Clinical Presentation Epilepsy and Seizure

Clinical Presentation of Epilepsy and Seizure - Epilepsy is a disorder that is best viewed as a symptom of disturbed electrical activity in the brain, which may be caused by a wide variety of etiologies. It is a collection of many different types of seizures that vary widely in severity, appearance, cause, consequence, and management. Seizures that are prolonged or repetitive can be life-threatening.

Seizures occur because a group of cortical neurons discharge abnormally in synchrony. Anything that disrupts the normal homeostasis of neurons and their stability can trigger hyperexcitability and seizures. There are thousands of medical conditions that can cause epilepsy, from genetic mutations to traumatic brain injury. A genetic predisposition to seizures has been observed in many forms of primary generalized epilepsy. Patients with mental retardation, cerebral palsy, head injury, or strokes are at an increased risk for seizures and epilepsy. The more profound the degree of mental retardation as measured by the intelligence quotient (IQ), the greater is the incidence of epilepsy. In the elderly, seizures are primarily of partial onset associated with the focal neuronal injury induced by strokes, neuro- degenerative disorders (e.g., Alzheimer disease), and other conditions.

In some cases, if an etiology of seizures can be found and corrected, the patient may not require chronic antiepileptic drug (AED) treatment. Patients can also present with unprovoked seizures that do not have an identifiable cause, and thus by definition have idiopathic or cryptogenic epilepsy. Idiopathic etiology is the term used for suspected primary generalized seizures, whereas cryptogenic etiology is used if no obvious cause is found for partial-onset seizures. The incidence of idiopathic epilepsy is higher in children. Many factors have been shown to precipitate seizures in susceptible individuals. Hyperventilation can precipitate absence seizures.

Sleep, sleep deprivation, sensory stimuli, and emotional stress increase the frequency of seizures. Hormonal changes occurring around the time of menses, puberty, or pregnancy have also been associated with the onset of or an increased frequency of seizures. A careful history should be obtained from patients presenting with seizures because theophylline, alcohol, high-dose phenothiazines, antidepressants (especially maprotiline or bupropion), and street drug use have been associated with provoking seizures. Perinatal injuries and small gestational weight at birth are also risk factors for the development of partial-onset seizures. Immunizations have not been associated with an increased risk of epilepsy.
Clinical Presentation

The International League Against Epilepsy (ILAE) has proposed two major schemes for the classification of seizures and epilepsies: the International Classification of Epileptic Seizures and the International Classification of the Epilepsies and Epilepsy Syndromes. The International Classification of Epileptic Seizures (Table bellow) combines the clinical description with certain electrophysiologic findings to classify epileptic seizures. Seizures are divided into two main pathophysiologic groups—partial seizures and generalized seizures— by EEG recordings and clinical symptomatology.

Partial (focal) seizures begin in one hemisphere of the brain and— unless they become secondarily generalized—result in an asymmetric motor manifestation. Partial seizures manifest as alterations in motor functions, sensory or somatosensory symptoms, or automatisms. Partial seizures with no loss of consciousness are classified as simple partial (SP). In some cases, patients will describe somatosensory symptoms as a “warning” prior to the development of a GTC seizure. These warnings are in fact simple partial seizures and frequently are termed auras. Partial seizures with an alteration of consciousness are described as complex partial (CP). With CP seizures, the patient can have automatisms, periods of memory loss, or aberrations of behavior. Some patients with CP epilepsy have been mistakenly diagnosed as having psychotic episodes. CP seizures also can progress to GTC seizures.

Patients with CP seizures typically are amnestic to these events. Generalized seizures have clinical manifestations that indicate involvement of both hemispheres. Motor manifestations are bilateral, and there is a loss of consciousness. Generalized seizures can be further subdivided by EEG and clinical manifestations. A partial seizure that becomes generalized is referred to as a secondarily generalized seizure. Generalized absence seizures are manifested by a sudden onset, interruption of ongoing activities, a blank stare, and possibly a brief upward rotation of the eyes. They generally occur in young children through adolescence. It is important to differentiate absence seizures from complex partial seizures.

International Classification of Epileptic Seizures

I. Partial seizures (seizures begin locally)
     A. Simple (without impairment of consciousness)
          1. With motor symptoms
          2. With special sensory or somatosensory symptoms
          3. With psychic symptoms
     B. Complex (with impairment of consciousness)
         1. Simple partial onset followed by impairment of consciousness with or without automatisms
         2. Impaired consciousness at onset with or without automatisms
     C. Secondarily generalized (partial onset evolving to generalized tonic-clonic seizures)

II. Generalized seizures (bilaterally symmetrical and without local onset)
     A. Absence
     B. Myoclonic
     C. Clonic
     D. Tonic
     E. Tonic-clonic
     F. Atonic
     G. Infantile spasms
III. Unclassified seizures
IV. Status epilepticus

GTC seizures are what many people think of as epilepsy. The seizure results in a sudden sharp tonic contraction of muscles followed by a period of rigidity and clonic movements. During the seizure, the patient may cry or moan, lose sphincter control, bite the tongue, or develop cyanosis. After the seizure, the patient may have altered consciousness, drowsiness, or confusion for a variable period of time (postictal period) and frequently goes into a deep sleep. Tonic and clonic seizures can occur separately. Brief shock-like muscular contractions of the face, trunk, and extremities are known as myoclonic jerks. They can be isolated events or rapidly repetitive. A sudden loss of muscle tone is known as an atonic seizure. This can be described as a head drop, the dropping of a limb, or a slumping to the ground. These patients often wear protective head ware to prevent trauma.

