Epileptic seizure

From Wikipedia, the free encyclopedia

"Seizure" redirects here. For other uses, see Seizure (disambiguation).

Epileptic seizure

Generalized 3 Hz spike and wave discharges in EEG

Classification and external resources

Specialty

Neurology

ICD-10

G40, P90, R56

ICD-9-CM

345.9, 780.3

DiseasesDB

19011

MedlinePlus

003200

eMedicine

neuro/415 neuro/694

MeSH

D012640

An epileptic seizure (colloquially a fit) is a brief episode of signs or symptoms due to abnormal
excessive or synchronous neuronal activity in the brain.[1] The outward effect can vary from
uncontrolled jerking movement (tonic-clonic seizure) to as subtle as a momentary loss of awareness
(absence seizure). The disease of the brain characterized by an enduring predisposition to generate

epileptic seizures is called epilepsy,[1][2] but seizures can also occur in people who do not have
epilepsy. Additionally, there are a number of conditions that look like epileptic seizures but are not.
A first seizure generally does not require treatment unless there is a specific problem on
either electroencephalogram or brain imaging.[3]
510% of people who live to 80 years old have at least one epileptic seizure[3] and the chance of
experiencing a second seizure is between 40% and 50%.[4] About 50% of patients with an
unprovoked apparent first seizure have had other minor seizures, so their diagnosis is epilepsy.
[5]
Epilepsy affects about 1% of the population currently[6] and affects about 4% of the population at
some point in time.[3] Most of those affectednearly 80%live in developing countries.[6]
Contents
[hide]

1 Signs and symptoms

o

1.1 Focal seizures

1.2 Generalized seizures

1.3 Duration

1.4 Postictal

2 Causes
o

2.1 Metabolic

2.2 Mass lesions

2.3 Medications

2.4 Infections

2.5 Other

3 Mechanism

4 Diagnosis

4.1 Classification

4.2 Physical examination

4.3 Tests

4.4 Differential diagnosis

5 Prevention

6 Management
o

6.1 Medication

6.2 Other

7 Prognosis

8 Epidemiology

9 History

10 Society and culture

o

10.1 Economics

10.2 Driving

11 Research

12 References

13 External links

Signs and symptoms[edit]

See also: Seizure types
The signs and symptoms of seizures vary depending on the type. [7] The most common type of
seizures are convulsive (60%).[8] Two-thirds of these begin as focal seizures and
become generalized while one third begin as generalized seizures.[8] The remaining 40% of seizures
are non-convulsive, an example of which is absence seizure.[9]

Focal seizures[edit]
Focal seizures are often preceded by certain experiences, known as an aura.[7] These may include:
sensory, visual, psychic, autonomic, olfactory or motor phenomena.[10]
In a complex partial seizure a person may appear confused or dazed and can not respond to
questions or direction. Focal seizure may become generalized. [10]
Jerking activity may start in a specific muscle group and spread to surrounding muscle groups
known as a Jacksonian march.[11] Unusual activities that are not consciously created may occur.
[11]
These are known as automatisms and include simple activities like smacking of the lips or more
complex activities such as attempts to pick something up. [11]

Generalized seizures[edit]
There are six main types of generalized seizures: tonic-clonic, tonic, clonic, myoclonic, absence, and
atonic seizures.[12] They all involve a loss of consciousness and typically happen without warning. [13]

Tonic-clonic seizures present with a contraction of the limbs

followed by their extension, along with arching of the back for 10
30 seconds.[13] A cry may be heard due to contraction of the chest

muscles.[13] The limbs then begin to shake in unison.[13] After the

shaking has stopped it may take 1030 minutes for the person to
return to normal.[13]

Tonic seizures produce constant contractions of the muscles. [13] The

person may turn blue if breathing is impaired.[13]

Clonic seizures involve shaking of the limbs in unison. [13]

Myoclonic seizures involve spasms of muscles in either a few areas

or generalized through the body.[13]

Absence seizures can be subtle, with only a slight turn of the head
or eye blinking.[10] The person often does not fall over and may
return to normal right after the seizure ends, though there may also
be a period of post-ictal disorientation.[10]

Atonic seizures involve the loss of muscle activity for greater than
one second.[11] This typically occurs bilaterally (on both sides of the
body).[11]

Duration[edit]
A seizure can last from a few seconds to more than five minutes, at which point it is known as status
epilepticus.[14] Most tonic-clonic seizures last less than two or three minutes. [14] Absence seizures are
usually around 10 seconds in duration.[9]

