Fits, Faints and Funny Turns Anne Grover CN1 Neurology

Objectives To appreciate the wide range of disorders that present with ‘clinical events’ To discuss epileptic ‘lookalikes’ To outline history taking

Seizures Are characterized by a sudden change in movement, behaviour, sensation or consciousness produced by a sudden burst of excessive electrical activity in brain cells causing a chemical (neurotransmitter) imbalance. 10% of the general population will experience one seizure in a lifetime (WHO)

Causes of seizures Brain infection, including meningitis, encephalitis Fever (particularly in young children) Heart disease Very high blood pressure ie malignant hypertension Stroke, ischemic stroke, intracranial haemorrhage Brain tumour Paraneoplastic limbic encephalitis Metabolic and endocrine induced seizures- hyponatremia, hyper/hypocalcaemia, hypomagnesia, hypo/hyperkalemia, hypoglycaemia Head injury Drug abuse, recreational drugs- cocaine, amphetamines Toxins- heavy metals Liver or kidney failure Withdrawal from alcohol or certain medicines Medications- antipsychotic, antidepressants, narcotics, anti malarial, cytotoxic, anti arrthymic agents

Epilepsy Epilepsy – refers to a group of different neurological conditions characterised by recurrent, unprovoked epileptic seizures A manifestation(s) of epileptic excessive usually self-limiting activity of neurons in the brain Epilepsy derived from the Greek word to be seized, to be overwhelmed. Epilepsy refers to a group of different neurological conditions characterised by recurrent epileptic seizures. Think the epilepsies Diagnosis usually made after 2 seizures. Active epilepsy is defined as a seizure has occurred in the previous two years

Epilepsy Affects 1 in 115 people Prevalence in Ireland <42 000 people with epilepsy Approximately 50 million worldwide One of the most common serious chronic neurological conditions 1. Joint Epilepsy Council. Epilepsy prevalence, incidence and other statistics. 2011; 2. Brainwave 2009 Next to migraine one of the most common neurological disorders. Highest incidence rates in children and elderly. . Prognosis usually good. 70 % patients managed by AED’s. Most seizures are self terminating.

Focal Generalised SEIZURE CLASSIFICATION INTERNATIONAL LEAGUE AGAINST EPILEPSY (ILAE) 2010 Focal Focal discharges Some loss of awareness Generalised Discharges coming from both hemispheres Complete loss of consciousness Tonic clonic Convulsion Absence ‘Blank spell’ Atonic Drop attack ‘Aura’ Motor/sensoryChange in awareness and behaviour Myoclonic jerk Twitch/jerk Tonic Stiffness Secondary generalised Usually tonic clonic convulsion Classification International League against epilepsy Focal epileptic seizure currently either motor , sensory or according to where in the brain they arise, frontal, temporal, parietal Sensory, taste, smell, hear things, clicking, ringing hear voices, feel pins and needles, numbness. Feel like they are spinning or floating. Visual hallucinations, illusions. Motor seizures- change in muscles activity, jerking finger arm stiffening. Déjà vu, fear, automastisms, chewing , lip smacking, swallowing, drooling, pick at clothes. Generalised originating at some point within rapidly engaging , bilaterally both sides of brain, absence Tonic clonic, myoclonic, atonic tonic. Copyright © 123Rf Ltd. or their partners. Images may not be copied or downloaded without permission from 123RF Limited IE/BUC/12/0304 10 10

Electroclinical syndromes Defined as an ‘electroclinical’ pattern of clinical features and investigation findings may have different aetiologies. Common electroclinical syndromes eg- Childhood absence epilepsy - Juvenile absence epilepsy - Juvenile myoclonic epilepsy - Lennox Gastaut Electroclinclincal syndromes arranged by group. Features form part of the electroclinical syndrome pattern, age of onset, seizure type, EEG findings, developmental problems. Guides investigations, treatment goals, prognosis risks

