SEISURE DISORDER
By; Abebe Dendir
CONTENTS
Defination
Epidimology
Mecanism
Classification
Etiology
Aproach to patients
Complication
Status epilepticus
EEG
Treatment of seizure & epilepsy
Defination
Seisure; is a paroxysmal event due to
abnormal excessive or synchronyous
neuronal activity in the brain.
manifestation can be;
subtle or dramatic
motor, sensory, autonomic or psychiatric features
Epilepsy; is two or more unprovoked
seizres. due to chronic underlying process
in the brain
Sensory Psychic Autonomic Motor
Visual Dysmnestic Dyspepsia Tonic
Auditory Dreaming Nausea/Pale Clonic
Olfaction Psychic Palpitation/Vertigo
Paresthesia Emotion Pupil ↑, pilo-erect
Incontinence
4
Epidimology
5-10% of population will have at least
one seizure in their life time.
Highest incidence is in early childhood
& late adulthood
Epilepsy affect 0.5-4% of world
population.
In ethiopia; [Teklehymanot R. study]
prevalence of active epilepsy- 5.2/1000
highest incidence- male with age 11-20 yrs.
commonest type- GTC (60%)
ETHIOPIA
Results of the study
Attitude of rural people in central
Ethiopia toward epilepsy
• By 45% believed to be contagious through
physical contacts during an attack
• Negative attitudes were strong on matrimonial
association, sharing of accommodation and
physical contacts with affected persons.
• social deprivations and, at times, rejection of the
sufferers
• Traditional views evil spirits and superstition
Classification
• Focal (partial) seizures
o restricted to discrete areas of the
cerebral cortex.
o usually associated with structural
abnormalities of the brain.
o Accounts 70% of seizure in
adults(40% in children)
• Generalised seizures
o involve diffuse regions of the brain
simultaneously.
o result from cellular, biochemical, or
structural abnormalities that have a
more widespread distribution.
Classification con….
Based on clinical features & associated EEG findings;
1. Focal Sz
Focal Sz with out dyscognitive features(simple)
Focal Sz with dyscognitive features(complex)
Focal sz with secondory generalization
2. Generalized Sz
Absence Sz
Typical absence Sz
Atypical absence Sz
Generalized tonic clonic Sz
Tonic clonic Sz
Tonic Sz
Clonic Sz
Atonic Sz
Myoclonic Sz
Unclassifiable Sz
IMPORTANT FEATURES OF DIFFERENT
TYPES OF SEISURES
Focal Sz; are seizures originated within
neuronal networks limited to one
cerebral hemisphere.
1.Focal Sz with out dyscognitive features
Focal seizures causing motor,
sensory, autonomic, or psychic symptoms
without impairment of cognition.
Frontal Lobe Partial Seizures (Focal Motor and
Jacksonian Seizures)
• Attributable to a discharging lesion of the opposite frontal lobe
• The most common type
– takes the form of a turning movement of the head and eyes to the side opposite the irritative focus,
– often associated with a tonic contraction of the trunk and limbs on that side
• Versive or adversive
– begin with forceful, sustained deviation of the head and eyes, or entire body
• The jacksonian motor seizure
– begins with a tonic contraction of the fingers of one hand, the face on one side, or the muscles of one foot.
– This transforms into clonic movements in these parts in a fashion analogous to that in a generalized clonic-tonic-clonic
convulsion
• Todd's paralysis- a transient paralysis of the affected limbs
• Seizure discharges arising REALEASE of a word from the cortical language areas may give rise to
– ictal aphasia and, or, more frequently, a vocal arrest
Focal motor Sz(FLP Sz)
A)jaksonian march
• Jerky movements typicaly begin in very
restricted region such us at the angle of the
mouth or in the thumb and index finger
• Spreading to involve the whole limb with in
seconds or min.
• The clinical evidence of this spread of activity
is called the “march of seizure” representing
the spread of seizure activity over a
progressively larger region of motor cortex.
