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

Outline of Presentation Some basic terminologies Brief overview of seizures Video demonstrations

Part 1: Basic Terminologies

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

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

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

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

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

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

Part 2: Brief overview of seizures

Classification of seizures

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

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

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

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

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

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

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

Complex partial seizure - Types

Generalized seizures

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

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

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

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

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

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

Part 3: Video Demonstrations

CS 2 D:\HMR_ROM1\AVI\CS2.AVI Video 1

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

CS 12 D:\HMR_ROM1\AVI\CS12.AVI Video 12

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

CS 15 D:\HMR_ROM1\AVI\CS15.AVI V 15

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

CS 17 Patient was asked to hyperventilate in the beginning D:\HMR_ROM1\AVI\CS17.AVI v17

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

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

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

CS 20 D:\HMR_ROM1\AVI\CS20.AVI

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

CS 23 D:\HMR_ROM1\AVI\CS23.AVI

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

CS 29 D:\HMR_ROM1\AVI\CS29.AVI

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

CS 30 D:\HMR_ROM1\AVI\CS30.AVI

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

CS 32 D:\HMR_ROM1\AVI\CS32.AVI

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

CS 33 D:\HMR_ROM1\AVI\CS33.AVI

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

CS 34 D:\HMR_ROM1\AVI\CS34.AVI

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

CS 35 D:\HMR_ROM1\AVI\CS35.AVI

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

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

CS 27 D:\HMR_ROM1\AVI\CS27.AVI

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

D:\HMR_ROM1\AVI\CS24.AVI

Absence with mild clonic component

D:\HMR_ROM1\AVI\CS26.AVI

Absence with tonic component Head mainly affected

CS 3 D:\HMR_ROM1\AVI\CS3.AVI

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

CS 4 D:\HMR_ROM1\AVI\CS4.AVI

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)

CS 13 D:\HMR_ROM1\AVI\CS13.AVI

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

THE END Questions?