Epilepsy Seizure

1. Epilepsy
 By Rima Jani (PT)
(M.P.T. Pediatric Science)

2. Definitions
 Epileptic seizure- a transient occurrence of signs
and/or symptoms due to abnormal excessive
pattern of excitability and synchrony among
neurons in select brain areas.
 Epilepsy- persistent epileptogenic abnormality of
the brain that is able to spontaneously generate
paroxysmal activity
 Recurrent seizures (two or more)which are not provoked by systemic or acute
neurologic insults
 Epilepsy syndrome- complex of signs and
symptoms that define a unique epileptic condition

3. Epilepsy is a disease of the brain
defined by any of the following
conditions
1. A least two unprovoked (or reflex) seizures
occurring >24 h apart
2. One unprovoked (or reflex) seizure and a
probability of further seizures similar to
the general recurrence risk (at least 60%) after
two unprovoked seizures, occurring
over the next 10 years
3. Diagnosis of an epilepsy syndrome

4. • A seizure is the event
• Epilepsy is the disease associated
with spontaneously recurring
seizures
Seizure versus Epilepsy

5. Epilepsy Facts
 1 in 26 people will develop epilepsy during
their lifetime
 More common then autism, cerebral palsy,
MS and Parkinson’s disease combined

6. Risk of Epilepsy
 Highest at extremes of life ( 1st year of life
and in elderly)
 Risk of having at least 1 seizure in lifetime
is 10%, and 1/3 will develop epilepsy

7. Incidence and
Prevalence in Pediatric
Population
 5 per 1000 in school-aged children
 1.5 per 1000 in preschool-aged children
 Affects more then 300,000 children under
age 15

8. Cellular Mechanisms of
Seizure Generation
 Excitation (too much)
Ionic --- inward Na+, Ca++ currents
Neurotransmitter --- Glutamate, Aspartate
 Inhibition (too little)
Ionic --- inward Cl-, outward K+ currents
Neurotransmitter --- GABA

11. Seizure Classification
 International League Against Epilepsy (ILAE)
2010 revised classification
 Based on known causes of epilepsy:
Genetic
Structural/metabolic
Unknown cause

12. •Generalized: Seizures produced by widespread
abnormal electrical impulses present throughout
the entire brain.
•Partial (sometimes referred to as focal or
localized): Seizures produced by electrical
impulses that generate from a relatively small or
“localized” part of the brain (referred to as the
focus).
Seizure types

14. Seizures take on many different forms and
have a
• beginning (prodrome and aura),
• middle (ictal) and
•end (post-ictal) stage.
Phases of Seizure

17. •Generalized tonic-clonic (Grand
Mal). Symptoms: The patient loses consciousness
and usually collapses. The loss of consciousness is
followed by generalized body stiffening (called the
"tonic" phase of the seizure), then by violent jerking
(called the "clonic" phase of the seizure), after which
the patient goes into a deep sleep (called the
"postictal" or “after-seizure” phase). During grand-
mal seizures, injuries and accidents may occur, such
as tongue biting and urinary incontinence.
Generalized epilepsy
classifications

18. Generalized epilepsy
classifications
Absence. Symptoms: Brief loss of
consciousness (just a few seconds) with few or
no symptoms. The patient typically interrupts an
activity and stares blankly. These seizures
begin and end abruptly and might occur several
times a day. Patients are usually not aware that
they are having a seizure, but may have a
feeling of "losing time.”

19. Generalized epilepsy
classifications
Myoclonic. Symptoms: Sporadic and brief
jerking movements, usually on both sides of the
body. Patients sometimes describe the jerks as
brief electrical shocks. When violent, these
seizures might result in dropping or involuntarily
throwing objects.

20. Generalized epilepsy
classifications
Clonic. Symptoms: Repetitive, rhythmic jerking
movements that involve both sides of the body at
the same time.
Tonic. Symptoms: Muscle stiffness and rigidity.
Atonic. Symptoms: Consist of a sudden and
general loss of muscle tone, particularly in the
arms and legs, which often results in a fall.

21. Partial epilepsy
classifications
Simple partial (awareness
maintained). Symptoms: Simple partial seizures
are further divided into four groups according to
the nature of their symptoms:
1. Motor. Motor symptoms include movements
such as jerking, stiffening, muscle rigidity,
spasms, and head-turning.

22. Partial epilepsy
classifications
Simple partial (awareness
maintained). Symptoms: Simple partial seizures
are further divided into four groups according to
the nature of their symptoms:
2. Sensory. Sensory symptoms involve unusual
sensations affecting any of the five senses (vision,
hearing, smell, taste, or touch). The term “aura” is
used to describe sensory symptoms that are
present only (and not motor symptoms).

23. Partial epilepsy
classifications
Simple partial (awareness maintained).
3. Autonomic. Autonomic symptoms most often
involve an unusual sensation in the stomach
termed “gastric uprising”.

