Seizure disorders

and its
management
Dr. Lalit kumar
Assistant Professor
Department of Medicine
SEIZURE

 A Transient occurrence of
signs and/or symptoms due
to abnormal excessive
hypersynchronous neuronal
activity in brain
 Have to identify if the
seizure is focal onset or
generalised onset
 Identify the cause –seizure
 Most important
investigation :MRI and EEG
EPILEPSY

 It is defined as 2 or more unprovoked seizure or >60./.

Risk of a second seizure –without an identifiable cause –it
refers to a clinical phenomenon more than a disease –
with a chronic underlying pathology lurking deep down
somewhere
 “Epilepsy is a disorder of brain characterised by an
enduring predisposition to generate epileptic seizure”
Classification of seizure types

 1. Focal Onset
 (Can be further described as having intact or impaired awareness, motor or
 nonmotor onset, or evolve from focal to bilateral tonic clonic)
 2. Generalized Onset
 a. Motor
 Tonic-clonic
 Other motor (e.g., atonic, myoclonic)
 b. Nonmotor (absence)
 3. Unknown Onset
 a. Motor, nonmotor, or unclassified
Focal onset seizure

 Focal seizures arise from a neuronal network either discretely

localized within one brain region or more broadly distributed but still
within a cerebral hemisphere.
 FOCAL ONSET SEIZURE WITH AWARENESS:-
 Focal activity: Focal onset seizure
 Consciousness normal: with no loss of consciousness
 Next step : MRI(Tuberculoma in fronto-parietal part of brain)
 EEG:-After the episode of seizure is normal as there is no structural
deformity producing the seizure.
 Typically clonic movements at 2-3hz with abnormal movements of face
synchronous with the limbs
 Focal onset seizures with awareness-Always medical cause –Focal
motor(M.C)-Tonic clonic –IOC:MRI-EEG :Normal -No role for antiepileptics
 Non motor onset (very rare)-sensory,autonomic or emotional symptoms -
aura
 Jacksonian march :Spread of
seizure activity over a large area-
Distal to proximal.

Todd’s palsy:- Post ictal

Terms hemiplegia –can last upto
related to 24hours.
focal onset
seizures Epilepsia Partialis Continua:-
with (Hours to days)-Associated with
awareness:- CKD/Uremia
Focal onset seizures with impaired
awareness

 Has no identifiable cause –enduring predisposition

 Epileptiform syndrome –medial temporal lobe-MC
Pathology mesial hippocampal sclerosis(MRI)-EEG
manifestations-start anti epileptics
 History of febrile seizures in childhood
 Aura is seen in focal seizures with impaired
awareness,aura is never seen in Generalised seizures
 3A’s-AURA,AUTOMATISM,ARREST
GENERALISED SEIZURE

 ABSENSE SEIZURE-TYPICAL,ATYPICAL
 ATONIC SEIZURE
 TONIC SEIZURE
 CLONIC SEIZURE
 TONIC CLONIC SEIZURE
 MYOCLONIC SEIZURE
 JUVENILE MYOCLONIC SEIZUE
Generalised onset seizures
 ABSENCE SEIZURES:-
 Child 5-7yrs,median age of 6yrs
 Loss of consciousness
 A part of epilepsy syndrome
 Sudden brief lapses of consciousness without loss of postural
control
 Lasts for only seconds,regains consciousness quickly and no post
ictal confusion
 Pause or stare >automatisms >eye involement ,aura never seen
 Associated with genetically determined epilepsies in childhood
 Day dreaming with normal IQ,Hyperventilation provocative
 3Hz spike and wave discharge on EEG
ATYPICAL ABSENCE SEIZURE
 Loss of consciousness of longer duration
 More obvious motor sign
 Generalized asymmetrical slow spike and wave pattern

 ATONIC SEIZURE
 Complete loss of muscle tone
 Loss of consciousness
 Falling and striking floor
 100% part of epilepsy syndrome usually lennox gestaut
syndrome
 Associated with myoclonic seizures
  Sudden brief shock like contraction
 Part of epilepsy syndrome-predominant in
Juvenile myoclonic epilepsy
 Focal onset myoclonic seizures can be a part of
CKD,Uremia
MYOCLONIC  Generalised /face and trunk/individual muscles
SEIZURE  Very subtle to dramatic and short lasting
 Impossible to determine LOC due to very short
nature
 Component of absence/GTCS-multiple seizure
types-Lennox gastaut syndrome
JUVENILE MYOCLONIC EPILEPSY

 Adolescents,female>male,normal cognition.
 Upon awakening/triggered by sleep deprivation
 Upper limb >>>lower limb
 Life long anti seizure therapy,DOC-Valproate
 Other drugs-leviteracetam/lamotrigine/topiramate
 EEG:Poly spike and wave pattern
GENERALISED TONIC CLONIC
SEIZURE(GTCS)

 Pseudoseizures :-
 Usually in adolescent girls
 Same intensity movements
 Can recollect/remember during episodes
 No dilation of pupil
 Thrusting /axial movements
 No tongue bite
 No urinary and fecal discharge
DIFFERENCE B/W SEIZURE &
SYNCOPEZ
CAUSES

