Seizures

1. Seizures Tutor: Professor V. Wong Presentation by: Daniel Tsang, Dragon Man, Michele Yuen

2. Outline of Presentation • Some basic terminologies • Brief overview of seizures • Video demonstrations

3. Part 1: Basic Terminologies

4. Some stuff you probably know already… • Epilepsy: • group of syndromes • characterized by paroxysmal transient disturbances of the brain function • Seizure: a single episode of epilepsy

5. Consciousness • Consciousness: awareness or responsiveness to external stimuli • Awareness: contact with events during the period in question • Responsiveness: ability to carry out simple commands or willed movement

6. Drowsiness or somnolence • Drowsiness or somnolence: sleep state from which the patient can be aroused to make appropriate motor and verbal responses • Stupor: state from which the patient can be aroused by painful or other vigorously applied stimuli to make avoidance movements

7. Aura • component of seizure which occurs before consciousness is lost and for which memory is retained afterwards • In seizures that occur without lost of consciousness, the aura is the whole seizure

8. Automatisms • Involuntary motor activity occurring during the state of clouding of consciousness either in the course of, or after an epileptic seizure • Continuation of an activity that was going on when the seizure occurred vs. new activity developed in associated with the ictal impairment of consciousness • Related to discharge in the limbic system

9. Types of Automatisms • Eating automatisms • Automatisms of mimicry • Gestural automatisms • Ambulatory automatisms • Verbal automatisms → Absence seizures Complex partial + absence seizures

10. Part 2:Brief overview of seizures

11. Classification of seizures

12. Partial seizures Consciousness Hemispheric involvement Simple partial seizure Intact Unilateral; Bilateral involvement rare Complex partial seizure Impaired Primarily unilateral; often bilateral in course of seizure

13. Simple partial seizure Several types: • With motor signs • With somatosensory or special sensory symptoms • Seizures with autonomic symptoms • With psychic symptoms

14. Simple partial seizures with motor signs • Strictly focal • Spread to contiguous cortical area → sequential involvement of body parts • “Epileptic march” / Jacksonian seizure • Presentations: • Head turns to one side (usually contralateral to discharge) • Speech arrest / vocalization • Epileptic palilalia • Todd’s paralysis • Epilepsia partialis continua

15. Simple partial seizure with somatosensory or special sensory symptoms • Somatosensory • “pins-and-needles / numbness • Proprioception or spatial perception disorders • Special sensory • Visual: flashing lights, structured visual halluncinations • Auditory: crude auditory sensations, highly integrated functions (e.g. music) • Olfactory: unpleasant odours • Gustatory: crude (salty, sour, sweet, bitter), sophisticated (‘metallic’) • Vertiginous: falling in space, floating, totatory vertigo

16. Simple partial seizures with autonomic symptoms • Vomiting • Pallor • Flushing • Sweating • Piloerection • Pupil dilatation • Borborygmi • Incontinence

17. Simple partial seizure with psychic symptoms • Dysphasia: motor, sensory, global aphasia • Dysmnesic: distortion of time sense, deja-vu, jamais-vu, deja-entendu, jamais-entendu, panoramic vision • Cognitive disturbances: dreamy state, distortion of time sense, unreality, depersonalization • Affective: extreme pleasure or displeasure, fear, anger, rage • Illusions: objects appear deformed • Structured hallucination

18. Complex partial seizure • Gradualimpairment of consciousness (c.f. abrupt impairment in absence seizures) • Presentations: • Limited to impairment of consciousness • With additional psychic, motor and autonomic symptoms

19. Complex partial seizure - Types

20. Generalized seizures

21. Absence seizures • Sudden in onset, interruption of ongoing activities, blank stare • Non-responsive • Vanish in second • Atypical • Can associate with other components • Tonus, clonus, automatism

22. Myoclonic seizures • Sudden, brief • Generalized to individual muscle group • Ddx • Spinal cord, brainstem and cortices lesions

