Seizures July 4, 2013

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Seizures

Tutor: Professor V. Wong

Presentation by: Daniel Tsang,Dragon Man, Michele Yuen

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Outline of Presentation

1. Some basic terminologies

2. Brief overview of seizures

3. Video demonstrations

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Part 1:

Basic Terminologies

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Some stuff you probably know

already

Epilepsy:

group of syndromes

characterized by paroxysmal transientdisturbances of the brain function

Seizure: a single episode of epilepsy

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Consciousness

Consciousness: awareness or

responsiveness to external stimuli

Awareness: contact with events during

the period in question

Responsiveness: ability to carry out

simple commands or willed movement

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Drowsiness or somnolence

Drowsiness or somnolence: sleep statefrom which the patient can be aroused tomake appropriate motor and verbal

responses

Stupor: state from which the patient can

be aroused by painful or other vigorouslyapplied stimuli to make avoidancemovements

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Aura

component of seizure which occurs before

consciousness is lost and for which

memory is retained afterwards

In seizures that occur without lost of

consciousness, the aura is the whole

seizure

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Automatisms

Involuntary motor activity occurring duringthe state of clouding of consciousness eitherin the course of, or after an epileptic seizure

Continuation of an activity that was going onwhen the seizure occurred vs. new activity

developed in associated with the ictalimpairment of consciousness

Related to discharge in the limbic system

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Types of Automatisms

1.Eating automatisms

2.Automatisms of mimicry

3.Gestural automatisms

4.Ambulatory automatisms

5.Verbal automatisms

Absence seizures

Complex partial +

absence seizures

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Part 2:

Brief overview of seizures

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Classification of seizuresSeizure

Partial Generalized

Simple ComplexSecondarily

Generalized

1. Motor

2. Somatosensory

3. Special sensory

4. Autonomic

5. Psychic

1. Simple partial at

onset

2. Impairment of

consciousness at

onset

1. Simple to generalized

2. Complex to

generalized

3. Simple to complex to

generalized

1. Absence

2. Myoclonic

3. Clonic

4. Tonic

5. Tonic-clonic

6. Atonic

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Partial seizures

Hemispheric involvementConsciousness

Primarily unilateral; often

bilateral in course of

seizure

ImpairedComplex

partial

seizure

Unilateral;

Bilateral involvement rare

IntactSimple

partial

seizure

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Simple partial seizure

Several types:

1. With motor signs

2. With somatosensory or special sensory

symptoms

3. Seizures with autonomic symptoms

4. With psychic symptoms

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Simple partial seizures with

motor signs Strictly focal

Spread to contiguous cortical area sequentialinvolvement of body parts

Epileptic march / Jacksonian seizure Presentations:

Head turns to one side (usually contralateral todischarge)

Speech arrest / vocalization Epileptic palilalia

Todds paralysis

Epilepsia partialis continua

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Simple partial seizure with somatosensory

orspecial sensory symptoms

Somatosensory pins-and-needles / numbness

Proprioception or spatial perception disorders

Special sensory Visual: flashing lights, structured visual

halluncinations

Auditory: crude auditory sensations, highly integratedfunctions (e.g. music)

Olfactory: unpleasant odours

Gustatory: crude (salty, sour, sweet, bitter),sophisticated (metallic)

Vertiginous: falling in space, floating, totatory vertigo

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Simple partial seizures with

autonomic symptoms

Vomiting

Pallor

Flushing

Sweating

Piloerection

Pupil dilatation

Borborygmi

Incontinence

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Simple partial seizure with

psychic symptoms

Dysphasia: motor, sensory, global aphasia

Dysmnesic: distortion of time sense, deja-vu,jamais-vu, deja-entendu, jamais-entendu,

panoramic vision Cognitive disturbances: dreamy state, distortion

of time sense, unreality, depersonalization

Affective: extreme pleasure or displeasure, fear,

anger, rage Illusions: objects appear deformed

Structured hallucination

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Complex partial seizure

Gradualimpairment of consciousness (c.f.

abruptimpairment in absence seizures)

Presentations:

Limited to impairment of consciousness

With additional psychic, motor and autonomic

symptoms

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Complex partial seizure - Types

Complex partial seizure

Temporal Extratemporal

Start with an empty stare +

Clouding of consciousness

Automatism (oral, mimic, gestural, verbal)

