Semiological Seizure

Classification
Introduction

EUN, SO-HEE
Pediatric Neurology
Korea University Ansan Hospital
Classification of Epileptic Seizures
ILAE, 1981

Clinical and electrographic classification

Simple partial seizure

Partial Complex partial seizure
Partial seizure with secondarily generalization

Absence
Tonic, Clonic, Tonic-clonic seizure
Generalized
Myoclonic seizure
Atonic seizure

Unclassified
Classification of Epileptic Seizures
ILAE, ~ 2010

Generalized Onset Focal Onset

Originating at some point

within, and rapidly engaging, Originating within networks
bilaterally limited to one hemisphere
distributed networks
Classification of Epileptic Seizures
ILAE, ~ 2010

Generalized seizures
Tonicclonic (in any combination)
Absence
Myoclonic
Clonic
Tonic
Atonic
Focal seizures
Unknown
Epileptic spasms
Descriptors of focal seizures according to
degree of impairment during seizure

Without impairment of consciousness or awareness

- observable motor or autonomic components
- subjective sensory or psychic phenomena only

With impairment of consciousness or awareness

Evolving to a bilateral, convulsive seizure

Terms in the Glossary of 2001 ILAE report

Epilepsia 42(9):1212-8, 2001
 Semiology ()

That branches of linguistics concerned
with signs and symptoms

Ictus

A sudden neurologic occurrence such as a
stroke or an epileptic seizure

Glossary of 2001 ILAE report

Epilepsia 42(9):1212-8, 2001
 Detailed Analysis of Seizure
Semiology

Seizure - main symptom of epilepsy

Seizure control - target of treatment

Classification of the epilepsy syndrome

Presurgical workup

Differentiate between epileptic and nonepileptic
seizures
 Diagnosis of Epilepsy

EEG Neuroimaging

Analyze separately
Seizure
Integrate
Evolution
Define precisely

Functional
Clinical History Neuroimaging
Neurologic Exam
 Seizure Semiology

1998, Lders et al.

Semiological seizure classification

2001, ILAE Commission Report

Glossary of descriptive terminology for
ictal semiology
Ictal Phenomena
4 categories

Motor

Sensory

Consciousness

Autonomic
Semiological Seizure Classification
Lders et al. (1998)

Prominent
Features Epileptic Seizure

Motor sphere  Motor seizure

Sensorial sphere  Aura

Consciousness  Dialeptic seizure

Autonomic sphere  (Autonomic aura)

Autonomic seizure
 Motor Seizures

2 major subgroups
Simple : Simple, unnatural
Reproducible by direct stimulation of the
primary motor cortex
Complex : Complexity of movement
Generated by widespread neuronal matrices
Inappropriate for the situation
 Simple Complex
Myoclonic
Tonic Hypermotor
Epileptic spasm
Automotor
Clonic
Tonic-clonic Gelastic
Versive

Subtypes
- duration of the muscle contraction
- rhythmicity of movement repetition
- muscles involved
 Auras

Somatosensory
Visual

Auditory
Gustatory

Olfactory
Autonomic

Abdominal
Psychic

Unclassifiable
 Dialeptic Seizures

Dialeptic, old Greek, means to interrupt, stand
still, or pass out

Alteration of consciousness

Episodes of unresponsiveness or decreased
responsiveness that area not caused by motor
alterations

Associated with complete or at least partial
amnesia for the episode
 Autonomic Seizures

Objective proof of the autonomic alteration

(i.e., tachycardia documented by EKG
monitoring)

vs Autonomic Aura
 Special Seizures

Atonic seizures

Astatic seizures

Negative myoclonic seizures

Akinetic seizures

Aphasic seizures

Hypomotor seizures
 Summary of Lders Classification
I. EPILEPTIC SEIZURE
1. Motor seizure
Simplea Tonica Clonica Myoclonica
Versivea Tonic-clonic Epileptic spasma
Complexb Hypermotorb Automotorb Gelastic
2. Aura Somatosensorya
Visuala Auditory Olfactory Gustatory
Autonomica
Abdominal Psychic
3. Dialeptic seizureb
4. Autonomic seizurea
5. Special seizure Atonica Astatic Hypomotorb
Akinetica Aphasicb Negative myoclonica

II. PAROXYSMAL EVENT Organic Psychogenic

a: Localizing modifiers (L, R, axial, gen, bilat, asymm; hand, etc)
b: Lateralizing modifiers (left hemispheric or right hemispheric)
2001 ILAE, Terms Describing
Epileptic Seizure Semiology
 Ictal Phenomenology
: Glossary of Ictal Semiology

To provide a standard terminology to communicate

Seizure semiology
Ictal semiology : motor / nonmotor / autonomic
Modifier : somatotopic / timing / duration / severity
Peri-ictal : prodrome / postictal phenomenon
 ILAE
Terminology
1. Motor

Motor - Elementary

Sensory - Automatism

Consciousness
2. Nonmotor

Autonomic
3. Autonomic

Involves musculature in any form.

