Non-Epileptic Attacks

Question 1

What are some examples of functional attacks?

Answer 1

Dissociative seizures
Non-epileptic attack disorder
Pseudoseizures
Psychogenic non-epileptic seizures
Hysterical seizures

Question 2

What are functional attacks related to?

Answer 2

Traumatic events
Physical/sexual abuse
Other stress
Anxiety or depression
Other

Question 3

How are functional attacks diagnosed?

Answer 3

History
Linguistic analysis
Outpatient EEG and video with provocation
Longterm video EEG monitoring

Question 4

Where do seizures result from?

Answer 4

Abnormal electrical discharge in part of brain- not all of the brain is active at once
Can mimic area of brain function
This is how seizure semiology is used

Question 5

What will be felt in somatosensory auras?

Answer 5

Numbness
Tingling
Electric shocks
Thermal sensations
Pain

Question 6

Where are somatosensory auras from?

Answer 6

Somatosensory cortext (parietal lobe)
Occasional insular cortex

Question 7

What can be seen in visual auras?

Answer 7

Simple shapes
Static
Flashing
Moving lights
Colours

Question 8

Where are visual auras from?

Answer 8

Occipital love

Occasionally temporal

Question 9

Where are vertiginous auras from?

Answer 9

Temporal-parietal lobe, near visual and auditory association areas

Question 10

Where are autonomic auras from?

Answer 10

Temporal lobe (insula, amygdala, etc)

Question 11

What are some features of functional attacks?

Answer 11

Attacks with prominent motor activity
Episodes of collapse with no movement
Abreactive attacks- fear, gasping, hyperventilation
Duration often prolonged eg 10-20mins

Question 12

How are functional attacks treated?

Answer 12

Removal of any diagnosis of epilepsy
Withdrawal of antiepileptic drugs
Explanation of the nature of the attacks
Positive support
Appropriate counseling for any previous traumatic events
Treatment of any associated anxiety or depression
CBT

Question 13

What is status epilepticus?

Answer 13

Recurrent epileptic seizures without full recovery of consciousness
Continuous seizure activity lasting more than ?30 minutes

Question 14

What are the types of status epilepticus?

Answer 14

Generalized convulsive status epilepticus
Non convulsive status- conscious but in “altered state”
Epilepsia partialis continua- continual focal seizures, consciousness preserved

Question 15

What are some precipitants of status epilepticus?

Answer 15

Severe metabolic disorders- hyponatraemia, pyridoxine deficiency
Infection
Head trauma
Sub-arachnoid haemorrhage
Abrupt withdrawl of anti-convulsants
Treating absence seizures with CBZ

Question 16

What is convulsive status epilepticus?

Answer 16

Generalised convulsions without cessation

Question 17

Why can convulsive status epilepticus cause lasting damage?

Answer 17

Due to the excess cerebral energy demand and poor substrate delivery

Question 18

What can convulsive status epilepticus cause?

Answer 18

Respiratory insufficiency and hypoxia
Hypotension
Hyperthermia
Rhabdomolysis

Question 19

What can occur in uncontrolled status epilepticus?

Answer 19

Glutamate release
Excitotoxicity
Neuronal death

Question 20

How is status epilepticus managed?

Answer 20

ABCDE
Identify cause- emergency bloods +- CT
Anti-convulsants- phenytoin (check levels), keppra, valproate, benzos

Question 21

How should prolonged and serial seizures be treated by carers at home?

Answer 21

Diazepam 10-20mg rectal

Midazolam 10-20mg buccal

Question 22

What immediate antiepileptic drug treatment can be given in status epilepticus?

Answer 22

Lorazepam 4mg IV (preferred as long duration of action)

Diazepam 10-20mg IV(respiratory depression, hypotension)

Question 23

If there is a delay in gaining IV access, what antiepileptic drug treatment can be given for immediate control of status epilepticus?

Answer 23

Diazepam 10-20mg rectal

Midazolam 5-10mg IM

Question 24

What should be given in status epilepticus if there is any suggestion of hypoglycaemia?

Answer 24

50ml 50% glucose

Question 25

What should be given in status epilepticus if there is any suggestion of alcoholism or impaired nutritional status?

Answer 25

IV Thiamine

Question 26

What antiepileptic drug treatment should be given for sustained control of status to epilepticus in patients with established epilepsy?

Answer 26

Re-establish usual AED treatment by NG tube/orally/(IV for phenytoin)

Question 27

What antiepileptic drug treatment should be given for sustained control of status to epilepticus in patients without established epilepsy or if seizures are continuing?

Answer 27

Fosphenytoin 18mg(PE)/kg IV, 100-150mg/min with ECG monitoring
Phenytoin 18mg/kg IV, <50mg/min with ECG monitoring
Phenobarbital 15mg/kg IV 100mg/min (fosphenytoin or phenobarbital preferable as can be given more rapidly)
Maintain phenobarbital/phenytoin levels by NG tube/IV/orally

Question 28

If status epilepticus persists beyond drug treatment, what should be done?

Answer 28

ITU transfer within 1hr of admission
Control status with GA with thiopentone or propofol
Monitor control with full EEGs or cerebral function monitor

Question 29

What should be considered in any patient presenting with an acute confusional state?

Answer 29

Possibility of partial status epilepticus

Question 30

How is partial status epilepticus confirmed?

Answer 30

EEG recording

Question 31

How is partial status epilepticus treated?

Answer 31

As for convulsive status epilepticus short of GA and ITU admission