Seizures

Subject: MEDICINE Topic: SEIZURES Lecturer: DR. ROBERT BARJA Shifting /Date: JULY 16, 2008 Trans group: JAVICI CODE SEIZURES abnormal excessive, hypersynchronous electrical discharges of cerebral cortical neurons increased excitatory neurotransmitter, diminished inhibitory neurotransmitter paroxysmal or episodic cerebral dysfunction characterized by: 1. motor disturbances 2. sensory disturbances 3. autonomic disturbances 4. alteration of consciousness 5. behavioral or psychic disturbances

INTERNATIONAL CLASSIFICATION SEIZURES: I. Partial Seizures II. Generalized Seizures III. Unclassified Seizures

I.

EPILEPTIC SEIZURE (FIT)  the manifestation of an abnormal and excessive synchronized discharge of a set of cerebral neurons

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EPILEPSY  a chronic condition, of various etiologies, characterized by recurrent, usually spontaneous, epileptic seizures  when 2 or more unprovoked seizure fits occur

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EPILEPTOGENESIS  the transformation of a normal neuronal network into one that is chronically hyperexcitable  an injury initiates a process that gradually lowers the seizure threshold until a spontaneous seizure occurs

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EPILEPSY SYNDROME  disorder in which epilepsy is a predominant feature  with sufficient evidence (clinical EEG, radiologic, genetic) to suggest a common underlying mechanism  more common in pediatric age group

EPIDEMIOLOGY:  second most common neurological condition after headache  incidence in developing countries: 100190/100,000 population  incidence in developed countries: 40-70/100,000  age incidence: 50-60% <16 years o prevalence: 5-10 per 1,000

EPILEPTIC

PARTIAL SEIZURES (Focal Seizures) A. Simple Partial Seizures 1. with motor signs 2. with sensory symptoms 3. with autonomic symptoms or signs 4. with psychic symptoms

B.

Definition of Terms:

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Complex Partial Seizures (Temporal Lobe or Psychomotor Seizures; consciousness impaired) 1. simple partial onset, followed by impairment of consciousness a. with simple partial features followed by impaired consciousness b. with automatisms 2. with impairment of consciousness at onset a. with impairment of consciousness only b. with automatisms

C. Partial Seizures Evolving to Secondary Generalized Seizures (Tonic-Clonic, Tonic or Clonic) 1. simple partial seizures evolving to generalized seizures 2. complex partial seizures evolving to generalized seizures 3. simple partial seizures evolving to complex partial seizures, evolving to generalized seizures

II.

GENERALIZED SEIZURES (Bilaterally Symmetrical And Without Local Onset, Convulsive Or Nonconvulsive) A. Absence (petit mal) seizures B. Myoclonic seizures C. Clonic seizures D. Tonoi\ic seizures E. Tonic Clonic (grand mal) seizures F. Atonic seizures

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UNCLASSIFIED SEIZURES Includes all seizures that cannot be classified because of inadequate or incomplete data and some that defy classification in any of the above categories. This includes some

MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY TLE JAM CECILLE DENESSE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU RACHE ESTHER JOEL GLENN TONI

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neonatal sezixures (eg. rhythmic eye movements) chewing and swimming movements (eg. infantile spasm) PARTIAL SEIZURES  focal EEG features  seizure activity restricted to discrete areas of the cortex  variety of clinical symptoms used to localize focus Two Types: 1. Simple Partial Seizures  generally brief  not associated with alteration of consciousness 2. Complex Partial Seizures  associated with altered consciousness/ lack of contact with the environment 1. Simple Partial Seizures  caused by a focal cortical discharge that result in seizure symptoms appropriate to the function of the area of the brain, without impairment of consciousness o with motor signs o with sensory symptoms o with autonomic symptoms or signs o with psychic symptoms  EEG: Focal Spikes 2. Complex partial Seizures  temporal lobe or psychomotor seizures  medial temporal lobe or inferior frontal lobe origin  transient impairment of ability to maintain normal contact with environment o simple partial onset, followed by impairment of consciousness o with impairment of consciousness at onset