Postictal[edit]
After the active portion of a seizure, there is typically a period of confusion called
the postictal period before a normal level of consciousness returns.[7] This usually lasts 3 to 15
minutes[15] but may last for hours.[16] Other common symptoms include: feeling tired, headache,
difficulty speaking, and abnormal behavior.[16] Psychosis after a seizure is relatively common,
occurring in between 6 and 10% of people.[17] Often people do not remember what occurred during
this time.[16]

Causes[edit]
Main article: Causes of seizures
Seizures have a number of causes. Of those with seizure about 25% have epilepsy.[18] A number of
conditions are associated with seizures but are not epilepsy including: mostfebrile seizures and
those that occur around an acute infection, stroke, or toxicity.[19] These seizures are known as "acute
symptomatic" or "provoked" seizures and are part of the seizure-related disorders. [19] In many the
cause is unknown.
Different causes of seizures are common in certain age groups.

During the neonatal period and early infancy the most common
causes include hypoxic ischemic encephalopathy, central nervous
system (CNS) infections, trauma, congenital CNS abnormalities,
and metabolic disorders.

The most frequent cause of seizures in children is febrile seizures,

which happen in 25% of children between the ages of six months
and five years.[20]

During childhood, well-defined epilepsy syndromes are generally

seen.

In adolescence and young adulthood, non-compliance with the

medication regimen and sleep deprivation are potential triggers.

Pregnancy and labor and childbirth, and the post-partum, or postnatal period (after birth) can be at-risk times, especially if there are
certain complications like eclampsia.

During adulthood, the likely causes are alcohol related, strokes,

trauma, CNS infections, and brain tumors.[21]

In older adults, cerebrovascular disease is a very common cause.

Other causes are CNS tumors, head trauma, and other
degenerative diseases that are common in the older age group,
such as dementia.[22]

Metabolic[edit]
Dehydration can trigger epileptic seizures if it is severe enough. [23] A number of disorders
including: low blood sugar, low blood sodium, hyperosmolar nonketotic hyperglycemia,high blood
sodium, low blood calcium and high blood urea levels may cause seizures.[13] As may hepatic
encephalopathy and the genetic disorder porphyria.[13]

Mass lesions[edit]

cavernoma or cavernous malformation is a treatable medical

condition that can cause seizures, headaches, and brain
hemorrhages.

arteriovenous malformation (AVM) is a treatable medical condition

that can cause seizures, headaches, and brain hemorrhages.

space-occupying lesions in the brain (abscesses, tumours). In

people with brain tumours, the frequency of epilepsy depends on
the location of the tumor in the cortical region.[24]

Medications[edit]
Both medication and drug overdoses can result in seizures,[13] as may certain medication and drug
withdrawal.[13] Common drugs involved include: antidepressants,antipsychotics, cocaine, insulin, and
the local anaesthetic lidocaine.[13] Difficulties with withdrawal seizures commonly occurs after
prolonged alcohol or sedative use.[13]

Infections[edit]

Infection with the pork tapeworm, which can

cause neurocysticercosis, is the cause of up to half of epilepsy
cases in areas of the world where the parasite is common.[25]

parasitic infections such as cerebral malaria

infection, such as encephalitis or meningitis[26]

Other[edit]
Seizures may occur as a result of high blood pressure, known as hypertensive encephalopathy, or in
pregnancy as eclampsia when accompanied by either seizures or a decreased level of
consciousness.[13] Very high body temperatures may also be a cause.[13] Typically this requires a
temperature greater than 42 C (107.6 F).[13]

Head injury may cause non-epileptic post-traumatic

seizures or post-traumatic epilepsy

About 3.5 to 5.5% of people with celiac disease also have seizures.
[27]

Seizures in a person with a shunt may indicate failure

Hemorrhagic stroke can occasionally present with

seizures, embolic strokes generally do not (though epilepsy is a
common later complication); cerebral venous sinus thrombosis, a
rare type of stroke, is more likely to be accompanied by seizures
than other types of stroke

multiple sclerosis may cause seizures

Electroconvulsive therapy (ECT) deliberately sets out to induce a seizure for the treatment of major
depression.

