QuestionSBA
QuestionChoice
This is a typical description of a generalised tonic-clonic seizure. The onset of stiffness characterises the tonic part, which can cause a patient to fall. Rhythmic jerking motions characterise the clonic part. Incontinence and tongue biting are not unique to seizures but are also common features of seizure, with lateral tongue biting being more suggestive of seizure and tip tongue biting being more suggestive of syncope. Post-ictal state (drowsiness lasting up to 30 minutes post-seizure) is common after generalised tonic-clonic seizures
33708
a
Generalised tonic-clonic seizure
QuestionChoice
Focal seizures originate in a single part of the brain, most often in the temporal lobe. Post-ictal state is common, and this seizure may progress to involve the whole brain (secondary generalisation). However, the seizure started as a generalised seizure, in this case, making a generalised tonic-clonic seizure more likely
33709
b
Focal seizure with impairment of consciousness
QuestionChoice
Atonic seizures are characterised by the sudden loss of muscle tone (atonia) without the patient losing consciousness. As this patient lost consciousness and had stiffness, not atonia, a diagnosis of atonic seizure is unlikely
33711
d
Atonic seizures
QuestionChoice
Vasovagal syncope usually occurs after prolonged standing or strong emotion (e.g. seeing blood). The patient may feel dizzy before the episode, will have a faint to the ground with or without some jerking of all four limbs, but will quickly recover within minutes. The presence of stiffness, lateral tongue biting, and a post-ictal state makes a vasovagal syncope diagnosis unlikely
33712
e
Vasovagal syncope
QuestionChoice
Myoclonic seizures present with involuntary contraction of muscles leading to jerking. However, the patient remains conscious and don't have any post-ictal state, making this diagnosis unlikely
33710
c
Myoclonic seizure
Concept
Chapter
# Summary

Epilepsy is a neurological disorder characterised by an enduring predispotion to generate epileptic seizures. Affecting around 50 million people globally, it is one of the most common neurological conditions. Seizures can be either focal or generalised, with various triggers and symptoms. Differential diagnoses include syncope, transient ischemic attacks (TIA), migraines, panic disorder, and non-epileptic attack disorder (NEAD). Treatment primarily involves antiseizure medications (ASMs), tailored to the type of epilepsy, with surgery and psychological support as additional options in refractory cases. Complications include status epilepticus, psychiatric issues, and Sudden unexpected death in epilepsy (SUDEP).

# Definition

Epilepsy is a neurological disorder characterised by an enduring predisposition to generate epileptic seizures and the neurobiological, cognitive, psychological, and social consequences of this condition. 

Seizures are transient occurrences of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain. 

# Epidemiology

Epilepsy affects approximately 50 million people worldwide, making it one of the most common neurological disorders.

It has a lifetime prevalence of 7.6 per 100 people.  

Incidence rates vary depending on age, with higher rates in the very young and the elderly. Both males and females are affected equally.

# Aetiology

There is a strong debate amongst epileptologists regarding the classification of epilepsy syndromes by aetiology. 

Broadly, epilepsy syndromes can be classified into:

1. Idiopathic Generalised Epilepsies (IGEs):

- Childhood Absence Epilepsy
- Juvenile Absence Epilepsy
- Juvenile Mycolonic Epilspy
- Generalised Tonic Clonic Seizures Alone

2. Structural aetiology:

- Acquired
	- Stroke
	- Trauma
- Genetic
	- Malformations of cortical development 

3. Genetic aetiology
4. Infectious aetiology
4. Metabolic aetiology
5. Immune aetiology
6. Unknown aetiology


# Signs and symptoms

Signs and symptoms vary between focal and generalized seizures:

- **Focal seizures**: 
  - *With impaired consciousness ('complex')*: patients lose consciousness, usually post an aura or at seizure onset. Commonly originate from the temporal lobe, and post-ictal symptoms such as confusion are common.
  - *Without impaired consciousness ('simple')*: patients retain consciousness, experiencing only focal symptoms. Post-ictal symptoms are absent.
  - *Evolving to a bilateral, convulsive seizure ('secondary generalised')*: patients first experience a focal seizure that evolves into a generalized seizure, typically tonic-clonic.