B)Todds paralysis
• Some patients may experience a localized
paresis for minutes to many hours in the
involved region following the jacksonian
seizure called Todds paralysia
• C)EPILEPSIA PARCIALIS CONTINUA-The
jacksonian seizure may continue for hours
or days called epilepsia partialis continua.it
often refractory to medical therapy.
Somatosensory, Visual, and Other Types of
Sensory Seizures
• Somatosensory seizures
– numbness, tingling, , sensation of crawling (formication), electricity, pain and thermal sensations
• Visual seizures
– visual sensations of darkness or sparks and flashes of light, which may be stationary or moving and
colorless or colored
– red is the most frequently reported color, followed by blue, green, and yellow
• Auditory hallucinations
– buzzing or roaring, human voice, the sound of music
• Vertiginous sensations- on rare occasions
• Olfactory hallucinations- disagreeable or foul
• Gustatory hallucinations
• Visceral sensations -arising in the thorax, epigastrium, and abdomen are among the
most frequent of auras
Complex Partial Seizures
• Characterized by focal seizure activity accompanied by a transient impairment of consciousness
• Seizures frequently begin with an aura(i.e., a simple partial seizure) that is stereotypic for the patient
• Start of the ictal phase is often a sudden behavioral arrest or motionless stare
– usually accompanied by automatisms, which are involuntary, automatic behaviors that have a wide range of
manifestations
– chewing, lip smacking, swallowing, or "picking" movements of the hands, or display of emotion or running.
• Patient is typically confused following the seizure, and
– the transition to full recovery of consciousness may range from seconds up to an hour.
• Examination immediately following the seizure may show
– an anterograde amnesia or,
– in cases involving the dominant hemisphere, a postictal aphasia.
• EEG -often normal or may show brief discharges termed
– epileptiform spikes, or sharp waves.
– seizure focus is often detected using sphenoidal or surgically placed intracranial electrodes
Focal Sz with secondary generalization
Mistaken for primary generalized seizure
Ask history suggesting aura-simple partial
seizure
Focus is usually frontal lobe
Usually tonic-clonic
EEG to establish the diagnosis
Treatment is different for both primary and
secondary generalized
Generalized Sz;seizures that arise at
some point in the brain but immediately
and rapidly engage neuronal networks
in both cerebral hemispheres.
Absence (petit mal)
Brief loss of consciousness- /5-10sec/
No loss of postural muscle control
No post ictal confusion
Motor manifestation: subtle
• Bilateral blinking of eye lids
• Chewing movements
• Clonic movement of the hands
• Coexist with GTC or Myoclonic
Main seizure type in children (4-8 yr)
• Accounts for 15-20%
• First clue-day dreaming or decreased school performance
EEG:3 Hz generalized spikes-and-wave-abrupt
• Provoked by hyperventilation
Treatment response is very good
– 60-70% have spontaneous remission during adolescence.
20
Atypical absence Sz
longer duration
less abrupt onset and cessation
more obvious motor sign
less responsive to anticonvulsants
The Generalized Tonic-Clonic Seizure
(Grand Mal)
• Main seizure type in ~10% of all persons with
epilepsy
• Most common seizure type resulting from
metabolic derangements
– frequently encountered in many different clinical
settings
Premonitory symptoms (prodrome)
• Only in some patients
– patient may feel apathetic, depressed, irritable, or, very rarely, the
opposite ecstatic
– One or more myoclonic jerks of the trunk or limbs on awakening
– turning of the head and eyes or whole body or intermittent jerking of a
limb
• a few seconds before consciousness is lost
– Abdominal pains or cramps, a sinking, rising, or gripping feeling in the
epigastrium,
– pallor or redness of the face, throbbing headache, constipation, or
diarrhea
Tonic phase
• Most often, the seizure strikes without warning
• sudden loss of consciousness and fall to the ground
• The initial motor signs
– brief flexion -trunk, an opening -mouth and eyelids, and upward deviation -eyes
• arms -elevated and abducted, elbows -semiflexed, and hands -pronated
• followed by a more protracted extension (tonic) phase,
– involving first the back and neck, then the arms and legs
• piercing cry
– air is forcibly emitted through the closed vocal cords.
