Seizures and Epilepsy
Presented by
Chan Hau Yee
Chan Wai Chung
Kwok Vansie
Lee Kin Tong
Seizure VS Epilepsy
What is the difference?
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Seizure:
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manifestation of paroxysmal involuntary
disturbance of brain function
Abnormality/dysfunction of
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Consciousness, motor activity, behaviour, sensory, or
autonomic functions
Epilepsy:
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Recurrent seizures
Unrelated to fever or to an acute cerebral insult
Local Data
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The period prevalence rate of epilepsy in
1997 (January to December) is estimated to
be 4.5 per 1000 children aged < 19 years
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Wong V. Study of seizure and epilepsy in Chinese children in Hong Kong: period prevalence and patterns.
J Child Neurol. 2004 Jan;19(1):19-25
Classification of seizures
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Partial seizure (55.4%)
Generalized seizure(38.7%)
Unclassified
Epilepsy syndrome
Fong GC, et al. A prevalence study of epilepsy in Hong Kong. Hong Kong Med
J. 2003 Aug;9(4):252-7.
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What is the difference between partial and
generalised seizures?
Partial Seizure
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Simple partial
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With motor signs
With somatosensory or special symptoms
With autonomic symptoms
With psychic symptoms
Complex partial
Partial seizure with secondary generalisation
How can we differentiate between simple partial and
complex partial seizure?
Simple partial
seizure
Complex partial
seizure
Conscious
Impaired
Duration
Aura
Automatisms
10-20s
1- 2 min
+
-
+/-
Common
Post-ictal
phenomenon
-
+
Consciousness
EEG
Spikes or sharp
waves bilaterally or
unilaterally or a
multifocal spike
pattern
Interictal EEG
anterior temporal
lobe sharp waves or
focal spikes and
multifocal spikes
(80%)
Generalized seizure
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Absence
Myoclonic
Clonic
Tonic
Tonic-clonic
atonic
Status epilepticus
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Consciousness does not return in between
attacks
Lasts more than 30 mins
May be life threatening
Terminate the seizure as soon as possible
Category
Localization-related
Generalized
Idiopathic (42%)
Benign epilepsy of
childhood with
centrotemporal spikes
(benign rolandic epilepsy)
Benign occipital epilepsy
Benign familial neonatal
convulsions
Benign myoclonic epilepsy in
infancy
Childhood absence epilepsy
Juvenile absence epilepsy
Juvenile myoclonic epilepsy
Epilepsy with generalized tonicclonic seizures on awakening
Symptomatic (of
underlying
structural
disease) (40.8%)
Temporal lobe
Frontal lobe
Parietal lobe
Occipital lobe
Early myoclonic encephalopathy
Early infantile epileptic
encephalopathy
with suppression-burst (Ohtahara
syndrome)
Cortical dysgenesis
Metabolic abnormalities
West syndrome
Lennox-Gastaut syndrome
Cryptogenic
(16.8%)
Any occurrence of
partial seizures without
obvious pathology
Epilepsy with myoclonic-astatic
seizures
Epilepsy with myoclonic absences
West syndrome (with unidentified
pathology)
Lennox-Gastaut syndrome (with
unidentified pathology)
Cont’d (Epilepsy Syndromes)
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Special syndromes
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Febrile convulsions
Isolated unprovoked seizures or isolated status epilepticus
Seizures occurring only with toxic or metabolic provoking
factors
Neonatal seizures of any etiology
Epilepsy with continuous spike-wave of slow wave sleep
(electrical status epilepticus of sleep)
Acquired epileptic aphasia (Landau-Kleffner syndrome
Modified ILAE Classification of Epilepsy Syndromes
Kwong KL et al .Epidemiology of childhood epilepsy in a cohort of 309
Chinese children. Pediatr Neurol. 2001 Apr
Video demonstration
of seizures
Simple partial seizure
with motor signs
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-
may remain strictly focal or epileptic “march”
Speech:
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speech arrest
occasionally vocalization
partial dysphasia
Todd’s paralysis
Simple partial seizure
with somatosensory symptoms
1.
2.
3.
4.
5.
6.
