on the neurology Ward a seven-year-old male called Stefan is brought by his mother his mother is worried because he's had several episodes every day where he loses Consciousness for a few seconds his teacher also complains that she often catches him daydreaming during the lesson next to Stefan there's a 17-year-old male called Jacob who seems sluggish and tired his friends brought him because he suddenly started shaking and jerking and he lost Consciousness for about 2 minutes his medical history is otherwise insignificant now there's also an 11-year-old female called Megan who also seems lethargic her father is very upset because he witnessed an episode of twitching her left foot that lasted a few minutes Megan was unconscious and has no memory of the event finally there's a 19-year-old female named Joanna that's had repetitive episodes of sudden and Rapid jerking movements with loss of consciousness for the past few months they usually happen when she wakes up in the morning and especially during periods of sleep deprivation all right so all of them had a seizure episode a seizure is a paroxysmal motor sensory or autonomic event that happens due to abnormal excessive and synchronous electrical discharges from neurons in the brain seizures usually last less than 5 minutes if it lasts more than 5 minutes it's called status epilepticus epilepsy is a chronic disease of the brain that predisposes an individual to having recurrent unprovoked seizures that is seizures without a clear triggering cause epilepsy is typically diagnosed when an individual has two or more unprovoked seizures separated by at least 24 hours all right now seizures are broadly classified into two types generalized and focal seizures generalized seizures arise from both cerebral hemispheres at the same time while focal seizures arise from specific areas in one cerebral hemisphere however focal seizures can spread to both Central hemispheres causing a generalized seizure when this happens it's appropriately called secondary generalization of a focal seizure all right so now let's take a closer look at the different subtypes of generalized seizures generalized seizures are subclassified into motor and non-motor seizures regardless of the subtype generalized seizures almost always causes sudden impairment of Consciousness generalized motor seizures include tonic clonic tonic clonic atonic and myoclonic seizures tonic seizures involve sudden stiffening of the muscles while clonic seizures involve rhythmic twitching of the muscles however these clinical features are usually combined so individuals commonly have a tonic clonic seizure in a generalized tonic clonic seizure a person might have a sudden contraction of their vocal cord muscles causing them to involuntarily scream or cry during a seizure contraction of the ocular muscles can cause UPR rolling of the eyes contraction of the oral Fingal muscle muscles can impair swallowing causing respiratory secretions to pull in the oral ferins contraction of the jaw muscles may cause the individual to bite their tongue individuals with tonic clonic seizures might also develop urinary and feal incontinence after the tonic clonic seizure ends individuals enter a period called the postal phase during which the individual's Consciousness is still impaired for minutes to hours so they seem sluggish and tired or hard to wake up so on the exam look for these subtle clues that indicate a postal pH next are myoclonic seizures for the test remember that myoclonic seizures involve sudden rapid muscle contractions this sounds a lot like clonic seizures but the key difference is that in myoclonic seizures the contractions are much faster happening at a rate of .1 seconds whereas in clonic seizures the contractions happen at a rate of about 1 to 2 seconds myoc clonic seizures typically happen in the morning and are usually triggered by stress or sleep deprivation and that's something you also have to know for the exams all right now atonic seizures translates to no muscle tone therefore they're characterized by sudden loss of postural muscle tone lasting 1 to 2 seconds causing the individual to collapse to the ground out of the blue all right moving on to the other arm of generalized seizures there are the generalized non-motor seizures these are called absence seizures and they're very high yield they're commonly found in children and Adolescence episodes are characterized by sudden brief loss of consciousness for seconds to minutes without any change in the individual's muscle tone so they could be sitting in class listening to a lecture and suddenly lose Consciousness without falling down unfortunately episodes can happen dozens or even hundreds of times per day and are classically described by parents and teachers as staring into space or daydreaming or being inattentive in fact many children with absence seizures are actually misdiagnosed with attention deficit hyperactivity disorder because teachers often presume that a child is just not paying attention all right now another high yield topic is focal seizures previously called partial seizures focal seizures are classified into those that do not impair Consciousness and those