The International Classification of Epilepsies and Epilepsy Syndromes adds components such as age of onset, intellectual development, findings on neurologic examination, and results of neuroimaging studies to define epilepsy syndromes more fully. Syndromes can include one or many different seizure types (e.g., Lennox-Gastaut syndrome). The syndromic approach includes seizure type(s) and possible etiologic classifications (e.g., idiopathic, symptomatic, or unknown). Idiopathic describes syndromes that are presumably genetic but also those in which no underlying etiology is documented or suspected. A family history of seizures is commonly present, and neurologic function is essentially normal except for the occurrence of seizures. Symptomatic cases involve evidence of brain damage or a known underlying cause. 

A cryptogenic syndrome is assumed to be symptomatic of an underlying condition that cannot be documented. Unknown or undetermined is used when no cause can be identified. This syndromic classification is more important for prognostic determinations than for a classification based simply on seizure type. The syndrome classification scheme requires more information and, in return, provides a more powerful tool for comprehensive clinical management. A patient’s epilepsy is classified based on seizure type (i.e., generalized versus partial) and syndromic type (i.e., idiopathic, symptomatic, or cryptogenic).

Clinical Presentation of Epilepsy

General
In most cases, the healthcare provider will not be in a position to witness a seizure. Many patients (particularly those with CP or GTC seizures) are amnestic to the actual seizure event. Obtaining an adequate history and description of the ictal event (including time course) from a third party (e.g., significant other, family member, or witness) is critically important. With treatment the typical clinical presentation of the seizure may change. 

Symptoms
Symptoms of a specific seizure will depend on seizure type. Although seizures can vary between patients, they tend to be stereotyped within an individual.
  • CP seizures can include somatosensory or focal motor features.
  • CP seizures are associated with altered consciousness.
  • Absence seizures can be almost nondetectable with only very brief (seconds) periods of altered consciousness.
  • GTC seizures are major convulsive episodes and are always associated with a loss of consciousness.
Signs
Interictally (between seizure episodes), there are typically no objective or pathognomonic signs

Laboratory Tests
There are currently no diagnostic laboratory tests for epilepsy. In some cases, particularly following GTC (or perhaps CP) seizures, serum prolactin levels can be transiently elevated. Laboratory tests can be done to rule out treatable causes of seizures (e.g., hypoglycemia, altered electrolyte concentrations, infections, etc.) that do not represent epilepsy.

Other Diagnostic Tests
  • EEG is very useful in the diagnosis of various seizure disorders.
  • An epileptiform EEG is found in only approximately 50% of the patients who have epilepsy.
  • A prolactin serum level obtained within 10 to 20 minutes of a tonic-clonic seizure can be useful in differentiating seizure activity from pseudoseizure activity but not from syncope.
  • Although magnetic resonance imaging (MRI) is very useful (especially imaging of the temporal lobes), a computed tomography (CT) scan typically is not helpful except in the initial evaluation for a brain tumor or cerebral bleeding.
Salam

by Umaee
Source: pharmacotherapy 7th
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7 comments:

williamsmarkseo said...

My son is diagnosed with epilepsy at the age of 8 years old. During this time, he has only a few hours of sleep over a three-day period. Doctor prescribe him generic lamictal, usually fine for the most part.

faryal naaz said...

All very good points to note!!! Looking forward to seeing what is in the baggies!
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Anonymous said...

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Prince Arnold said...

Hello my son is 8 years old and had is first seizure at 2 years he was diagnosed with generalized epilepsy at 5 years old has been on medication since until doctor got him off and on he broke out on a seizure lasting almost 10 minutes he was put back on medication and the meds even increased ever since were back to his moody ness, tantrums, waking up every morning struggling and at night when asleep his body is constantly twitching mostly from his upper body, he had another big seizure and were still at it with all these moods. we tried different meds nothing was really working. I never stopped battling it, I’m open and supportive when looking at alternative and procedures. I saw someone comment on a website. Her daughter had seizure and she used a herbal medicine for her daughter seizure and she was seizure free. I’m glad that it was possible. I was ready to try anything that we help my son, i had a conversation with the Dr . I decided try the herbal medicine, I purchased the medicine. my son started taking the medicine. I was shocked to see my son improve, he stop having seizures. his more active and no more seizure. I’m so happy to see my son seizure free. Do as much google research as you can and do not give up on trying. If there is improvement continue, if there is no improvement stop and try something else Everyone is different. thank God my son is seizure free. you can email him on dr.lewisamenico@yahoo.com

clad hagel said...

