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Seizures E PILEPTIC / N on Epileptic What is that ???. Al- Quds University School of Medicine Lectures 5 th year Updated September, 2012. Dr. Samir Khalil Consultant Pediatric Neurologist Makassed Hospital Clinical Assistant Professor Al-Quds University. CONCEPTS & GLOSSARY.

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SeizuresEPILEPTIC / NonEpilepticWhat is that ???

Al-Quds University

School of Medicine

  • Lectures 5th year

  • Updated September, 2012

Dr. SamirKhalil

Consultant Pediatric Neurologist

Makassed Hospital

  • Clinical Assistant Professor

  • Al-Quds University


CONCEPTS & GLOSSARY

  • Attack

  • Convulsion

  • Seizure

  • Fit


Attack

  • A violent act starting on with vigor


Attack

  • Is used

  • to describe

  • epileptic &

  • non-epileptic

  • disorder.


Attack

  • Is used

  • to describe

  • epileptic &

  • non-epileptic

  • disorder.


attack

  • Is used

  • to describe

  • epileptic &

  • non-

  • epileptic

  • disorder.

  • We say:

    • Attack of laughing

    • Breath Holding Attack / or spell

    • An attack of febrile convulsion

    • Conversion Reaction

    • Epileptic attack


attack

  • ?

  • Is used

  • to describe

  • epileptic &

  • non-

  • epileptic

  • disorder.


attack

  • ?

  • Is used

  • to describe

  • epileptic &

  • non-

  • epileptic

  • disorder.


convulsion

An intense, paroxysmal, involuntary contraction

or series of contractions of

voluntary muscles


convulsion

  • Is used to

  • describe

  • epileptic &

  • non-

  • epileptic

  • motor act /

  • shaking


convulsion

  • Is used to

  • describe

  • epileptic &

  • non-

  • epileptic

  • motor act /

  • shaking


convulsion

If there is no movement

(displacement in place), the term “convulsion” is not applied.

The term “convulsion” implies movement/s


convulsion

  • We say:

    • Clonic convulsion but not tonic convulsions

    • Tonic-clonic convulsions

    • Myoclonic convulsion but not absence

    • convulsion.

  • ……Absence / Petit male is not a convulsion

    • Neither arrhythmia nor tachycardia nor apnea


seizure

  • A sudden, involuntary event/s that may include:

    • Motor activity

    •  Altered level of consciousness

    • Somatosensory symptoms


seizure

  • Used to describe epileptic disorders


Seizure vsConvulsion

  • A convulsive attack:

    • Always labeled as seizure

    • Contrary, not all seizures convulse

  • So a seizure is not synonym to convulsion

  • We say

    • Epileptic seizure/s.

    • Grand male seizure/s.

    • Petit male seizure/s.

    • His absence seizures are completely controlled by Valproic acid


  • Fit

    • A seizure or convulsion

    • especially those of

    • epileptic nature


    Seizureswork up

    Pattern

    Duration

    • Frequency

    Diagnosis

    Physiopathology

    Classification


    Seizures’ Patterns

    • TONIC

    • CLONIC

    • TONIC-

    • CLONIC

    • Myoclonic

    • ATONIC

    • Absence

    Infantile Spasm

    • Opso

    • Myoclonic

    Un Classified

    Status Epilepticus


    Seizures’ Pattern

    • TONIC


    Seizures’ Pattern

    • CLONIC


    Seizures’ Pattern

    • TONIC-

    • CLONIC

    • ?


    Seizures’ Pattern

    • Myoclonic


    Seizures’ Pattern

    • Myoclonic

    • (Startels)


    Seizures’ Pattern

    • Absence


    Seizures’ Pattern

    • Infantile Spasms


    Seizures’ Pattern

    • OpsoMyoclonic


    Seizures’ Pattern

    • OpsoMyoclonic


    Seizures’ Pattern

    • Un Classified


    Seizures’ Pattern

    • Status

    • Epilepticus

    A seizure for more than 30 minutes

    Or

    Frequent Seizures without Regaining

    Usual State of Consciousness


    Seizures’ Pattern

    • Status

    • Epilepticus


    Seizures’ Pattern

    • Intermittent Illumination

    • Provoked Seizures


    duration

    • Pre-ictal

    • Ictal

    • (Inrtra-ictal)

    • Post-ictal

    • Immediate Post-ictal

    • LatePost-ictal


    frequency

    • Attacks

    • per hour

    • per day

    • per month

    • Per year


    Seizures’ Pattern

    • Q

    StatusEpilepticus

    Versus

    AbundantAttacks


    Seizureswork up

    • 1st Key

    • Question

    • Is

    • it

    • a

    • seizure ?