Mechanism[edit]
Normally brain electrical activity is non synchronous.[10] In epileptic seizures, due to problems within
the brain,[28] a group of neurons begin firing in an abnormal, excessive,[8] and synchronized manner.
[10]
This results in a wave of depolarization known as a paroxysmal depolarizing shift.[29]
Normally after an excitatory neuron fires it becomes more resistant to firing for a period of time.
[10]
This is due in part from the effect of inhibitory neurons, electrical changes within the excitatory
neuron, and the negative effects of adenosine.[10] In epilepsy the resistance of excitatory neurons to
fire during this period is decreased.[10] This may occur due to changes in ion channels or inhibitory
neurons not functioning properly.[10] This then results in a specific area from which seizures may
develop, known as a "seizure focus".[10] Another cause of epilepsy may be the up regulation of
excitatory circuits or down regulation of inhibitory circuits follow an injury to the brain. [10][30] These
secondary epilepsies, occur through processes known as epileptogenesis.[10][30] Failure of the blood
brain barrier may also be a causal mechanism.[31]
Focal seizures begin in one hemisphere of the brain while generalized seizures begin in both
hemispheres.[12] Some types of seizures may change brain structure, while others appear to have
little effect.[32] Gliosis, neuronal loss, and atrophy of specific areas of the brain are linked to epilepsy
but it is unclear if epilepsy causes these changes or if these changes result in epilepsy.[32]

Diagnosis[edit]

An EEG can aid in locating the focus of the epileptic seizure.

It is important to distinguish primary seizures from secondary causes. Depending on the presumed
cause blood tests and/or lumbar puncture may be useful.[3] Hypoglycemia may cause seizures and
should be ruled out. An electroencephalogram and brain imaging withCT scan or MRI scan is
recommended in the work-up of seizures not associated with a fever.[3][33]

Classification[edit]
Seizure types are organized by whether the source of the seizure is localized (focal seizures) or
distributed (generalized seizures) within the brain.[12] Generalized seizures are divided according to
the effect on the body and include tonic-clonic (grand mal), absence (petit mal), myoclonic, clonic,
tonic, and atonic seizures.[12][34] Some seizures such as epileptic spasms are of an unknown type.[12]
Focal seizures (previously called partial seizures[8]) are divided into simple partial or complex partial
seizure.[12] Current practice no longer recommends this, and instead prefers to describe what occurs
during a seizure.[12]

Physical examination[edit]

Someone who has bitten the tip of their tongue while having a seizure

Most people are in a postictal state (drowsy or confused) following a seizure. They may show signs
of other injuries. A bite mark on the side of the tongue helps confirm a seizure when present, but only
a third of people who have had a seizure have such a bite.[35]

Tests[edit]
An electroencephalography is only recommended in those who likely had an epileptic seizure and
may help determine the type of seizure or syndrome present. In children it is typically only needed
after a second seizure. It cannot be used to rule out the diagnosis and may be falsely positive in
those without the disease. It certain situations it may be useful to prefer the EEG while sleeping or
sleep deprived.[36]
Diagnostic imaging by CT scan and MRI is recommended after a first non-febrile seizure to detect
structural problems inside the brain.[36]MRI is generally a better imaging test except when intracranial
bleeding is suspected.[3] Imaging may be done at a later point in time in those who return to their

normal selves while in the emergency room.[3] If a person has a previous diagnosis of epilepsy with
previous imaging repeat imaging is not usually needed with subsequent seizures. [36]
In adults testing electrolytes, blood glucose and calcium levels is important to rules these out as
causes.[36] As is an electrocardiogram.[36] A lumbar puncture may be useful to diagnose a central
nervous system infection but is not routinely needed.[3] Routine antiseizure medical levels in the
blood are not required in adults or children.[36] In children additional tests may be required.[36]
A high blood prolactin level within the first 20 minutes following a seizure may be useful to confirm an
epileptic seizure as opposed to psychogenic non-epileptic seizure.[37][38]Serum prolactin level is less
useful for detecting partial seizures.[39] If it is normal an epileptic seizure is still possible[38] and a
serum prolactin does not separate epileptic seizures from syncope.[40] It is not recommended as a
routine part of diagnosis epilepsy.[36]

Differential diagnosis[edit]
Differentiating an epileptic seizure from other conditions such as syncope can be difficult.[7] Other
possible conditions that can mimic a seizure include: decerebrate posturing,psychogenic
seizures, tetanus, dystonia, migraine headaches, and strychnine poisoning.[7] In addition, 5% of
people with a positive tilt table test may have seizure-like activity that seems to be due to cerebral
hypoxia.[41] Convulsions may occur due to psychological reasons and this is known as a psychogenic
non-epileptic seizure. Non-epileptic seizuresmay also occur due to a number of other reasons.