23. Clonic seizure • Generalized seizure sine tonic component • Postictal phase is usually short • May progress to tonic phase, clonic-tonic-clonic seizure

24. Tonic seizures • Rigid, violent muscular contraction fixing the limbs in some strained position • Deviated eyes, head towards one side, alteration in posture • Pale, flushed and ultimately livid

25. Tonic-clonic seizures • Vague ill-described warning • Tonic phase: • Sudden, sharp, tonic contraction of muscles (+ stridor), cyanosis • Fall on ground, tongue bitten, urine incontinence • Clonic phase: • Grunting • drooling • Deep respiration, all muscle relax, remain unconscious for variable time, • Awake with soreness and drowsiness, deep sleep

26. Atonic seizures • Sudden reduction in muscle tone • Head drop, slacking of jaw, dropping of limb or slumping to the ground • Drop attack • Ddx: brainstem ischaemia, narcolepsy

27. Part 3:Video Demonstrations

28. CS 2 • D:\HMR_ROM1\AVI\CS2.AVI

29. CS 2: Simple partial seizure with motor signs and march • No loss of consciousness • Rhythmic twitching of the fingers of the left hand, spreading through arm to shoulder • He held his affected hand • Simple partial seizure with motor signs • Focal

30. CS 12 • D:\HMR_ROM1\AVI\CS12.AVI

31. CS 12: Simple partial seizure with psychic symptoms and dysphasia • With dysphasic symptoms • Clicking of tongue, mumbling incomprehensible words and smiles • Fully understand commands but unable to speak properly

32. CS 15 • D:\HMR_ROM1\AVI\CS15.AVI

33. CS 15: Complex partial seizure, simple partial onset, impairment of consciousness • Slight loss of postural tone • Preserved orientation reflex • Impaired consciousness

34. CS 17 • Patient was asked to hyperventilate in the beginning • D:\HMR_ROM1\AVI\CS17.AVI

35. CS 17: Complex partial seizure vs generalized absence • Patient suddenly stopped hyperventilating • Motionless and blank facial expression • Regain consciousness with told nurse her had vague stomach sensation • EEG: localized right frontal activity pre and postictally favours a partial seizure

36. CS 19 • Patient with right frontal ganglioglioma • D:\HMR_ROM1\AVI\CS19.AVI

37. CS 19: Complex partial seizure, impairment of consciousness at onset • Sudden sat up and started to roll about • Lying on his belly • Manipulated his genitals (frontal automatism)

38. CS 20 • D:\HMR_ROM1\AVI\CS20.AVI

39. CS 20: Simple partial seizure with secondary generalization • Left arm started jerking • Still responsive • Coarse jerking of arms, stretching of back, tonic contraction of face, open mouth • Loss of consciousness • Twitching of all limbs and head • Relaxation and postictal sleep

40. CS 23 • D:\HMR_ROM1\AVI\CS23.AVI

41. CS 23: Typical absence seizure • Slight loss of tone in neck muscle when stop hyperventilation • Seizure started • Mild eyelid clonus • Regain responsiveness later

42. CS 29 • D:\HMR_ROM1\AVI\CS29.AVI

43. CS 29: Generalized atypical absence seizure • Head drop gradually • Not responsive • Later responded to staff and gradually regain upright position

44. CS 30 • D:\HMR_ROM1\AVI\CS30.AVI

45. CS 30: Generalized myoclonic seizure • Brief repetitive movements of the limbs

46. CS 32 • D:\HMR_ROM1\AVI\CS32.AVI

47. CS 32: Generalized clonic seizure • Opening of eyes and massive myoclonic jerks • Continuous clonic movement of limbs • Repetitive vocalization with clonic movement of the chest

48. CS 33 • D:\HMR_ROM1\AVI\CS33.AVI

49. CS 33: Tonic seizure • Gradual elevation of both hands and stopped walking • Took 2 steps and then passed urine • Bent body strongly forward but kept standing • Dropped handkerchief

50. CS 34 • D:\HMR_ROM1\AVI\CS34.AVI