Eldoret CME 12.03.15

Dr. Dilraj Singh Sokhi BMedSci(Hons) MBChB(Hons) MRCP(UK)(Neurology)Honorary Teacher in Adult Clinical Neurology - University of Sheffield (UK)Visiting Trainee Neurologist / ILAE Epilepsy Teacher - Aga Khan Uni. Hospital (Nairobi)Graduate Research Fellow in Epilepsy - ILRI Research Institute (Kenya)

TLOC – A Quiz

Eldoret CME 12.03.15

Outline

Introduction

Causes and risk factors

Classification of seizures

Diagnosis and investigation

Management

Social aspect

Conclude

Q1. TLOC (“Blackouts”)

Blackouts

A1. TLOC (“Blackouts”)

Blackouts

Problem with blood circulation

(Syncope)Primary disturbance

of brain function

Epilepsy Non-epileptic attacks

Idiopathic generalised epilepsy

Focal epilepsyUnclassifiable epilepsy

Non-cardiacCardiac

Q2. Syncope

Definition

Causes

Investigations

A2. Syncope

Definition: short loss of consciousness and muscle strength - fast onset, short duration, and spontaneous recovery - due to decreased blood flow to brain

Causes:

InvestigationsECGECGLying/standing BPLying/standing BP

3a. ECG 1 – usually in older people

3b. ECG 2 – genetic or drug related

3c. ECG – can be after MI

3d. ECG – must NOT be missed!

3e. ECG – bonus points! (rare)

ECG and TLOC – Important!Important!

Q4. Syncope vs. Seizures

A4. Syncope vs. Seizures

- P osture- P osture

- P rovoking factor- P rovoking factor- P rodrome- P rodrome

- P rompt recovery- P rompt recovery

Q5. Epilepsy – Burden

Africa: 2x incidence + prevalence, 3-5x mortality

Kenya: Similar figures. Approx 400,000 (1% of Approx 400,000 (1% of popn)popn)

A5. Epilepsy – Burden

Seizure:

Epilepsy:

Active Epilepsy:

Q6. Epilepsy - definitions

Seizure: transient signs and/or symptoms due to abnormal excessive synchronous neuronal activity in the brain.

Epilepsy: enduring predisposition to repeated and unprovoked seizures occurring more than twice in a year.

Active Epilepsy: ≥ 2 unprovoked seizures >24 hours apart in one year

National Epilepsy Guidelines www.epilepsykenya.orgwww.epilepsykenya.org

A6. Epilepsy - definitions

Q7. Causes of Epilepsy

A7. Causes of Epilepsy

Infections Metabolic (acquired and genetic) Head trauma Perinatal injury Toxic SOL Vascular Congenital Degenerative

• TiBa-Diop et al, 2014

Causes of Epilepsy in Africa

Q8. Seizure Classification

A8. Seizure Classification

Focal Epilepsy

Q9. Classification of Epilepsies

A9. Classification of Epilepsies

Q10. Diagnostic Workup

A10. Diagnostic Work-up

It’s all in the HISTORY!It’s all in the HISTORY!Always always always get a collateral history (?video)

Onset age of first seizure Association with a particular event, accident, illness, fever? Is there always fever with the seizures?

Pre-ictal phase Any precipitating factors? Are there any prodromal symptoms?

History (cont…)

lctal phase – semiology (description of seizure itself) Is there an aura? What does it consist of? Does the patient scream? Where in the body? How does the event start (e.g. turning face) Does the patient jerk? If so, both arms and legs, or one side? Are they unconscious? Does the patient fall down? Does the patient have incontinence of urine or stool? Does the patient bite the tongue? Does the patient make irrational or abnormal movements? Breathing: stertorous/snoring, shallow/deep, hyperventilating? How long is the ictal phase?

History (cont…)

Post-ictal How long does the convulsion last? (incl. post-ictal phase) How is the patient's behaviour after the seizure? Is there any focal sign? How long is the recovery phase?

Other important details Time: At what time of the day or night do the seizures occur

(daytime, when sleeping or awakening)? Frequency: when was the first / last / worst seizure?

How frequent have the seizures been?Has there been a change in the frequency?What is the interval between seizures?

History (cont…)

Family history

Pregnancy and perinatal history

Developmental history (milestones)

Past Medical History

Medicines or alcohol used?

Social History

Q11. Investigations?

A11. Investigations?

IT’S ALL IN THE HISTORY! IT’S ALL IN THE HISTORY! (and the video!)

