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052 Diagnosis and classication of seizure and epilepsy

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Diagnosis and Classification of Seizures and Epilepsy Youmans chapter 52
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Page 1: 052 Diagnosis and classication of seizure and epilepsy

Diagnosis and Classification of Seizures and Epilepsy

Youmans chapter 52

Page 2: 052 Diagnosis and classication of seizure and epilepsy

Outline

• Seizure and Epilepsy Classification• Diagnosis of Epilepsy

Page 3: 052 Diagnosis and classication of seizure and epilepsy

Seizure and Epilepsy Classification

• Partial seizure• Generalized seizure• Cause of epilepsy

Page 4: 052 Diagnosis and classication of seizure and epilepsy

Partial seizure• Those in which the first clinical and electrographic

changes indicate initial activation of a system of neurons in one hemisphere and are subclassified based on the presence or absence of impairment of consciousness

• Simple partial seizures are associated with minimal change in awareness, as indicated clinically by the patient’s complete recollection of the event

• Complex partial seizures are characterized by alteration of awareness and amnesia for at least a portion of the seizure

Page 5: 052 Diagnosis and classication of seizure and epilepsy

Partial seizure• Motor, autonomic, somatosensory, special sensory, or

psychic• Both simple and complex partial seizures can propagate

throughout the brain to become secondarily generalized seizures

Page 6: 052 Diagnosis and classication of seizure and epilepsy

Generalized seizure• those in which the first clinical changes indicate initial

involvement of both hemispheres• Subclassification : absence, myoclonic, clonic, tonic,

tonic-clonic, and atonic seizures.

Page 7: 052 Diagnosis and classication of seizure and epilepsy

Absence(petit-mal seizuire)

• Impair consciousness with mild or no motor involvement

• Typical absence • Atypical absence : more heterogenous with

more variable EEG pattern then typical absence,seizure may be longer

Page 8: 052 Diagnosis and classication of seizure and epilepsy

Cause of epilepsy

• Cerebrovascular disease,most frequently, senior adults

• Developmental disorders, neonates and young children

• Head trauma, adolescents and adults• Brain tumor, adolescents and adults• Infection, neonates and young children• Degenerative disorders

Page 9: 052 Diagnosis and classication of seizure and epilepsy

Diagnosis of Epilepsy• two unprovoked seizures occurring more than 24 hours

apart• ILAE recently proposed that

– “epilepsy is a disorder of the brain characterized by an enduring predisposition to generate epileptic seizures and by the neurobiologic, cognitive, psychological, and social consequences of this condition. The definition of epilepsy requires the occurrence of at least one epileptic seizure”

Page 10: 052 Diagnosis and classication of seizure and epilepsy

Diagnosis of Epilepsy

• History of the experience of the seizure (especially the aura, or initial symptoms), description by a reliable witness

• Physical examination• Electroencephalogram (EEG)• Structural neuroimaging

Page 11: 052 Diagnosis and classication of seizure and epilepsy

Approach to the First Seizure Acute evaluation

• If mental status and the neurological examination have not normalized within minutes after the event appears to end– First, is there an underlying medical or neurological

condition that requires immediate treatment? – Second, has the seizure ended?

• Serum glucose, sodium, urea nitrogen, creatinine, and calcium and hepatic enzyme concentrations

• Arterial blood pH, oxygen, and carbon dioxide are important to measure

Page 12: 052 Diagnosis and classication of seizure and epilepsy

Approach to the First Seizure Acute evaluation

• Toxicology : ethyl alcohol, cocaine, amphetamines, benzodiazepines, opioids, phencyclidine, tricyclic antidepressants, and antipsychotic drugs

• Hypothyroidism with myxedema coma in rare case• CT Brain : to exclude a structural cerebral abnormality

such as hemorrhage, tumor, abscess, or contusion• If significant temperature elevation, nuchal rigidity,

leukocytosis, or other signs of possible central nervous system inflammation are present, a lumbar puncture : to exclude infection or subarachnoid hemorrhage. 

Page 13: 052 Diagnosis and classication of seizure and epilepsy

Approach to the First Seizure Acute evaluation

• If the patient has a possible history of seizures, anticonvulsant medications should be identified and serum concentrations determined.

• EEG : recommended for any patient whose mentation does not begin to normalize within minutes after a witnessed seizure or any patient without clearly defined cause of the mental status change

Page 14: 052 Diagnosis and classication of seizure and epilepsy

Approach to the First Seizure Seizure in the ambulatory setting

• The subsequent evaluation aims at answering four questions– Was the paroxysmal change in behavior or symptom

a seizure?– What is the classification of the seizure?– Is there a cause that requires specific treatment?– What is the probability of another seizure?

• cardiac syncope, dysautonomia, conversion disorder, or panic attacks.

