by Kailas Nath K M, S8, 2017 MBBS, Azeezia Institute of Medical Sciences and Research

1. SEIZURES
KAILAS NATH K M
S8, 2017 MBBS Regular
AZEEZIA INSTITUTE OF MEDICAL SCIENCES AND RESEARCH

2. DEFINITION
The occurrence of signs and/or symptoms due to
abnormal, excessive or synchronous neuronal activity in
brain.
The tendency to have unprovoked seizures.
- there are repeated seizure activities.
SEIZURE :
EPILEPSY :

3. PATHOPHYSIOLOGY
Normally,
Continual balance
between excitation
and inhibition is
maintained -
Remaining responsive
to environment while
avoiding continued
unrestrained
spontaneous activity
GABA
– Gamma-aminobutyric acid
– Inhibitory transmitter
– act on ion channels  enhance Cl- inflow  Reduce AP
formation
Glutamate & Aspartate
– Excitatory amino acids
– Allow inflow of Na+ and Ca2+ --> Produce AP
– Opposite effect of GABA
Seizures result from the imbalance between the excitation
and inhibition

4. PATHOPHYSIOLOGY
Trigger factor for seizures :
• Sleep Deprivation
• Missed doses of anti-epileptic drugs
• Alcohol ( particularly withdrawal)
• Recreational drug misuse
• Physical and mental exhaustion
• Flickering lights, including TV and computer screens
• Intercurrent infections and metabolic disturbances
• Uncommon: loud noises, music, reading, hot baths

5. Classification of Seizures
(2010 International League Against Epilepsy classification)

6. FOCAL EPILEPSY
• localized disturbance in the cortex
• disturbance of cortical architecture and function
• focal infection,
• tumor,
• hamartoma or
• trauma-related scarring
• If focal seizures remain localized, symptoms experienced depend on which cortical
area is affected.
• Example : If areas in the temporal lobes become involved, then awareness of the
environment becomes impaired but without associated tonic–clonic movements
• The seizure may subsequently spread to the rest of the brain (secondary
generalization) via diencephalic activating pathways

7. FOCAL EPILEPSY
Focal Seizures
WITHOUT IMPAIRMENT OF
CONSCIOUSNESS/AWARENESS
(Simple Partial)
WITH IMPAIRMENT OF
CONSCIOUSNESS /AWARENESS
(Complex Partial)
EVOLVING TO A BILATERAL,
CONVULSIVE SEIZURE
(Secondarily Generalised Seizure)
• FOCAL MOTOR
• FOCAL SENSORY
• Tonic
• Clonic
• Tonic–clonic

8. GENERALISED EPILEPSIES
• Genetic Generalised Epilepsies (GGES)
(Idiopathic Generalised Epilepsies)
• Probably originating in the central
mechanisms controlling cortical activation
• In GGEs, the abnormal electrical
discharges originate from the
Diencephalic Activating System and
spread simultaneously to all areas of the
cortex

9. GENERALISED EPILEPSIES
Absence
Tonic-clonic
(in any
combination)
Myoclonic
Absence
Eyelid
Myoclonia
Myoclonic
Clonic
Tonic Atonic
With special features
Typical
Atypical
Myoclonic Myoclonic - Atonic Myoclonic - Tonic
GENERALISED SEIZURES

10. Clinical Features
• Focal seizures
• Temporal lobe
• Impaired awareness
• Stopping and staring blankly, repetitive blinking
• Smacking movement of lips
• Frontal lobe (anterior parts)
• Limb posturing
• Sleep walking
• Ill-directed motor activity
• Incoherent screaming
• Abrupt onset, nocturnal preponderance, relative brevity etc indicate frontal origin.

