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Seizures, Epilepsy & Status Epilepticus


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excessive, uncontrolled discharge of cerebral neurons
two or more non-febrile seizures
Status epilepticus
two or more seizures without full recovery of consciousness between them, or multiple epileptic seizures lasting for more than 30 minutes
Partial vs generalized seizure
Partial seizures are those in which the ictal focus begins in one cerebral hemisphere. Generalized seizures begin in both cerebral hemispheres simultaneously. Partial seizures can generalize via the corpus callosum.
Simple vs complex seizure
Simple seizures (except simple Absence), are those in which CONSCOUSNESS IS PRESERVED. Complex seizures are those in which it is IMPARED (CONTRIVERSIAL).
Absence siezure
Another form of generalized (non-convulsive) seizure disorder. Contrasted with tonic-clonic seizures by their BREVITY AND PAUCITY OF MOTOR ACTIVITY. . “Pyknoepilepsy” refers to the large frequency of this type of seizure disorder: several hundred spells occurring in a given day. Absence seizures may occur without warning and consist of a sudden interruption of consciousness. The term “absence” refers to being “not present.” Characterized by the patient staring and stop talking for brief periods. Some patients may have a brief burst of clonic movements of the eyelids (“blinking” or “fluttering” of the eyelids), facial muscles or fingers. The patient with absence seizures may manifest AUTOMATISMS characterized by stereotypic lip smacking, chewing and fumbling movements of lips and fingers. The spells typically last several seconds, these type of patients do not typically fall to the ground. After the patient reasserts contact with realty, they may only experience the loss of a thread of a conversation or losing their place in reading a book to punctuate this “blank” period. Typical absence rarely begins before 4 years or after puberty.
Absence Variants (Juvenile Myoclonic Epilepsy of Janz)
This form of epilepsy is characterized by myoclonic jerks that affect the flexor muscles of the neck and shoulders. There is a tendency towards the seizures beginning shortly after awakening. Intelligence is generally not affected. The response to anti-epileptic medications is usually excellent, but requires lifelong treatment.
Characterized by the onset between ages 2-6. Associated with a mixture of atonic, motor, tonic-clonic and partial seizures associated with intellectual impairment. Demonstrates a distinctive slow (1-2 1/2 Hz) spike and wave EEG pattern.
West Syndrome
Characterized by INFANTILE SPASMS, “HYPSARRYTHMIA” EEG pattern consisting of continuous multifocal spikes and slow waves of large amplitude associated with INTELLECTUAL DEVELOPMENT ARREST (mental retardation).
Jacksonian (March) Motor Seizures
begin with a tonic contraction of the fingers of one hand, face or the foot. This evolves into clonic movements in these body parts analogous to a generalized tonic-clonic seizure. In the classic jacksonian form the seizure spreads from the hand, up to the face, down the leg opposite the side of the cerebral irritative focus. In this fashion appears to MARCH from the body part first affected to other body parts.
Rolandic Epilepsy (Benign Childhood Epilepsy with Centrotemporal Spkes)
A self-limited epilepsy of childhood that begins typically between the ages of 5-9 years and abates spontaneously by the teenage years. Transmitted as an autosomal dominant trait Characterized by nocturnal tonic-clonic seizures of focal onset. Seizures evolve into clonic contractions of one side of the body.
Epilepsia Partialis Continua
Another type of focal motor epilepsy characterized by clonic movements of one muscle group. Typically the face, arm or leg demonstrate clonic movements that are repeated at regular intervals for many hours, days or months. Thought to represent a form of focal motor status epilepticus. Poorly controlled by anti-convulsant medications.
Somatosensory and Visual Seizures-
nearly always indicative of a seizure focus in or near the post-rolandic (sylvian) convolution of the opposite cerebral hemisphere to the sensory phenomenon.Typically described as a “tingling” or “pins and needles” sensation or as a crawling sensation of the affected body part.
Visual Seizures:
Occur near the occipital lobe and usually produce visual sensations of darkness or sparks or flashes of light
Auditory Hallucinations:
Infrequent, occasionally the patient with a seizure focus in one superior temporal convolution will report a “buzzing” or “roaring” sensation in the ear.
Vertiginous Sensations
are usually caused by a lesion localized to the superior-posterior temporal region or the junction between the parietal and temporal lobes. Characterized by giddiness or light headedness.
Olfactory Hallucinations
Often associated with lesions of the inferior & medial aspects of the temporal lobe in the region of the hippocampal convolution or uncus (termed UNCINATE SIEZURES OR ‘FITS BY JACKSON’). Usually the perceived odor is projected out into the environment and is described as foul (CACOSMIA).
Gustatory Hallucinations:
have also been described with temporal lobe lesions.
Psychomotor or Temporal Lobe Epilepsy
Differ from major generalized and absence types of seizures in that the aura may occur with a focal seizure of simple type or a hallucination or perceptual hallucination. Instead of a complete loss of control of thought and motor skills, there is a period of altered behavior and consciousness, for which the patient is later found to be amnestic.
Febrile Seizures
peculiar to infants and children between 6 months and 3 years of age with a strong inherited tendency. Generally regarded as a benign condition. Takes the form of a generalized motor seizure occurring as the body temperature reaches its peak. The spell typically does not last longer than a few minutes (e.g. less than 15 minutes with no FOCALITY to the spell) and recovery is usually complete. The risk of developing epilepsy later in life is little different than that of the general population. Febrile seizures should not be confused with an acute encephalitic state that presents as a febrile illness. This type of presentation is typically characterized by FOCAL OR PROLONGED seizures, GENERALIZED OR FOCAL EEG abnormalities and REPEATED episodes of febrile convulsions. This type of process can progress to status epilepticus and prove fatal to the child.
Reflex Epilepsy
- a term to describe a small subgroup of seizures that occur in response to a specific stimulus: VISUAL, AUDITORY, SOMATOSENSRY, WRITING, READING, or EATING. Visually evoked seizures are the most common type of reflex epilepsy and are typically generalized, triggered by the photic stimulation of television or video games.
Hysterical (Pseudo) Seizures
Not a true seizure disorder. They are spells that on casual examination, appear to have features suggestive of a seizure. They are in fact NON-EPILEPTIC in nature. In other words these spells are NOT CAUSED by an abnormal cerebral neuronal discharge. Often they may occur with psychiatric disorders as a symptom of hysteria. Pseudoseizures are characterized by a motor display of stereotypic asynchronous thrashing of the limbs and repeated “to an fro” movements of the head, hand biting, kicking, struggling against restraints, pelvic thrusting, opisthotonus, and screaming or talking during the “ictus”.
The terms: “Déjà vu” and “Jamais vu” in the context of epilepsy clinical manifestations.
Characteristic of complex partial seizure. They may experience feelings of an increased familiarity with objects or people never seen before (déjà vu) or a feeling of strangeness or unfamiliarity (jamais vu) of objects or people that have been seen before and would ordinarily be known to the patient. Epigastric and abdominal phenomena are frequent
The Nature of the Discharging Lesion and the phenomenon of Kindling & the phenomenon of Todd’s paralysis.
The epileptic seizure is defined by a sudden alteration of CNS function resulting from a high voltage electrical discharge. The discharge arises from an arrangement of excitable neurons in parts of the cerebrum, sub-cortical and brainstem structures as well. Under the proper circumstances, a seizure can be elicited in a normal cerebrum such as DRUG INGESTION (COCAINE), by the administration or withdrawal of alcohol, or by repeated cerebral stimulation with sub-convulsive electrical impulses (KINDLING). The neurons surrounding the ictal focus are hyperpolarized from the beginning and are GABAergic in nature, inhibiting the neurons within the seizure focus. Once the intensity of the seizure discharge exceeds a certain critical threshold, it overcomes the inhibitory influence of the surrounding neurons and spreads to adjacent cortical and sub-cortical regions. Soon after the spread of excitation begins, diencephalocortical inhibition begins and alters the persistent discharge characteristics of the tonic phase of the seizure, to the intermittent bursts characteristic of the clonic phase. The intermittent clonic burst become less and less frequent and finally cease altogether as the neurons exhaust their fuel supply (glucose). This may explain the phenomenon of TODD’S PARALYSIS; a condition of temporary monoparesis or paralysis of the affected extremity after a seizure.
The Genetics of Epilepsy.
 Most clearly observed in absence spells with 3-per-second spike and wave discharge and Rolandic Epilepsy. These types of epilepsies are transmitted as incompletely penetrant autosomal dominant traits. Other epileptic syndromes of proven inheritence are benign myoclonic epilepsy of childhood (autosomal recessive) and benign neonatal familial convulsions (autosomal dominant). The tendency to develop febrile seizures is probably inherited. It is unclear whether the mode of inheritance is polygenic or autosomal dominant in nature. The overall concordance rate for epilepsy in monozygotic twins is 60% and 13% for dizygotic twins.
The diagnostic and evaluative approach towards seizures and epilepsy.
if neuro exam is normal and hx is unclear it is considered ok to delay treatment until next episode as AEs of AEDs can be severe
HOWEVER, unless hx is clear for non-neuro event most patients get CT, EEG (MONTAGE), and LP
The treatments for seizures and epilepsy: Pharmacologic, Non-pharmacologic, and Surgical.
AEDs—watch out for stevens-johnson-syndrome & Toxic Epidermal Necrolysis

