WHEN THE LIGHTS GO OUT: FIRST SEIZURE ASSESSMENTDR REBECCA KERR, GP WITH SPECIAL INTEREST IN EPILEPSY, RBWH

CASE STUDY: PT X

• 21 year old presents to your clinic saying she had a seizure 24 hours ago. She

didn’t go to emergency because she thought it was from stopping her benzos

abruptly. She just came to get her benzo script. She is well known to you and

you believe she really did have a seizure. Where to from here?

• Always check health pathways for most up to date information

• Currently it’s desirable to get EEG within 48 hours of the seizure if possible so in this case

would need to contact neurology for urgent assessment

• Less urgent if they present after the 48 hour window

IS IT A SEIZURE?

• This patient had an event in the context of weaning down her benzos and

starting dexamphetamine as per her psychiatrist. What do we want to know?

Detailed description:

• Trigger (Ask about sleep deprivation, alcohol, drugs, specifics of how rapidly she had

stopped her medications and doses)

• Very specifically she didn’t stop abruptly! Her diazepam weaned from 15mg-> 10mg->

5mg-> stop. Each step over three days.

• Ask about posture, auras/warnings, how the event evolved, loss of consciousness

• tongue biting, loss of bowel or bladder control.

• How they felt afterwards. What do they remember? (headache)

WITNESSES ARE GOLD, PICK UP THE PHONE

• How long did each part of the event last?

• loss of awareness or responsivity.

• the patient's colour during the event (e.g., pale, blue).

• type and frequency of any motor activity during the event.

• the patient's state after regaining consciousness.

• Advise the patient's family to try to record any further episodes if possible e.g., by

video.

DRUG WITHDRAWAL SEIZURES

• Alcohol: Seizures occur in about 5% of people withdrawing from alcohol. They

occur early (usually 7–24 hours after the last drink), are generalising type (ie,

generalised, not focal) and usually (though not always) occur as a single

episode.

• Benzodiazepine: Abrupt discontinuation in patients on high doses for a long

period of time are highest risk.

PROVOKED SEIZURE VERSUS SEIZURE TRIGGER

• Provoked seizure: an insult that if applied to any brain can cause a seizure

• Ie hyponatraemia, hypoglycaemia, stroke

• A seizure trigger: an insult that can trigger a seizure in a vulnerable brain but

wouldn’t trigger one in a brain that wasn’t

• Ie Sleep deprivation, alcohol

DEFINITION OF EPILEPSY

• The diagnosis of epilepsy is made primarily on clinical grounds

• According to the 2014 practical definition of epilepsy of the International

League Against Epilepsy, epilepsy can be diagnosed:

• after at least two unprovoked seizures > 24 hours apart;

• after one unprovoked (or reflex) seizure when there is 60% chance of seizure recurrence

(similar to that after two unprovoked seizures) over the next 10 years;

• or when an epilepsy syndrome can be identified.

IT WAS DEFINITELY A SEIZURE, IS IT EPILEPSY?(WHAT TO ASK PATIENT THE NEXT)

• Have there been previous events: focal seizures may go unrecognised. Ask

about thinks about generalised: jerks, absence seizures and focal - funny

feelings/odd turns, etc

• Seizure Risks: birth details, febrile convulsions, cerebral infections, head

injuries, drug and alcohol history, family history

• Current medical and psychiatric history and medications

EXAMINATION AND INVESTIGATION

• Examination: BP lying/standing, Heart sounds, neurological examination

• Investigations:

• ECG (QTc)

• bloods (glucose, e/LFT, CMP, FBE)

• Imaging: CT brain as screening. MRI brain epilepsy series is better, preference at RBWH

would be this was done on the MRI machine here and reviewed by a neuroradiologist

• EEG

FIRST SEIZURE AND ALL TESTS NORMAL SO ARE THEY FINE? DOES THAT MEAN NO EPILEPSY AND THEY CAN DRIVE?

