József Janszky Department of Neurology, Univ Pécs
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1 Epilepsy and epileptic seizures I. József Janszky Department of Neurology, Univ Pécs
2 Definition of epileptic seizure Objective or subjective clinical symptom(s) Cause: abnormal synchronous activation of a brain neuronpopulation
3 Epileptic seizure Epilepsy
4 Definition of epilepsy Recurrent Spontaneous (not provoked and not caused by serious acute illness Epileptic seizures
5 Differential-diagnostic questions of epilepsy and epileptic seizures Prevalence of epilepsy: % 5% of the total population had once a seizure in his/her life 10-20% of the total population undergo various diagnostic procedures due to suspicion on epilepsy: Two main differentialdiagnostic questions: 1. Did the patient have an epileptic seizure? ( Differentialdiagnosis ) 2. If yes: Is it an epilepsy? (Diagnosis)
6 Is it an epileptic seizure? ( Differential-diagnosis ) 1. Metabolic disorders (hypoglycemia) 2. Transient ischemic attack (TIA) (negative symptoms!, > 10 min) 3. Migraine (the aura phase is > 10 min starts and ends slowly and gradually and the aura is followed by headache) 4. Sleep disorders: Hypersomnias (narcolepsy), Parasomnias (night terror, sleep walking) 4. Psychiatric disorders: Pseudoseizure = Non-epileptic psychogenic seizures 5. Syncope: Seizures with falls
7 The two most important differential-diagnostic problems: 1. First seizure in life: Epileptic seizure vs. Syncope (loss of consciousness due to lowering of CBF) 2. Recurrent seizures: epileptic seizures vs. Psychogenic seizures The two main tools in differentialdiagnosis: 1. Heteroanamnesis (eyewitness) 2. Autoanamnesis
8 Syncope Cause: transient hypoperfusion of the brain Diagnostic tools: Patient s history, heteroanamnesis, Echocardiography, Holter-ECG Convulsive syncope (>10s generalized decrease of brain perfusion) : 1-3 jerks, small tonic contractions. Occasionally tongue biting and enuresis(!), sometimes a lateral or vertical deviation of bulbi Differential diagnosis convulsive syncope from GM: 1. Syncope may be preceded by presyncopic symptoms ( I felt I would faint, ) 2. ABSENCE OF a LONGER TONIC PHASE (unlike epileptic sz.) 3. Only 2-3 jerks 4. < 20 seconds (epileptic seizure lasts min) 5. No postconvulsive confusion Often Cause of convulsive syncope: SSS (long-term ECG!)
9 Causes of the Syncope Cardiovascular 26% Ventricular Tachycardia 10% SSS 5% Aorta-stenosis 2.5% Supraventricular tachycardia 1.5% III. Degree AV block 1.5% Significant bradycardia 1% Mobitz II AV block 1% AMI 1% Pulmonal hypertension 1% Pacemaker-defect 0.4% Carotis sinus syncope 0.4% Aneurysma aortae 0.4% Pulmonal e mboli 0.4% Non-cardiovascular 26% Situative syncope 7% Orthostatic hypotension 7% Vasodepressive syncope 4% Drug-induced (antiarrhytmic, or antihypertensive drugs) 3% TIA 1.5% Epileptic seizures 1.5% Unknown 48%
10 Pseudoseizure = psychogenic nonepileptic seizure = hysteric seizure - onset: early adulthood - women:men 3:1 - The most common cause of status epilepticus in adulthood (a very common diagnostic mistake in intensive units)
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12 Pseudoseizures: Differentaldiagnosis is often difficult may require video-eeg monitoring Usually longer (minutes, half an hour) than epileptic seizures Show a great variability (no sterotypia) Long-lasting bilateral motor phenomena with unimpaired consciousness is very unusual in epilepsy Postictal confusion, lateral tongue biting, enuresis, nocturnal occurrence is rare in pseudoseizures (these are the features of epileptic seizures) Psychiatric disorder ( conversion-disorder )
13 Differential-diagnosis of falling seizures Impaired consciousness Motor phenomena Eyes Tongue biting Enuresis End of the seizure Syncope Yes > 5sec CBF Usually not but: 2-3 Convulsions if > 10 sec CBF Usually open Rare Rare Fast Pseudoseizure (psychogenic seizure) Partly impaired (pain reaction) Changeable, bilateral motor phenomena with unimpaired awerness Usually closed or if they are open then: blinking Rare Very rare Changeable + emotional component Epileptic (Grand mal) seizures Impaired Tonic-clonic component, showing a sequence Open Frequent (lateral) Frequent Postictal confusion
