and funny turns
Dr Dominic Heaney
Consultant Neurologist and Honorary Senior LecturerNational Hospital for Neurology and NeurosurgeryQueen Square
1 October 2013
Aims of presentation
• Faints, fits and funny turns– Definitions
• Epilepsy– Epidemiology, morbidity, mortality– Types of seizures– Treatment
• Neurologist’s view about epilepsy at work
Faints, fits, funny turns
• Transient alteration in awareness, consciousness– Usually poorly described by patient– Poorly witnessed– Uncertainty
• “Faints, fits, funny turns” -– Syncope (vasovagal, cardiogenic, other…)– Migraine– Cerebrovascular events – Epileptic seizure– Funny turns..
What a neurologist doesn’t want to miss
What a neurologist doesn’t want to see
Morbidity of Epilepsy• Concurrent illness increased
• Neoplasms• Respiratory infections• Cardiovascular diesease• Depression• Sleep disorders• Osteoporosis/fractures
• Accidents increased • Drowning • Suicide• Accidental injury
• High psycho-social morbidity• Unemployment• Deprivation
Mortality of Epilepsy
• Mortality is 2 - 3x that of the general population– Standardised Mortality Rates• Overall: 2 - 3 • In the first 5 years: 4 - 5• 20 - 40 years old 5 - 8• Chronic epilepsy: 8 - 15
• Proportional Mortality Rates– neoplasms, respiratory, accidents, epilepsy
Mortality of epilepsy
• Epilepsy as the cause of death• status epilepticus• Sudep
– SUDEP• > 600 cases a year in the UK• aetiology unknown • risk factors seem to be related to severity and
frequency of seizures
Epileptic seizures vs Epilepsy vs Cause
• Seizure – type, anatomy
• Epilepsy syndrome – other symptoms, age, EEG
• Aetiology – genetic, other
Generalised Focal
Classification of Seizures
“epilepsy
Seizure classification (International League Against Epilepsy)
Simple partial Absence
Myoclonic Complex partial Atonic
TonicSecondary generalised Tonic clonic
Partial Generalised
Determining seizure type
Clinical features
• Symptoms• Behavioural manifestations during and after
seizure• Witness account
EEG
• Inter-ictal • Ictal
focal discharge
generalised discharge
Generalised tonic-clonic seizure
•loss of consciousness•‘epileptic cry’•fall (injury)•tonic phase then clonic jerking•tongue biting, incontinence, cyanosis•sudden onset, gradual recovery •post-ictal confusion, sleep, •headache, muscle pain• aura/partial features if SGS
Generalised absence seizure
• blank stare• loss of consciousness• cessation of motor activity • blinking, eye rolling, minor tone change• sudden onset, rapid recovery• brief, many attacks per day• usually in IGE
• generalised spike and wave discharge
Myoclonic jerks
• brief jerk, single or cluster• one muscle → generalised jerks • intensity: slight tremor → massive jerks• consciousness probably preserved• IGE (diurnal pattern)• symptomatic epilepsies with other
seizure types + neurological deficit
• generalised spike and polyspike wave
Juvenile myoclonic epilepsy
Simple partial seizures
• no alteration in consciousness• no amnesia• sudden onset and cessation• focal symptoms or signs: motor sensory and special sensory psychic (dysmnestic, cognitive, affective,
hallucinations, illusions)
• reflect anatomical origin of the seizure• due to focal cortical pathology
Complex partial seizures
• Temporal lobe 60%• Extra-temporal 40%
(mostly frontal lobe)
Complex partial seizure arising from temporal lobe
• aura (as SPS: visceral, dysmnestic), brief • altered consciousness • amnesia• automatism (oro-alimentary, gestural, verbal)• sudden onset, gradual recovery
focal spikes
rhythmic ictal discharge
Frontal lobe CPS
• brief stereotyped seizures• frequent attacks with clustering• nocturnal +• sudden onset and cessation• complex bilateral motor automatisms • secondary generalisation
• interictal and ictal EEG variable
Other extra-temporal partial seizures
Central Contralateral jerks (march) Contralateral sensory Posturing EEG often normal
Parietal Somatosensory
Illusion of change in body size/shape Vertigo Gustatory
Occipital Elementary visual hallucinations Visuo-spatial distortion Amaurosis Head turning (usually adversive) Eyelid flutter, blinking, nystagmus
May propagate to adjacent cortical regions
EEG : focal / non-localised / anterior
Investigation 1
• History + witnessed account• Family history• History of meningitis/head injuries/febrile
convulsions• Alcohol and drug history
• 30% not epilepsy in tertiary referral clinic• Syncopal jerking• Non-epileptic seizures with a pyschological
basis
Psychogenic seizures
Epilepsy Non-epilepticEmotion Rare Common
Onset Rapid Gradual
Aura Various Panic, confusion
Vocalisation Various Tears, crying
Consciousness Complete/incomplete
Unresponsive but normal alpha
Movements Flailing, pelvic
Injury Tongue bite, fall Occasional
Incontinence Common Sometimes
Duration Few mins Long, variable
Investigation
• EEG– at least 1% false positive– repeat and sleep - still 20% false negative– 24 ambulatory EEG – increases yield– Video-telemetry
• Imaging– MRI preferred to CT
• partial epilepsy, refractory epilepsy, neurological deficit
• Other– ECG, FBC, U&E, LFT etc.
