NEUROLOGY: EPILEPSY | S.M.

CHOK (Manchester Medical School)

Epilepsy:
transient occurrence of signs or symptoms due to abnormal electrical activity in the brain, leading to a disturbance
of consciousness, behaviour, emotion, motor function or sensation.
Epilepsy: >2 unprovoked episodes of periodic disturbance in neurological function.
Epilepsy is not a single diagnosis but is a symptom with many underlying causes.

Partial Seizure
Simple Partial Seizure (SPS)
Presentation

Somatosensory:
tingling of contralateral limb, face, side of body
Focal Motor:
tonic-clonic movements of specific limb
Facial:
grimacing
head and eyes turned to opposite side
Visual:
flashes of light
scotomas (partial loss of vision)
unilateral/bilateral blurring
Auditory:
hears ringing, hissing or noises
Autonomic:
sweating
flushing/pallor
epigastric sensations

Complex Partial Seizure (CPS)

Frontal Lobe:
Jacksonian
march of involuntary movement from one muscle
group to the next (begins with face or hand)
Todd's paralysis
weakness after tonic/clonic phase
supplementary motor area can cause stereotyped
complicated movement:
eg cycling, often during sleep
Parietal Lobe:
paraesthesia/tingling
sensation of distortion of body image
Temporal Lobe:
commoner in medial or lateral part, hippocampus
visceral
taste/smell hallucinations, lip smacking/wetting,
epigastric fullness, nausea, choking sensation,
pallor, pupillary dilatation, tachycardia
memory
Deja vu (smthg's happened before), jamais vu
(unfamiliarity), depersonalisation, derealisation,
flashback, visual/auditory hallucination
motor
fumbling movement, rubbing, chewing, semipurposeful limb movement, automatism (picking
at clothes), ?dysphasia
affective
displeasure, pleasure, depression, fear
Occipital Lobe:
uncommon
visual hallucination-line or flash

important
features!

no change in level of consciousness

auras (warning signs) patient has before altered/

loss of consciousness (generalised epilepsy) are SPS

brief episode, last for a short period of time

confusion and headache post-ictal are common

Frontal and Parietal seizures indicate structural

brain disease, the focal onset localising the lesion.

Full Ix is needed: patients often have mesial

temporal lobe sclerosis with cell loss and atrophy

EEG

repetitive sharp waves over one region

eg R central: focal motor seizure, left arm and hand

Risk Factors

most of the time: unknown aetiology

PMHx: head injury, brain infection, stoke, brain tumour

repetitive sharp wave over on region

eg L temporal: left temporal lobe seizure

NEUROLOGY: EPILEPSY | S.M.CHOK (Manchester Medical School)

Generalised Seizure
Presentation:
HPC

Tonic-Clonic (Grand Mal)

Absence (Petit Mal)

Myoclonic

Onset

sudden

sudden
abrupt

sudden
often in the morning

Site

all 4 limbs affected

simultaneous and almost equal

(ATYPICAL)
tends to have multifocal or
generalized cerebral pathology

may involve body segment

may be generalized
may be mediated by cortical,

involvement of both hemispheres

subcortical, brainstem or spinal

cord mechanism
Character

Associated
Symptoms

Tonic phase
loss of consciousness
epileptic cry
muscle contraction
generalised stiffening of body
opisthotonus (back arched)
Clonic phase
clonic jerks of limbs and body
eyes blinking
tongue biting
Post-ictal phase
unresponsive
limbs and body limp, myalgia
confused, loss of memory
headaches
lethargy
disorientation

During
vacant stare
eyes roll upward
cessation of activity
lack of response
impaired alertness
After
returns to normal right after
no post-ictal symptom

autonomic signs:

without aura
generally simple/brief automatic

tachycardia
HPTN
cyanosis
salivation/salivary drooling

(ATYPICAL)
motor symptoms
focal preponderance sometimes
post-ictal confusion

non-epileptic muscle jerks

generalised muscle contraction
can be single or repetitive

Juvenile Myoclonic Epilepsy

(common)
begins during teenage year
generalized muscle jerks soon after
awakening typically in the morning
Reflex Epilepsies
musicogenic epilepsy (music)
reading epilepsy (reading)
arithmetical epilepsy (calculation)
West Syndrome
infants
following birth trauma or asphyxia
Lennox-Gastaut Syndrome
between 1-7y/o
associated with disorders:
hypoxia
intracranial haemorrhage
toxoplasmosis
cytomegalovirus
tuberous sclerosis
Lance-Adams Syndrome
post-anoxic syndrome after
prolonged cardiac arrest
Creutzfeldt-Jakob disease
transmissible spongiform
encephalopathy
Prion-induced dementing illness
can be rare late form of measles or

subacute sclerosing panencephalitis

movements may be observed

eyes fluttering (~3s)
lip movements

sweating
incontinence

Time

Triggers

non-specific, vaguely defined

prodromes or can have no

promontory symptoms at all

(ATYPICAL)
children lag in meeting normal
development milestones
brief (~10s)

brief

hyperventilation

spontaneous
can be provoked by sensory

stimulation (reflex) or limb action

NEUROLOGY: EPILEPSY | S.M.CHOK (Manchester Medical School)

Causes:
PMHx

DHx
SHx

Newborn Onset
asphyxia
intracranial haemorrhage
metabolic disorders
uraemia
hypoglycaemia
hypo/hyper-natraemia
hypo/hyper-calcaemia
hyperbilirubinaemia
water intoxication
inborn errors of metabolism

