Neurology · MU Sofia

64. Epilepsy: examination, diagnosis, treatment

Walks through the clinical approach to epilepsy, starting with history taking on seizure features and triggers, then the neurological examination. It covers EEG as the key test, MRI and CT imaging, laboratory screening, and differential diagnosis against syncope, psychogenic seizures, TIA and migraine. Treatment is set out by seizure type with antiepileptic drug choices, status epilepticus management, surgery, vagus nerve stimulation and the ketogenic diet, ending with prognostic factors.

Inside: 1 section · 16 flashcards · 2 min

Topic 64 of 88 in the MU Sofia syllabus for Neurology (Medicine, Year 4). The free AceMed note covers it in 1 section, about 284 words (2 min of reading), with 16 flashcards.

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  1. Epilepsy - examinaiton, diagnosis, treatment

Epilepsy - examinaiton, diagnosis, treatment

Clinical Examination

1.History (Most Important)

Diagnosis is primarily clinical.

Obtain information about: Description of seizure. Duration. Frequency. Triggers (sleep deprivation, alcohol, stress). Aura. Loss of consciousness. Tongue biting. Urinary incontinence. Postictal confusion

2.Neurological Examination

  • Usually normal between seizures
  • Look for focal neurological deficits suggesting structural brain disease

Diagnosis

A. Electroencephalography (EEG) – Most Important Test

Detects epileptiform activity: Spikes. Sharp waves. Spike-and-wave complexes

Typical Findings

  • Absence seizures → 3-Hz spike-and-wave pattern
  • Focal epilepsy → focal epileptiform discharges

Normal EEG does not exclude epilepsy.

B. Neuroimaging

MRI Brain (Preferred)

  • Used to detect: Tumors.Stroke. Hippocampal sclerosis. Cortical malformations

CT Brain

  • Useful in emergencies: Trauma. Acute hemorrhage

C. Laboratory Tests

  • Used to identify provoking causes: Blood glucose. Electrolytes (Na⁺, Ca²⁺). Renal function. Liver function. Toxicology screen

D. Differential Diagnosis

1.Syncope: Brief LOC due to cerebral hypoperfusion. Rapid recovery. No postictal confusion

2.Psychogenic Non-Epileptic Seizures (PNES): Normal EEG during attacks.Psychological origin

3.Transient Ischemic Attack (TIA): Focal deficits without convulsions

4.Migraine: Aura may mimic focal seizure

Treatment

A. General Principles: Avoid triggers.Regular sleep. Avoid alcohol/drug abuse. Adherence to medication

B. Antiepileptic Drugs (AEDs):

  • Focal Seizures: Carbamazepine. Lamotrigine. Levetiracetam
  • Generalized Tonic-Clonic Seizures: Valproate. Levetiracetam. Lamotrigine
  • Absence Seizures: Ethosuximide (drug of choice). Valproate

C. Status Epilepticus (Emergency)

Definition: Seizure lasting >5 min or recurrent seizures without recovery.

Treatment

  • Benzodiazepine (Lorazepam/Diazepam)
  • Antiepileptic loading (Levetiracetam, Valproate, Phenytoin)
  • ICU management if refractory

D. Surgical Treatment

Indications: Drug-resistant focal epilepsy

Examples: Temporal lobectomy. Lesionectomy

E. Other Treatments

  • Vagus Nerve Stimulation (VNS): For refractory epilepsy.
  • Ketogenic Diet: Especially in children with refractory epilepsy. Alternates how the brain generates energy and processes neurotransmitters

Prognosis

  • Good prognostic factors: Good response to first AED. Normal neurological examination. Normal MRI
  • Poor prognostic factors: Structural brain lesions. Frequent seizures. Drug-resistant epilepsy

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