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Movement disorders
- 11. Seizure is an ACUTE Manifestation Epilepsy is a Chronic DISEASE
- 12. SEIZURE AND EPILEPSY • SEIZURE – Episode of paroxysmal and transient brain dysfunction. • EPILEPSY - Recurrent chronic seizures. Seizures are the indispensable characteristic of epilepsy
- 13. SEIZURE • It is episodes of abnormal motor , sensory , autonomic or psychic activity ( or combination of this ) that result from sudden excessive discharge from cerebral neuron.
- 14. Classification for causes of seizures Non-recurrent (Acute) With Fever Extra-cranial Infections Febrile Convulsions Intracranial Infections Meningitis Encephalitis Brain Abscess Subdural abscess Extra dural abscess Septic venous thrombosis Without Fever Traumatic Toxic Hypoxic Metabolic Vascular Recurrent (Chronic) Epilepsy Diagnosis requires the occurrence of at least ≥2 unprovoked seizures in a time frame of >24 hrs
- 15. Causes Acquired cause Cerebro vascular disease Brain tumor Brain infection Allergies Hypoxemia Fever Hypertension Drug & alcohol withdrawl Idiopathic cause Genetic Devlopmental defect
- 16. CAUSE ACCORDING TO AGE 0-1 MONTH Birth injury Asphyxia Hypoxia Infection Congenital malformatio n 1-6 MONTH CNS infection Traumatic Congenital malformatio n 6MONTH- 3YEAR Infection condition Idiopathic cause 3-6 year Febrile convulsion Idiopathic cause
- 18. PATHOPHYSIOLOGY Due to any cause ↓ Prolonged depolarization and other chemical changes ↓ Discharge the neurons in an uncontrolled manner ↓ Spreads to adjacent areas of brain or distant areas of the CNS ↓ SEIZURE
- 21. CLASSIFICATION A.GENERALIZED SEIZURES • Tonic-clonic seizures (Grandmal) • Absence seizures (petit mal) • Atonic and akinetic seizures • Myoclonic seizures B .PARTIALSEIZURES . Simple partial seizures . . Complex partial seizures. . Partial seizure with secondary generalization
- 22. MAIN DIFFERENCE Generalized Partial Both Cerebral Hemispheres Only a part of a hemisphere Loss of Consciousness No loss of consciousness Treated by Valproate Treated by Carbamazipine
- 24. PARTIAL SEIZURES • focal origine,Consciousness is fully preserved • Activity is restricted to discrete areas of cerebral cortex. • Typically associated with structural abnormalities of the brain.
- 25. PARTIAL SEIZURES • 1.Simple partial seizures with motor signs • Characterized by • Localized motor symptoms. • Abnormal discharges remain unilateral. • Manifestations • Aversive seizure • Eyes and head turn away from the side of the focus. • Awareness of movement .
- 26. CONTI,…. • Sylvan (Rolandic) seizure • Tonic-clonic movements involving the face salivation • Arrested speech • Most common during sleep. • Jacksonian march Orderly, sequential progression of clonic movements beginning in a foot, hand, or face and moving or “marching” to adjacent body parts.
- 27. 2.Simple partial seizures with sensory signs • Characterized by numbness, tingling, prickling, paresthesia or pain originating in one area.(eg. face or extremities) and spreading to other parts of the body. • Visual sensations. • Equillibrium. • Alteration in hearing,alfaction • Autonomic symptoms • Odd internal feelings • Uncommon in children younger than 8 years
- 28. 3.Complex partial seizures (psychomotor seizures) If counsciousness is imapired, symptomatically more complex then simple seizure is termed as”Complex seizure” • Unable to respond appropriately to visual or verbal commands during seizure. • Impaired recollection of awareness of Ictal phase. • Aura Ictal phase Post ictal phase
- 29. Partial Seizures with Secondary Generalization • Partial seizures can spread to involve both cerebral hemispheres and produce a generalized seizure, usually of the tonic-clonic variety. • Is often difficult to distinguish from a primarilly generalized tonic-clonic seizure. • Careful history identifies a preceding aura
- 30. GENERALIZED SEIZURES • Tonic-clonic seizures (Grandmal) • Absence seizures (petit mal) • Atonic and akinetic seizures • Myoclonic seizures
- 31. 1.Tonic-clonic seizures (Grandmal) • Tonic phase • Eyes roll upward • Immediate loss of consciousness • Stiffens in generalized, symmetric, tonic contraction of entire body musculature • Arms usually flexed • Legs, head & neck extended • Ictal cry • Apenic, may become cyanotic • Increased salivation and loss of swallowing reflex
- 32. Clonic Phase • Violent jerking movement and relaxation of muscles • May foam at the mouth • May be incontinent of urine & faeces. • Last no more than 1 minute.
