Seizures
Tutor: Professor V. Wong
Presentation by: Daniel Tsang,
Dragon Man, Michele Yuen
Outline of Presentation
1. Some basic terminologies
2. Brief overview of seizures
3. 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
Types of Automatisms
1.Eating automatisms → Absence seizures
2.Automatisms of mimicry
Complex partial +
3.Gestural automatisms
absence seizures
4.Ambulatory automatisms
5.Verbal automatisms
Part 2:
Brief overview of seizures
Classification of seizures
Seizure
Partial
Simple
1.
2.
3.
4.
5.
Motor
Somatosensory
Special sensory
Autonomic
Psychic
Complex
1. Simple partial at
onset
2. Impairment of
consciousness at
onset
Generalized
Secondarily
Generalized
1. Simple to generalized
2. Complex to
generalized
3. Simple to complex to
generalized
1.
2.
3.
4.
5.
6.
Absence
Myoclonic
Clonic
Tonic
Tonic-clonic
Atonic
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:
1. With motor signs
2. With somatosensory or special sensory
symptoms
3. Seizures with autonomic symptoms
4. 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
 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
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
Complex partial seizure
Temporal
Extratemporal
Start with an empty stare +
Clouding of consciousness
↓
Automatism (oral, mimic, gestural, verbal)
Frontal type: Fronto-cingular epilepsy
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-tonicclonic 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
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
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
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
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
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)
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
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
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?