NO AND NO

• “The standard EEG has variable sensitivity and specificity in determining whether an

individual has had an epileptic seizure. In the primary papers reviewed the sensitivity

ranged from 26% to 56% and specificity from 78% to 98%. *The Epilepsies: The Diagnosis and

management of the epilepsies in adults and children in primary and secondary care (2012)

• So what then? Encourage your patients to attend their neurology appointment even when

their MRI and first EEG is normal. A sleep deprived EEG or ambulatory EEG may be

higher yield

• Sleep deprived EEG can potentially add 18% more diagnostic yield (King 1998)

CONVULSIVE SYNCOPE VERSUS SEIZURENICE GUIDELINES RECOMMEND AGAINST EEG FOR CONVULSIVE SYNCOPE

Seizure Convulsive Syncope

Warning No warning. Sometimes aura, hard to describe,

rising feeling, smell, dejavu

Felt faint, lightheaded, blurred/darkening vision,

tunnel vision, tinnitus,

Onset Sudden, any position Only when standing or sitting. Usually avoidable

by posture change

Features Eyes open/may roll back, rigid tone and then

tonic activity 1-2 minutes typically

More likely to have convulsive syncope activity if

isn’t immediately laid down (stays propped in

sitting position). Shorter duration of convulsive

activity usually less than 30 seconds.

Recovery Post ictal 10-20 minutes (can be difficult to

quantify). Confused, sleepy, headache

Pale, washed out, sweaty but rapidly orientated

usually within minutes (alcohol and head injuries

can confuse this picture)

Other features Tongue biting, loss of bladder control more

common

Loss of bladder control rarer but can occur

SYNCOPE: A VIDEOMETRIC ANALYSIS OF 56 EPISODES OF TRANSIENT CEREBRAL HYPOXIA - LEMPERT T, BAUER M, SCHMIDT D

90% had myoclonic activity

Eye movements in syncope:

https://www.youtube.com/watch?v=cuROrv-6c0o

DRIVING

• A Privilege not a right – Jet’s Law

• Fitness to drive for details (Default 12 months, special consideration 6 months)

• Annual medical review for conditional licence, after one seizure, for five years

• Commercial driver’s require special consideration

• Can’t just stop driving, need to notify the transport department

• If a patient wishes to reduce medication under supervision then a substantial

period of non driving will be necessary.

WHAT LEADS TO BETTER OUTCOMES IN EPILEPSY IN PRIMARY CARE? (FROM NCGC)

• Regular structured review with GP (are they having events, Encourage compliance,

about potential triggers alcohol/sleep/drugs, Check for side effects of medications,

Check on mood, Women – check contraception/pregnancy planning)

• Maximum interval between review should be 1 year

• Having a comprehensive care plan

• Managing lifestyle and medical issues

• https://www.epilepsyingeneralpractice.com/gp-care-plans

GPWSI ROLES

• Benefit to patients:

• Holistic care, hopefully will decrease wait times

• I understand (hopefully) what I can and can’t hand back to the GP

• Benefit to me

• Upskilling

• working again in a team environment with supportive colleagues

• Attending MDT meetings – seeing all the recordings of seizure types including PNES is so

helpful

• Benefit to Hospital

• Hopefully decrease wait times

• Look at the way we can expand sharing care of epilepsy patients with more GP colleagues

REFERENCES

• Perucca et al (2018); The management of epilepsy in children and adults;

MJA 208 (5)

• Lempert et al (1994); Syncope: a videometric analysis of 56 episodes of

transient cerebral hypoxia; Ann Neurol. 36(2):233-7

• National Clinical Guideline Centre (2012) The Epilepsies: The diagnosis and

management of the epilepsies in adults and children in primary and

secondary care; Partial Pharmacological update of clinical guideline 2012 (20)

• NICE guideline (2012); Epilepsies Diagnosis and Management;

nice.org.uk/guidance/cg137