• breathing is suspended, skin and mucous membranes may become cyanotic
• pupils are dilated and unreactive to light.
• The bladder may empty at this stage or later
• The tonic phase of the seizure lasts for 10 to 20 s
The clonic phase
• At first there is a mild generalized tremor,
– It begins at a rate of 8/s and coarsens to 4/s ;
– then it rapidly gives way to brief, violent flexor spasms that come in rhythmic salvos and agitate
the entire body.
• The face becomes violaceous and contorted by a series of grimaces, and often the
tongue is bitten.
• Autonomic signs are prominent:
– the pulse is rapid, blood pressure is elevated, pupils are dilated, etc
• Clonic jerks decrease in amplitude and frequency over a period of about 30 s.
• Patient remains apneic until the end of the clonic phase,
– which is marked by a deep inspiration.
• Seizures may be abbreviated or limited in scope by anticonvulsive medications.
Post ictal
• Patient lies still and limp, in a deep coma.
• The pupils, equal or unequal, begin to contract to light.
• Breathing may be quiet or stertorous.
• This state persists for several minutes,
• Patient opens his eyes, begins to look about, confused and may be agitated
• The patient may speak and later not remember anything that he said.
• Undisturbed, he becomes drowsy and falls asleep,
– sometimes for several hours, sometimes awakens with a pulsatile headache
• When fully recovered, the patient has no memory of any part of the spell
• a fracture, periorbital hemorrhages, subdural hematoma, or burn may have been
sustained in the fall
Atonic Seizures
• Characterized by sudden loss of postural muscle tone lasting 1–2 s
• Consciousness is briefly impaired, but there is usually no postictal confusion
• A very brief seizure may cause only a quick head drop or nodding
movement,
– while a longer seizure will cause the patient to collapse.
– substantial risk of direct head injury with the fall
• EEG
– brief, generalized spike-and-wave discharges
– followed immediately by diffuse slow waves
• Usually seen in association with known epileptic syndromes
Myoclonic Seizures
• Myoclonus
– sudden and brief muscle contraction that may involve one part of the body or the entire body
• Pathologic myoclonus is most commonly seen in association with
– metabolic disorders, degenerative CNS diseases, or anoxic brain injury
• Myoclonic seizures are considered to be true epileptic events
– since they are caused by cortical dysfunction
• EEG may show bilaterally synchronous spike-and-wave discharges synchronized with
the myoclonus,
– although these can be obscured by movement artifact
• usually coexist with other forms of generalized seizure disorders
– predominant feature of juvenile myoclonic epilepsy
Etiology
Perinatal hypoxia and ischemia
Intracranial hemorrhage and trauma
Neonates(<1month)
Developmental disorders
Genetic disorders
Febrile seizures
Infants & children(1mon-1year) Genetic disorders
Developmental disorders
Trauma
Adolescents(12-18yr) Genetic disorders
Brain tumor
Trauma
young adults(18-35yrs) Alcohol withdrawal
Illicit drug use
Cerebrovascular disease
Older adults(>35yr) Brain tumor
degenerative CNS diseases
...
• NB: CNS infections, metabolic
disturbance & ideopathic causes are
common & important causes of seizure
disorders in most age groups.
Mechanisms
Two hypothesis;
1.Selective inhibitatory neuronal damage
2.Aberant exitatory circute formation
Pathogenesis
1) Seizure Initiation
A) High frequency bursts of Action potentials ( AP )
* Influx of Ca++ opening of voltage dependent Na+ channel
Influx of Na+ repetitive AP.
B) Hyper synchronization – Spike discharges on EEG.
2) Seizure propagation
Repetitive Discharge Recruitment of surrounding neurons loss of
surrounding inhibition propagation via ( local cortical connection or long
commissural pathways.
Aproach to patients
patient present shortly after seizure
patient not acutely ill
(acutely ill)
V/S & cardio respiratory managment
identify life threatrning underlyng conditions &
manage apropriatly
assess history of preveous seisure
11st seizure
seizure
st known
knownepileptic
epilepticpatient
patient
known
knownepileptic
epilepticpatient
patient
is medication adequuate?
what peciptate?
is their adherance?
