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Seizures Tutor: Professor V. Wong

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Presentation on theme: "Seizures Tutor: Professor V. Wong"— Presentation transcript:

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 Eating automatisms (chewing and swallowing) Automatisms of mimicry (expressing the emotional state during the seizure – usu. fear) Gestural automatisms – crude or elaborate; directed toward either the subject him/herself or the environment Ambulatory automatisms Verbal automatisms

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
“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
Gradual impairment 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 Video 1

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 Video 12

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 V 15

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

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

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) In the past, this must be classified as hysteria Artifacts in eeg caused by movement


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


41 CS 23: Typical absence seizure
Slight loss of tone in neck muscle when stop hyperventilation Seizure started Mild eyelid clonus Regain responsiveness later Next time a pretty girl stares at you and blinks her eyes, don’t think that she is trying to give u “electric shock”…she is just having an absence seizure


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


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


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


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 Usually patients do not walk but keep standing


51 CS 34: Tonic clonic seizure
Suddenly bent forward with extended arm and legs Twitching in face and body Tonic stretching of arms and legs


53 CS 35: Atonic seizures Sudden relaxation of muscles
Head drop, floppy limbs and slumping to the ground

54 Some more videos if we have time
Otherwise, THE END.


56 CS 27: Absence seizure With automatism
Not necessarily specific for complex partial seizures


58 Absence with mild clonic component


60 Absence with tonic component
Head mainly affected


62 CS 3: Partial seizure with motor signs and march
Complex partial seizure → partial motor seizure with secondary generalization Not a Jacksonian seizure: consciousness was impaired before the march starts


64 CS 4: Simple partial seizure with motor signs and versive movements
Sudden start of seizure from sleep Version of trunk towards the right Left arm bent at the elbow, fingers forcefully stretched Right arm beats on arm of chair to warn nurse Tonic contraction of face and eyes EEG: not interpretable due to artifacts (pseudospike waves)


66 CS 13: Simple partial seizure with psychic, dysmnesic and affective symptoms and hallucinations
Happily talking Deja-vu Spontaneous hyperventilation Facial expression of suffering with weeping and crying No loss of contact; can give age, date and name of objects Cries and yells; feels very bad and asks for help; weeps – affective sympoms

67 THE END Questions?

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