Frontal type: Fronto-cingular epilepsy

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Generalized seizures

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Absence seizures

Sudden in onset, interruption of ongoing

activities, blank stare

Non-responsive

Vanish in second

Atypical

Can associate with other components Tonus, clonus, automatism

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Myoclonic seizures

Sudden, brief

Generalized to individual muscle group

Ddx Spinal cord, brainstem and cortices lesions

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Clonic seizure

Generalized seizure sine tonic component

Postictal phase is usually short

May progress to tonic phase, clonic-tonic-clonic seizure

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Tonic seizures

Rigid, violent muscular contraction fixing

the limbs in some strained position

Deviated eyes, head towards one side,

alteration in posture

Pale, flushed and ultimately livid

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Tonic-clonic seizures

Vague ill-described warning

Tonic phase: Sudden, sharp, tonic contraction of muscles (+ stridor), cyanosis

Fall on ground, tongue bitten, urine incontinence

Clonic phase: Grunting

drooling

Deep respiration, all muscle relax, remain unconsciousfor variable time,

Awake with soreness and drowsiness, deep sleep

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Atonic seizures

Sudden reduction in muscle tone

Head drop, slacking of jaw, dropping of

limb or slumping to the ground

Drop attack

Ddx: brainstem ischaemia, narcolepsy

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Part 3:Video Demonstrations

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CS 2

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CS 2: Simple partial seizure with

motor signs and march

No loss of consciousness

Rhythmic twitching of the fingers of the left

hand, spreading through arm to shoulder

He held his affected hand

Simple partial seizure with motor signs

Focal

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CS 12


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psychic symptoms and dysphasia

With dysphasic symptoms

Clicking of tongue, mumblingincomprehensible words and smiles

Fully understand commands but unable to

speak properly

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CS 15


CS 15: Complex partial seizure

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CS 15: Complex partial seizure,

simple partial onset, impairment of

consciousness

Slight loss of postural tone

Preserved orientation reflex Impaired consciousness

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CS 17

Patient was asked to hyperventilate in the

beginning


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CS 17: Complex partial seizure vs

generalized absence

Patient suddenly stopped hyperventilating

Motionless and blank facial expression

Regain consciousness with told nurse herhad vague stomach sensation

EEG: localized right frontal activity pre and

postictally favours a partial seizure

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CS 19

Patient with right frontal ganglioglioma


CS 19: Complex partial seizure

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CS 19: Complex partial seizure,impairment of consciousness at

onset Sudden sat up and started to roll about

Lying on his belly

Manipulated his genitals (frontal

automatism)

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CS 20


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secondary generalization

Left arm started jerking

Still responsive

Coarse jerking of arms, stretching of back,tonic contraction of face, open mouth

Loss of consciousness

Twitching of all limbs and head Relaxation and postictal sleep

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CS 23


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CS 23: Typical absence seizure

Slight loss of tone in neck muscle when

stop hyperventilation

Seizure started

Mild eyelid clonus

Regain responsiveness later

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CS 29


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CS 29: Generalized atypical

absence seizure

Head drop gradually

Not responsive

Later responded to staff and graduallyregain upright position

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CS 30


CS 30 G

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CS 30: Generalized myoclonic

seizure

Brief repetitive movements of the limbs

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CS 32


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CS 32: Generalized clonic seizure

Opening of eyes and massive myoclonic

jerks

Continuous clonic movement of limbs

Repetitive vocalization with clonic

movement of the chest

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CS 33


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CS 33: Tonic seizure

Gradual elevation of both hands and

stopped walking

Took 2 steps and then passed urine

Bent body strongly forward but kept

standing

Dropped handkerchief

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CS 34


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CS 34: Tonic clonic seizure

Suddenly bent forward with extended arm

and legs

Twitching in face and body

Tonic stretching of arms and legs

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CS 35


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CS 35: Atonic seizures

Sudden relaxation of muscles

Head drop, floppy limbs and slumping to

the ground

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Some more videos if wehave time

Otherwise, THE END.

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CS 27


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CS 27: Absence seizure

With automatism

Not necessarily specific for complex partial

seizures

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Absence with mild clonic

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Absence with mild clonic

component

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Absence with tonic component

Head mainly affected

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CS 3


CS 3: Partial seizure with motor

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CS 3: Partial seizure with motor

signs and march

Complex partial seizure partial motor

seizure with secondary generalization

Not a Jacksonian seizure: consciousness

was impaired before the march starts

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CS 4



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p pmotor signs and versive

movements Sudden start of seizure from sleep

Version of trunk towards the right

Left arm bent at the elbow, fingersforcefully stretched

Right arm beats on arm of chair to warnnurse

Tonic contraction of face and eyes

EEG: not interpretable due to artifacts(pseudospike waves)

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CS 13



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p ppsychic, dysmnesic and affective

symptoms and hallucinations Happily talking

Deja-vu

Spontaneous hyperventilation Facial expression of suffering with

weeping and crying

No loss of contact; can give age, date andname of objects

Cries and yells; feels very bad and asksfor help; weeps affective sympoms

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THE ENDQuestions?

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