This document discusses seizures and epilepsy. It defines a seizure as abnormal excessive neuronal activity in the brain and epilepsy as a predisposition to recurrent seizures. Seizures are classified as acute symptomatic, occurring within a week of an injury or illness, or unprovoked. Epilepsy is diagnosed if there are two unprovoked seizures or one seizure and high risk of recurrence. Causes include genetic, structural, metabolic, immune and infectious factors. Seizures are also classified as focal or generalized. Treatment involves controlling seizures with antiseizure medication while minimizing side effects and maintaining quality of life. Goals are seizure freedom, monitoring for side effects, and considering medication withdrawal after being seizure-free for two years.

1. Seizure and Epilepsy
Dr. Navin Adhikari
IM Resident

2. Definition
• A seizure is a transient occurrence of motor, sensory or
autonomic signs or symptoms due to abnormal excessive or
synchronous neuronal activity in the brain.
• Epilepsy- Epilepsy is a state of an enduring predisposition to
recurrent seizures.

3. Acute symptomatic seizure – An acute symptomatic seizure
(also referred to as a provoked seizure or reactive seizure) is a
seizure that occurs in close temporal association with an
acute systemic illness or brain insult.
• within one week of stroke, traumatic brain injury, anoxic
encephalopathy, or intracranial surgery.
• at first identification of subdural hematoma .
• during the active phase of a central nervous system infection;
• within 24 hours of a severe metabolic derangement) Examples
include hyponatremia, hypocalcemia, high fever, toxic
exposure .
• Acute symptomatic seizures are not classified as epilepsy
unless they become a recurrent process beyond the acute
illness .

5. • Unprovoked seizure – An unprovoked seizure is a seizure that
occurs in the absence of a potentially responsible clinical
condition or occurs in relation to a preexisting brain lesion or
progressive nervous system disorder beyond the time interval
recognized for acute symptomatic seizure .

6. Epilepsy if any one of following :
1. At least two unprovoked (or reflex) seizures occurring more
than 24 hours apart. Reflex seizures are seizures evoked by
specific external (eg light flashes) or internal (eg, emotion,
thoughts) stimuli .
2. One unprovoked (or reflex) seizure and a probability of further
seizures that is similar to the general recurrence risk after two
unprovoked seizures (eg, ≥60 percent), occurring over the
next 10 years. Examlpes are structural lesions such as stroke,
central nervous system infection, or certain types of traumatic
brain injury.
3. Diagnosis of an epilepsy syndrome.

7. The causes of seizures and epilepsy can be broadly classified into
six categories
• Genetic
• Structural
• Metabolic
• Immune
• Infectious
• Unknown

8. Causes of Seizures based on Age

13. CLASSIFICATION OF SEIZURE

15. FOCAL SEIZURES
• Caused by localised cortical activity with retained awareness.
• Awareness may become impaired if spread occurs to the
temporal lobes.
• Abnormal motor movements may begin in a very restricted
region such as the fingers and gradually progress (over
seconds to minutes) to include a larger portion of the
extremity - described by Hughlings Jackson and known as a
Jacksonian march.
• Patients may experience a localized paresis (Todd’s paralysis)
for minutes to many hours in the involved region following
the seizure

16. AURA
• subjective, “internal” events that are not directly observable
by someone else are referred to as auras.
• Occurs before seizure, mostly seen in focal seizures.
• describe odd, internal feelings such as fear, a sense of
impending change, detachment, depersonalization, déjá vu,
or illusions that objects are growing smaller (micropsia) or
larger (macropsia).

21. GENERALISED SEIZURES
• Typical absence seizures are characterized by sudden, brief
lapses of consciousness without loss of postural control. The
seizure usually lasts for only seconds, consciousness returns
as suddenly as it was lost, and there is no postictal confusion.
• Atypical absence seizures have features that deviate both
clinically and electrophysiologically from typical absence
seizures. For example, the lapse of consciousness is usually of
longer duration and less abrupt in onset and cessation, and
the seizure is accompanied by more obvious motor signs that
may include focal or lateralizing features.

22. • Atonic seizures are characterized by sudden loss of postural
muscle tone lasting 1–2 s. Consciousness is briefly impaired,
but there is usually no postictal confusion.
• Myoclonus is a sudden and brief muscle contraction that may
involve one part of the body or the entire body. A normal,
common physiologic form of myoclonus is the sudden jerking
movement observed while falling asleep.

24. Features that suggest seizure in older adults:
• Confusion, behavioral change, or unresponsiveness
• Sudden falls with no recall or warning
• Recurrent events occurring in various positions or
circumstances
• Arousal from sleep with confusion or disorientation

29. Approach to Seizure

31. If History of Eilepsy present

32. If No history of Eilepsy present

33. ANTIEPILEPTIC DRUGS

43. Management of Epilepsy
three main goals:
• controlling seizures,
• avoiding treatment side effects, and
• maintaining or restoring quality of life

44. Controlling seizure
• Antiseizure medication therapy is usually not necessary in
individuals after a single seizure, particularly if a first seizure is
provoked by factors that resolve.
• Classify the patient's seizure type
• Seizure types and epilepsy syndromes are classified primarily
upon clinical grounds, assisted by laboratory,
neurophysiologic, and radiographic studies.

47. Monitoring of therapy
• Regular follow-up visits should be scheduled to check drug
concentrations, blood counts, and hepatic and renal function,
when indicated.
• Address concerns about taking the medication and possible
side effects, or psychosocial aspects of their disorder.

48. Discontinuation of therapy
• Withdrawal of medication may be considered after a patient
has been seizure-free for more than 2 years
• Childhood-onset epilepsy, particularly classical absence
seizures, carries the best prognosis for successful drug
withdrawal.
• Other epilepsy syndromes, such as juvenile myoclonic
epilepsy, have a marked tendency to recur after drug
withdrawal.
• Patients should be advised of the risks of recurrence, to allow
them to decide whether or not they wish to withdraw. If
undertaken, withdrawal should be done slowly, reducing the
drug dose gradually over weeks or months.

50. Mortality in Epilepsy
• Risk of death that is roughly two to three times greater than
expected .
• Most of the increased mortality is due to the underlying
etiology of epilepsy (e.g., tumors or strokes in older adults).
However, a significant number of patients die from accidents,
status epilepticus, and a syndrome known as sudden
unexpected death in epilepsy (SUDEP ).
• The cause of SUDEP is unknown, it may result from brainstem-
mediated effects of seizures on pulmonary, cardiac, and
arousal functions.

52. Status Epilepticus
consist of the following :
• ≥5 minutes of continuous seizures, or
• ≥2 discrete seizures between which there is incomplete
recovery of consciousness.
Refractory SE: Refractory status epilepticus is defined as
ongoing convulsive or nonconvulsive seizures following
administration of an initial benzodiazepine and a
nonbenzodiazepine antiseizure medication, given in
appropriate doses.

54. Management of SE

61. Complications
• Cardiac arrhythmias
• Hypoventilation and hypoxia
• fever, and leukocytosis
• Aspiration pneumonitis
• Neurogenic pulmonary edema
• Respiratory failure

62. References
• Harrison's Principles of Internal Medicine,
20th Edition
• Davidsons Principle and Practice of Medicine
• Katzungs Principles of Pharmacology.
• Uptodate 2020