The motor event could consist of an increase (positive) or decrease
(negative) in muscle contraction to produce a movement.
 1.1 Elementary motor 1.2 Automatism
1.1.1 Tonic
1.2. 1 Oroalimentary
1.1.1.1 Epileptic spasm
1.2. 2 Mimetic
1.1.1.2 Postural
1.2. 3 Manual or pedal
1.1.1.2.1 Versive
1.2. 4 Gestural
1.1.1.2.2 Dystonic
1.2. 5 Hyperkinetic
1.1.2 Myoclonic
1.2. 6 Hypokinetic
1.1.2.1 Negative myoclonic
1.2. 7 Dysphasic
1.1.2.2 Clonic
1.2. 8 Dyspraxic
1.1.2.2.1 Jacksonian march
1.2. 9 Gelastic
1.1.3 Tonic-Clonic
1.2.10 Dacrystic
1.1.3.1 Generalized tonic-clonic
1.2.11 Vocal
1.1.4 Atonic
1.2.12 Verbal
1.1.5 Astatic
A single type of contraction of More or less coordinated,
a muscle or group of muscles repetitive, motor activity
 ILAE
Terminology

1. Motor

Motor

Sensory 2. Nonmotor

Consciousness - Aura / Sensory seizure
- Dyscognitive

Autonomic
3. Autonomic
 2.1 Aura / 2.2 Sensory Seizure
2.2.1 Elementary 2.2.2 Experiential
2.2.1.1 Somatosensory
2.2.1.2 Visual
2.2.1.3 Auditory 2.2.2.1 Affective ()
2.2.1.4 Olfactory 2.2.2.2 Mnemonic ()
2.2.1.5 Gustatory 2.2.2.3 Hallucinatory ()
2.2.1.6 Epigastric 2.2.2.4 Illusory ()
2.2.1.7 Cephalic
2.2.1.8 Autonomic
Affective, mnemonic, or composite
A single, unformed phenomenon
perceptual phenomena including
involving one primary sensory
illusory or composite hallucinatory
modality
events
 2.3 Dyscognitive Seizure

1. Disturbance of cognition : most apparent features

2. 2 following components involved or undetermined

Perception : sensory information
Attention : selection of perception or task
Emotion : appropriate affection of a perception
Memory : store and retrieve percepts or concept
Executive function : motor activity
3. Autonomic Events

3.1 Autonomic aura

3.2 Autonomic seizure

4. Somatotopic Modifiers
4.1 Laterality
4.1.1 Unilateral
4.1.1.1 Hemi-
4.1.2 Generalized (syn. "bilateral")
4.1.2.1 Asymmetrical
4.1.2.2 Symmetrical

4.2 Body part

4.3 Centricity
4.3.1 Axial
4.3.2 Proximal limb
4.3.3 Distal limb
5. Modifiers and Descriptors of
Seizure Timing
5.1 Incidence
5.1.1 Regular, irregular
5.1.2 Cluster
5.1.3 Provocative factor
5.1.3.1 Reactive
5.1.3.2 Reflex

5.2 State dependent

5.3 Catamenial
6. Duration 6.1 Status epilepticus

7. Severity
8. Prodrome

9.1 Lateralizing phenomenon

9.2 Non-lateralizing phenomenon

9. Postictal 9.2.1 Impaired cognition

phenomenon 9.2.1.1 Antegrade amnesia

9.2.1.2 Retrograde amnesia

9.2.2 Psychosis
 Summary of ILAE Classification

Ictal semiology
Motor : elementary, automatism
Nonmotor : aura, sensory, dyscognitive
Autonomic : aura, seizure
Modifier
Somatotopic : laterality, body part, centricity
Timing : incidence, state, catemenial
Duration : status epilepticus
Severity
Peri-ictal
Prodrome
Postictal phenomenon : lateralizing, non-lateralizing