Generalised Tonic Clonic Seizure Prodromes – non-epileptic clinical alteration prior to onset of an epileptic seizure Aura – “warning sign” – epileptic seizure experienced prior to GTCS Initial tonic phase -Epileptic cry, eyes open, roll upwards, jaw clamps shut Limbs stiff & extended, arms may flex, cyanosis Genralised tonic clonic seizure type most recognised. Person may experience prodrome- premonitry symptoms for hours/ days before seizure- mood changes, sleep disturbance, light headedness, anxiety, difficulty concentrating. Aura focal seizure few seconds, minutes, fear, stomach sensation, unpleasant smell. Epileptic cry-The muscles involved in respiration contract forcing air out of the lungs heard as a cry, followed by short phase of apnoea during which consciousness is lost

Clonic Phase Rhythmic jerking of all 4 limbs, jaw & facial muscles May froth at the mouth, bite tongue, urinary incontinence Jerking gradually slows before stopping In the clonic phase Breathing is impaired. Excessive salivation may present as frothing at the mouth. HR and BP may increase.

Itcal phase Followed by flaccidity of muscles Consciousness slowly regained, may lapse into deep sleep minutes to hours after GTCS generally self-limiting, last 1-2 minutes Muscles begin to relax and become flaccid. Breathing can become stertenorus may last 2 to 25 minutes. Consciousness regained slowly. Patient may remain confused and drift off into deep sleep. Can report headache and sore muscles, dislocation shoulder tongue injury

ACTION A Assess the situation, ABC’s. Get assistance. Remove any object that could cause harm C Cushion patient’s head to protect from injury T Time, note the time the seizure started I Identify possible cause O Over, put patient into recovery position when possible, note what happened, time seizure ended. N Never restrain the patient, or put anything into their mouth.

Provoking factors Illness or fever Sleep deprivation Missing doses AED’s Alcohol Stress Provoking factors can include a combination of factors---late night, alcohol, missed medication. Only a small number of people with epilepsy are effected by flashing lights (3-5%) photosensitive, detected on EEG

Prolonged acute epileptic seizures Definition of status epilepticus: A seizure lasting >5 minutes, or Two or more seizures without a return of consciousness between seizures1 Immediate treatment is recommended for: Prolonged seizures ≥5 minutes, or Repeated convulsive seizures (≥3 in an hour)2 Treatment delay lessens the chance of successful response to a single medication3 Status epilepticus is a medical emergency, requires immediate treatment

Women’s issues Menstrual cycle Fertility Contraception Pregnancy Women may experience More seizures during first few days cycle. Fertility may be lower Contraception can be affected by AED’s. Good pregnancy planning, medication review. Pregnancy register.

Lifestyle implications Social issues Driving Working Personal safety Good nutrition, special diets Memory problems Mood changes Mood changes can be an initial side effects medication. Sometimes Memory can be effected by epilepsy, memory controlled by temporal lobe, some AED’s can effect memeory Also concentration mood changes and tiredness can affect memory too problems Driving In Ireland law requires person to be 12 months seizure free before being eligible to drive motor cycle, car, light van, work vehicle. Exceptions- first or single seizure sleep seizures, provoked seizures, seizures with retained awareness. Then need doctors certificate. Contact www.rsa.ie Work Job suitability depends on seizure type and type work. When seizures controlled more choices, some jobs less safe if they involve heights, water, sharp tools, dangerous chemicals, . The employment Equality Act 1998 promotes equality in employment on nine grounds, outlaws discriminatory practice in relation to employment expect for Army, Navy Gardai or Prison Service who are exempt. Contact sports individual assessment. often possible, wear head gear, Football, tennis volleyball basket ball generally safe. Boxing not safe. Extreme sports unadvisable- bungee jumping , parachuting, hang gliding. Neber do water sports aloneSwimming in pool under supervision not lake river sea. Wear helmet on bike. Sailing rowing possible if seizures controlled Safety at home- in the kitchen, knives stoves. Shower better then bath shower chair. Bedroom- ventilated pillow insyead of soft pillow. Living room fires, avoid glass. Care on stairs. .Living alone- alarms, detect seizures Epilepsy app id bracelet, Good nutrition avoid missing meals, ketogenic diet, modified Atkins for adults, high fat fat to carbohydrate ratio- Neurologist and Dietician support