- **Generalized seizures**:
  - *Absence seizures*: brief pauses for less than 10 seconds.
  - *Tonic-clonic seizures*: characterized by loss of consciousness, stiffening (tonic), and jerking (clonic) of limbs. Post-ictal confusion is common.
  - *Myoclonic seizures*: sudden jerks of a limb, trunk, or face.
  - *Atonic seizures*: sudden loss of muscle tone, causing the patient to fall, with consciousness retained.

Specific epilepsy syndromes to note:

- Temporal lobe epilepsy
 - Associated with complex partial seizures
 - Can present with initial sensory auras e.g. smelling burnt toast, feelings of deja vu or jamai vu (feeling unfamiliar in familiar surroundings), automatisms such as lip smacking
 - Patients often exhibit postictal confusion after each episode
- Jacksonian March
	- A type of focal motor seizure that progressively 'marches' through adjacent areas of the brain
	-  Typically starts in the hand or face then gradually spreads to other muscle groups following the smatotopic organisation of the motor cortex (starting from hand and spreading to arm, shoulder and face)
	-  The seizure may progress into a generalised tonic clonic seizure
	-  Often associated with structural brain lesions
- Todd's Paresis
	- Refers to temporary postictal weakness or paralysis following a seizure
	- Usually lasts minutes to hours but can last up to 48 hours 
	- Usually unilateral but can be bilateral
	- It is transient so the patient will reover following resolution of the postictal state



# Differential diagnosis

The differential diagnosis for seizures includes:

- **Syncope**: characterized by a sudden, transient loss of consciousness and postural tone followed by spontaneous recovery. Triggered by low blood flow to the brain.
- **Transient Ischemic Attack (TIA)**: brief episodes of focal neurologic dysfunction caused by ischemia that does not cause lasting brain injury. Symptoms depend on the brain area affected.
- **Migraines**: characterized by recurrent headaches often accompanied by a variety of symptoms such as visual disturbances (auras), nausea, vomiting, dizziness, extreme sensitivity to sound, light, touch and smell, and tingling or numbness in the extremities or face.
- **Panic Disorder**: sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something terrible is going to happen.
- **Non-Epileptic Attach Disorder (NEAD)**: characterized by episodes that resemble epileptic seizures but occur without abnormal electrical activity in the brain. NEAD is often associated with psychological or emotional stress, and symptoms may include convulsions, loss of consciousness, or other seizure-like movements. Diagnosis is confirmed by video EEG monitoring, showing no seizure activity during an episode.

# Investigations

Diagnostic workup of epilepsy includes:

- Detailed history and neurological examination
- Collateral history and, if present, reviewing any videos of previous episodes (with the patient's consent)
- Imaging such as CT or MRI
- Electroencephalogram (EEG)
	- Video-EEG telemetry can also be considered in select cases
- Other investigations can be considered to investigate contributory causes which include blood tests, lumbar puncture and more advanced imaging investigations.


# Management

The goal of epilepsy treatment is to minimize seizures and optimise the patient's quality of life via a biopsychosocial model.

Antiseizure medications (ASMs) remain the mainstay of treatment, with the specific drug chosen based on seizure type, patient age, comorbidities, potential side effects, and the patient's personal considerations. 

Principles of epilepsy ASM management include:

- Aim for optimum quality of life through seizure control, balanced against potential side effects, particularly teratogenesis in women of childbearing age.
- Initiation of medication may not always be appropriate after a "provoked" first seizure; discuss such cases with a specialist.
- The choice of antiepileptic drugs involves complexity due to the lack of head-to-head trials comparing different medications.
- Interactions with other medications, particularly with phenytoin and carbamazepine, should be considered.
- Issues regarding teratogenicity, particularly with valproate, which carries a high risk of neural tube defects, should be considered. Lamotrigine is a better choice for women of childbearing age.