Infancy/Childhood Onset
Adult Onset
febrile convulsion
trauma/cranial surgery
CNS infections eg meningitis,
CNS infection
encephalitis
intracranial haemorrhage
trauma: more significant if with
tumours
loss of consciousness>30min
vascular disease
post-traumatic amnesia>30min
hypoglycaemia
focal neurological findings
nerodegenerative diseases eg
Ix shows structural brain injury
Alzheimer's, multi-infarct dementia
congenital defects
genetic diseases
inborn errors of metabolism
metabolic disorders
tumours
phenothiazines, isoniazid, tricyclic antidepressants, overdose of DM medication causes hypoglycaemia
Alcohol
Drug use
Other
binge drinking
benzodiazepines
severe sleep deprivation
sudden alcohol withdrawal
sedatives (sudden withdrawal)

Examinations and Investigations:

EEG

Tonic-Clonic (Grand Mal)

Absence (Petit Mal)

Myoclonic

tonic:
generalized fast, repetitive spikes
(10-14Hz) and muscle artifact
clonic:
generalized spikes and slow waves
post-ictal:
generalized attenuation

3/sec generalized spike-and-wave

JME:
bilaterally synchronous, irregular
spike-wave or polyspike discharge
at 4-6Hz repetitively, but no focal
epileptic discharge
Creutzfeldt-Jakob disease:
periodic sharp and slow wave
complexes recurring at 1-2Hz

discharges

O/E

check for neurological or cerebrovascular signs, but usually unremarkable

Other Ix

MRI: more sensitive than CT, can

detect small tumour, cortical

dysplasia or hippocampal sclerosis,
which will be missed on CT

ECG: should be done in all seizure

patients. Prolonged QT syndrome

can mimic epilepsy syndrome

DDx:
syncope (vasovagal attack)
evoked by strong emotion (eg fear) or pain or
prolonged standing
pallor, nausea, sweating, light headedness, blur vision
attack may passed off after patient sits down, or
proceed to brief loss of consciousness (<2min)
anoxic seizure (limb jerking) can happen (uncommon) if
impaired blood flow is prolonged
no post-ictal state
hypoglycaemia
rapid fall of sugar associated with catecholamine
release (sweating, palpitations etc)
PMHx of diabetes
DHx of insulin/diabetic medication

metabolic Ix: fasting glucose for

insulinoma; synacthen test for

Addison's disease
bloods include: electrolytes,
calcium, renal function, liver
function, and urine biochemistry

cardiac arrythmias
eg complete heart block
prolonged arrest of cardiac rate may cause loss of
consciousness, tonic jerks, cyanosis, stertorous
respiration, fixed pupils, extensor plantar responses
prognosis dependant on severity of affected brain
ECG monitoring is needed
postural hypotension
change position suddenly eg from lying to sitting or
sitting to standing
very brief episode (few seconds)
lightheadedness, dizziness, unsteadiness, 'head rush'
DHx of tricyclic antidepressant or antihypertensive
drugs

NEUROLOGY: EPILEPSY | S.M.CHOK (Manchester Medical School)

Treatments
Tonic-Clonic (Grand Mal)

Absence (Petit Mal)

Myoclonic

Focal

First Line

Sodium Valproate
Lamotrigine
Carbamazepine
Oxcarbazepine

Sodium Valproate
Lamotrigine
Ethosuximide

Sodium Valproate
Levatiracetam
Topiramate

Sodium Valproate
Carbamazepine
Lamotrigine
Levatiracetam
Oxcarbazepine

Adjunctive

Clobazam
Lamotrigine
Sodium Valproate
Topiramate

Ethosuximide
Lamotrigine
Sodium Valproate

Levatiracetam
Sodium Valproate
Topiramte

Carbamazepine
Clobazam
Gabapentin
Lamotrigine
Levatiracetam
Oxcarbazepine
Sodium Valproate
Topiramate

May want
to consider

Clobazam
Clonazepam
Levetiracetam
Topiramate
Zonisamide

Clobazam
Clonazepam
Piracetam
Zonisamide

Eslicarbazepine acetate
Lacosamide
Phenobarbital
Phenytoin
Pregabalin
Tiagabine
Vigabatrin
Zonisamide

Carbamazapine
Gabapentine
Oxcarbazepine
Phenytoin
Pregabalin
Tiagabine
Vigabatrin

Carbamazepine
Gabapentine
Oxcarbazepine
Phyntoin
Pregabalin
Tiagabine
Vigabatrin

DO NOT
offer AEDs

Main SE of AEDs:
Sodium Valproate: abdo pain, hair loss, weight gain, thrombocytopenia, tremor
Lamotrigine: rash (Steven-Johnson syndrome), drowsiness
Carbamazepine/Oxcarbazepine: rash, drowsiness, ataxia, diplopia, hyponatraemia, thrombocytopenia
Phenytoin: gum hypertrophy, acne, ataxia, diplopia, skin thickening, neuropathy
Phenobarbitone: sedation, behavioural changes, withdrawal seizure
Gabapentine/Pregabalin: drowsiness, ataxia, weight gain
Topiramide/Zonisamide: drowsiness, weight loss, renal stones, paraesthesia
Levetiracetam: irritability, weight loss