Seizures

Snapshot

A 16-year-old girl presents to the emergency department with a recent convulsive episode. The mother reports that this episode occured a few hours after awakening, described her movements as myoclonic, and involving the upper extremity. As time progressed, her myoclonus evolved into a generalized tonic-clonic seizure that lasted 3-4 minutes. The patient reported to sleeping only a few hours per night due to upcoming examinations. Physical exam is unremarkable. EEG shows 5-Hz polyspike and slow-wave discharges. (Juvenile myoclonic epilepsy)

Introduction

Clinical definition synchronized and high-frequency neuronal depolarization that results in abnormal behavior and patient experience this is different from epilepsy, which can be simply described as a tendency to have recurrent seizures that are unprovoked febrile seizures are not considered to be epilepsy Other definitions ictal during the seizure postictal after the seizure interictal between seizures aura foc for example, patients may describe a rising epigastric visceral sensation in a seizure affecting the medial temporal limbic structures status epilepticus life threatening seizure episode that occurs continuously or in rapid successions Etiology can be divided into provoked and unprovoked causes provoked substance abuse (e.g., cocaine and MDMA) space occupying lesion (e.g., malignancy and abscess) stroke (e.g., ischemic and hemorrhagic) meningitis and encephalitis hypo- or hyperglycemia hyponatremia hypocalcemia hypomagnesemia medication withdrawal (e.g., benzodiazepine and alcohol) unprovoked underlying neurological disorder (e.g., childhood absence epilepsy and neurofibromatosis) Seizure classification classification is based on the International League Against Epilepsy (ILAE) seizures can be initially divided into focal and generalized

Focal Seizures

Clinical definition  abnormal neuronal activity in a localized (focal) part of the brain Partial seizures can secondarily generalize be subdivided into simple partial seizures complex partial seizures

Focal Seizure Types Seizure Type Clinical Features Focal onset seizures with awareness Consciousness is spared Symptoms are dependent on the anatomical location of the seizure e.g., abnormal shapes or flashes when there is a seizure in the primary visual cortex Typically no postictal deficits in brief simple partial seizures Focal onset seizures without awareness  Consciousness is impaired this can be complete or mild Symptoms are dependent on the anatomical location of the seizure May have automatisms Most common location is in the temporal lobes

Generalized Seizures

Clinical definition abnormal neuronal activity in both hemispheres of the brain Generalized seizures is almost always associated with impaired consciousness generalized tonic-clonic (grand mal) seizures is the most common type of generalized seizure

Generalized Seizure Types Seizure Type Clinical Features Absence (petit mal seizures) Most commonly occurs in children Can occur many times in a day Brief episodes (~10 seconds) of unresponsiveness parents may report the patient had a blank stare can occur many times in a day No postictal deficits and automatisms Characteristic EEG finding is generalized 3-4-Hz spike and wave discharges Myoclonic Patients can present with quick and repetitive jerks Tonic-clonic Typically begins with a tonic phase contraction of all muscles for 10-15 seconds leads to a fall "like a tree" The clonic phase follows the tonic phase rhythmic jerking of the bilateral extremities There are postictal deficits Tonic Patients can present with stiffening Atonic Patients can present with "drop" seizures can be mistaken as fainting

Febrile Seizures Seen in pediatric patients with fever temperatures exceeding 38°C with no other seizure-provoking etiology Categories simple: generalized, do not last longer than 15 minutes, and no recurrence within 24 hours. complex: focal, do last longer than 15 minutes, and/or recurrence within 24 hours. Treatment Supportive

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