Pins-and-needles, feeling of numbness,
proprioception, spatial perception
Visual
Auditory
Olfactory
Gustatory
Vertiginous
13
Simple partial seizure
with psychic symptoms
Dysphasia
Dysmnesic symptoms 
1.
2.
•
3.
4.
5.
6.
Déjà vu, jamais-vu
Cognitive symptoms 
Affective symptoms 
Illusions
Structured hallucinations
Simple partial seizure
with autonomic symptoms
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Vomiting
Pallor
Flushing
Sweating
Piloerection
Pupil dilatation
Borborygmi
Incontinence
18
Complex partial seizures
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Primary involvement of only one hemisphere
(but often bilateral involvement in the course
of seizure)
Impaired consciousness (gradually increasing)
Partial Seizures with Secondary Generalization
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Onset: Spontaneous
Description of Seizure
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Simple partial
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Takes his left hand in his right to prevent it
from shaking
Turn to the right, left arm starts jerking
Coarse jerking of arms, stretching of back,
tonic contraction of face, open mouth
Jerks predominant in left arm and eye, eye
blinking, head and eyes to the left
Partial Seizures with Secondary Generalization
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Secondary generalization
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Generalized jerks in face, arms and legs
Left arm bent, right arm stretched
Relaxation and Postictal sleep
Absence Seizures
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Onset: provoked by hyperventilation
Description of Seizure
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Stop hyperventilation
Slight loss of tone in neck muscles
2 eye blinks about 1 second apart
Regains awareness 1.5 second before paroxysm stops
The duration of impaired consciousness is often
shorter than the duration of spike and wave
discharge series. It starts later and ends earlier.
Absence Seizures with atonic components
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Onset: Spontaneous
Description of Seizure
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Head drop
Atonic Seizure vs Atonic Absence
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Atonic Seizure: general loss of tone often
resulting in a sudden fall
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Atonic Absence: loss of tone is often
restricted to the head that gradually goes
down
Absence Seizure with tonic component
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Onset: Spontaneous
Description of Seizure
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Upward movement of the eyeballs for 15 seconds
Immediate regain of consciousness
Tonic Seizure vs Tonic
Absence
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Tonic Seizure: tonic seizure affects the whole
body resulting in bending forward with
abduction of the arms and reddening of the
face, sometimes a loss of balance
Tonic Seizure: Head is mainly affected, often
with retropulsion of the head and upward
deviation of the eyes
Myoclonic seizure
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Single or multiple, sudden, brief, shock-like jerky
contraction
Generalized / face & trunk / one or more extremities
/ individual muscles or group of muscle
Around hr of going to sleep / awake from sleep
Myoclonic jerks can also be seen in:
- spinal cord diseas
- dyssynergia cerebellaris myoclonica
- subcortical segmental myoclonus
Clonic seizure
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Tonic seizure with periodic interruptions
(shaking)
The diagnosis is rare
When a generalized seizure occasionally lack
a tonic component / as a co-existing event in
other type of seizure
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Myoclonic seizure
jerky contraction of
muscles
Regarded as an
isolated event
Considered as a
separate epilepsy type
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Clonic seizure
tonic seizure with
periodic interruption
(shaking)
rarely as a diagnosis
usu get involved in
other type of seizure
(eg. Absence seizure
with mild clonic
components)
Tonic seizure
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Rigid, violent muscular contraction, fixing the body &
limbs in strained position
Usu deviation of eyes and head
Colour of face distorted:
unchangedpaleflushedultimately livid(black &
blue; as spasm of respiratory muscle)
Tonic-clonic seizure
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Most common type of generalized seizure
Also known as ‘grand mal’
Tonic phase (~10sec):
- falls
- stridor, cry or moan, cyanosis
- incontinence
Clonic phase (~1-2mins):
Postictal phase:
- muscles relax
- remain unconscious
- go into deep sleep
Atonic seizure
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Sudden reduction in muscle tone
‘drop attack’
Prolonged atonic attacks:
progressive drop in a rhythmic, successive
relaxation manner
Causes of seizures
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Epileptic
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Idiopathic( ~70%)
Congenital dysgenesis or
malformation
Cerebral trauma
Space occupying lesion
Neurogenerative disorder
Syndrome
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Non-epileptic
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Infection: fever,
meningitis, encephalitis,
sepsis
Metabolic: acidosis,
hypoglycaemia
Drugs, toxins
Trauma
Approach to a patient with seizure
attack
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History of present illness
Review of systems
Important relevant aspects
 Perinatal
 Development
 Past medical
 Drug
 Social
 Family
 Diet
What would you ask in a patient with epilepsy?
