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