1. Epilepsy: what I need to know
Nik Sanyal FY2

2. Aims Be able to define what a seizure is and what epilepsy is
Be able to define different types of epilepsy
Be able to establish a management plan involving investigations and medications.
Be able to explain to a patient the implications of epilepsy on their life
If time – discuss the special case of epilepsy in pregnancy.

3. Definition
A seizure is an episode of uncontrollable electrical activity in the brain.
Epilepsy is defined as a condition that causes a pre-disposition to seziures – must have had 2+.
It is important to remember that we can all have a seizure as we all have a seizure threshold.
Can you think of anything that lowers the seizure threshold?

4. Secondary generalised
Subtypes
Epilepsy
Focal (Partial)
Generalised
They can also be simple or complex depending on whether consciousness is lost
Secondary generalised
Absence
Myoclonic
Tonic
Clonic
Tonic-clonic
Temporal lobe
Jacksonian
Simple motor

5. http://youtu.be/obbg1BFt26Q - absence
- tonic clonic

6. Key things from history
Is this the first time?
Was the “seizure” witnessed?
Does the person remember what happened before, during and after?
Did they lose continence or bite their tongue?
Which part of the tongue is bitten?
What happened after the seizure?
On any medication/relevant PMHx/social hx etc?

7. Investigations Bedside: BMs, sats, obs, ECG
Bloods: FBC, U+Es, bone profile (LFTs + γGT - alcoholic), septic screen. Can any blood test distinguish a pseudoseizure from a seizure?
Imaging: CXR (if think seizure related to infection), CT/MRI
MRI if <2 or focal neurology
Special tests: EEG? How easy is one to get done?
Useful to look for specific patterns
Normal in some with epilepsy, abnormal in some without it.

8. Management Initial – ABCDE – give oxygen + control seizures
Review status epilepticus
BMs!!!
Alcohol withdrawal? – chlordiazopoxide + pabrinex
Septic screen if appropriate
Long-term management:
Lifestyle advice
Start low and go slow with medication
Control with lowest dose of fewest drugs

9. Medications Focal Generalised First line: Sodium valproate
First line: Carbamazepine
First line: Sodium valproate
Absence: Ethosuxomide

10. Side effects PCBRAS + OADEVICES Drug Side effect Sodium valproate N+V
Weight gain
Inhibits CYP450
Lamotrigine
SJS + TEN, aggression, dizziness, tremors
Carbamazapine
Dry mouth, swollen tongue
Induces CYP450
Phenytoin
Gum-hypertrophy
Cerebellar signs
PCBRAS + OADEVICES
PCBRAS: phenytoin, carbamazepine, barbiturates, rifampicin, alcohol (chronic), sulphonylureas
ODEVICES: omeprazole, Allopurinol disulfiram, erythromycin, valproate, isoniazid, cipro, ethanol (acute) + sulphonamides

11. Pregnancy + epilepsy
Ideal world – a woman with epilepsy will be planning a pregnancy in advance – clearly not always the case.
Risks of epilepsy in pregnancy – to mother and child
Drugs are all teratogenic but some are less teratogenic than others – best in pregnancy was lamotrigine – convert to this.
Risk of seizure worse than teratogenicity
Take folic acid – dose?

12. Advice re driving
Have to establish if Group 1 or 2 licence (1 is normal cars, 2 is lorries/buses/taxis
Group 1: can drive again if an isolated seizure after 6 months or free of seizure for 1 year if recurrent. Unless having seizures only when asleep.
Group 2: 5 years free if isolated or 10 years if they are recurrent.

13. Conclusions Clinical dx therefore the history is vital!
Think carefully of investigations – always ask “why am I ordering this?”
Start low and go slow
Advise advance planning in young women of child-bearing age.
Counsel re impact on life – driving rules, avoiding triggers if appropriate, don’t go swimming alone.
Prognosis: 1st seizure = 10% recur if provoked, 50% if not.

14. Questions + resources Thank you
Good sites = + epilepsy society.