Seizures & Epilepsy: MCCQE1 Preparation Guide

Introduction

Seizures and epilepsy represent a significant portion of neurology questions on the MCCQE1. Understanding the classification, acute management (Status Epilepticus), and long-term care in the Canadian context is essential for medical students and International Medical Graduates (IMGs).

According to Epilepsy Canada, approximately 0.6% of the Canadian population has epilepsy. As a future Canadian physician, you must be proficient in distinguishing between a provoked seizure and epilepsy, managing the acute phase, and counseling patients regarding lifestyle implications, particularly driving regulations set by the Canadian Medical Association (CMA) and provincial transportation ministries.

Classification of Seizures (ILAE 2017)

The International League Against Epilepsy (ILAE) 2017 classification is the standard used in Canadian medical education.

Etiology

For MCCQE1, remember that etiology is highly age-dependent.

Canadian Mnemonic: VITAMINS

• Vascular (Stroke - most common cause in elderly)
• Infection (Meningitis, Encephalitis, Abscess)
• Trauma (TBI)
• Autoimmune (SLE, Anti-NMDA)
• Metabolic (Hypoglycemia, Hyponatremia, Hypocalcemia, Uremia)
• Idiopathic / Iatrogenic (Drug withdrawal - Alcohol/Benzos)
• Neoplasm
• Schi- (Psychogenic Non-Epileptic Seizures - PNES)

Common Causes by Age Group

Diagnostic Approach

For the MCCQE1, the clinical approach follows the CanMEDS Medical Expert role: gathering history, performing a physical, and ordering appropriate investigations.

Management

1. Acute Management: Status Epilepticus

Status Epilepticus (SE) is a medical emergency defined as a seizure lasting >5 minutes or two or more seizures without full recovery of consciousness in between.

2. Chronic Management: Anti-Seizure Medications (ASMs)

Treatment is generally started after the second unprovoked seizure. Treatment after the first seizure is considered if high risk of recurrence (abnormal MRI/EEG).

Common ASMs in Canada:

Canadian Guidelines

Driving and Epilepsy

This is a high-yield topic for the MCCQE1 and fits under the “Health Advocate” and “Professional” CanMEDS roles. Physicians have a duty to report (mandatory in some provinces like Ontario, discretionary in others like Alberta/Quebec—check local laws, but for the exam, know the CMA guidelines).

CMA Driver’s Guide (Private License - Class 5):

• Standard: A patient must be seizure-free for 6 months on or off medication to drive a private vehicle.
• Exceptions:
  • First unprovoked seizure: May drive after a complete neurological workup is normal and seizure-free for 3 months (varies by province, often 3-6 months).
  • Nocturnal seizures only: May drive if pattern established for at least 12 months.
  • Medication change: If tapering/switching, typically should not drive during the change and for 3 months after establishing the new dose.

Women of Childbearing Age

• Folic Acid: All women with epilepsy of childbearing potential should take Folic Acid (0.4 mg to 5 mg daily). Most guidelines suggest higher doses (4-5 mg) for those on enzyme-inducing ASMs or Valproate.
• Teratogenicity: Valproic acid has the highest risk of major congenital malformations (neural tube defects) and lower IQ in offspring. Avoid Valproate in this population unless no other option exists.

Key Points to Remember for MCCQE1

• Status Epilepticus: Treat immediately if >5 mins. Lorazepam IV is the first-line drug of choice.
• First Seizure: Does not always require ASM. Investigate with MRI and EEG.
• Elderly: Stroke is the most common cause of new-onset seizures.
• Alcohol Withdrawal: Seizures typically occur 6-48 hours after cessation. Treat with Benzodiazepines.
• Absence Seizures: 3Hz spike-and-wave pattern on EEG. Treat with Ethosuximide (children) or Valproic Acid.
• Reporting: Know the difference between Mandatory vs. Discretionary reporting provinces, but prioritize patient safety (CMA Guidelines).

// Quick Reference Abbreviations
ABBREVIATIONS = {
  "GTC": "Generalized Tonic-Clonic",
  "ASM": "Anti-Seizure Medication",
  "SUDEP": "Sudden Unexpected Death in Epilepsy",
  "JME": "Juvenile Myoclonic Epilepsy",
  "PNES": "Psychogenic Non-Epileptic Seizures"
}

Sample Question

Clinical Scenario

A 27-year-old female is brought to the Emergency Department by EMS. Her partner reports that she had a generalized tonic-clonic seizure at home. The seizure activity stopped spontaneously after 2 minutes, but she remained confused. Upon arrival at the ED, 30 minutes after the first event, she begins seizing again. She has a history of epilepsy and recently ran out of her medication. Her vital signs are: BP 135/85 mmHg, HR 110 bpm, RR 22/min, O2 Sat 94% on room air. IV access has been established.

Question

Which one of the following is the most appropriate immediate pharmacologic intervention?

• A. IV Phenytoin
• B. IV Propofol
• C. IV Lorazepam
• D. Rectal Diazepam
• E. IV Lacosamide

References

1. Epilepsy Canada. Epilepsy Facts. Available at epilepsy.ca .
2. Canadian Medical Association (CMA). CMA Driver’s Guide: Determining Medical Fitness to Operate Motor Vehicles, 9th Edition.
3. Fisher, R. S., et al. (2017). Operational classification of seizure types by the International League Against Epilepsy. Epilepsia.
4. Canadian Association of Emergency Physicians (CAEP). Guidelines for the Management of Status Epilepticus.
5. Choosing Wisely Canada. Neurology: Don’t order an EEG for headaches. Available at choosingwiselycanada.org .