 METABOLIC:-
 1-HYPOGLYCEMIA
 2-HYPONATREMIA
 3-HYPOCALCEMIA
 4-HYPOMAGNESEMIA
 5-SEPSIS
 6-HEPATIC ENCEPHALOPATHY
 7-RENAL:CKD,UREMIC SEIZURES
 8-TOXINS
DRUGS

 Theophylline
 Imipenem
 Cefepime
 Quinolones
 Lithium
 Alcohol ,barbiturate , BZD withdrawal can precipitate
seizures
 Acute structural brain injury in stroke can causes focal
seizure & depending on the extent of stroke of stroke
can have secondary generalisation
OTHER CAUSES:-
 VIRAL ENCEPHALITIS:-
 Especially of HSV & Japanese encephalitis,usually seen as status
epilepticus

 AUTOIMMUNE ENCEPHALITIS:-
 Hashimoto’s,SLE,Amyloid
 Anti NMDA antibodies are seen

 PARANEOPLASTIC ENCEPHALITIS:-
 Anti-Hu antibodies –small cell lung cancer-precipitate seizure
 Seizure +,but EEG might be normal-suggested to do PET scan to
rule out paraneoplastic syndrome
APPROCH TO PATIENT WITH
SEIZURE DISORDER
 HISTORY
 Precipitating factor
 Feeling of light headedness just before the faint
 Gradual loss of consciousness
 Presence of an aura
 Prolong duration of seizure may suggest conversion disorder
 Recovery time usually quick in syncope
 Tongue biting never occur in syncope
 Injury during fall
 Incontinence of urine, limb stiffness & twitching(true & pseudo
both)
  TIMING OF SEIZURE
 Seizure occurs in the presence of others , not
when alone(conversion disorder)
 Brief jerking movements soon after falling
asleep(benign sleep myoclonus)

Continue…  Angry child who is having a temper tantrum and

hold their breath before seizure occurs(breath
holding attack)
 Family conflict –conversion disorder
 Palpitation
 Association with exertion(cardiac syncope)
PHYSICAL EXAMINATION

 Presence or absence of tongue biting

 Urinary incontinence
 Presence of post-ictal state(suggest true seizure)
 Hypotension,sweating,clamminess(suggest vasovagal but may also be
cardiac)
 Pulse,bradycardia or tachyarrythmia
 Abnormal seizure movements-conversion disorder
IF PATIENT IS HAVING SEIZURE
DURING PRESENTATION
 When a patient presents shortly after a seizure, the first priorities are
attention to vital signs, respiratory and cardiovascular support, and
treatment of seizures if they resume . Life-threatening conditions such
as CNS infection, metabolic derangement, or drug toxicity must be
recognized and managed appropriately.
 PRIMARY SURVEY
 A-Airway with cervical spine(keep on lateral position)
 B-Breathing
 C-Circulation
 D-Disability
 E-Exposure
IF NOT WITH SEIZURE

 When the patient is not acutely ill, the evaluation will initially focus on
whether there is a history of earlier seizures. If this is the first seizure,
then the emphasis will be to
 (1) establish whether the reported episode was a seizure rather than
another paroxysmal event,
 (2) determine the cause of the seizure by identifying risk factors and
precipitating events, and
 (3) decide whether antiseizure drug therapy is required in addition to
treatment for any underlying illness. In the patient with prior seizures or
a known history of epilepsy, the evaluation is directed toward
 (1) identification of the underlying cause and precipitating factors, and
(2) determination of the adequacy of the patient’s current therapy.
IF NOT WITH SEIZURE

FOCAL NEUROLOGICAL SIGNS- BLOOD PRESSURE-hypertensive

TEMPERATURE-Infection,alcohol
Peripheral weakness,altered encephalopathy,cerebrovascular
withdrawal
sensation,altered reflexes attack

Signs of raised intracranial Bulging anterior fontanelle (in

pressure:papilloedema ,bradycardi children <18months) shows raised
a,hypotension,lateral gaze palsy ICP
INVESTIGATIONS

 RBS
 CBC,LFT,KFT
 ELECTROLYTES-NA+,K+,CA++
 TOXINS SCREENING
 NCCT HEAD,MRI
 EEG
 LUMBER PUNTURE
 CXR,USG
MEDICATION
FOR ECLAMPSIA

 Magnesium sulphate is drug of choice

 Should be continued after 24hr of last seizure or after delivery
 The regimen call for using
 0hr dose of 4gm 20% concentration mgso4 iv,followed by 10gm
50% mgso4 given im
 A maintainenance does of 50% mgso4 is given 4 hourly.
APPROCH
STATUS EPILEPTICUS

 status epilepticus is condition resulting either from the failure of

mechanism responsible for seizure termination or from the
initiation of mechanisms,which lead to abnormally,prolonged
seizures
 It is a condition,which can have long term
consequences ,including neuronal death,neuronal injury and
alteration of neuronal networks,depending on the type and
duration of seizure
MANAGEMENT
 THANK YOU