Division of Neurology

McMaster Objectives: Epilepsy

Overall Goal:

The overall goal for members of the adult neurology training program at McMaster University during the Epilepsy Rotation is the development of the necessary knowledge and skills with respect to epilepsy and electroencephalography. This includes:

  • To develop knowledge of the diagnosis, investigations, and management of adults with a variety of seizure disorders ranging from first seizure to those with intractable epilepsy
  • To develop an understanding of the investigations and decision-making process regarding adults undergoing evaluation for possible epilepsy surgery
  • To develop knowledge of the medical and non medical treatments available to epilepsy patients
  • To understand the principles of electroencephalography and approach to its utility
  • Critical appraisal skills
  • Ability to communicate effectively with members of the epilepsy team
  • Acceptance of the obligation for continuing self-education and teaching of others
  • Understanding the principles of cost effectiveness and continuous quality assurance

  1. Medical Expert/Clinical Decision-Maker
  2. Communicator
  3. Collaborator
  4. Manager
  5. Health Advocate
  6. Scholar
  7. Professional

1. Medical Expert/Clinical Decision-Maker

  • Define epilepsy, epileptic seizures, and status epilepticus
  • Discuss the pathophysiology of the various epileptic disturbances of neurotransmitter function, the role of glia, and histological changes
  • List and discuss the importance of the known etiologic factors for seizures including head trauma later in life, mass lesions, stroke, alcohol and drug withdrawal, metabolic abnormalities, and genetic factors
  • Discuss the physiological and biochemical changes which may occur during epileptic seizures and the possible pathological and clinical consequences of prolonged or uncontrolled epileptic seizures
  • Classify seizures according to the international classification and describe the various phenomenological and EEG manifestations in individual seizure types
  • Classify and discuss the following epileptic syndromes in terms of age of onset, pathology, genetics, EEG features, prognosis, and management:
    • temporal lobe epilepsy +/- MTS
    • lateral temporal lobe epilepsy
    • Autosomal dominant nocturnal frontal lobe epilepsy
    • JME
    • GEFS+
    • Cortical dysplasias and other malformations of cortical development
  • Know the known genetic mutations associated with epilepsy
  • Differentiate conditions which may be mistaken for epilepsy including:
    • syncope
    • panic attacks
    • tics
    • sleep disorders
    • psychogenic pseudo-seizures
  • Outline the indications for and the usefulness of laboratory and other investigations used in diagnosing epilepsy and determining the etiology of seizures including:
    • EEG with/without special electrodes or activation procedures
    • prolonged EEG/video monitoring
    • CT, MRI
  • Outline the management approach to a patient with a first seizure
  • Outline general management principles for epileptic patients by seizure type including drug selection, lifestyle modification, and the advantage for monotherapy
  • Outline for the various anti-epileptic drugs their mechanism of action, their efficacy in various seizures types, their pharmacokinetics, side effects, clinical use, and cost
  • Discuss the use and benefits of anti-epileptic drug serum levels including serum free drug levels in the management of epilepsy
  • Describe the more common drug interactions seen between anti-epileptic drugs and between other drugs and anti-epileptic drugs
  • Outline the indications for withdrawing anti-epileptic drug therapy and describe how to best accomplish drug withdrawal
  • Discuss the epidemiology and natural history of epilepsy in adults
  • Discuss special treatment considerations in the pregnant epileptic patient including drug dosages, the use of serum drug levels, and possible teratogenic effects upon the fetus
  • Understand the relationship between febrile seizures and adult epilepsy
  • Discuss the management of post-traumatic seizures, alcohol withdrawal seizures, seizures due to accidental drug ingestion, and the management of the patient whose seizures remain uncontrolled despite medial therapy
  • Outline the role of neurosurgery in epilepsy management and the criteria used in determining patient selection for surgery
  • Define status epilepticus and discuss the etiology, differential diagnosis, and management of status epilepticus
  • Discuss the behavioral, psychiatric, and psycho-social aspects of epilepsy
  • Describe and discuss local regulations with regards to epilepsy and the operation of motor vehicles

EEG

  • to develop an understanding of the following principles of EEG:
    • volume conduction principles
      • basic electronics
        • electric fields
        • equipotential lines
      • electric dipole
      • volume conduction
      • generators of EEG
  • EEG recording principles
    • amplifiers
    • filters
    • conventions
    • 10-20 system
  • montage design
    • referential
    • bipolar
  • artifacts
    • electrical
    • mechanical
    • biological
  • EEG patterns of questionable significance
    • benign epileptiform transients of sleep (BETS)
    • 14&6 hz and 6hz phantom spikes
    • wicket spikes and rhythmic mid-temporal discharged
    • subclinical epileptiform discharges of the adult (e.g. SREDA)
  • sleep
    • development
    • normal pattern
    • abnormalities
  • special procedures
    • photic stimulation
    • hyperventilation
    • sleep deprivation
  • abnormal interictal EEG patterns
    • focal spikes
    • focal sharp waves
    • polyspikes
    • generalized 3Hz spike-and-wave
    • generalized slow 1-2 Hz spike-and-wave
    • other generalized spike-and-wave (e.g. 4-6 Hz)
    • hypsarrhythmia
    • FIRDA
    • Triphasic waves
    • Slowing, generalized or focal; intermittent or continuous
  • ictal EEG patterns
    • focal
    • generalized
  • post ictal EEG findings

Evoked Potentials

  • to develop an understanding of the following principles:
    • to understand the methodology and the generators of somatosensory, auditory and visual evoked potentials
    • to know the clinical indications for and applications of these evoked potentials
    • to be able to evaluate and interpret evoked potential reports and utilize these in the diagnosis and management of neurological disorders
    • to understand basic recording techniques
    • to know the typical waveforms for normal evoked potentials
    • to know about developmental changes
    • to know the generators of the evoked potentials
    • to know characteristic patterns in specific diseases
    • to know the abnormalities that can show up on evoked potentials and the causes thereof

 


2. Communicator

  • to communicate effectively and maintain professional relationships with other healthcare providers
  • to prepare documentation that is accurate, professional, and timely
  • to communicate effectively with parents and families and show appropriate behaviour recognition of the terrifying effect which the occurrence of a seizure can have on patient and family and the potential disruptive effect which uncontrolled seizures can have on a patient’s life

 


3. Collaborator

  • to consult effectively with members of the neurology/epilepsy team
  • to communicate and work effectively in a multidisciplinary environment

 


4. Manager

  • to understand resource issues related to both investigations and care of adults with epilepsy
  • to demonstrate an ability to manage time effectively

 


5. Health Advocate

  • to understand the needs and rights of both patients and society when dealing with issues such as provision of an appropriate education environment at school, fitness for work in certain occupations, or the operation of motor vehicle
  • to recognize and respond appropriately in advocacy situations

 


6. Scholar

  • to develop initiative and curiosity in dealing with clinical problems
  • to critically appraise and synthesize medical literature in order to provide evidence-based care
  • to develop further knowledge through attendance and participation in epilepsy/electrophysiology-related educational activities
  • to demonstrate a strategy for personal continuing education
  • to supervise and teach other health staff/students and other health professionals
  • to consider basic or clinical research in the field of epilepsy/electrophysiology
  • demonstrate the ability to teach more junior residents about level-appropriate topics in neurophysiology and epilepsy

 


7. Professional

  • to show a recognition of limitations and demonstrate ability to seek consultation as needed
  • to be sensitive to cultural/ethnic issues
  • to communicate effectively with members of the epilepsy team