- 34. POSTICTAL STATE • Appear to relax • May remain semiconscious and difficult to arouse • May awaken in a few minutes to hours • Remains confused for several hours. • Poor coordination • Mild impairment of fine motor movement • May have visual and speech difficulties • May vomit or complain of severe head ache. • On awakening is fully conscious • Usually feels tired • No recollection of entire event.
- 35. 2. ABSENCE SEIZURES • Sudden,Brief loss of consciousness • Counsciousness return as suddenly as it was lost and no post ictal confusion. • Onset usually between 4 and 12 years of age. • More common in girls than in boys • Usually cease at puberty • Minimal or no alteration in muscle tone • Abrupt onset suddenly develops 20 or more attacks daily • Events can be precipitated by hyperventilation ,hypoglycemia, fatigue.
- 36. 3. ATONIC AND AKINETIC SEIZURES • Characterized by • Onset usually between 2 and 5 years of age • Sudden, momentary loss of muscle tone and postural control • Events recur frequently during the day, particularly in the morning hours and shortly after awakening. • Manifestations • Loss of tone causes child to fall to the floor violently • Unable to break fall by putting out hand • Loss of consciousness only momentary
- 37. 4. MYOCLONIC SEIZURES • Sudden and brief muscle contraction. • No postictal state • May or may not be symmetric • May or may not include loss of consciousness
- 38. EPILEPSY • It is a group of syndromes characterised by unprovoked , recurring seizures
- 39. • A chronic neurologic disorder manifesting by repeated epileptic seizures (attacks or fits) which result from paroxysmal uncontrolled discharges of neurons within the central nervous system (grey matter disease).
- 40. CAUSES • 1.Idiopathic cause • 2.Acquired cause Birth trauma , Asphyxia, Head injuries Infection like bacterial , viral & parasitic Toxicity like carbon monoxide & lead poisoning Circulatory problem Fever Metabolic & nutritional disorder Drug or alcohol intoxication Brain disease like brain tumor , brain abscess & congenital malformations.
- 41. CLINICAL MANIFESTATION Aura phase Convulsion phase Post ictal phase
- 42. PATHOGENESIS • The 19th century neurologist Jackson suggested “a sudden excessive disorderly discharge of cerebral neurons“ as the causation of epileptic seizures. • Recent studies in animal models of focal epilepsy suggest a central role for the excitatory neurotransmiter glutamate (increased in epi) and inhibitory gamma amino butyric acid (GABA) (decreased)
- 43. Epilepsy - Classification The modern classification of the epilepsies is based upon the nature of the seizures rather than the presence or absence of an underlying cause.
- 44. Epilepsy - Classification • Focal seizures – account for 80% of adult epilepsies - Simple partial seizures - Complex partial seizures - Partial seizures secondarilly generalised • Generalised seizures • Unclassified seizures
- 45. STATUS EPILEPTICUS • It is a series of generalized seizures that occours without fully recovery of consciousness between attacks. • Lasting atleast 30 minutes. • Withdrawl of antiseizure medication,Fever and concurrent infection.
