Epilepsy BY RUTENDO GANYANI AND SARAH FOLKERTS. Case 52 yr man brought to A&E Wife witnessed:...
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Transcript of Epilepsy BY RUTENDO GANYANI AND SARAH FOLKERTS. Case 52 yr man brought to A&E Wife witnessed:...
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Epilepsy
BY RUTENDO GANYANI AND SARAH FOLKERTS
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Case
52 yr man brought to A&E
Wife witnessed: while standing at bus stop he fell to the ground & she was unable to rouse him
Breathing stopped for about 20s -> after that jerking movements affecting his arms & legs ~ 2mins
There was some urinary incontinence & his face became blue
After regaining consciousness he remained drowsy with a headache
No symptoms prior to episode
What are your main DDs?
What investigations would you perform?
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- Syncope & epileptic fit are the main DDs - Syncope often while standing, stressful events & associated w/ arrythmia- Try to assess for prodromal & postictal symptoms
- Syncope -> dizziness & lightheadedness before- Epileptic fit -> confusion & sleepiness after
- Investigations: - FBC- U&E (exclude uraemia, hyponatraemia, hypoglycaemia & hypocalcaemia)- Also check gamma-GT for possible alcohol abuse- CT scan to exclude mass lesion or cerebrovascular event- Refer to neurologist for EEG
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What is epilepsy?
Epilepsy is the most common neurological disorder.
Characterised by abnormal electrical activity in the brain.
Can be focal or generalised
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What is it’s aetiology?
Changes in neuronal excitability!!!!
Reduction in GABA
Increase in Ach transmission
Increase in Na+ transmission
Decrease in K+ transmission
Mutations found in K+, Na+, Ach and GABA receptors (channelopathies)
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How does it present?
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PARTIAL SEIZURES!
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• Symptoms depend on site of origin
• No loss of consciousness or post-ictal confusion
• What symptoms would you see if the seizure originated in the:
1. Temporal region?2. Parietal region?3. Frontal region?4. Occipital region?
ANSWERS
• Temporal: aura-smell/taste, déjà vu, jamais vu, emotional changes, oral automatisms, gestures eg dystonic or fidgeting
• Frontal: mainly motor, often bilateral e.g. kicking, cycling, violent.
• Parietal: Sensory, nausea, choking, sinking sensations, Illusions of body distortion
• Occipital: Visual hallucinations – simple or complex (shapes to scenes),Vision may black out, Visuo-spatial distortions, headache, nausea
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• Altered consciousness, but may seem fully aware
• Symptoms: automatisms (chewing, swallowing, repeated displacement behaviour)
• Generally temporal lobe in origin, can progress to generalised
• Prior to onset may experience sense of déjà vu/jamais vu, perceptual changes, auras
• May have some post-ictal confusion
Question• So where is the main
difference between this type of seizure and a simple partial seizure?
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GENERALISED SEIZURES!
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• Also called Grand Mal seizures• Easiest to diagnose• N o warning of onset• Whole brain involved• Tonic phase -:
whole body stiffness breathing may stop (cyanosis) ask about this when taking a collateral Hx loss of bladder control patient may report that they were wet when they regained
consciousness. Ask about this when taking Hx. Also tongue biting• Clonic phase –:
muscle jerks• Post-ictal-: unconsciousness, muscle relaxation, slow regain of consciousness,
confusion, sleepy, headaches and aching limbs, no recall of episode ask about post-ictal symptoms when taking Hx eg tiredness
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• Also called Petit Mal
• Rare in adults
• Generally start between 6-12 yrs
• Affect Girls > Boys
• Symptoms: seem to ‘switch-off’ (~10 s) but cannot be alerted or woken up
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The in-betweener!
Partial with secondary generalised
Simple partial seizure, patient conscious and aware progressing to generalised (Grand-Mal)
Seizures becomes generalised when abnormal electrical activity hits the thalamus
The ‘simple’ part of the seizure depends on site of origin
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‘Other’
psychogenic non-epileptic seizures
Myoclonic – sudden jerks (like when falling asleep), possibly familial
Clonic – repeated twitches and jerks no stiffness
Tonic – all muscle contract, whole body stiffness
Atonic – ‘drop attacks,’ muscle tone lost
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TREATMENT OF EPILEPSY
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Options
Pharmacological :
First line approach for seizures
Anticonvulsants
Surgical
removal of aberrant areas (found by MRI/CAT/electrical stim)
Implants
VNS – vagal nerve stimulation
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Seizure type 1st line 2nd line
Simple PartialComplex partial
Partial with secondary
generalised
CarbimazepineSodium Valproate
LamotrigineOxcarbazepine
Gabapentin Pregabalin Tiagabine
Topiramate etc
Tonic-Clonic Seizure (Grand Mal)
Sodium ValproateLamotrigine
Carbimazepine
ClobazamLevetiracetamOxcarbazepine
Topiramate
Absence Seizures
(Petit Mal)
EthosuximideSodium Valproate
ClonazepamLamotrigine
Status Epilepticus
(medical emergency)
IV Lorazepam (repeated after 10 mins)After 25 mins: phenytoin sodium, fosphenytoin, or phenobarbital sodiumAfter 45 mins: Anaesthetize with thiopental, midazolam or propofolBuccal Midazolam/Rectal diazepam (if resusc facilities not available, e.g. at home) Secure airway!
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Anti-epileptic hypersensitivity syndrome
- 1-8 weeks from treatment initiation- Initial signs: fever, rash, swollen lymph nodes- Severe signs: Blood, liver, kidney abnormality, vasculitis & organ failure
- Withdraw drugs immediately- Topical steroids & antihistamines- Systemic corticosteroids?- Beware of rebound seizures activity
Be aware of this!
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GABAa targets
• Enhance activation of GABAA mediated channels via: Action at co-agonist sites Inhibition of GABA breakdown Inhibition of GABA uptake GABA mimetics
• Benzodiazepines: Act on GABAa receptor (γ subunit) to increase activity, thereby reducing neuronal transmission by enhancing inhibition.
• Barbiturates: as above but bind the β-subunit of the GABAa receptor
• GABA transporter inhibitors e.g. Tiagabine
• GABA transaminase inhibitors e.g. Vigabatrin
Side effects of Benzodiazepines and barbiturates• Short-term use only (< 12 weeks)• Tolerance and dependency can develop• Impaired motor coordination (↓muscle tone)• Impaired cognitive performance• Sedation• Disturbed sleep patterns• Retrograde amnesia• Withdrawal on termination
Benzo overdose: use
flumazenil
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1. Sodium Valproate2. Ethosuximide3. Diazepam4. Carbamazepine
a. Ca-channel blockerb. Na-channel blockerc. GABA receptor modulator
1. Sodium Valproate – b. Na-channel blocker2. Ethosuximide – a. Ca-channel blocker3. Diazepam – c. GABA receptor modulator4. Carbarmazepine – b. Na-channel blocker
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Any Questions???