ECG is mandatory

Examination (BP, temp, neuro)

Video EEG is gold standard

EEG and brain imaging reasonable

Not much room for other investigations except: FBC, U&E, Mg, Ca, glucose, inflammatory markers

Q12. Case Study 1 Video

Q13. Case Study 2 Video

Q14. Case Study 3 Video

Abversek et al, 2011

A14. PNES vs Epilepsy

ILAE PNES TF Global Survey

We will collect Pan-African, including Kenyan, data this year

Has been approved by local ethics board!

www.TinyURL.com/PNESKenya

Q15. Acute Seizures – First Aid

Move patient away from fire, traffic or water Take away any objects that could harm the patient Loosen tight clothes, remove glasses Put wooden stick into the mouth to prevent injury Put something soft under the head Turn patient on his or her left side, so that saliva and

mucus can run out of the mouth Try to stop the jerking, or restrain the movements. Remain with patient until regains consciousness Give them something to drink during the seizure Put them in the recovery position at the end

A15. Treatment – First Aid

Move patient away from fire, traffic or water Take away any objects that could harm the patient Loosen tight clothes, remove glasses

Put wooden stick into the mouth to prevent injury Put something soft under the head Turn patient on his or her left side, so that saliva and mucus can run out of the mouth

Try to stop the jerking, or restrain the movements. Remain with patient until regains consciousness

Give them something to drink during the seizure Put them in the recovery position at the end

The recovery position

Unconscious patients should be placed in this semi-prone/recovery position to minimize the risk of obstruction or inhalation of vomitus

Q16. Case Study 4

A 24 year old male known to have epilepsy and is on phenytoin is brought in by the wife as he has had 2 generalized tonic clonic seizures in the last 15 minutes and is currently still drowsy, GCS 6. She did not know how to give the rescue medication. Whilst you are assessing him he has another GTCS in casualty.

How will you manage this man?

A16. Status Epilepticus

• ABC• DEFG!

• Quick History• Examine + vitals• Treat underlying

condition

Diazepam 0.3mg/kg @1mg/min (max 10mg adults, 5mg children)

Q17a. Case Study 5

A 3 year old is brought in by the mother as she has been running a temperature for 2 days, and she has had two GTCS – one yesterday evening and one today morning, each lasting less than 10 minutes. She is currently awake, alert but a bit irritable, not meningitic but has a temperature of 39oC.

How will you manage this girl?

Q17b. Febrile Seizures

Exclude CNS disease and electrolyte imbalanceUsually treat with anti-pyretics, ?diazepam of prolongedSeizure recurrence based on if was:Complex vs simple: >15 minutes≥ 2 seizures in 24 hoursFocal features (in seizure history or on examination)Short duration (<1 hour) of fever? Family history

Q18a. Case Study 6

A 34 year old boda boda rider travelling from Busia has a side collision with a car. He is ejected from his seat at approx. 50kph, and lands a few meters away. He is found unconscious but recovers and is brought in to your hospital for check up. Luckily he has not sustained any significant injuries.

How do you gauge severity of head injury?

Q18b. Case Study 6 (cont.)

He was discharged home but returned 3 weeks later as he had a witnessed single GTCS. He has no focal neurological deficit.

How would you manage this man now?

Q19. Case Study 7

A 19 year old man with nocturnal episodes for 3 years, which occur every few months but now more frequently. He wakes up having wetted the bed and bit his tongue. Recently he also had an attack when revising for exams, witnessed by a friend and sounds like a generalised tonic clonic seizure.

What will you do for this young man?

Q20. Why Control Chronic Epilepsy?

Prevent injury

Prevent death when in water, SUDEP

Reduce interruption of daily life Driving regulations in UK

Prolonged seizures (>30 mins) = brain damage

A20. Why Control Chronic Epilepsy?

Chronic Treatment Considerations

Confirmed diagnosis of active epilepsy: ≥ 2 unprovoked seizures > 24 hours apart in a year Rarely can start after single seizure. Evidence needed:

- relevant neurological deficit- abnormal EEG: epileptiform activity or focal slowing- patient, after adequate counselling, desires treatment

Counsel patients – precipitating factors, adherence, social impact, safety, side effects etc

Also consider: - gender and age - Other meds esp cART- Other PMH

Q21. What Trigger Factors?

A21. What Trigger Factors?

Non-adherence to treatment / stopping treatment Sleep deprivation / exhaustion Acute infections and fever Flickering lights e.g. televisions, computers, disco Alcohol intake/withdrawal Substance abuse/withdrawal Hormonal imbalances (catamenial-seizures) Dehydration Emotional Stress Hyperventilation

Treatment (1)

Initiation of treatment Start with one drug and small doseStart with one drug and small dose Gradually adjust dosage at two weeks intervalsGradually adjust dosage at two weeks intervals

until: - complete seizure control - maximum tolerated dose is reached

If no seizure control, add second drug and consider gradually reducing or maintaining the initial drug

The aim of treatment is to achieve the lowest maintenance dose which provides complete seizure control.