- 46. Epilepsy Differential Diagnosis The following should be considered in the diff. dg. of epilepsy: • Syncope attacks • Cardiac arrythmias • Migraine • Hypoglycemia • Narcolepsy – inappropriate sudden sleep episodes • Panic attacks
- 47. INVESTIGATION • History collection • Physical and neurological examination • Complete blood count • Blood & CSF glucose level • Serum electrolytes, BUN, calcium • LP for cerebrospinal infection • X-ray, CT scan • EEG
- 48. MEDICAL TREATMENT Partial Tonic- clonic Absence Myoclonic Atonic Carbamazepine Phenitoiin Valproic acid Lamotrigine Valproic acid Lamotrigine Ethosuximide Valproic Acid Valproic Acid
- 49. SURGICAL MANAGEMENT • Temporal resection • Cortical resection • Hemispherectomy
- 52. NURSING INTERVENTIONS • During a seizure • Indications of difficulties with airway or breathing. • Significant pressurize events • Behaviour before the seizure, aura • Type of movements observed • Time seizure began and ended • Site where twitching or contraction began • Areas of the body involved. • Movements of the eyes and changes in pupil size . • Apparent degree of consciousness during the seizure • Incontinence • Colour change • Mouth
- 53. • After a seizure • After Seizure(Postictal) • Vitals & Neuro checks • Keep patient on side • Allow to rest • Document seizure • Record: • Seizure-Date, time, duration Where seizure began-body part first involved • Any aura prior to seizure? • Any Progression movement • Type of seizure-generalized or local • Type of movement-tonic, clonic, automatism, blinking, staring • Changes in pupil size & any eye deviation • LOCs & alertness • Bladder &Bowel continence • Presence of apnea, cyanosis, & salivation • Pt Postictal status-weak or drowsy, confusion-keep in calm,quiet atmosphere, re- orient
- 54. NURSING DIAGNOSIS • Risk for injury related to seizure activity • Ineffective breathing pattern related to spasms of respiratory musculature • Social isolation related to the feelings about seizures or public fears and misconceptions. • Chronic low self-esteem related to lack of control over seizures.
- 55. NURSING INTERVENTIONS • Use preventive measures • Make sure the patient can be readily observed. • During a seizure, monitor vital signs and assess neurological status frequently. • After a seizure, check the patient frequently and report the following. • Behavior changes • Irritability • Restlessness • Listlessness
- 56. PREVENTING RESPIRATORY ARREST • Clear the area around • Do not restrain • Loosen the clothing around the neck • Turn the pt on side so saliva can flow out of the mouth. • Place a small, folded blanket under the head to relevant trauma if the seizure occurs when the pt is on the floor. • Suction the pt. and administer o2 as necessary • Do not give anything by mouth or attempt to lace anything in the mouth. • After the seizure, place the pt in a side lying position
- 57. Chorea • CHOREA is an inherited, degenerative brain disorder which results in loss of both mental and physical control. • CHOREA also known as Huntington Chorea (chorea mean to dance-like movement that is uncontrollable)
- 59. PATHOPHYSIOLOGY Chorea is a chromosome disorder that occurs on 4p16.3 At 4p16.3 juncture, the Huntington gene (HTT) contain a sequence of DNA bases (cytosine-adenine-guanine, CAG) This sequence repeat many times (CAG-CAG- CAG-CAG-CAG-CAG-CAG-CAG) Repeating of the CAG bases create a protein called huntingtin (Htt) < 36 repeat is Htt but > 36 is mHtt
- 60. NUMBER OF CAG REPEATING DETERMINE ONSET Repeated count Classification Disease Status < 27 Normal unaffected 27-35 intermediate unaffected 36-39 Reduce penetrance +/- affected >39 Full penetrance affected
- 61. Huntington’s chorea Note loss of caudate and putamen
- 62. SYMPTOMS • Motor • Cognitive • psychosocial • Chorea, muscle rigidity, unbalanced gait, tremor, dysphasia and choking Difficulty processing information and concentration, loss of memory, poor judgment • Aggressive antisocial behavior, aggression toward others, depression
- 63. GENETIC ASSOCIATION • Single gene & chromosome related disorder • Is autosomal dominant disorder • HD is inheritance/ sporadic mutation due to (radiation, chemical, and viral infection)
- 64. Drugs Treatment 1.Antipsychotics: hallucinations, delusions, violent outbursts 2.Antidepressants: depression 3.Tranquilizers: anxiety, chorea haloperidol, chlorpromazine, olanzapine fluoxetine, sertraline hydrochloride benzodiazepines, paroxetine, beta-blockers Tetrabenazine: chorea
- 65. Nursing Diagnosis • Risk for injury • Risk for self-mutilation (suicide) • Risk for imbalance nutrition less the body requirement • Mobility impair • Risk for ineffective airway • Chronic confusion • Powerlessness • Hopelessness • Memory impairment • Impaired communication
- 66. Intervention • Monitor pt for self-harm (sleeping, home safety) • Keep pt away from sharp objects • Feed pt slowly • Use communication strategies • Encourage pt to be socially active • Group homes or nursing home • Outpatient therapy (physical/speech) • Educate family • palliative care