14 Differential-diagnostic questions of epilepsy and epileptic seizures 1. Is it an epileptic seizure? ( Differential diagnosis ) 2. If it is an epileptic seizures, then: Is it an epilepsy? (Diagnosis)
15 1. Epilepsy: 0.5% 2. Epileptic seizure: 5% 3. Susceptibility on epileptic seizures: 100%
16 First epileptic seizure in life 1. Acute symptomatic epileptic seizure (a symptom of a serious acute disorder affecting CNS) 2. Provoked epileptic seizure (caused by well-defined provoking factors and not by a disorder) 3. Isolated Epileptic Seizure = First, unprovoked epileptic seizure without acute serious illness (It may be the first sign of an epilepsy)
17 Acute symptomatic epileptic seizures CNS infection (HSV encephalitis) CNS trauma (serious contusion, subdural hematoma) Brain sinus thrombosis (venous thrombosis) SAH Stroke Metabolic disorder (uraemia, hypoglicaemiainduced seizures) Intoxication
18 Provoked epileptic seizures Febrile seizures in childhood Sleep deprivation Alcohol- and drug withdrawal
19 Isolated Epileptic Seizure = First sign of an epilepsy or NOT? Epilepsy = Recurrent (at least 2) Unprovoked Epileptic seizures
20 Most often causes of epilepsy Genetics: 30-40% Post-stroke Benign brain tumor Vascular malformations of the brain Post-encephalitis Malformations of Posttraumatic cortical development (dysgeneses) Hippocampal sclerosis
21 Classification of epileptic seizures and epilepsies is extremely complicated Classification of epileptic seizures Classification of epileptic syndromes ( epilepsies )
22 Classification of epileptic seizures Partial (origin: circumsribed brain region) Simplex Motor (cloni, version) Sensory (auras: somatosensory, temporal auras) Complex (loss of consciousness with oral and manual automatisms) Generalized Absence Myoclonic Generalized tonicclonic (grand mal seizure)
23 Classification of epileptic seizures Partial Simplex Motor (cloni, version) Sensory (auras: somatosensory, temporal auras) Complex (loss of consciousness with oral and manual automatisms) Generalized Absence Myoclonic Generalized tonicclonic (grand mal seizure)
24 Simplex aura Somotasensory aura (hemi-paresthesia)
25 Auras orgin from temporal lobe: Gastric sensation De ja vu, jamaiv vu Smell-sensation ( uncinatory seizures ) Auras usually but not always may proceeded by complex partial seizures (loss of consciousness) or generalized (grand mal) seizures)
26 Simplex motor seizures (depends on the activated brain region): Clonic seizures (Jackson seizures) Tonic seizures Versiv seizures
27 seizures /psychomotor seizures/
28 Classification of epileptic seizures Partial Simplex Motor (cloni, version) Sensory (auras: (somatosensory, temporal auras) Complex (loss of consciousness with oral and manual automatisms) Generalized Absence Myoclonic Generalized tonicclonic (grand mal seizure)
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30 Generalized tonic-clonic seizure: it may be primer, But can be preceeded by any other seizure types. ( secundarily generalized seizure : final common pathway) sequence: tonic phase (with apnea), clonic phase, postictal confusion or postictal sleep Postictal examination (not obligate signs): tongue biting, enuresis, muscle pain, trauma, Todd paresis
31 Epilepsy syndrome = a chronic condition with a typical symptoms Typical seizure type Typical etiology (genetics vs. Acquired) Typical localisation of the seizure focus in the brain (circumscribed or non-localisable) Typical age at onset
32 Classification of epilepsy syndromes Two main axis: Genetical or acquired Focal (localisation-related) or generalized
33 Focal epilepsy Generalaized epilepsy Benign centro-temporal epilepsy Absence epilepsy Juvenile myoclonic epilepsy Idiopathic (genetical) epilepsies Grand mal epilepsy on awaking Non-idiopathic epilepsies (symptomatic, cryptoenic) West syndrome Lennox-Gastaut syndrome Temporal lobe epilepsy Fontal lobe epilepsy Parietal lobe epilepsy Occipital lobe epilepsy
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