EPILE

PSY

PRESENTA

TION

JOANNA W

YKES, F

Y2

Learning Objectives

• To be able to define epilepsy

• To classify the common seizure types

• To learn some causes of seizures and classify which are epilepsy and which are not

• To be able to recognise a patient presenting with a seizure

• To know the common important investigations that should be carried out for each patient presenting with a seizure

• To describe common medical and surgical management of epilepsy

• To describe some limitations epilepsy places on people’s lives and how these can be managed, for example driving, pregnancy

Case study: AMU

You are on call in AMU in your first placement in FY1. Your next patient from A+E is a 25 year old lady Paula who presented ?epilepsy. The history sheet from A+E says that her partner was sitting next to her on the sofa when she started plucking her clothes and smacking her lips. When he asked her what she was doing she did not reply but dropped to the floor and started “all over body jerking. When she woke up she didn’t know where she was and there was blood running from her mouth.

1) You are not sure whether this is a seizure or a vasovagal syncope from the history. What questions do you need to ask to differentiate between your two diagnoses?

1) What questions do you need to ask to differentiate between your two diagnoses?More likely to be epilepsy

• Deep cyanosis

• Deeply bitten lateral border of the tongue

• Post event confusion of more than two minutes

• Prolonged tonic (stiff) then clonic (rhythmic) movement

• Epileptic activity of more than two minutes

Less likely to be epilepsy

• Bitten tongue tip

• Pallor

• Post event fatigue

• Brief twitching and jerking

• Associated with blood phobia

• Stopped from falling to the ground: anoxia

Can happen in both

• Incontinence

• Confusion on rousing

Which diagnosis is more likely now?

Paula’s partner tells you that her lips were blue, her limbs seemed to all shake at the same time and she didn’t know where she was for about 20 minutes after the event. When you examine her you notice her tongue is still bleeding from the lateral borders.

Paula says that she has never had a seizure before. She asks you why it should suddenly start now?

What reasons could there be for Paula having a seizure now where one has never occurred before?

What reasons could there be for Paula having a seizure now where one has never occurred before?• Head injury

• Alcohol withdrawal

• Drugs

• Metabolic disturbance

• Stroke

• Onset of epilepsy

What do you need to do for Paula before the post take ward round?

What do you need to do for Paula before the post take ward round?• Full history including PMH e.g. previous brain injury, DH e.g.

on opiods higher risk of epilepsy, SH e.g. withdrawing from alcohol, FH e.g. of epilepsy

• Full examination: neurological deficit? Cardiac cause for collapse? Long term confusion may suggest SOL?

• Bloods FBC, U&Es, LFTs, CRP, Calcium, Mg, PO4, Glucose

• Glucose

• ECG

• Urine dip

• Neuro obs, normal obs including temperature

• Collateral history

Post take ward round

It is now the post take ward round and you know you will be grilled by your consultant. You present Paula’s case.

Your consultant wants to know:

• How would you classify the fit Paula has had?

How would you classify the fit Paula has had?

Paula has had a complex partial seizure originating from the temporal lobe with progression into a secondary generalised seizure.

Complex means there is a loss of awareness during the event whereas simple would mean maintenance of awareness

Partial means arising from a localised region of the brain

Generalised means simultaneous involvement of the whole cortex

The consultant is impressed with your answer and wants to take this further. He asks you to describe myoclonic and absence seizures to the rest of the post take ward round.

Myoclonic: Sudden, brief, involuntary muscle jerks, a bit like the kind everyone has when a foot or leg suddenly jerks in bed. May be mild and affect only part of the body, or be strong enough to throw the person abruptly to the floor.

Absence: Seizures are characterized by a momentary lapse in awareness.  The patient may stop what they are doing, stare, blink or look vague for a few seconds before carrying on with what they were doing

Paula is now well and the acute medical consultant tells you to book a CT scan. He says if it is normal she can go home with an outpatient EEG and neurology follow up.

What is the important thing the consultant needs to tell her before she can go home?

Driving restrictions with seizures

For a first seizure she should not drive for 6 months. Paula should inform the DVLA of her seizure.

… 2 months later you’ve moved on to a peaceful placement in neurology, so much so that you’ve got time to sit in on some clinics

Paula walks into the clinic with her partner. You wave awkwardly in her direction. She looks at you like you are a little strange. She doesn’t remember who you are. Oh well, you win some you loose some.

Paula tells the consultant that she has had a further seizure similar to the first one. She is finding not driving is becoming a bit of an impairment on her life, meaning she has to take the bus to work. She is keen to get some treatment started and get back to driving, especially as her partner and she live in the countryside.