Ketogenic diet – low sugar

Left vagal nn stimulation
Reproductive issues relating to women with epilepsy.
estrogen = proconvulsant
progesterone = anticonvulsant
AEDs can be teratogenic = but 90% of women w/ epilepsy have normal healthy babies
The relationship between bone health and the administration of antiepileptic drugs.
AED’s impair bone health in children and adults. Problems include rickets, osteomalacia, osteoporosis and fractures.
secondary to a deficiency of active Vitamin D, calcium or phosphorus. Clinical manifestations may include: hypotonia, weakness, “bowing deformity” (genu varum) or “knock kneed” deformity (genu valgum) or “rachitic rosary” of the chest wall.
- Refers to a softening of bone secondary to a defect of bone mineralization, but in contrast to rickets occurs after bony growth as stopped. Involves only the long bones, but not the growth plate.
Described as a reduction in bone mass that may cause an increased risk for fracture. The diagnosis of osteoporosis currently is dependent upon measurement of bone mineral density (BMD) via a technique known as dual-energy x-ray absorptiometry (DXA or “Dexa scan”).
The medico-legal implications of driving with the diagnosis of epilepsy.
If you have had an alteration in consciousness that is likely to be recurrant physician MUST LEGALLY advise patient not to drive. This must be put in chart given to health department which in turn goes to DMV. DMV decides patients fitness to drive.

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