• priciptants
– sleep deprivation
– systemic disease
– etiology & metabolic
derangment
– drug use
– alcohol use
11st seizure
seizure
st
is realy seizure? • DDx;
– syncope
– psychiatric disorders
– metabolic disturbance
determine the cause
(Hx,PEx,Ix) – migraine
– TIA
– sleep disorder
decide need for
anticonvelsant in addition to
– movement disorders
RX of underlining cause
11st seizure
seizure
st
is realy seizure?
determine the cause • Hx;
(Hx,PEx,Ix)
– patient & witness
– pre-ictal, ictal ,post-
decide need for
ictal conditions
anticonvelsant in addition to – etiologies, precipitants
RX of underlining cause
11st seizure
seizure
st
is realy seizure?
determine the cause • PEx;
(Hx,PEx,Ix)
– sxn of systemic infections
– sxn of neurocutaneus
decide need for
syndrome
anticonvelsant in addition to – sxn of CLD, CKD, CVD
RX of underlining cause
– sxn ofTrauma
– sxn of druge use
– complete neurologic exam
11st seizure
seizure
st
is realy seizure?
determine the cause • Ix;
(Hx,PEx,Ix)
– blood study
– OFT
decide need for – toxin screen
anticonvelsant in addition to – brain imaging
RX of underlining cause
– LP
– EEG
– HIV test etc
Complications of seizure disorders
Status epilepticus
Accidents
Hypoxic brain damage
Mental retardation and impairment of
intellectual function
Sudden death
Psychosocial (Social stigma).
Status Epilepticus
Definition :
Continuous convulsion lasting for > 30 minutes
OR
Serial convulsions for > 30 min b/n which there is no
return of consciousness
** Status epilepticus is a neurologic and medical
emergency
41
Types of Status Epilepticus
1. Convulsive status epilepticus(>80%)
- Generalized tonic-clonic, tonic, clonic
2. Nonconvulsive status
- complex partial, absence
3. Myoclonic status
4. Epilepsia partialis continua
5. Neonatal status epilepticus
42
...
complications of status epilupticus
– Aspiration
– Hypoxia
– Metabolic acidosis
– Hypotension
– Hyperthermia
– Rhabdomyolysis and associated myoglobinuria
– Multiple physical injures including vertebral bone
fracture
– irreversible neuronal injury
special issue related to women & epilepsy
catamenieal epilepsy; increased frequency
of seizure around the time of menses
pregnancy
– 50% no change
– 30% increased
– 20% decreased
contraception
breast feeding
Electrophysiologic Studies
• All patients who have a possible seizure disorder
– should be evaluated with an EEG as soon as possible
• The presence of electrographic seizure activity during the clinically evident
event
– abnormal, repetitive, rhythmic activity having an abrupt onset and termination—
clearly establishes the diagnosis
• The absence of electrographic seizure activity does not exclude a seizure
disorder,
– simple or complex seizures may originate from a region of the cortex that is not
within range of the scalp electrodes.
• The EEG is always abnormal during generalized tonic-clonic seizures
EEG
• 21 electrodes
• 10-20 system
Recordings
• Unipolar
• Bipolar
46
10-20 system of electrode placement
• EEG is also used for classifying seizure disorders
– and aiding in the selection of anticonvulsant medications
• The routine scalp-recorded EEG may also be used to assess the prognosis of
seizure disorders;
– a normal EEG implies a better prognosis,
– abnormal background or profuse epileptiform activity suggests a poor outlook.
• EEG has not proved to be useful in predicting which patients with
predisposing conditions,
– such as head injury or brain tumor, will go on to develop epilepsy, because
– epileptiform activity is commonly encountered regardless of whether seizures
occur.
Seizure Onset
references
• Harrison's principle of medicine 18th Ed.
• UptoDate 19.3
• standard treatment guideline 2010
• Jimma lecture note
thank you!