    Seizureswork up

    • 1st Key

    • Question

    • Is

    • it

    • a

    • seizure ?


    Seizureswork up

    • 1st Key

    • Question

    • Is

    • it

    • a

    • seizure ?


    Seizureswork up

    • 1st Key

    • Question

    • Is

    • it

    • a

    • seizure ?


    Seizureswork up

    • 2nd Key

    • Question

    • Is it

    • epileptic

    • or

    • non

    • epileptic

    • ?


    Seizureswork up

    • 2nd Key

    • Question

    • Is it

    • epileptic

    • or

    • non

    • epileptic

    • ?


    Seizureswork up

    • 3rd Key

    • Question

    • which

    • Type

    • of

    • epilepsy

    • ?


    Seizureswork up

    • 3rd Key

    • Question

    • which

    • Type

    • of

    • epilepsy

    • ?


    Seizureswork up

    • 3rd Key

    • Question

    • which

    • Type

    • of

    • epilepsy

    • ?


    Seizureswork up

    • 3rd Key

    • Question

    • which

    • Type

    • of

    • epilepsy

    • ?


    Seizureswork up

    • 3rd Key

    • Question

    • which

    • Type

    • of

    • epilepsy

    • ?


    Seizureswork up

    • 3rd Key

    • Question

    • which

    • Type

    • of

    • epilepsy

    • ?


    Seizureswork up

    • 3rd Key

    • Question

    • which

    • Type

    • of

    • epilepsy

    • ?


    Seizureswork up

    • 1st Key Question

      • Is it a seizure ?

    • 2nd Key Question

    • Is it epileptic or

    • non epileptic ?

    • 3rd Key Question

    • Which type of epilepsy ?

    • 4th Key Question

    • How to classify ?


    Classification of

    Seizures

    Epileptic

    Non-epileptic


    What epilepsy is ?

    Classification of

    Seizures

    Epileptic

    Non-epileptic


    Classification of

    Seizures

    Non

    epileptic

    Epileptic Seizures

    are

    non occasional (non-provoked) chronic seizures in which one single attack is not considered as epilepsy.


    Classification of

    Seizures

    Epileptic

    Non-epileptic seizures

    are

    occasional (provoked) seizures produced by an acute identified cause

    (pyretic, infectious, traumatic or metabolic)


    Classification of

    Seizures

    Epileptic

    Seizures

    Non Occasional

    Chronic

    Non-Epileptic Seizures

    Occasional

    Acute


    definition of epilepsy

    A chronicclinical condition defined as

    2 or more seizures

    resulting from

    hypersynchronous electrical discharge of a population of neurons and not secondary to specific provocation factor such as fever, infection, electrolyte imbalances or trauma


    Pathophysiology of

    epilepsy

    Epilepsy

    Abnormal, hypersynchronous electrical

    activation of a population of neurons in the cerebral cortex, either in:

    • Localized area

    • Focal //Partial seizure

    • Multiple areas

    • Generalized seizure


    Pathophysiology of

    epilepsy

    Neurotransmitters

    Excitatory

    Inhibitory

    (GABA)

    Gamma

    Aminobutyric

    Acid

    Acetylcholine (Ach)

    Glutamate

    Aspartate


    Pathophysiology of

    epilepsy

    Neurotransmitters

    Excitatory

    Inhibitory

    Acetylcholine (Ach)

    Glutamate

    Aspartate

    (GABA)

    Gamma

    Aminobutyric Acid

    Any perturbation that interferes with the synthesis, release, re-uptake or metabolism of these neurotransmitters may result in the occurrence of a seizure.


    Pathophysiology of

    epilepsy

    • Many pharmacologic therapies for seizures act upon these neurotransmitters

    • Increase

    • Inhibition

    • Decrease

    • Excitation


    Pathophysiology of

    epilepsy

    Controversy exists regarding the duration of seizure necessary to cause neuronal cell injury.

