SeizuresEPILEPTIC / Non Epileptic

What is that ???

Dr. Samir KhalilConsultant Pediatric Neurologist

Makassed Hospital

Clinical Assistant Professor

Al-Quds University

Al-Quds University

School of Medicine

Lectures 5th year

Updated September, 2012

CONCEPTS & GLOSSARY

Attack

Seizure

Convulsion

Fit

Attack

A violent act starting on with vigor

Attack

Is used to describe epileptic & non-epileptic disorder.

Attack

Is used to describe epileptic & non-epileptic disorder.

attack

Is used to describe epileptic & non- epileptic disorder.

We say:

Attack of laughing

Breath Holding Attack / or spell

An attack of febrile convulsion

Conversion Reaction

Epileptic attack

attack

?

Is used to describe epileptic & non- epileptic disorder.

attack

?

Is used to describe epileptic & non- epileptic disorder.

convulsion

An intense, paroxysmal, involuntary contraction or series of contractions of voluntary muscles

convulsion

Is used to describe epileptic & non- epileptic motor act / shaking

convulsion

Is used to describe epileptic & non- epileptic motor act / shaking

convulsion

If there is no movement (displacement in place), the term “convulsion” is not applied.

The term

“convulsion”

implies

movement/s

convulsion

We say:

Clonic convulsion but not tonic convulsions Tonic-clonic convulsions Myoclonic convulsion but not absence

convulsion.

……Absence / Petit male is not a convulsion

Neither arrhythmia nor tachycardia nor apnea

seizure

A sudden, involuntary event/s that may include:

Motor activity

Altered level of consciousness

Somatosensory symptoms

seizure

Used to

describe

epileptic

disorders

Seizure vs Convulsion

A convulsive attack:

Always labeled as seizure Contrary, not all seizures convulse

So a seizure is not synonym to convulsion

We sayEpileptic seizure/s. Grand male seizure/s.Petit male seizure/s.His absence seizures are completely controlled by Valproic acid

Fit

A seizure or convulsion

especially those of

epileptic nature

Seizureswork up

Pattern Duration

Frequency

Physiopathology

Diagnosis Classification

Seizures’ Patterns

Myoclonic

Infantile

Spasm

OpsoMyoclonic

Un

Classified

Status

Epilepticus

TONIC CLONIC TONIC-

CLONIC

ATONIC

Absence

Seizures’ Pattern

TONIC

Seizures’ Pattern

CLONIC

Seizures’ Pattern

TONIC-CLONIC

?

Seizures’ Pattern

Myoclonic

Seizures’ Pattern

Myoclonic(Startels)

Seizures’ Pattern

Absence

Seizures’ Pattern

Infantile Spasms

Seizures’ Pattern

Opso Myoclonic

Seizures’ Pattern

Opso Myoclonic

Seizures’ Pattern

Un

Classified

Seizures’ Pattern

StatusEpilepticus

A seizure for more than 30 minutes

Or

Frequent Seizures without Regaining

Usual State of

Consciousness

Seizures’ Pattern

StatusEpilepticus

Seizures’ Pattern

Intermittent

Illumination

Provoked

Seizures

duration

Pre-ictal

Post-ictal

Ictal (Inrtra-ictal)

Immediate Post-ictal

Late Post-ictal

frequency

Attacksper hourper day

per monthPer year

Seizures’ Pattern

QStatus Epilepticus

Versus

Abundant Attacks

Seizureswork up

1st Key Question

Is it a seizure ?

Seizureswork up

1st Key Question

Is it a seizure ?

Seizureswork up

1st Key Question

Is it a seizure ?

Seizureswork up

1st Key Question

Is it a seizure ?

Seizureswork up

2nd Key Question

Is it epileptic or non epileptic

?

Seizureswork up

2nd Key Question

Is it epileptic or non epileptic

?

Seizureswork up

3rd Key Question

which Type of epilepsy

?

Seizureswork up

3rd Key Question

which Type of epilepsy

?

Seizureswork up

3rd Key Question

which Type of epilepsy

?

Seizureswork up

3rd Key Question

which Type of epilepsy

?

Seizureswork up

3rd Key Question

which Type of epilepsy

?

Seizureswork up

3rd Key Question

which Type of epilepsy

?

Seizureswork up

3rd Key Question

which Type of epilepsy

?

1st Key Question

Is it a seizure ?

3rd Key Question

Which type of epilepsy ?

4th Key Question

How to classify ?

2nd Key Question

Is it epileptic or non epileptic ?

Seizureswork up

Classification of Seizures

Epileptic Non-epileptic

What epilepsy is ?

Classification of Seizures

Epileptic Non-epileptic

Classification of Seizures

Nonepileptic

Epileptic Seizures are

non occasional (non-provoked) chronic seizures in which one single attack is not

considered as epilepsy.