Page 15: 052 Diagnosis and classication of seizure and epilepsy

Approach to the First Seizure Seizure in the ambulatory setting

• EEG– for every patient in whom a seizure is a reasonable

diagnosis• Magnetic resonance imaging (MRI)

– recommended for these patients unless the clinical history, family history, and EEG strongly indicate a primary generalized epilepsy or a definite nontraumatic provocation such as transient hypoglycemia is known

Page 16: 052 Diagnosis and classication of seizure and epilepsy

Component of the seizure experience

• Aura : patient is often aware of the initial evolution of seizure

• Visceral/abdominal– Ascending sense of constriction or warm in the

abdominal region epigastric sensation– “I feel like I am dropping quickly in an elevator” or “it

feels like the drop on a rollercoaster ride.

Page 17: 052 Diagnosis and classication of seizure and epilepsy

Component of the seizure experience

• Psychic– déjà vu– sense of dissociation from the environment– Depersonalization– sense of never being in a familiar place (jamais vu)

• Special sensory– Olfactory– Less frequently gustatory

• Somatosensory auras– tingling or electrical sensation– contralateral to a parietal epileptogenic region

Page 18: 052 Diagnosis and classication of seizure and epilepsy

Component of the seizure experience

• Visual– formed or unformed hallucinations– visual distortion such as change in size or apparent

speed of motion– It is important to understand that seizures arising from

the region of the visual cortex my not have visual auras and that visual auras can occur with seizures beginning in areas other than the occipital lobe

Page 19: 052 Diagnosis and classication of seizure and epilepsy

Clinical Semiology

• Mesial temporal lobe– Ipsilateral motor automatisms(tapping, patting, or

rubbing movements)– contralateral dystonic flexor posturing of the wrist and

hand• Temporal lobe

– Oral automatisms such as lip smacking, licking, or repetitive swallowing

– Complete behavior arrest

Page 20: 052 Diagnosis and classication of seizure and epilepsy

Clinical Semiology

• Lateral premotor seizures– Focal tonic or clonic motor seizures

• orbitofrontal or frontopolar seizures– hypermotor/frenetic (“motor agitation”) behavior

Page 21: 052 Diagnosis and classication of seizure and epilepsy

Lateralizing and localizing semiology

• Lateralizing = side of cerebral hemisphere• Localizing = location• Ictal symptomatogenic zone,these may be ictal onset

zone or ictal propagation• It should be consider with EEG and imaging

• วทิยาการโรคลมชกั, ชยัชน โลวเ์จรญิกลู

Page 22: 052 Diagnosis and classication of seizure and epilepsy

Highly reliable lateralizing semiology

• Dystonic limb posturing– contralateral hemispheric lateralization– 100% in temporal lobe epilepsy(TLE)– Electric from contralateral basal ganglion– Not use in tonic limb posturing and unilateral immobile limb

because not accurate

• Unilateral limb automatism– Ipsilateral hemispheric lateralization– 80%, more accuracy with dystonic limb posturing – Contralateral dystonic posturing with ipsilateral automatism can

distinguish mesial temporal lobe epilepsy from neocortical temporal lobe epilepsy

• วทิยาการโรคลมชกั, ชยัชน โลวเ์จรญิกลู

Page 23: 052 Diagnosis and classication of seizure and epilepsy

Highly reliable lateralizing semiology

• Version– contralateral hemispheric lateralization– TLE, symptom develop after seizure 30 s then secondary GTC

following : 100%– FLE,symptom develop initial seizure : 91% , with clonic

seizure ,twitching of facial expression contralateral, mouth deviation to contralateral

– Early head turning : not accuracy in lateralization– Late ipsiversion : ipsilateral direction, develop in late GTC

• วทิยาการโรคลมชกั, ชยัชน โลวเ์จรญิกลู

Page 24: 052 Diagnosis and classication of seizure and epilepsy

Highly reliable lateralizing semiology

• Unilateral clonic– Contralateral lateralization motor cortex– FTL or neocortical TLE

• Automatism with preserve responsiness(AVR)– Non-speech dominant in TLE

• Asymmetrical tonic limb posturing(ATLP) or figure 4 sign– 66% in focal epilepsy(53% in extra temporal epilepsy and 75% in

TLE)– Contralateral lateralization to tonic limb, 91% TLE, 88% ETE

• วทิยาการโรคลมชกั, ชยัชน โลวเ์จรญิกลู

Page 25: 052 Diagnosis and classication of seizure and epilepsy

Highly reliable lateralizing semiology

• Asymmetrical clonic ending of secondarily GTC• 43% in MTLE• Ipsilateral hemispheric lateralization to upper limb that stop seizure

later

• Postictal nose wiping(PINW) or rubbing• TLE > ETE• Temporal lobe ipsilateral to hand that rub nose• More accuracy in rubbing more than one time

• Postictal(Todd’s) paralysis• 13.4%, irritating contralateral motor cortex• Contralateral hemispheric lateralization• 100%-77% have motor seizure(unilateral clonic seizure,dystonic

posturing)