AM PHILOMINA, THANKS TO DR OSAZE WHO CURED ME FROM FIVE YEARS SEIZURE ELPILEPSY DIESEASE & HYPERTENTION, MY LIFE BECAME MISERABLE BECAUSE OF THE ELPILEPSY SICKNESS, PEOPLE RUN AWAY FROM ME BECAUSE THEY SAID THAT I HAVE A CONTAGEOUS DIESEASE, I WAS BEEN STIGMANTISE, I WAS BEEN TREATED LIKE A SECOND CLASS CITIZEN ANY WHERE I GO, NO COMPANY WANTS TO EMPLOY ME, I HARDLY GO TO CHURCH OR PUBLIC PLACES, BECAUSE IT USUALLY DISGRACE ME AT PUBLIC FUNCTIONS, THIS WHOLE TERRIBLE SITUATION CONTIINUE AND PESISTED UNTIL I SAW DR OSAZE RECONMENDATION AND TESTIMONIES ONLINE, ON HOW HE HAS BEEN CURING PEOPLE OF ELPILEPSY DIESEASE WITH HIS HERBBAL MEDICATION, AND I DECIDED TO CONTACT HIM ALSO, AND HE ADMINISTERED HIS HERBAL MEDICATION ON ME, TO MY GREATEST SUPPRISE, WITHIN A MONTH AND A WEEK, ALL THE SYMPTOMS WAS GONE, I NEVER HARD ANY FALL IN FIRST TWO WEEKS EVER I STARTED TAKING HIS MEDICATIONS, I GAVE MYSELF EXTRA ONE MONTH, THEN I VISITED MY DOCTER, TO MY GREATEST SUPPRISE, MY PERSONAL DOCTOR COMFIRMED ME ELPILEPSY FREE, HE TOLD ME, THAT THERE IS NO TRACE OF ELPILEPSY IN MY BLOOD, IN CASE YOU ARE PASSING THROUGH SIMLAR CONDITION, YOU CAN ALSO REACH DR OSAZE ON HIS EMAIL: DROSAZE39@GMAIL.COM OR WHATSAP +2347089275769.

Sanchez Thompson said...

My son was diagnosed with a rare form absence status epilepsy. His seizures show no symptoms until the seizure has lasted for hours! The only warning we had was he started acting only tired at first then gradually he started acting confused and from there for 24 hours he didn't know what year it was, where he went to school, or even what grade he was in etc. his motors skills were perfect and he talked to everyone normal the entire time, he just couldn't answer certain questions. The hospital kept him overnight and gave him fluids and in 24 hours he slowly started remembering and they said he was good and sent us home. We know now that he was having a constant seizure the ENTIRE TIME of his confusion! Almost 3 months later he begins having the same symptoms when I woke him up for his 2nd day of school. we are sent for an EEG, which revealed at 10 am he was actually having what the neurologist referred to as the worst EEG he had seen) we then were sent to a different children's hospital where they observed him until 8:00pm, all this time my son passes every test, he is talking and his motor skills are completely normal! They finally begin his EEG around 9:00pm. It reveals he is still in seizure! They are blown away. Say they have never seen an absence case like his and they quickly gave him a big dose of adavan which immediately stops the seizure and he is able to regain his memory immediately. Does anyone have a child who has these same symptoms? His neuro doctor ordered a brain glucose test, but when we went for a follow up last week they said the test had been canceled and they had no idea what happened? When I asked if they were going to draw his blood and re do the test, they said that his medicine was controlling the seizures so far so they didn't feel the need to do the test! I need advice and some direction. I searched further; visited epilepsy websites, blogs. I find info about someone having the same symptoms. I was really determined. Fortunately for me, I stumbled on a testimony of someone who had epilepsy for several years and was cured through herbal medication. I read awesome stories of people whose condition were worse . But due to numerous testimonies. I was more than willing to try it. I contacted the doctor Gabriel, and my son used the Nectar herbs. It became a miracle for my son free from rare form absence status epilepsy within 3 months. The Nectar medicine worked without any trace of side effects on my son. totally cure. I decided to share my son story to tell people out there, that there is a hope for those with epilepsy using nectar medicine and anyone who suffers from seizures can be cured. Email dr.gabriel474@gmail.com

John said...

When you try to find the right medicine to treat seizure it can feel like a shot in the dark. I have heard epilepsy cannot be cured, but what baffles me is how fast the pharmaceutical companies come up with various medications laden with side effects for its treatment. I am glad HILTON Herbal Medicine my Aunt used got permanently cured from a 12 years seizure. Inquire about this natural herbal medicine at drajaymohanbose@gmail.com or visit the blog https://seizurecure.blogspot.com/. Epilepsy is not like what most doctors say by keeping patients and caregivers under fear, homeopathic treatment through herbs like HILTON, healthy keto diet and exercise will put you on the path to make permanent recovery. Read reply to know about HILTON and contact Mohan for details.

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