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Faints, fits and funny turns

Faints, fits and funny turns. Dr Dominic Heaney Consultant Neurologist and Honorary Senior Lecturer National Hospital for Neurology and Neurosurgery Queen Square 1 October 2013. Aims of presentation . Faints, fits and funny turns Definitions Epilepsy Epidemiology, morbidity, mortality

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Faints, fits and funny turns

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  1. Faints, fits and funny turns Dr Dominic Heaney Consultant Neurologist and Honorary Senior Lecturer National Hospital for Neurology and Neurosurgery Queen Square 1 October 2013

  2. Aims of presentation • Faints, fits and funny turns • Definitions • Epilepsy • Epidemiology, morbidity, mortality • Types of seizures • Treatment • Neurologist’s view about epilepsy at work

  3. Faints, fits, funny turns • Transient alteration in awareness, consciousness • Usually poorly described by patient • Poorly witnessed • Uncertainty • “Faints, fits, funny turns” - • Syncope (vasovagal, cardiogenic, other…) • Migraine • Cerebrovascular events • Epileptic seizure • Funny turns..

  4. What a neurologist doesn’t want to miss

  5. What a neurologist doesn’t want to see

  6. Morbidity of Epilepsy • Concurrent illness increased • Neoplasms • Respiratory infections • Cardiovascular diesease • Depression • Sleep disorders • Osteoporosis/fractures • Accidents increased • Drowning • Suicide • Accidental injury • High psycho-social morbidity • Unemployment • Deprivation

  7. Mortality of Epilepsy • Mortality is 2 - 3x that of the general population • Standardised Mortality Rates • Overall: 2 - 3 • In the first 5 years: 4 - 5 • 20 - 40 years old 5 - 8 • Chronic epilepsy: 8 - 15 • Proportional Mortality Rates • neoplasms, respiratory, accidents, epilepsy

  8. Mortality of epilepsy • Epilepsy as the cause of death • status epilepticus • Sudep • SUDEP • > 600 cases a year in the UK • aetiology unknown • risk factors seem to be related to severity and frequency of seizures

  9. Epileptic seizures vs Epilepsy vs Cause • Seizure – type, anatomy • Epilepsy syndrome – other symptoms, age, EEG • Aetiology – genetic, other

  10. Classification of Seizures Generalised Focal “epilepsy

  11. Seizure classification (International League Against Epilepsy) Simple partial Absence Myoclonic Complex partialAtonic Tonic Secondary generalisedTonic clonic Partial Generalised

  12. Determining seizure type Clinical features • Symptoms • Behavioural manifestations during and after seizure • Witness account EEG • Inter-ictal • Ictal focal discharge generalised discharge

  13. Generalised tonic-clonic seizure • loss of consciousness • ‘epileptic cry’ • fall (injury) • tonic phase then clonic jerking • tongue biting, incontinence, cyanosis • sudden onset, gradual recovery • post-ictal confusion, sleep, • headache, muscle pain • aura/partial features if SGS

  14. Generalised absence seizure • blank stare • loss of consciousness • cessation of motor activity • blinking, eye rolling, minor tone change • sudden onset, rapid recovery • brief, many attacks per day • usually in IGE • generalised spike and wave discharge

  15. Myoclonic jerks • brief jerk, single or cluster • one muscle → generalised jerks • intensity: slight tremor → massive jerks • consciousness probably preserved • IGE (diurnal pattern) • symptomatic epilepsies with other • seizure types + neurological deficit • generalised spike and polyspike wave • Juvenile myoclonic epilepsy

  16. Simple partial seizures • no alteration in consciousness • no amnesia • sudden onset and cessation • focal symptoms or signs: • motor • sensory and special sensory • psychic (dysmnestic, cognitive, affective, • hallucinations, illusions) • reflect anatomical origin of the seizure • due to focal cortical pathology

  17. Complex partial seizures • Temporal lobe 60% • Extra-temporal 40% • (mostly frontal lobe)

  18. Complex partial seizure arising from temporal lobe • aura (as SPS: visceral, dysmnestic), brief • altered consciousness • amnesia • automatism (oro-alimentary, gestural, verbal) • sudden onset, gradual recovery focal spikes rhythmic ictal discharge

  19. Frontal lobe CPS • brief stereotyped seizures • frequent attacks with clustering • nocturnal + • sudden onset and cessation • complex bilateral motor automatisms • secondary generalisation • interictal and ictal EEG variable

  20. Other extra-temporal partial seizures Central Contralateral jerks (march) Contralateral sensory Posturing EEG often normal Parietal Somatosensory Illusion of change in body size/shape Vertigo Gustatory Occipital Elementary visual hallucinations Visuo-spatial distortion Amaurosis Head turning (usually adversive) Eyelid flutter, blinking, nystagmus May propagate to adjacent cortical regions EEG : focal / non-localised / anterior

  21. Investigation 1 • History + witnessed account • Family history • History of meningitis/head injuries/febrile convulsions • Alcohol and drug history • 30% not epilepsy in tertiary referral clinic • Syncopal jerking • Non-epileptic seizures with a pyschological basis

  22. Psychogenic seizures

  23. Investigation • EEG • at least 1% false positive • repeat and sleep - still 20% false negative • 24 ambulatory EEG – increases yield • Video-telemetry • Imaging • MRI preferred to CT • partial epilepsy, refractory epilepsy, neurological deficit • Other • ECG, FBC, U&E, LFT etc.

  24. Bromide of potassium for “hysterical epilepsy” – curing 13 of 14 cases Sir Charles Locock (1799-1875) Obstetrician to Queen Victoria

  25. Side effects • By 1870’s 2.5 tons of bromide used every year at the National Hospital, Queen Square • “As you see he is broken down in appearance, has large abscesses in his neck, and is altogether in a bad condition. But this is better than to have epilepsy” An introduction to dermatology (1905) Bromide Rash

  26. Formulary ‘management’

  27. Drugs for seizures • First-choice • Partial onset: LTG, CBZ, LEV, (OXC) • Generalised onset: VPA, LEV, LTG • Adjunctive • TOP, ZON, LAC • PHT, PB, CLOB • PGB, TIA,

  28. Refractory epilepsy • 20-30% of patients with epilepsy • very few of these patients (5-10%) are suitable for epilepsy neurosurgery • Recently launched AEDs, render possibly less than 2% of this group seizure free

  29. Epilepsy in the workplace • Challenges finding a job • Lack of training, skills, on-the-job experience • Lack of transportation • Negative attitude of employers towards epilepsy • Concerns about safety, liability, effectiveness, “crazy”, customer view • Negative attitudes of co-workers

  30. Considerations in the workplace: • The epilepsy: • What type of epilepsy and what type of seizures? • Frequency, severity, duration? • Warning? • Call an ambulance? • Recovery period? • Triggers? (e.g. shift work, long shifts, stress, ??photosensitivity) • Medication • The job: • Equipment, heights, water, other? • Working alone? • Responsible for vulnerable individuals?

  31. Reasonable adjustment • making their workspace safer in case they have a seizure • avoiding lone working, so that someone else can help if they have a seizure • exchanging some tasks of the job with another employee’s tasks • adapting or providing equipment or support to help them do their job • time off for medical appointments that is separate from sick leave.

  32. Conclusions • Not all seizures are due to epilepsy • Epilepsy is a broad description given to a range of conditions

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