• วทิยาการโรคลมชกั, ชยัชน โลวเ์จรญิกลู

Page 26: 052 Diagnosis and classication of seizure and epilepsy

Highly reliable lateralizing semiology

• Postictal aphasia– TLE, ipsilateral lateralization to speech dominant

• Postictal heminnopsia– Contralateral lateralization– Occipital lobe

• Ictal speech– 90% TLE, non-speech dominat

• Olfactory aura– 10% in focal epilepsy– Mesial temporal lobe, amygdala

Page 27: 052 Diagnosis and classication of seizure and epilepsy

Highly reliable lateralizing semiology

contralateral ipsilateral1.Dystonic limb posturing2.Version3.Unilateral clonic4.Asymmetrical tonic limb posturing(ATLP)5.Postictal(Todd’s) paralysis6.Postictal heminnopsia

1.Unilateral limb automatism2.Asymmetrical clonic ending of secondarily GTC3.Postictal nose wiping(PINW) or rubbing

• วทิยาการโรคลมชกั, ชยัชน โลวเ์จรญิกลู

Page 28: 052 Diagnosis and classication of seizure and epilepsy

Rarely reported and less reliable lateralizing semiology

• Ictus emeticus(ictal vomiting) 9/31– Rt.cerebral hemisphere,100%– Postictal vomiting, no significant

• Unilateral blinking 14/930– ipsilateral lateralization– TLE,ELE

• Ictal smile 5%– Rt.cerebral hemisphere, posterior cortex

• Somatosensory aura 11%– Contralateral temporal lobe(80%)

• วทิยาการโรคลมชกั, ชยัชน โลวเ์จรญิกลู

Page 29: 052 Diagnosis and classication of seizure and epilepsy

Rarely reported and less reliable lateralizing semiology

• Ictal/postictal coughing 11%– Lt.cerebral hemisphere– TLE, ETE

• Preictal headache– TLE, ipsilateral lateralization 9/10– TLE FLE,contralateral lateralization 1

• Gyratory seizure 5%– Contralateral to side that turn– TLE, FLE

• วทิยาการโรคลมชกั, ชยัชน โลวเ์จรญิกลู

Page 30: 052 Diagnosis and classication of seizure and epilepsy

Rarely reported and less reliable lateralizing semiology

• Ictal urinary urge 2/12– Nondominant temporal lobe, insular cortex

• Peri-ictal water drinking– Nondominant temporal hemispere

• Orgasmic aura– Rt.cerebral hemisphere

• Ictal splitting 2%– Lt.temporal lobe

• วทิยาการโรคลมชกั, ชยัชน โลวเ์จรญิกลู

Page 31: 052 Diagnosis and classication of seizure and epilepsy

Rarely reported and less reliable lateralizing semiology

• Ictal lateral tongue biting– Ipsilateral lateralization to tongue biting

• Lateral bradycardia– Temporal lobe,no lateralization

• Prolong post-ictal confusion– Amygdala, TLE

• Unilateral piloerection 0.4%– Ipsilateral lateralization to piloerection– TLE

• วทิยาการโรคลมชกั, ชยัชน โลวเ์จรญิกลู

Page 32: 052 Diagnosis and classication of seizure and epilepsy

Physical examinationPhy• Commonly normal• Some neurological syndromes are often associated with

seizures and specific physical abnormalities• tuberous sclerosis complex : facial angiofibromas,

hypomelanotic macules, shagreen patches, ungual fibromas, and retinal hamartomas

• neurofibromatosis type 1 : café au lait spots, axillary freckling, cutaneous neurofibromas, and iris hamartomas (Lisch nodules)

• Temporal lobe epilepsy : frequenly but overlooked– Asymmetrical facial movement with spontaneous smiling

Page 33: 052 Diagnosis and classication of seizure and epilepsy

Physical examinationPhy

Page 34: 052 Diagnosis and classication of seizure and epilepsy
Page 35: 052 Diagnosis and classication of seizure and epilepsy

Electroencephalography• Indispensible• Various type• Single EEG sensitivity 50%, third record > 90 %• Interictal sharp wave : mesial temporal origin

Page 36: 052 Diagnosis and classication of seizure and epilepsy

Neuroimaging• First Goal : exclude a progressive od dangerous lesion

such as tumour or AVM• MRI to be superior to CT in identifying small

– T1-weighted scans with short repetition time/echo time (TR/TE) : anatomic relationships with superior resolution

– T2-weighted long TR/TE : more sensitive for focal pathology– New strategies such as “short flip angle” scans have been

suggested to identify small calcifications or hemorrhages. 

Page 37: 052 Diagnosis and classication of seizure and epilepsy

Thank you

Page 38: 052 Diagnosis and classication of seizure and epilepsy

• The anatomic location of the wound has also been shown to have an impact on the incidence of infection, with head and scalp wounds exhibiting the lowest rate of infection and the foot the highest rate. This is probably due to the inherent colonization of bacteria and difference in tissue vascularity that characterizes the foot and the face


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