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Cognitive disturbance – sense of derealization, depersonalization

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Psychomotor activity – automatic stereotyped activity o lip smacking o picking at clothing o masticatory movement o simple gestures such as scratching or stroking

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Psychosensory illusions)

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Speech disturbance – sppech arrest, dysarthric, dysphasic

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Affective disturbance –stereotyped behavior and recurs during attack o sadness, crying, happiness, laughing, feeling of ecstasy Autonomic activity o Epigastric pain, borborygmi, sweating, palpitation, piloerection, excessive

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phenomena

9hallucination,

salivation, pallor, flushing, dilatation or constriction

papillary

GENERALIZED SEIZURES  generalized EEG features, bilaterally synchronous onset  non-focal features clinically (though may be asymmetric) and characterized by diffuse cerebral involvement  may result from cellular, biochemical, or structural abnormalities with widespread distribution Case 1:  7 y/o boy

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consult due to frequent “blank stares” that would last for a few seconds, several times a day, in the past 6 months academic record deteriorated in the last few months NE: Normal

1. Absence (Petit Mal)  begins in childhood (4-8 y/o) or adolescence  sudden, brief lapses of consciousness w/o loss of postural control  rapidonset and offset with change in facial expression, motionless blank stare and automatism  no post-ictal confusions  patient continues previous activities  EEG: generalized, symmetric 3 Hz spike and wave 2. Generalized Tonic-Clonic (Grand Mal)  in 10% of patients with epilepsy  most common type resulting from metabolic abnormalities Tonic Phase  sudden loss of consciousness with decerebrate posturing with all muscles in tonic contraction  “ictal cry”

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contraction of jaw muscles from a few sec to 3 mins (10-20 sec) with absence of respiration and cyanosis enhanced sympathetic tone

Clonic Phase  muscle relaxation superimposed on tonic contraction  bilateral jerking movement which maybe accompanied by violent expiratory contractions with expulsion of saliva Post-ictal Phase  coma, confusion, irritability, severe headache, muscle aches, extreme fatigue, somnolence  stridor, partial airway obstruction

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urinary and bladder incontinence

3. Tonic  characterized by the sudden onset of sustained contraction or extensor axial muscles and limb musculature with loss of consciousness  EEG: Rapid Spikes 4. Clonic  Bilateral jerks  EEG: Rapid Spikes with Slow Waves 5. Myoclonic  sudden, brief, shock like contractions maybe generalized or confined to trunk or face or one more extremities or individualized muscles or group of muscles  EEG: Spikes, Polyspikes and Wave 6. Atonic  sudden diminution of muscle tone leading to drop attacks EPILEPSY SYNDROMES  epilepsy is predominant feature  common underlying mechanism I. II. III. IV. I.      II.  

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Juvenile Myoclonic Epilepsy Lennox-Gestaut Syndrome West Syndrome Mesial Temporal Lobe Epilepsy Syndrome Juvenile Myoclonic Epilepsy generalized seizure, unknown cause early adolescence, (+) family hx bilateral myoclonic jerks, single or repetitive most frequent in am after awakening provoked by sleep deprivation benign, AED responsive Lennox-Gestaut Syndrome begins in children triad o multiple seizure types, mental retardation, 22.5 Hz spike-wave EEG activity 25% has West syndrome Seizures maybe tonic-clonic, tonic-atonic or atypical absence Intellectual, cognitive and psychosocial deficits are permanent and status epilepticus is common Treatment is usually unsatisfactory West Syndrome

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triad of infantile spasm, mental retardation and EEG findings of hypsarrythmia infantile spasm o occurs before 1 year of age (peak at 3 months) o brief head nodding to violent flexion of the head, limbs and trunk

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o hundreds of seizures may occur per day once the disorder appears, patients show rapid deterioration with loss of previously attained developmental level Mesial Temporal Lobe Epilepsy Syndrome most common syndrome associated with complex partial seizures partial epilepsy hippocampal sclerosis on MRI AED treatment refractory responds to surgery