Specific ASMs:

- According to [NICE Guidelines](https://bnf.nice.org.uk/treatment-summaries/epilepsy/#focal-seizures-with-or-without-secondary-generalisation), Lamotrigine or Levetiracetam should be considered as first-line for focal seizures.  
- Sodium valproate can be offered as first-line for myoclonic seizures in males.
- Ethosuximide is the drug of choice for absence seizures.
- Carbamazepine may worsen myoclonic seizures.

Surgical intervention may be an option in cases where AEDs are ineffective. 

Psychological support is a vital part of comprehensive epilepsy management.

Specific guidance on patients presenting with a 'first fit':

- Usual protocols will advise to refer to outpatient neurology following a patient's first seizure
- Most neurologists would start an ASM after a second seizure, unless there is a specific structural cause or a second fit would be unacceptable to the patient. 
- Following a discussion regarding the risks and benefits of starting an ASM, patients are given information on reducing risks e.g. driving advice or taking showers rather than baths. 
- Patient education via leaflets or online websites are utilised heavily as part of the initial discussions and further follow up or advice is usually relayed via a dedicated epilepsy nurse

# Complications

Complications of epilepsy include:

- **Status epilepticus**: Seizures lasting more than 5 minutes, necessitating immediate medical intervention OR more than 2 seizures within 5 minutes without returning to normal between each seizure.
- **Psychiatric complications**: Increased risk of depression and suicide.
- **Sudden unexpected death in epilepsy (SUDEP)**: Thought to occur due to excessive electrical activity inducing a cardiac arrhythmia and subsequent death.

# Side Effects of Anti-Epileptic Drugs

Side effects of common anti-epileptic drugs include:

- **Topiramate**: Abdominal pain, cognitive impairment, confusion, mood changes, muscle spasm, nausea and vomiting, nephrolithiasis, tremor, weight loss.
- **Lamotrigine**: Blurred vision, arthralgia, ataxia, diarrhoea, dizziness, headache, insomnia, rash, tremor.
- **Carbamazepine**: Ataxia, blood disorders, blurring of vision, fatigue, hyponatraemia, skin problems.
- **Sodium Valproate**: Ataxia, Anaemia, confusion, gastric irritation, haemorrhage, hyponatraemia, tremor, weight gain.
- **Phenytoin**: Acne, anorexia, constipation, dizziness, gingival hypertrophy, hirsutism, insomnia, rash, tremor.

# Driving Guidance

The DVLA has issued guidelines on driving with medical conditions, including epilepsy:

- For car/motorbike licence: reapply after 6 months for a one-off seizure, or after 1 year for more than one seizure. After a seizure following a change in anti-epileptic medications, reapply to drive if the seizure was more than 6 months ago or you've been back on the previous medication for 6 months.
- For bus/coach/lorry licence: reapply after 5 years for a one-off seizure if no anti-epileptic medications have been taken during this period. For more than one seizure, reapply after 10 seizure-free years during which no anti-epileptic medication has been taken.

The DVLA's complete guidelines for epilepsy and driving can be found [here](https://www.gov.uk/epilepsy-and-driving).

# References

[ILAE Guidelines](https://www.ilae.org/guidelines)

[NICE Guidelines](https://www.nice.org.uk/guidance/ng217)

[Driving Guidance on Gov.uk](https://www.gov.uk/epilepsy-and-driving)

194
195
Epilepsy
Topic
34
Neurology
Video
Concept
195
Epilepsy
129
9WkzgUc
images/videos/neurology.png
Epilepsy syndromes
Video
Concept
195
Epilepsy
247
Dy6PDaW
images/videos/neurology.png
Quesmed Tutorial: Neurology
6742
A 25-year-old man presents to the emergency department after a transient loss of consciousness 15 minutes ago. His mother reports that he was getting ready for work when he suddenly went stiff, fell to the ground and then began shaking his limbs. He lost control of his bladder and bit both sides of his tongue. You attempt to gain a history from him, but he is drowsy.

What is the most likely diagnosis?
a