Epilepsy and Epilepsy and SeizuresSeizures

DefinitionDefinition The epilepsies are a group of disorders

characterized by chronic recurrent paroxysmal changes in neurologic function caused by abnormalities in the electrical activity of the brain

Epilepsy vs. Epilepsy vs. SeizuresSeizures

• A seizure is defined by release of excessive and uncontrolled electrical activity in the brain. Seizures themselves are not a disease, they are an event.

• Epilepsy (seizure disorder) is a neurological condition, that in different times produce brief disturbances in the electrical functions of the brain. Seizures are a symptom of epilepsy.

Classification of Classification of SeizuresSeizures

• Seizures are classified into partial and generalized

• Partial seizures are divided intoo Simple partial - Consciousness is not impairedo Complex partial - Consciousness is impairedo About 2/3 of people with epilepsy have complex partial seizures

II. GENERALIZED SEIZURES

A. Absence seizuresB. Generalized tonic-clonic seizuresC. Myoclonic seizuresD. Tonic & atonic seizures

Absence SeizuresAbsence Seizureso Sudden onseto Interruption of ongoing activitieso Blank stare o Brief upward rotation of eyeso Duration: a few seconds to 1/2 minuteo Evaporates as rapidly as it startedo Mild eyelid clonuso Slight loss of neck muscle toneo Oral automatisms

Generalized Tonic-Generalized Tonic-Clonic SeizuresClonic Seizures

Tonic Phaseo Sudden sharp tonic

contraction of respiratory muscle: stridor / moan

o Fallso Respiratory inhibition

cyanosiso Tongue bitingo Urinary incontinence

Clonic Phaseo Small gusts of grunting

respirationo Frothing of salivao Deep respirationo Muscle relaxationo Remains unconsciouso Goes into deep sleepo Awakens feeling sore,

headaches

Myoclonic SeizuresMyoclonic Seizureso Sudden, brief, shock-likeo Predominantly around the hours of

going to or awakening from sleepoMay be exacerbated by volitional

movement (action myoclonus)o Symmetrical myoclonic jerks

Tonic SeizuresTonic Seizureso Rigid violent muscle contractiono Limbs are fixed in strained position

• patient stands in one place • bends forward with abducted arms• deep red face• noises - pressing air through a closed mouth

• Elevates both hands• Extreme forward bending posture• Keeps walking without faling• Passes urine

Atonic SeizuresAtonic Seizureso Sudden reduction in muscle tone o Atonic head dropo Loss of consciousness

Myoclonus A single abrupt shock like extensor movement of a limb. myoclonic seizures.Petit Mal Used to describe absence seizures as well as atypical absence.Tonic Sustained contraction of one or more muscle groups, independent of position (i.e. can be flexed, extended, or opisthotonic).Aura A generic term for a warning. A colloquial term for simple partial seizure.Convulsion Tonic, clonic or tonic-clonic seizure

Tonic and ClonicTonic and Clonic(Most often, these alternate)(Most often, these alternate)

PATHOPHYSIOLOGYPATHOPHYSIOLOGY• A seizure is a temporary involuntary disturbance

of brain function that may be manifested as impaired consciousness, abnormal motor activity, sensory disturbances or autonomic dysfunction.

PATHOPHYSIOLOGYPATHOPHYSIOLOGY• Seizures are accompanied by abnormal

electrical discharges in the brain that can usually be detected by electroen- cephalography.

• Increased permeability of neuronal cell membranes causes an increase in neuronal cell excitability.

PATHOPHYSIOLOGYPATHOPHYSIOLOGY• Things that can cause membrane instability:

o Deficiency in Oxygeno Deficiency in Glucose o Decrease in Calcium

Epilepsy - Epilepsy - Scientific BackgroundScientific Background

• When the brain functions normally, millions of fluctuating, simultaneous, tiny electrical charges go from the nerve cells to all parts of the body.

• People who have seizures / epilepsy have these normal electrical “patterns” interrupted by sudden and relatively intense bursts of electrical energy that may affect consciousness, body movements, and sensation.

Epilepsy -Epilepsy -Scientific BackgroundScientific Background

• Nerve cells normally transmit electrochemical signals and maintain a balance of excitatory and inhibitory neurotransmitters as well as sodium, potassium, and other factors critical to energy stability.

• When this balance is changed, a seizure may result.

CAUSESCAUSES• Adult-Onset Epilepsy most often indicates the

presence of a structural lesion of the brain.• Primary (genetic epilepsy) - 65% of persons with

recurrent seizures.