Classification of Seizures

Epileptic

Non-epileptic seizures are

occasional (provoked) seizures produced by an acute identified cause

(pyretic, infectious, traumatic or metabolic)

Classification of Seizures

Epileptic Seizures

Non Occasional Chronic

Non-Epileptic Seizures

Occasional Acute

definition of epilepsy

A chronic clinical condition defined as 2 or more seizures

resulting from hypersynchronous electrical discharge of a

population of neurons and not secondary to specific provocation factor such as fever, infection,

electrolyte imbalances or trauma

Pathophysiology of epilepsy

Epilepsy Abnormal, hypersynchronous electrical

activation of a population of neurons in the cerebral cortex, either in:

Localized area Focal //Partial seizure

Multiple areas Generalized seizure

Pathophysiology of epilepsy

(GABA) GammaAminobutyric Acid

Excitatory

Neurotransmitters

Acetylcholine (Ach) GlutamateAspartate

Inhibitory

Pathophysiology of epilepsy

(GABA) GammaAminobutyric Acid

Excitatory

Neurotransmitters

Acetylcholine (Ach) GlutamateAspartate

Inhibitory

Any perturbation that interferes with the synthesis, release, re-uptake or metabolism of these neurotransmitters may result in

the occurrence of a seizure.

Pathophysiology of epilepsy

Many pharmacologic therapies for seizures act upon these neurotransmitters

Increase Inhibition

Decrease Excitation

Controversy exists regarding the duration of seizure necessary to cause neuronal cell injury.

Most, brief seizures, do not cause brain damage.

Pathophysiology of epilepsy

classification ofepilepsy

Idiopathic (Primary)Epilepsy

Unknown etiology

Neurological Examine

absolutely normal

Paraclinical explorations are

normal

Secondary Epilepsy

A chronic affection of

the brain by means of

actual methods ofexploration

Cryptogenic Epilepsy

A chronic affection of

the brain which isobscure or

doubtful by means of actualmethods of

exploration

classification ofepilepsy

Idiopathic (Primary)Epilepsy

Unknown etiology

Neurological Examine

absolutely normal

Paraclinical explorations are

normal

Secondary Epilepsy

A chronic affection of

the brain by means of

actual methods ofexploration

Cryptogenic Epilepsy

A chronic affection of

the brain which isobscure or

doubtful by means of actualmethods of

exploration

classification ofepilepsy

Idiopathic (Primary)Epilepsy

Unknown etiology

Neurological Examine

absolutely normal

Paraclinical explorations are

normal

Secondary Epilepsy

A chronic affection of

the brain by means of

actual methods ofexploration

Cryptogenic Epilepsy

A chronic affection of

the brain which isobscure or

doubtful by means of actualmethods of

exploration

classification ofepilepsy

Idiopathic (Primary)Epilepsy

Unknown etiology

Neurological Examine

absolutely normal

Paraclinical explorations are

normal

Secondary Epilepsy

A chronic affection of

the brain by means of

actual methods ofexploration

Cryptogenic Epilepsy

A chronic affection of

the brain which isobscure or

doubtful by means of actualmethods of

exploration

Generalized Epilepsy

Secondary Generalized

Epilepsy

Status Epilepticus

Partial epilepsy (simple & complex)

Classification of epilepsy

Provoked seizures associated with a fever, electrolyte abnormality, or other metabolic derangement, are usually generalized rather than focal.

Presentationepilepsy

Thankyou

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Classification of Epilepsy(According to Extension)

By means of: Clinical presentation Electrical Guidance (EEG)

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Status Epilepticus

• A continuous seizure activity lasting

> 30 minutes, or

• The occurrence of ≥ 2 seizures in quick succession without return to usual level of consciousness

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An emergency neurologic sequelae or death if treatment is delayed

Seizure Presentation On arrival at the ER

• On active seizure• Shaking, deviation of eyes, frothy secretions,…. Staring• Breath holding (apneic) with cyanosis

• Early post-ictal Drowsy, in deep sleep, paralytic (odd),………

• Late post-Ictal • Free of any manifestation (conscious alert ……..the attack is

past).

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Seizure Presentation On arrival at the ER

• 1st attack• Previous attacks (1, 2 or more)

• Under treatment with AED (withdrawal)• Never been treated with AED

• fever

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Seizure Presentation On arrival at the ER

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The minority

New onset, non-febrile seizure

A very small %

Status epilepticus

Most not seizing upon arrival in the casualty department

The MajorityFebrile convulsion or A known previous seizures

Prognosis / expectations

• The majority of pediatric seizures are single events without neurologic sequelae and most recurrent seizures can be controlled with medications.

• Occasionally, however, seizures can be life-threatening (status epilepticus)

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Febrile Convulsions

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Incidence of Epilepsy

• More common in children than adults• 1st yr. of life / Highest incidence

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Incidence of Epilepsy

• About 3-5% of children will have at least one seizure by the age of 5 yr.:

• >50% Benign febrile seizures. • 15% acute provoked seizure:

– The leading cause:» Children under 5yr. /CNS infection» Adolescents / Head trauma

• 10% Single unprovoked seizure and will never have another seizure

• The remaining 25% Recurrent seizures or epilepsy

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Incidence of Epilepsy

• ¾ …… Idiopathic, with no known cause • ¼ ……Identifiable brain pathology or underlying metabolic

disorders.

• A family history of epilepsy in 1st-degree relatives was found in 46.6% of patients.

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Seizure work-up

To R/O conditions mimic seizures

• The exact nature of the seizure:– Does the child have a known seizure disorder? – If this is the child’s 1st seizure, was the seizure febrile or

non-febrile? – Was the seizure partial, generalized, or partial with

secondary generalization? – Was the seizure provoked or unprovoked?

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Jitterrness