11. Clinical Features
• Generalised seizures
• Tonic-clonic seizures
• Initial Aura
• Patient becomes rigid(tonic), unconscious
• Falls heavily if standing – “like a log”
• Breathing stops  central cyanosis develops.
• When cortical discharges reduce in frequency; jerking movements arise
• Flaccid state of deep coma afterwards.
• On regaining awareness; confused, disoriented, and/or amnesic
• Urinary incontinence, tongue biting during attacks
• Severely bitten, bleeding tongue after an attack of loss of consciousness:
pathognomonic

12. Clinical Features
• Absence seizures (petit mal)
• Starts in childhood
• Occurs frequently (20-30 times a day)
• Mistaken for daydreaming or poor concentration in school
• Myoclonic seizures
• Typically brief, jerking movements in the arms
• More marked in the morning or on waking up
• Provoked by fatigue, alcohol, sleep deprivation

13. Clinical Features
• Tonic seizures
• Generalised increase in tone
• Loss of awareness
• Seen as part of epilepsy syndrome.
• Clonic seizures
• Clinical features similar to tonic-clonic seizures.
• No preceding tonic phase
• Seizures of uncertain generalised or focal nature
• Marked contractions of axial musculature
• Lasts a fraction of seconds ,but recur in clusters (5-50)
• Often on awakening

14. Investigation of Epilepsy
• Focus of epilepsy – Standard EEG, Sleep EEG, EEG with Special electrodes
• Cause of epilepsy :
• Structural lesion : CT, MRI
• Metabolic disorder : Urea & Electrolytes
Blood glucose
LFT
Serum Ca, Mg
• Inflammation / Infection : Full blood count, ESR, CRP
Serology for syphilis, HIV, Collagen disease
Chest X-ray
CSF Examination
• Truly epileptic
nature of attacks : Ambulatory EEG
Videotelemetry

15. MANAGEMENT
IMMEDICATE CARE  FIRST-AID
• Move the person away from danger (fire, water, machinery, furniture)
• After convulsions cease, turn the person into the ‘recovery’ position (semi-prone)
• Ensure the airway is clear but do NOT insert anything in the mouth (tongue-biting
occurs at seizure onset and cannot be prevented by observers)
• If convulsions continue for more than 5 mins or recur without the person
regaining consciousness, summon urgent medical attention
• Do not leave the person alone until fully recovered (drowsiness and delirium can persist for
up to 1 hour)
LIFESTYLE ADVICE : Refrain from activities and environments which are likely
either to trigger an attack of seizure or to cause any danger to the person while
having a seizure.

16. MANAGEMENT
• Anti-Epileptic Drugs (AEDs)
 Increase inhibitory
neurotransmission in the brain
or
 alter neuronal sodium channels
to prevent abnormally rapid
transmission of impulses

17. MANAGEMENT
• Epilepsy surgery – Resection of epileptogenic brain tissue
• Indicated : Drug-resistant epilepsy
• Less invasive treatments : Vagal Nerve stimulation
: Deep Brain Stimulation

18. Contraception and Anti-epileptic drugs (AEDs)
• Some AEDs induce hepatic enzymes that metabolise synthetic hormones,
increasing the risk of contraceptive failure
• Carbamazepine, phenytoin & Barbiturates ; Lamotrigine, topiramate
• If AED cannot be changed, higher dose preparations of oral contraceptive
can be given
• Sodium valproate and Levetiracetam have no interaction with hormonal
contraception

19. Pregnancy & Reproduction
• Teratogenesis with use of AEDs
• Seizures may become more frequent during pregnancy
• Preconception treatment : Folic acid (5mg/day) + Small effective
doses of few AEDs  reduce risk of fetal abnormalities
• Menstrual irregularities and reduced fertility more common with
epilepsy – increased by sodium valproate
• Risk of osteoporosis

20. Status Epilepticus
• Seizure activity not resolving spontaneously, or recurrent seizure with
no recovery of consciousness in between.
• Persisting seizure activity has a recognized mortality and is a medical
emergency.
• Prolonged rigidity and/or clonic movements with loss of awareness
• Cyanosis, pyrexia, acidosis and sweating may occur
• Complications include aspiration, hypotension, cardiac arrhythmias and
renal or hepatic failure

21. Management of Status Epilepticus

22. Management of Status Epilepticus

23. THANK YOU