SEIZURES

• A seizure is an episode of abnormally

synchronized and high-frequency firing of
neurons in the brain that results in abnormal
behavior or experience of the individual.
• different types of seizures can occur
depending on the location in the brain and the
duration and type of abnormal electrical
activity.
• Epilepsy is a disorder in which there is a
tendency to have recurrent unprovoked
seizures.
• Thus, a seizure is a symptom of abnormal brain
function, which can occur in patients with or
• without epilepsy.
• seizures can occur in patients with epilepsy but
can also be provoked in normal individuals by
conditions such as electrolyte abnormalities,
alcohol withdrawal, electroshock therapy,
toxins, etc.
• Epilepsy in a given individual can be caused by
genetic, structural, metabolic or other
abnormalities, or the cause may be unknown.
• Epilepsy is a fairly common disorder, affecting
close to 1% of the population.
• The lifetime risk of having a single seizure is
even higher, with estimates ranging from 10%
to 15% of the population.
Classification
• Ictal means during a seizure, post-ictal means
immediately after a seizure, and interictal
means between seizures.
 epilepsy syndromes are divided
• localization-related (partial, focal, or local)
epilepsy
• and generalized, or primary generalized,
epilepsy.
 Partial seizures subdivided

• simple partial and complex partial seizures

 Simple partial
• consciousness is spared. For example, if a
patient has rhythmic twitching movements of
the left hand caused by a simple partial seizure
in the right motor cortex hand area, they will
remain alert, talk normally during the seizure,
and clearly recall the entire episode afterward.
• Partial seizures can have positive symptoms,
such as hand twitching, or negative symptoms,
such as impaired language abilities.
 The term “aura”
• means “breeze” and was originally used in ancient
Greece by Galen’s teacher Pelops to describe the
sensation felt by one of his patients in his leg prior
to having a large seizure.
• Auras are brief, simple partial seizures of any type
that are experienced by a patient with no outward
behavioral manifestations.
• They can occur in isolation, or they may serve as a
warning for a larger seizure, which begins as an aura
and then spreads.
 Simple partial seizures
• With brief, simple partial seizures there are
often no new deficits post-ictally.
• If the seizures are prolonged or recurrent,
there may be post-ictal depressed function of
the local region of cortex involved, producing
focal weakness (Todd’s paresis) or other
deficits
 Complex partial seizures
• there is impairment of consciousness
• Impairment of consciousness in complex partial
seizures may be complete or mild, sometimes
making the distinction from simple partial seizures
difficult.
• The most common localization for complex partial
seizures is the temporal lobes.
• Patients with complex partial seizures arising from
the temporal lobes are said to have temporal lobe
epilepsy (formerly known as psychomotor epilepsy)
 Medial temporal lobe–onset complex
partial seizures
• Often begin with an aura, as described earlier, of an
unusual, often indescribable sensation, or with
epigastric, emotional, or olfactory phenomena, or with
deja vu.
• Sometimes no aura can be recalled.
• The initial symptoms are followed by unresponsiveness
and loss of awareness, during which the patient may
have automatisms, which are usually repetitive
behaviors such as lip smacking, swallowing, or
stereotyped hand or leg movements such as stroking,
wringing, or patting.
 In temporal lobe seizures
• the ipsilateral basal ganglia are often involved, causing
contralateral dystonia or immobility while the ipsilateral
extremities remain free to exhibit automatisms.
• These behaviors can be falsely localizing to the
unpracticed eye, since the side ipsilateral to the
temporal lobe seizure shows movements (automatisms),
while the contralateral side is relatively still (dystonia).
• Sometimes, instead, there is simply bland staring,
immobility, and unresponsiveness.
• Autonomic phenomena such as tachycardia, pupillary
dilation, and piloerection can occur.
• Typical duration is 30 seconds to 1 to 2 minutes.
 Post-ictal deficits
• may last from minutes to hours and can include
unresponsiveness, confusion, amnesia, tiredness,
agitation, aggression, and depression.
• Headache is common.
• Patients with left temporal–onset seizures may have
post-ictal language deficits, although care must be
taken to distinguish such deficits from overall
decreased responsiveness, which is nonlocalizing.
• There may also be some mild post-ictal weakness or
hyperreflexia contralateral to the side of onset.
 Generalized seizure
• The most common type of generalized seizure is a
generalized tonic-clonic seizure, or grand mal
seizure
• Ageneralized tonic-clonic seizure can be
generalized from the onset, or it may begin focally
and then secondarily generalize.
• It typically begins with a tonic phase characterized
by loss of consciousness and generalized
contraction of all muscles lasting for 10 to 15
seconds.
 Generalized seizure
• Next is a clonic phase, characterized by rhythmic
bilateral jerking contractions of the extremities,
usually in flexion, at a frequency of about 1
hertz, which gradually slow down and then stop.
• Incontinence or tongue biting is common.
• There is usually a massive ictal autonomic
outpouring with tachycardia, hypertension,
hypersalivation, and pupillary dilation.
• Typical duration is 30 seconds to 2 minutes
 Generalized seizure
• Immediately post-ictally, patients lie immobile,
flaccid, and unresponsive, with eyes closed, breathing
deeply to compensate for the mixed metabolic and
respiratory acidosis produced by the seizure.
• Within a few minutes they usually begin to move and
respond.
• Post-ictal deficits last from minutes to hours and
include profound tiredness, confusion, amnesia,
headache, and other deficits related to the location of
seizure onset.
Typical absence seizures (petit mal seizures)