Gradual introduction of AED can produce therapeutic effects but with fewer side-effects.

Severe "intoxication" side-effects at the beginning of the treatment indicate too rapid or too large dose increases.

Treatment (2)

Maintenance Ideally, only one drug should be used. If the first drug has only produced a partial response, then a

second drug can be added gradually taking into consideration drug interactions.

The aim should be to have a maximum of two drugs. If the two drugs fail, then consult the next level.

Partnership between patient and provider is important to ensure that the patient understands the importance of adhering to treatment.

Treatment (3)

Follow up and monitoring

Holistic approach with partnership of patient, family and care providers enhances patient's insight and compliance.

Drug monitoring should be done by measuring serum levels in cases where there is difficulty in management.

Compliance is the key to successful seizure control, and counselling the patient is the most critical factor.

Treatment (4)

When to withdraw drugs – done by specialistsdone by specialists If the patient has been seizure-free for 2-3 years (depends) Prior to drug withdrawal, consider:

- Focal seizures are often very difficult to control especially hippocampus and other temporal lobe areas. Relapse rate is high. ? Carry on indefinitely- IGE generalised seizures have best remission rates- Perisistently abnormal EEG vs. seizures controlled- Patient views: may opt to remain on medications despite achieving prolonged remission. 5-10% chance getting another seizure anyway.

Counselling is very important to alert them of the chance of recurrence as a permanent cure cannot be assured.

Treatment Choices

First LinePhenobarbitonePhenytoinCarbamezapineSodium ValproateRescue medication

Second LineClonazepam, Clobazam, Lorazepam, Lamotrigine, Gabapentin,

Pregabalin, Ethosuximide, Methsuximide, Esclimezapine, Oxcarbazapine, Topiramate, Levetiracetam, Peramapanel, Tiagabine, Vigabatrin, etc etc

REFER TO GUIDELINES FOR RATIONALE OF CHOICES, DOSES, REGIMES ETC

Q22. Case Study 8

12 year old boy who had attacks of suddenly getting fearful and anxious with no precipitating factor, and on two occasions has run out of the house. The father followed him to the sugarcane farm and found him on the ground, with right leg twitching, unresponsive. This went on for 5 minutes and then he woke up and kept asking “I was in the home just now. Why are we here?” The younger brother then said he has witnessed him falling a few times and shaking when walking to school.

What will you do for this young boy?

A22. Case Study 8 – one option

Q23. Case Study 9

24 year old woman known to have seizures since she had meningitis 8 years previously, who is currently on phenytoin. She is well controlled on her treatment and has not had a seizure for 2 years. She recently got married and moved to Busia, and is on malaria prophylaxis (Doxicycline). She works as a secretary in a local business. Her and her husband want to have a baby and she has come to you for advice.

What will you do for this young woman?

Q23. Case Study 9

24 year old womanwoman known to have seizures since she had meningitis 8 years previously is currently on phenytoinphenytoin. She is well controlled on her treatment and has not had a seizure for 2 years2 years. She recently got married and moved to Busia, and is on malaria prophylaxis (doxicyclinedoxicycline). She works as a secretarysecretary in a local business. Her and her husband want to start a familystart a family and she has come to you for advice.

What will you do for this young woman?

A23. Case Study 9 - issues

About Stigma and Beliefs…

Drugs have to be taken for many years, possibly a life-time. Combination with herbal treatment might be dangerous as

interaction between the drugs and the herbs unpredictable. Not contagious and anyone can touch the person while they are

having a seizure (e.g. to remove them from the danger of fire or water) or in between the seizures.

Child of normal intelligence should be placed in normal school. Over-protection not helpful in a child's upbringing, but

reasonable precautions should be taken Epilepsy should be talked about with family, school, work etc Epilepsy is NOT a reason for not marrying or have a family.

Summary

3 main causes of TLOC; important to differentiate Clinical features of these 3 main types

Remember: Remember:

Fall + loss of consciousness + shaking + incontinence Fall + loss of consciousness + shaking + incontinence IS NOT ALWAYS A SEIZURE! IS NOT ALWAYS A SEIZURE!

Its all in the history! (and the video…) (some) Role of investigations: ECG always, EEG, CT/MRI Treatment options; status epilepticus Counselling patients and families/caretakers is key on all

aspects of their disease.

Acknowledgements

Professor Markus Reuber

Dr. Richard Grünewald

Dr. Stephen Howell

And of course Moi Teaching and Referral Hospital!