Seizure Station

Presenting Complaint - Seizure (likely to be described by patients as a fit/collapse/blackout)

History of Presenting Complaint (likely to need a collateral history):

• Before (to help identify any trigger or warning signs)
  • Days before – no recent illnesses, feeling unwell or feverish
  • Immediately before:
    • Activity at onset (e.g. standing, sitting, lying down, asleep, exercising, stressed) – she was standing up at home in her kitchen at the time of the seizure
    • Any possible triggers (e.g. pain, dehydration, emotional stress, trauma prolonged standing) – she cannot think of any possible triggers and said it happened suddenly
    • No aura or warning signs e.g.
      • Noticing an abnormal smell
      • Feelings of déjà vu
      • Tingling sensation
    • Denies feeling dizzy, lightheaded, or having palpitations beforehand (syncope is an important differential to consider)
  • During (collateral history or a video recording is crucial)
    • Sylvia’s mother was with her at the time and reported that Sylvia suddenly fell to the floor 3 hours ago and her arms and legs started jerking uncontrollably for around 30 seconds. Her eyes were open, and she bit the right side of her tongue. She did not have any incontinence. She did not sustain any head injury during the fall.
    • Sylvia has no recollection or awareness of the event
    • Important questions to ask include:
      • Duration of the seizure
      • Loss of consciousness
      • Movements (e.g. jerking, stiffening) – usually all limbs are affected in generalised tonic-clonic seizures
      • Eye signs (eyes are often open and fixed during the seizure)
      • Injury (high risk of head injury, fractures, tongue biting – often lateral)
      • Recollection of event – usually none
      • Awareness during the event (e.g. did they hear or see anything during the event?) – often impaired
      • Continence – urinary/faecal incontinence common during seizures
    • After
      • Recovery time – Sylvia feels drowsy and is complaining of a headache since the seizure (post-ictal confusion, headache and drowsiness often occur several minutes to hours following a seizure)
      • How did the seizure stop? The seizure stopped spontaneously
        • May have stopped spontaneously or may have needed medical intervention
        • If drugs were given, which ones, what dose and exact timings?
      • Memory of the event - none
      • Neurological symptoms after the event (e.g. feeling groggy, muscle pains/aches, confusion, fatigue, headache, drowsiness) – Sylvia complains of a headache, drowsiness and muscle aches following the seizure
      • Injuries from the fall e.g. head trauma - none

Previous Medical History

• No past medical history of note
• No history of epilepsy or recent seizures
• No febrile convulsions (during childhood)
• No previous malignancies – may have primary or secondary brain malignancy causing seizures
• No diabetes (hypoglycaemia can cause seizures)
• No cerebrovascular disease, strokes or TIAs (strokes can cause seizures)
• No cardiovascular problems e.g. aortic stenosis, heart failure or arrhythmias (may cause syncope, which presents similarly to seizures)

Drug History

• Nil regular
• Hypoglycaemic medications including insulin can cause hypoglycaemia-induced seizures
• Sedatives (e.g. benzodiazepines, barbiturates) can cause seizures if suddenly stopped
• If a patient has epilepsy, it’s important to ask about their anti-epileptic medications and to check their compliance, as the most common cause of seizures in epileptic patients is missed medications. Also ask about new OTC medications and any other medications the patient may be taking, which may interact with their usual anti-epileptic medications and lower the seizure threshold.

Allergies

• NKDA

Family History

• Her father has epilepsy
• She used to have febrile convulsions as a child 

Social History

• Drinks alcohol occasionally (alcohol withdrawal can cause seizures)

• Has never smoked or taken recreational drugs.

• Lives on her own and works as a receptionist at a law firm.

• She denies feeling stressed or anxious (emotional stress or impaired sleep can increase the risk of seizures. Emotional stress can also trigger psychogenic non-epileptic seizures (PNES), an important differential to consider).

• She drives to and from work every day. She takes showers and does not go swimming (driving with epilepsy can be dangerous whilst using bathtubs and swimming alone increases the risk of drowning)

ICE

• Ideas: “Do I have epilepsy?”

  Concerns: “I’m worried that my life won't ever be the same again if I get diagnosed with epilepsy”

  Expectations: “Can you tell me if I can drive or go back to work?”

• General Examination:
  • Looks well
  • Appears slightly tired and sleepy (post-ictal phase)
  • No signs of trauma (head injury can cause seizures and seizures can cause trauma)
• Heart Murmurs – none (heart murmurs e.g. aortic stenosis can cause syncope)
• Neurological Examination
  • Tone, Power, Reflexes, Sensation, Coordination - normal
  • Cranial nerves – normal

Most likely differentials:

First-time seizure due to:

• Epilepsy - first presentation
• Metabolic or chemical imbalance (e.g. hypoglycaemia, hyponatraemia, hypocalcaemia, kidney or liver failure)
• Brain tumour (primary or secondary)
• Other causes of a first-time provoked seizure include intracranial infection, stroke, alcohol or drug withdrawal

Management

• Bedside:
  • Routine observations including temperature (infection) and BMs (hypoglycaemia)
  • ECG (to rule out arrhythmias as a cause of syncope)
  • LSBP (to rule out orthostatic hypotension as a cause of syncope)
• Lab:
  • FBC (infection)
  • CRP (infection)
  • U&Es (kidney function, hyponatraemia)
  • Bone profile (hypocalcaemia)
  • LFTs (liver function)
  • Anti-epileptic drug levels (in someone taking anti-epileptic drugs)
  • Ammonia (to check for raised ammonia in someone taking sodium valproate or someone with liver disease/excessive alcohol intake)
• Imaging
  • CT/MRI head (to check for brain abnormalities like bleeding, tumours, or injury-related causes of seizures)
  • EEG (most common test for seizures, measures electrical activity in the brain)
• Other:
  • Lumbar Puncture (to check for brain infections such as meningitis or encephalitis)
  • Genetic Testing (if epilepsy is suspected due to hereditary conditions)

1. What is the difference between a seizure and epilepsy?

A seizure is a single event caused by excessive synchronous neuronal activity in the brain. Epilepsy, on the other hand, is a neurological condition in which a person has two or more unprovoked seizures (not caused by a temporary condition e.g. high fever, head injury, infection etc.) that occur more than 24 hours apart. Not everyone who has a seizure has epilepsy, but everyone with epilepsy experiences seizures.

2. What kind of people can have seizures?

Seizures can happen to anyone, but the causes and risks vary. Seizures can be broadly classified into provoked and unprovoked depending on whether the seizure is caused by an identifiable factor.

Provoked seizures can affect healthy individuals. They occur due to a temporary or reversible cause, such as:

• High fever (febrile seizures in infants and young children)
• Metabolic or Chemical imbalances (e.g. dehydration, hypoglycaemia, hyponatraemia, hypocalcaemia, kidney or liver failure)
• Infections (e.g. meningitis, encephalitis, sepsis)
• Alcohol or drug withdrawal
• Traumatic brain injury
• Brain tumours
• Intracranial Haemorrhage
• Stroke
• Eclampsia
• Malignant hypertension

These seizures are not necessarily a sign of epilepsy, and they typically stop once the underlying cause is treated.

In comparison, unprovoked seizures occur without an identifiable trigger. Risk factors for having an unprovoked seizure include:

• Epilepsy
• Genetic or hereditary seizure disorders
• Neurological conditions e.g. brain tumours, stroke, Alzheimer’s, Parkinson’s, brain injury

If a person has 2 or more unprovoked seizures that occur more than 24 hours apart, they may be diagnosed with epilepsy.