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Physical exam
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General
Neurological
Other systems when indicated (e.g. trauma, fever)
Investigations of Convulsion
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Depends on the clinical presentation and
history
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CBC
LFT, RFT, blood glucose level, ABG
Infection screen
Toxicology screen
EEG
CT, MRI
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EEG
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indicated when epilepsy
is suspected
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CT/MRI
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Late onset of seizure
Partial seizure
Interictal neurological
signs
Progression of seizure
despite good
complicance
Medical Treatment
Anti-epileptic drug (AED)
Seizure Type
Drug recommended
Partial
Carbamazepine
Valproate
Phenytoin
Tonic-clonic
Valproate
Carbamazepine
Phenytoin
Phenobarbital
Absence, Atonic, Myoclonic
Valproate
Clonazepam
Drug complication
Carbamazepin
Drowsiness; visual disturbance;
aplastic anemia; SLE
Valproate
Drowsiness; Transient hair loss;
GIT disturbance; pancreatitis;
hepatitis; thrombocytopenia
Phenytoin
Gingival hyperplasia; hirsutism;
Steven-Johnson syndrome; SLE
Phenobarbital
Sedation; Reduced cognition;
Hyperactivity; Steven-Johnson
Syndrome;
Clonazepam
Ataxia; Lethargy
Principle of medical treatment
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Start if seizure becomes recurrent
Monotherapy preferred
- decrease drug interaction & toxicity
- increase compliance
- decrease cost
- 50% of children have satisfactory control
Treatment- Pharmacological
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Aim: fit free
Common agents
 Sodium valporate
 Phenytoin
 Phenobarbitone
 Carbamazepine
Most of them have known side effects and monotherapy is
preferred for the sake of side effects
Withdrawal of drug therapy can be considered in a patient with
no relapse of seizure for 3 or more years; it should be withdrawn
slowly
Treatment: Diet
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Ketogenic Diet
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For recalcitrant seizures
Complex myoclonic epilepsy with associated tonicclonic convulsions
Restricts the quantity of carbohydrate and protein
(most calories provided as fat)
Mechanism of action unknown
? Anticonvulsant effect secondary to elevated
levels of beta-hydroxybutyrate and acetoacetate
resulting from the ketosis
Surgical Treatments
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Considered for children with
 intractable seizures unresponsive to
anticonvulsants
 Well-defined focus of epileptogenic
activity + identical structural lesion
on CT/MRI
Options
 Lobectomy and cortical resection
 Hemispherectomy
 Corpus Callosotomy
 Multiple Sub-pial Transection
 Vagal nerve stimulation
Vagal nerve stimulation
Education and support
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Good compliance is very important
May disturb the child’s school life
Management during fits
Side effects of the anticonvulsants
Avoid known provoking factors
References
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Fong GC, Mak W, Cheng TS, Chan KH, Fong JK, Ho SL. A prevalence
study of epilepsy in Hong Kong. Hong Kong Med J. 2003
Aug;9(4):252-7.
Kwong KL, Chak WK, Wong SN, So KT.Epidemiology of childhood
epilepsy in a cohort of 309 Chinese children. Pediatr Neurol. 2001
Apr;24(4):276-82
Leung GK, Fan YW, Fong KY. Temporal lobe resection for intractable
epilepsy: review of 11 cases. Hong Kong Med J. 1999 Dec;5(4):329336
Wong V. Study of seizure and epilepsy in Chinese children in Hong
Kong: period prevalence and patterns. J Child Neurol. 2004
Jan;19(1):19-25
Modified ILAE Classification of Epilepsy Syndromes
Nelson’s Textbook of Pediatrics Ch. 602
Video Atlas of epileptic seizures - Classical examples, International
League against epilepsy
Special Thanks to Prof. V.
Wong