Sir Charles Locock (1799-1875)Obstetrician to Queen Victoria
Bromide of potassium for “hysterical epilepsy” – curing 13 of 14 cases
Side effects
• By 1870’s 2.5 tons of bromide used every year at the National Hospital, Queen Square
– “As you see he is broken down in appearance, has large abscesses in his neck, and is altogether in a bad condition. But this is better than to have epilepsy”
An introduction to dermatology (1905) Bromide Rash
AED Year available Monotherapy licence
Phenobarbital 1912 Yes
Phenytoin 1938 Yes
Primidone 1952 Yes
Ethosuximide 1953 Yes
Carbamazepine 1963 Pre-1990
Diazepam 1965 No
Valproate 1973 Pre-1990
Clonazepam 1975 No
Clobazam 1986 No
(Vigabatrin)* 1989 No
Lamotrigine 1991 1995
Gabapentin 1993 Yes - rarely used
(Felbamate)* 1993 No
Topiramate 1995 Yes
Tiagabine 1998 No
Oxcarbazepine 2000 Yes
Levetiracetam 2000 Yes
Pregabalin 2004 No
Zonisamide 2005 Yes
Rufinamide 2007 No
Lacosamide 2008 No
Eslicarbazepine 2009 No
Retigabine 2011 No
Premapanel 2012 No
AED Year available Monotherapy licence
Tiagabine 1998 No
Oxcarbazepine 2000 Yes
Levetiracetam 2000 Post-2005
Pregabalin 2004 No
Zonisamide 2005 No
Rufinamide 2007 No
Lacosamide 2008 No
Eslicarbazepine 2009 No
Retigabine 2011 No
Premapanel 2012 No
AED Year available Monotherapy licence
Tiagabine 1998 No
Oxcarbazepine 2000 Yes
Levetiracetam 2000 Yes
Pregabalin 2004 No
Zonisamide 2005 Yes
Rufinamide 2007 No
Lacosamide 2008 No
Eslicarbazepine 2009 No
Retigabine 2011 No
Premapanel 2012 No
ZON TOP LAC PGB RTG PMPWeight
Mood
Cognition
Cardiac
Cosmetic
OD/BD/TDS
DDI
Teratogenicity…
On formulary?Gp to Px?
Efficacy?
Formulary ‘management’
Drugs for seizures
• First-choice– Partial onset: LTG, CBZ, LEV, (OXC)– Generalised onset: VPA, LEV, LTG
• Adjunctive– TOP, ZON, LAC– PHT, PB, CLOB– PGB, TIA,
Refractory epilepsy
• 20-30% of patients with epilepsy• very few of these patients (5-10%) are suitable
for epilepsy neurosurgery• Recently launched AEDs, render possibly less
than 2% of this group seizure free
Epilepsy in the workplace
• Challenges finding a job– Lack of training, skills, on-the-job experience– Lack of transportation– Negative attitude of employers towards epilepsy• Concerns about safety, liability, effectiveness, “crazy”,
customer view– Negative attitudes of co-workers
Considerations in the workplace:• The epilepsy:
– What type of epilepsy and what type of seizures?– Frequency, severity, duration?– Warning?– Call an ambulance?– Recovery period?– Triggers? (e.g. shift work, long shifts, stress, ??photosensitivity)– Medication
• The job:– Equipment, heights, water, other?– Working alone?– Responsible for vulnerable individuals?
Reasonable adjustment
• making their workspace safer in case they have a seizure
• avoiding lone working, so that someone else can help if they have a seizure
• exchanging some tasks of the job with another employee’s tasks
• adapting or providing equipment or support to help them do their job
• time off for medical appointments that is separate from sick leave.
Conclusions
• Not all seizures are due to epilepsy• Epilepsy is a broad description given to a
range of conditions