Fit, (falls) and funny turns. Richard J Davenport Consultant Neurologist Edinburgh

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1 Fit, (falls) and funny turns Richard J Davenport Consultant Neurologist Edinburgh

2 The plan Epilepsy nuggets 10 things I would like GPs to know This week s FS clinic

3 What is epilepsy? Characterised by two or more unprovoked seizures Heterogeneous syndrome The epilepsies 30+ different syndromes 40+ different seizure types More than just seizures Mood disorder (incl suicide) Cognitive impairment Other morbidity associated with underlying cause of epilepsy

4 What is an epileptic seizure? Clinical event Synchronous discharge of cortical neurones Whole brain = generalized seizure Part of the brain = focal seizure May occur: Unprovoked (epilepsy) Provoked (toxins, infection etc)

5 Classification Seizure type Epileptic syndrome (clinical and EEG) Primary (idiopathic) generalised syndromes Secondary (symptomatic) syndromes Unclassifiable

6 Terminology/definitions Epileptic seizure = fit = convulsion Delete from cerebral database Grand mal Petit mal Partial (replaced by focal) Aura

7 Epilepsy epidemiology Incidence ~ 50/100,000/year 75 new cases/day in UK At least x2 in developing world May occur at any age, most common in elderly Prevalence Overall ~ 1 in 130 people have epilepsy ~ in UK ( in Scotland) Higher in socially deprived

8 Seizure types Generalised (whole brain) Tonic-clonic (or tonic or clonic) Atonic Myoclonic Absence May be primary generalised or secondary generalised Focal (part of the brain) Sensory, motor Psychomotor Other weird ones

9 Primary (idiopathic) generalised syndromes Onset childhood/adolescence Software problem, leading to epileptic discharges in brain, leading to seizures Mainly genetic based Generalised seizures Tonic/clonic, tonic, or clonic Absence (incl petit mal) Myoclonic Atonic

10 Secondary (symptomatic) syndromes Secondary to structural brain pathology (i.e. hardware) Tumours, strokes, trauma etc.. Most still have normal brain imaging Bulk of epilepsy, occur at any age, increasing with age Seizures types Secondary generalised TC Focal Motor, sensory, weird (psychomotor) Myoclonic

11 Classification: summary Epilepsy Syndrome defined as 2 or more unprovoked seizures of any kind Classified according to seizure type and syndrome Primary (idiopathic) generalised (20%) Secondary (symptomatic) Affects investigations and treatment

12 Prognosis Risk of developing epilepsy after first ever seizure? 30-80% Many factors affecting risk Most common in first 12 months Prognosis of epilepsy? Remission with treatment ~70% within first year Influenced by numerous factors Remission rates increase with time Life long treatment not usually required

13 Mortality SMR in epilepsy x2/3 normal population Varies and can be much higher Death related to epilepsy Due to underlying disease (eg brain tumour) Epilepsy SE Trauma SUDEP Suicide Iatrogenic

14 10 things I would like GPs to know about epielpsy Not only cause of TLOC (nor even convulsions) No history = no diagnosis Disease of the elderly Incontinence is irrelevant. but tongue biting not Use any antidepressant you want The tests don t help (do an ECG) Do not check AED levels Remember driving Know your local services

15 1. TLOC causes Most are syncope Reflex Cardiac (exercise induced, FH, ECG) Dissociative seizures (NEAD, pseudoseizures) Epilepsy Shaking/jerking epilepsy

16 Not epileptic seizure = epilepsy Epilepsy = 2 unprovoked seizures Within 5 years? Provoked seizures Alcohol Drugs (usually recreational)

17 2. Epilepsy is disease of elderly

18 3. History It s all in the history. Patient Witness No history = no diagnosis Not quite the same as unwitnessed

19 4. History you can forget Incontinence Double incontinence Utterly irrelevant

20 5. What does matter? Circumstances Warning Event (witness) Sequence/length/colour Post event Post-ictal? Injuries (tongue biting) Headache Myalgia Not tiredness

21 6. Use any anti-depressant Depression common in epilepsy SSRIs: pro-convulsant? TCAs: in high dose, perhaps Treat the depression

22 7. The tests do not help ECG EEG Standard: at least 50% normal Sleep deprived Ambulatory Video EEG monitoring Brain imaging (MR) Most do not have brain tumours

23 8. AED levels CBZ/valp/PHT Do not routinely monitor If you do, ignore the result. unless you did it for compliance

24 9. Remember driving Individuals duty to inform DVLA But doctors duty to inform them of this requirement Not diagnosis based, symptom Any disturbance/loss consciousness Other than simple faint Document it

25 10. Know your local services First seizure clinic RefHelp (direct booking patients/gps) RIE WGH Epilepsy service (DCN) Drs Duncan & Derry Epilepsy specialist nurses x3

26 Summary Basics of epilepsy Other causes of TLOC Funny turns.falls.. Take the history

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