• are brief episodes of staring and unresponsiveness

lasting for about 10 seconds or less.
• There are no post-ictal deficits, except for a lack of
awareness of what occurred during the brief time
of the seizure.
• These seizures are accompanied by a characteristic
generalized 3–4 hertz spike and wave discharge on
electroencephalogram (EEG) recordings
• Although absence seizures are generalized,
they differ from grand mal seizures, which
begin with a prolonged high-frequency
electrical discharge that causes a more severe
disruption of brain function.
• Absence seizures are most common in
childhood and can occur multiple times per
day, causing impaired school performance.
• They often can be provoked by
hyperventilation, strobe lights, or sleep
deprivation.
 Status epilepticus
• When seizures of any type occur either
continuously or repeatedly in rapid succession,
the condition is referred to as status epilepticus.
• Generalized tonic-clonic status epilepticus is a
medical emergency that requires immediate
and aggressive treatment.
• When first-line agents such as benzodiazepines
and phenytoin are ineffective, intubation and
general anesthesia may be necessary.
 Status epilepticus
• EEG recording should always be performed
urgently in this situation to ensure that
electrographic seizure activity has stopped.
• Blood tests (see the next subsection), head CT,
and lumbar puncture (when appropriate)
should be performed without delay so that
other specific treatments can be initiated.
• Prognosis depends mainly on the promptness
of treatment and on the underlying etiology
 Diagnosis and Etiology
• Epileptic seizures are usually brief events that are
stereotyped from one episode to the next in a
given patient and often fit one of the typical
seizure patterns already described. If the events
are epileptic seizures, the next step is to
determine the type of seizure as well as the
localization if the seizures are focal in onset
• Finally, a cause for the seizures should be sought
 Causes of Seizures
• Head trauma • Alcohol, benzodiazepine, or
barbiturate
• Cerebral infarct
• withdrawal
• Intracerebral hemorrhage • Meningitis
• Vascular malformation • Encephalitis
• Cerebral venous thrombosis • Brain abscess
• Anoxia • Vasculitis
• Mesial temporal • Neoplasm
(hippocampal) sclerosis • Inborn error of metabolism
• Electrolyte abnormalities • Neuronal migrational
• Hypoglycemia abnormality
• Hereditary epilepsy syndrome
• High fever
• Neurodegenerative disorder
• Toxin exposure
• Nonepileptic seizures
The fundamental tools used for diagnosis in
epilepsy
• clinical history;
• physical exam;
• basic blood tests;
• MRI scan with special thin
• coronal cuts and pulse sequences used to view
the medial temporal, cortical and subcortical
structures in detail;
• an interictal EEG
 Additional
tests can be helpful in diagnosis and localization
• admission for continuous video and EEG
monitoring in an attempt to obtain an ictal
recording;
• ictal and interictal nuclear medicine tests, such as
SPECT (single photon emission computed
• tomography) and PET (positron emission
tomography) scans;
• neuropsychology testing. In patients who are
being considered for epilepsy surgery, additional
tests, including a Wada test are often performed
 Individual causes of seizures
• The most common causes vary with age, resulting in a
bimodal age distribution for the risk of developing
new-onset seizures.
• The risk of new-onset seizures is high in infancy and
childhood, declines in adulthood, and then rises again
in the elderly population.
• The most common causes of seizures in infancy and
childhood are febrile seizures, congenital disorders,
and perinatal injury.
• In contrast, the most common cause in patients over
age 60 years is cerebrovascular disease, followed by
brain tumors and neurodegenerative conditions.
• The risk of seizures after head trauma
increases with the severity of the injury.
• Minor head injuries with no clear structural
damage and only brief confusion or loss of
consciousness (for less than 30 minutes) do not
pose a significant risk for subsequent seizures.
• Hypoglycemia, electrolyte abnormalities such
as hyponatremia, hypernatremia,
hypocalcemia, or hypomagnesemia; metabolic
abnormalities, or exposure to a variety of
endogenous or exogenous toxic substances can
provoke seizures
• NB!!! It is therefore essential to check blood
chemistries, including glucose, sodium,
calcium, magnesium, liver function tests,
creatinine, and a toxicology screen when
assessing a patient with new-onset seizures,
especially in the acute setting, so that these
abnormalities can be corrected.
 Febrile seizures
• are fairly common, occurring in 3 to 4% of all children,
usually between the ages of 6 months and 5 years.
• These are usually brief, generalized tonic-clonic
seizures called simple febrile seizures, which are not
associated with increased risk of epilepsy.
• However, there is an increased risk of subsequent
epilepsy in children with complex febrile seizures,
defined as seizures lasting more than 15 minutes, or
occurring more than once in 24 hours, or having focal
features.
 Febrile seizures
• Some of these children may have an underlying
cause for epilepsy that is first unmasked in the
setting of fever.
• It has also been hypothesized that prolonged febrile
seizures cause subsequent temporal lobe epilepsy in
some patients, through a pathologic process called
mesial temporal sclerosis or hippocampal sclerosis,
in which there is marked neuronal loss and gliosis,
particularly in the CA1 sector of the hippocampus,
as well as in other medial temporal structures