Paula’s CT scan was normal but her EEG was suggestive of epilepsy.

What are the important points the consultant needs to address?

Diagnosis: Paula now has epilepsy. The World Health Organisation [WHO] define epilepsy as "a chronic disorder characterized by recurrent seizures, which may vary from a brief lapse of attention or muscle jerks, to severe and prolonged convulsions". This seems to be a idiopathic epilepsy i.e. no known cause, which is the most common type. Other causes: electrolyte abnormalities , hypoglycaemia, sepsis , alcohol and alcohol withdrawal (DTs) , vasculitis ,tumour

Driving: Paula must now be free from seizures for a year to drive

Treatment: Your consultant starts Paula on lamotragine as she is a women of child

bearing potential. He advises her about effective contraception. This would be the

implant/ injection/ condoms/ mirena. COC/ POP better avoided, if used doses of

the contraception and lamotragine may need to be adjusted/.

You have decided to do some locums in A+E after intense pressure from the HR department due to A+E understaffing

It is 4am and you are called to A+E resus. Staffing levels have got so desperate that all your seniors are busy with sick patients in resus and you have had an alert that a patient is coming in in status.

You think you might vomit with worry, but instead you decide to quickly scan your hospital guidelines for the treatment of status so that you are more prepared when the patient comes in.

What do you find in the guidelines?

Pre-hospital setting (0-10 minutes)Rectal diazepam 10-20 mg (repeated once 15 minutes later if status continues

to threaten)

If seizures continue, treat as below:Early status (0-30 minutes)Intravenous lorazepam 4 mg bolus, repeated once after 10-20 minutes). Give usual AED if already on treatment.

For sustained control or if seizures continue, treat as below. Established status (0-60 minutes)Intravenous phenytoin infusion 15mg/kg at a rate of (and not exceeding) 50

mg/minute or;  Refractory status (reached 60-90 minutes after initial therapy)General anaesthesia:Intravenous propofol (1-2 mg/kg bolus, then 2-10 mg/kg/hour) titrated to effect.

Unfortunately it is Paula who attends your resus area but you do a good job in treating her status.

What is the most likely cause for Paula’s state?

It is nearing the end of the year and it is your day off but unfortunately you have had to come in because you forgot to get your neurology consultant to sign off your e portfolio. You are hanging around outside your neurology consultant’s clinic, hoping to get your e portfolio signed off. “Come in”, he says “You might even learn something”.

Inwardly you groan, but outwardly you smile. “That would be lovely”, you say.

You sit down and surprise surprise it is Paula who walks in for a follow up appointment. Things have not been going well, even though Paula is now on a combination of therapy the seizures are becoming more frequent. She says that she has been reading on the internet about “electric shocks” or surgery for epilepsy so she could get rid of it for good.

What is Paula describing?

Non medical treatments

Vagus Nerve Stimulation therapy uses a pulse generator to send mild electrical stimulations to the vagus nerve with the aim of reducing the number, length and severity of seizures.

Vagus nerve stimulation (VNS) therapy is a type of treatment for epilepsy that involves a stimulator (or pulse generator) which is connected, inside the body, to the left vagus nerve in the neck. The stimulator sends regular, mild electrical stimulations to this nerve.

The vagus nerve sends these regular stimulations into the brain.  The aim is to help calm down the irregular electrical brain activity that leads to seizures

VNS therapy aims to reduce the number, length and severity of seizures. For some people their seizures become much less frequent, for some it may reduce their seizures a little, and for others it has no effect. VNS therapy may reduce the length or intensity of seizures but this does not happen for everyone. It may also reduce the time it takes to recover after a seizure. It is unlikely to completely stop seizures and it does not ‘cure’ epilepsy

Surgical: resection of affected areas

Paula isn’t so keen on these options now they have been described to her but she now desperately wants to have a baby. What might your consultant advise about this?

Keep taking antiepeleptics. In this case risk to baby from seizures is higher than the risk of the medication.

Tonic clonic seizures could be a risk to the baby therefore it might be worth waiting until Paula’s epillepsy is better controlled

There is a risk to the baby of congenital malformations through antiepileptics

Particularly important to go to development scans

Folic acid at 5mg a day

Paula decides to wait until her epilepsy is better controlled until she tries for a baby.

Summary

• Able to define epilepsy

• Classify the common seizure types

• Know some causes of seizures and classify which are epilepsy and which are not

• Able to recognise a patient presenting with a seizure

• Know the common important investigations that should be carried out for each patient presenting with a seizure

• Describe common medical and surgical management of epilepsy

• Describe some limitations epilepsy places on people’s lives and how these can be managed, for example driving, pregnancy

Thank you. Any questions?