24. Partial epilepsy
classifications
Simple partial (awareness maintained).
4. Psychological. Psychological symptoms are
characterized by various experiences involving
memory (the sensation of déjà vu), emotions
(such as fear or pleasure), or other complex
psychological phenomena.

25. Partial epilepsy classifications
Complex partial (awareness impaired).
Symptoms: Includes impairment of awareness.
Patients seem to be "out of touch," "out of it," or
"staring into space" during these seizures. Symptoms
may also involve some complex symptoms called
automatisms. Automatisms consist of involuntary but
coordinated movements that tend to be purposeless
and repetitive. Common automatisms include lip
smacking, chewing, fidgeting, and walking around.

26. Partial epilepsy
classifications
Partial seizure with secondary
generalization. Symptoms: A partial seizure
that evolves into a generalized seizure
(typically a generalized tonic-clonic seizure).
Approximately 70% of patients with partial
seizures can be controlled with medication.
Partial seizures that cannot be controlled with
medication can often be treated surgically.

27. Diagnosing Epilepsy
 Detailed history and physical examination
 EEG, video EEG
 Imaging ( CT, MRI, PET)

28. History
 Precipitating factors
 Aura
 Area of body first involved
 Progression of activity
 Specific activity observed (head or eye deviation, type of
movement or posturing)
 Level of consciousness
 Incontinence
 Apnea or cyanosis
 Duration of seizure
 Postictal symptoms ( confusion, hemiplegia, aphasia)

29. Seizure Triggers
 Missed dose of medication
 Sleep deprivation
 Illness
 Stress, anxiety, overstimulation
 Hormonal changes
 Alcohol and drugs of abuse
 Hyperventilation
 Flashing lights
 Temperature extremes
 dehydration

30. Not everything that looks
like a seizure is a seizure
 Migraine headache
 Syncope
 Behavioral outbursts
 Breath holding spells
 Tics
 Sleep disorders

31. Epilepsy Resolved
• Epilepsy is now considered to be resolved* for individuals
who had an age-dependent epilepsy syndrome but are now
past the applicable age or those who have remained seizure-
free for the last 10 years, with no seizure medicines for the
last 5 years.
Fisher et al, Epilepsia 55 (4): 475-482, 2014
*“Resolved” has the connotation of “no longer present,” but it does not
guarantee that epilepsy will never come back

32. Reflex Epilepsies
• Despite the fact that seizures are “provoked” in reflex epilepsies,
these are considered epilepsy, because…
• If the seizure threshold were not altered, these precipitants would
typically not cause seizures
– e.g., photosensitive epilepsy, eating epilepsy

33. Management Guideline
• Immediate antiepileptic drug (AED) therapy, as
compared with delay of treatment pending a
second seizure, is likely to reduce recurrence risk
within the first 2 years (Level B)
• Clinicians’ recommendations whether to initiate
immediate AED treatment after a first seizure
should be based on individualized assessments
that weigh the risk of recurrence against the
adverse events of AED therapy.
Courtesy of Jacqueline French

38. These are not Epilepsy because there is
small risk of a seizure in the absence of a
precipitating factor
• Febrile seizures in children age 0.5 – 6 years old
• Alcohol-withdrawal seizures
• Metabolic seizures (sodium, calcium, magnesium, glucose,
oxygen)
• Toxic seizures (drug reactions or withdrawal, renal failure)
• Convulsive syncope
• Acute concussive convulsion
• Seizures within first week after brain trauma, infection or
stroke

39. ILAE Definition of Acute Symptomatic
Epilepsy
Acute symptomatic seizures are events, occurring in close temporal
relationship with an acute CNS insult, which may be metabolic,
toxic, structural, infectious, or due to inflammation. The interval
between the insult and seizure may vary due to the underlying
clinical condition.
• Acute symptomatic seizures have also been called:
• Reactive seizures
• Provoked seizures
• Situation-related seizures
Beghi et al. Epilepsia 2010;51:671-675 Courtesy of Dale Hesdorffer

40. Defining time in acute
symptomatic seizures
Events within 1 week of:
• Stroke
• TBI
• Anoxic encephalopathy
• Intracranial surgery
• First identification of subdural hematoma
• Presence of an active CNS infection
• During an active phase of multiple sclerosis
or other autoimmune disease
Beghi et al. Epilepsia 2010;51:671-675 Courtesy of Dale Hesdorffer

41. Status Epilepticus
A seizure that lasts longer than 5 minutes, or having
more than 1 seizure within a 5 minutes period, without
returning to a normal level of consciousness between
episodes is called status epilepticus. This is a medical
emergency that may lead to permanent brain damage
or death.
In children, the main cause of status epilepticus is an
infection with a fever. Children with severe, refractory
seizure disorders can also have status epilepticus. In
adults, the common causes are: Stroke.

42. THANK YOU