Prevention[edit]
A number of measures have been attempted to prevent seizures in those at risk. Following traumatic
brain injury anticonvulsants decrease the risk of early seizures but not late seizures. [42]
In those with a history of febrile seizures medications (both antipyretics and anticonvulsants) have
not been found effective for prevention. Some, in fact, may cause harm.[43] In those without a history
of seizures and a subdural hematoma the evidence is unclear regarding a benefit versus harm from
using anticonvulsants.[44] This is also true following acraniotomy[45][needs update] as well as after stroke,[46][needs
update]
intracranial venous thrombosis,[47][needs update] and subarachnoid haemorrhage both in those who have
and have not had seizures.[48]

Management[edit]
Potentially sharp or dangerous objects should be moved from the area around a person
experiencing a seizure, so that the individual is not hurt. After the seizure if the person is not fully
conscious and alert, they should be placed in the recovery position. A seizure longer than five
minutes is a medical emergency known as status epilepticus.[14] Contrary to a common
misconception, bystanders should not attempt to force objects into the mouth of the person suffering
a seizure, as doing so may cause injury to the teeth and gums. [49]

Medication[edit]
The first line treatment of choice for someone who is actively seizing is a benzodiazepine, most
guidelines recommend lorazepam. This may be repeated if there is no effect after 10 minutes. If
there is no effect after two doses, barbiturates or propofol may be used.[33]
Ongoing medication is not typically needed after a first seizure and is generally only recommended
after a second one has occurred or in those with structural lesions in the brain. [33] After a second
seizure anti-epileptic medications are recommended. Approximately 70% of people can obtain full
control with continuous use of medication.[6] Typically one type of anticonvulsant is preferred.
In seizures related to toxins, up to two doses of benzodiazepines should be used. If this is not
effective pyridoxine is recommended. Phenytoin should generally not be used.[50]

Other[edit]
Helmets may be used to provide protection to the head during a seizure. Some claim that seizure
response dogs, a form of service dog, can predict seizures. Evidence for this, however, is poor.[51]

Prognosis[edit]
Following a first seizure, the risk of more seizures in the next two years is 40%50%. [3] The greatest
predictors of more seizures are problems either on the electroencephalogram or on imaging of the
brain.[3] In adults, after 6 months of being seizure-free after a first seizure, the risk of a subsequent
seizure in the next year is less than 20% regardless of treatment.[52] Up to 7% of seizures that
present to the emergency department (ER) are in status epilepticus. [33] In those with a status
epilepticus, mortality is between 10% and 40%.[7] Those who have a seizure that is provoked
(occurring close in time to an acute brain event or toxic exposure) have a low risk of re-occurrence,
but have a higher risk of death compared to those with epilepsy.[53]

Epidemiology[edit]
510% of people who live to 80 years old have at least one epileptic seizure[3][5] and the chance of
experiencing a second seizure is between 40% and 50%.[4] About 0.7% in the general population of
the United States go to an emergency department after a seizure in a given year,[7] 7% of them with
status epilepticus.[54] Known epilepsy though is an uncommon cause of seizures in the emergency
department, accounting for a minority of seizure-related visits.[54] About 50% of patients with an
unprovoked apparent first seizure have had other minor seizures, so their diagnosis is epilepsy.[5]

History[edit]
The word epilepsy derives from the Greek word for "attack." [55] Seizures were long viewed as an
otherworldly condition being referred to by Hippocrates in 400B.C. as "the sacred disease".[7]
In the mid 1800s the first anti seizure medication, bromide, was introduced.[56]
Following standardization proposals devised by Henri Gastaut and published in 1970,[57] terms such
as "petit mal", "grand mal", "Jacksonian", "psychomotor", and "temporal-lobe seizure" have fallen
into disuse.

Society and culture[edit]

Economics[edit]
Seizures result in direct economic costs of about one billion dollars in the United States. [3] Epilepsy
results in economic costs in Europe of around 15.5 billion Euros in 2004. [8] In India epilepsy is
estimated to result in costs of 1.7 billion USD or 0.5% of the GDP.[28] They make up about 1% of
emergency department visits (2% for emergency departments for children) in the United States. [21]

Driving[edit]
Many areas of the world require a minimum of six months from the last seizure before people can
drive a vehicle.[3]

Research[edit]
Scientific work into the prediction of epileptic seizures began in the 1970s. Several techniques and
methods have been proposed, but evidence regarding their usefulness is still lacking. [58]

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External links[edit]
Look up epileptic
seizure in Wiktionary, the
free dictionary.

Epileptic seizure at DMOZ

[show]

Symptoms and signs: general / constitutional (R50R61, 780.6

[show]

Seizures and epilepsy (G40G41, 345)

Categories:

Epilepsy

Symptoms and signs: General

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