    Most, brief seizures, do not cause brain damage.


    classification of

    epilepsy

    Idiopathic

    (Primary)

    Epilepsy

    Unknown etiology

    Neurological Examine

    absolutely normal

    Paraclinical

    explorations are normal

    Secondary

    Epilepsy

    A chronic affection of

    the brain by means of

    actual methods of

    exploration

    Cryptogenic

    Epilepsy

    A chronic affection of

    the brain which is

    obscure or doubtful by

    means of actual

    methods of exploration


    classification of

    epilepsy

    Idiopathic

    (Primary)

    Epilepsy

    Unknown etiology

    Neurological Examine

    absolutely normal

    Paraclinical

    explorations are normal

    Secondary

    Epilepsy

    A chronic affection of

    the brain by means of

    actual methods of

    exploration

    Cryptogenic

    Epilepsy

    A chronic affection of

    the brain which is

    obscure or doubtful by

    means of actual

    methods of exploration


    classification of

    epilepsy

    Idiopathic

    (Primary)

    Epilepsy

    Unknown etiology

    Neurological Examine

    absolutely normal

    Paraclinical

    explorations are normal

    Secondary

    Epilepsy

    A chronic affection of

    the brain by means of

    actual methods of

    exploration

    Cryptogenic

    Epilepsy

    A chronic affection of

    the brain which is

    obscure or doubtful by

    means of actual

    methods of exploration


    classification of

    epilepsy

    Idiopathic

    (Primary)

    Epilepsy

    Unknown etiology

    Neurological Examine

    absolutely normal

    Paraclinical

    explorations are normal

    Secondary

    Epilepsy

    A chronic affection of

    the brain by means of

    actual methods of

    exploration

    Cryptogenic

    Epilepsy

    A chronic affection of

    the brain which is

    obscure or doubtful by

    means of actual

    methods of exploration


    Classification of

    epilepsy

    • Generalized Epilepsy

    Partial epilepsy

    (simple & complex)

    • Secondary Generalized Epilepsy

    Status Epilepticus


    Presentation

    epilepsy

    Provoked seizures associated with a fever, electrolyte abnormality, or other metabolic derangement, are usually generalized rather than focal.


    • Thankyou


    Classification of Epilepsy(According to Extension)

    By means of:

    • Clinical presentation

    • Electrical Guidance (EEG)


    Status Epilepticus

    • A continuous seizure activity lasting

      >30minutes,

      or

    • The occurrence of ≥ 2 seizures in quick succession without return to usual level of consciousness

    An emergencyneurologic sequelae or death iftreatment is delayed


    Seizure Presentation On arrival at the ER

    • On active seizure

      • Shaking, deviation of eyes, frothy secretions,….

      • Staring

      • Breath holding (apneic) with cyanosis

  • Early post-ictal

    • Drowsy, in deep sleep, paralytic (odd),………

  • Late post-Ictal

    • Free of any manifestation (conscious alert ……..the attack is past).


  • Seizure PresentationOn arrival at the ER

    • 1st attack

    • Previous attacks (1, 2 or more)

    • Under treatment with AED (withdrawal)

    • Never been treated with AED

    •  fever


    Seizure PresentationOn arrival at the ER

    • The minority

    • New onset,non-febrile seizure

    The Majority

    Febrile convulsion

    or

    Aknown previous seizures

    A very small %

    Status epilepticus

    Most not seizing upon arrival in the casualty department


    Prognosis / expectations

    • The majority of pediatric seizures are single events without neurologic sequelae and most recurrent seizures can be controlled with medications.

    • Occasionally, however, seizures can be life-threatening (status epilepticus)


    Febrile Convulsions


    Incidence of Epilepsy

    • More common in children than adults

    • 1styr. of life / Highest incidence


    Incidence of Epilepsy

    • About 3-5% of children will have at least one seizure by the age of 5 yr.:

      • >50% Benign febrile seizures.

      • 15% acute provoked seizure:

        • The leading cause:

          • Children under 5yr. /CNS infection

          • Adolescents / Head trauma

      • 10% Single unprovoked seizure and will never have another seizure

      • The remaining 25% Recurrent seizures or epilepsy


    Incidence of Epilepsy

    • ¾ …… Idiopathic, with no known cause

    • ¼ ……Identifiable brain pathologyor

      underlying metabolic disorders.

    • A family history of epilepsy in 1st-degree relatives was found in 46.6% of patients.


    Seizure work-up

    To R/O conditions mimic seizures

    • The exact nature of the seizure:

      • Does the child have a known seizure disorder?

      • If this is the child’s 1st seizure, was the seizure febrile or non-febrile?

      • Was the seizure partial, generalized, or partial with secondary generalization?

      • Was the seizure provoked or unprovoked?


    Jitterrness


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