Seizure imitators Syncope Psychogenic non-epileptic seizures (PNES) Transient ischaemic attack Narcolepsy/cataplexy/sleep apnea Sleep-walking, night terrors Panic attack Complex migraines. Cardiac arrhythmias. 20

Syncope LOC & postural tone Brief stiffening or spasms & irregular jerks of the limbs Eyes open, roll upwards Urinary incontinence & trauma Generally less than 10 seconds Convulsive syncope - 70-90% Syncope- transient loss of consciousness, brief interruption blood supply, convulsive movements. Vasovagal fear pain. Reflex syncope- coughing ,micturition, valsalvas. Orthostatic hypotension. Cardiac arrhytmias. Patients report Dizzy light headed, nausea, grey coloured visual disturbances. Prolonged standing Main two imitators of GTCS Syncope PNES in amplitude of myoclonic jerks, degree of stiffening & recovery time Post ictal confusion may occur Standing up quickly, prolonged standing Sight of blood and painful stimuli Night time urination Reflex anoxic seizures in children Cardiogenic syncope Occur from any posture Periods of high exertion & emotion

Psychogenic non-epileptic seizures Appear to lose consciousness & fall Eyes closed Often lack stereotypical characteristics Jerking may be asymmetric, asynchronous, wax and wane Pelvic thrust, flailing & tremors Vocalise throughout Consciousness may be retained Psychogenic non epileptic seizures caused by a psychological process rather than electrical discharges, episodes can mimic epilepsy, Incidence 3/100,000, 4% of epilepsy. More common in women more likely as a young adult. 30% of people undergoing a Prolonged video EEG will have non epileptic events. Can be difficult to diagnose, influence life, economic cost. Evidence to suggest early diagnosis and intervention results in better prognosis. One in 6 people will experience cessation of events with appropriate treatment- CBT. People often find it difficult to feel comfortable with the diagnosis of non epileptic seizures Events often prolonged. May report urinary incontinence, tongue biting or injury. History of physical or sexual abuse No post ictal confusion Attempts to passively open eye often result in tightening of the eyelids Intractable to AEDs Can both epileptic and non epileptic events.

Diagnosis History

History Obtain a detailed account of the event from the patient and a witness Where, when, what happened? Any warning sign? Any triggers? First event? Other events? Progression- How did it start? After the event? Useful features Epilepsy- Over diagnosis, diagnosed with epilepsy when they have something else, unnecessary treatment, stigma, restrictions, under diagnosis- missed, potential treatment missed, misdiagnosis classified incorrectly or insufficiently. Correct diagnosis dependant on a good history. Lots of lookalikes Accurate detailed history is the starting point. Difficulties- often don’t occur in a location easy for observation, The patient may have no recollection, may not have the language to describe. events can be second hand, eye witnesses rarely witness the whole event the could be frightened, many ideas what a seizure looks like. Seizures often complex multiple features occurring simultaneously. Useful features- warning/aura, eyes open and deviation, ability to communicate, change in awareness/unresponsiveness, limb movements, laterality, automatisms, post event. Video record event- phone , I pad

Conclusion Epilepsy is one of the most serious, chronic neurological conditions Can be difficult to distinguish between imitators 20-30% of patients misdiagnosed A detailed history can assist with diagnosis

References Brainwave The Irish Epilepsy Association. Shedding Light on Epilepsy. A nurses information pack. Epilepsy Ireland. (2009).The prevalence of Epilepsy in Ireland Study. www.epilepsy.ie Murphy, S., Epilepsy-definitions, diagnosis and treatment. Nursing in General Practice. Nizam, S., Spencer, S.S. (2004). An approach to the evaluation of a patient for seizures and epilepsy. Wisconsin Medical Journal. 103:1. British Paediatric Neurology Association. (2013). Paediatric Epilepsy Training Level One Handbook. United Kingdom.

Thank you