CAUSESCAUSES• Secondary (acquired epilepsy) - 35% of persons

with recurrent seizures. • Most common secondary causes:

o Congenital abnormalitieso Perinatal Injurieso Metabolic and Toxic Disorders o Head Trauma o Tumorso Vascular Disease o Degenerative Disorderso Infectious Diseases

CAUSES OF SECONDARY CAUSES OF SECONDARY GENERALISED EPILEPSYGENERALISED EPILEPSY

Genetic- Inborn errors of metabolism, Storage diseasesCerebral birth injury Hydrocephalus Cerebral anoxia Drugs--Antibiotics: penicillin, isoniazid, metronidazoleAntimalarials: chloroquine, mefloquineCiclosporinCardiac anti-arrhythmics: lidocaine; disopyramidePsychotropic agents: phenothiazines, tricyclic antidepressants, lithiumAmphetamines (withdrawal)Alcohol (especially withdrawal) ToxinsHeavy metals (lead, tin), Organophosphates (sarin)

Metabolic diseaseHypocalcaemia, Hyponatraemia, Hypomagnesaemia, HypoglycaemiaRenal failureLiver failureInfectiveMeningitisPost-infectious encephalopathyInflammatoryMultiple sclerosis (uncommon)SLEDiffuse degenerative diseasesAlzheimer's disease (uncommonly)Creutzfeldt-Jakob disease (rarely)

TRIGGER FACTORSTRIGGER FACTORS• Fatigue• Decreased physical health• Alcohol ingestion• Emotional stress• Flashing lights• Menstrual cycle• Missed meals• Sleep deprivation• Recreational drug misuse• Physical and mental exhaustion• Intercurrent infections and metabolic disturbances• Uncommonly: loud noises, music, reading, hot baths

Patient EvaluationPatient Evaluation• Evaluation should include a complete history,

thorough general medical and neurological examination, and pertinent laboratory examinations.

Patient EvaluationPatient Evaluation• HISTORY: A precise and extensive history is the

most crucial step in the evaluation• A good description of the event and symptoms

and signs surrounding the event must be obtained

MEDICAL MEDICAL CONSIDERATIONSCONSIDERATIONS

• A thorough med. hx is key. Questions:o What medications are you taking?o What type of seizure do you have?o How often do you have a seizure?o What signals the onset of your seizure?o How long do your seizures last?o Have you ever been hospitalized?

MEDICAL MEDICAL CONSIDERATIONSCONSIDERATIONS

o partial loss of memoryo incontinento deep sleep o loss of consciousnesso musculoskeletal contractions and relaxations

Patient EvaluationPatient Evaluation• Pertinent information includes:

o Precipitating factorso Determination of the Presence of an Aura and its

Descriptiono Description of the evento Post Event Signs and Symptomso Effect of Consciousnesso Duration of Evento History of Previous Events

Patient EvaluationPatient Evaluation• It is important to determine common

risk factors:o Abnormalities of pregnancy, birth, and developmento Febrile seizureso Meningitis or encephalitiso Head trauma with loss of consciousnesso Drug and alcohol abuseo Predisposing medical/neurological conditions

Patient EvaluationPatient Evaluation• It is important to determine common

risk factors:o Family historyo Prescribed medicationso Birthmarks or skin lesionso Exposure to toxinso Metabolic or nutritional disturbanceso Vascular disturbances

Physical and Physical and neurological neurological examinationexamination

• A thorough general physical and neurological examination are required at the time of presentation

• The clinician must search for evidence of an underlying systemic or neurological disorder

Differential Seizure Differential Seizure DiagnosisDiagnosis

Conditions resembling seizures and epilepsyo Syncopeso Cardiac Arrhythmiaso Pseudoseizureso Paroxysmal torticolliso Movement disorderso Migraineso Hyperventilationo CVAo Hypoglycaemiao Breath-holding spells

FEATURES HELPFUL IN DISTINGUISHING SEIZURES FROM FAINTS

  Seizure FaintAura (e.g. olfactory) + -

Cyanosis + -Tongue-biting + -Post-ictal confusion + -

Post-ictal amnesia + -

Post-ictal headache + -

Rapid recovery - +

Status EpilepticusStatus EpilepticusStatus Epilepticus - A state of recurring seizures when consciousness does not return between seizure events.

o Can be very serious and at times fatal. This is a seizure that lasts for about 30 minutes, and can cause serious brain damage, if not aborted.

o Benzodiazepines like diazepam or lorazepam may be given to patients in the hospital for treatment.

Common MythsCommon Myths• Epilepsy is contagious• People may swallow their tongue during a seizure• Putting things in people’s mouths (like wallets or

a stick) while seizing is a good idea• Ambulance should be called immediately

o If the seizure lasts longer than 5 minutes, it is their first seizure, they request an ambulance, or have multiple seizures in a row

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