that impair Consciousness focal seizures that impair Consciousness are also followed by a postal phase whereas focal seizures that didn't affect Consciousness do not have a postal phase now focal seizures can be motor sensory or autonomic depending on the area of the cortex involved for example a focal seizure involving the primary motor cortex might cause tonic or clonic movements of the contralateral extremity whereas a focal seizure involving the occipital cortex might cause someone to see flashing lights sometimes focal seizures might begin as subtle neurological symptoms called auras during an aura individuals might exhibit subtle muscle movements called automatisms such as chewing lip smacking or rapid blinking of the eyes other forms of Aura include smelling unusual odors like kerosene a rising sensation in the abdomen or even feelings of fear or Deja Vu also an interesting phenomenon that happens after focal motor seizures is Todd's paralysis which describes a temporary paralysis of the affected extremity all right now it might be difficult to know if a seizure was a generalized tonic clonic right from the beginning or if it was a focal seizure that's secondarily generalized however a history of an aura unilateral shaking turning of the head to one side or Todd's paralysis is a clue that it might have been a focal seizure that's secondarily generalized take that with a grain of salt though because the absence of these historical features does not adequately exclude a focal seizure all right now a special subtype of seizures that happens in young children between the ages of 6 months and 5 years are febrile seizures these only happen when the child develops a fever and they can be generalized or focal because of this febal seizures are classified differently and include simple and complex febal seizures simple febril seizures are usually generalized last less than 15 minutes and do not happen again within 24 hours complex febr seizures are usually focal in onset last more than 15 minutes and often happen more than once in the span of 24 hours for your exam remember that infection with human herpes virus 6 or hhv6 has a particularly High association with Feb seizures this virus also causes Rosa and Phantom a disease characterized by the development of a high-grade fever for about 3 to 5 days then the fever goes away and immacula papular rash appears in the trunk and spreads to the extremities so remember fever first rash later diagnostic investigations focus on looking for the cause of fever and excluding serious pathology for example a lumbar puncture might be performed to exclude menitis all right now seizures are just a symptom much like chest pain or shortness of breath and therefore there are numerous causes of seizures we can categorize them based on the pneumonic vitamins v stands for vascular which includes es schic or hemorragic Strokes or intracerebral Hemorrhage eyes for infection which includes menitis en sephtis or brain abscess T is for trauma especially penetrating traumatic brain injury like from a gunshot T is also for toxins and this includes drugs of abuse like cocaine or amphetamine overdose or alcohol withdrawal which typically develops 48 hours after the last drink Additionally the anti-tuberculosis medication isid can potentially cause seizures secondary to Pur doxine or vitamin B6 deficiency the anti-depressant bupropion can also cause seizures especially if given in individuals with eating disorders like anorexia or bulimia A is for autoimmune like central nervous system vasculitis or lupus M is for metabolic and this category includes a bell view of electrolyte imbalances like hyponatremia or hypocalcemia or other metabolic imbalances like hypoglycemia or hyperglycemia hyperthyroidism hepatic and cyop in liver disease or ureic incopy in kidney disease also worik incopy caused by thymine deficiency should be considered especially in alcoholic individuals I is for idiopathic which means epilepsy n is for neoplasm and S is for the differential diagnosis like psychogenic seizures or Syncopy also one separate diagnosis that should be specifically considered in pregnant females is eclampsia this is when they have preeclampsia which is high blood pressure during pregnancy and organ damage and then develop seizures all right so when an individual presents with a history of a paroxysmal event it's important to first make sure the event was truly seizure an important differential diagnosis of a seizure is syncopy Syncopy is usually preceded by a prodrome of ladness or sweating followed by a brief loss of consciousness lasting seconds similar to seizures tonic or clonic movements can also be presented in Syncopy however unlike seizures Syncopy does not have a postal phase and individuals regain full Consciousness a few seconds after the event next is diagnosing seizures the first step is to determine if the individual has had prior seizures in which case they have epilepsy on the other hand for a firsttime seizure it's important to start by considering all potential causes a diagnostic workup should include a complete blood count or CBC electrolytes liver function tests serum glucose levels the toxicology screen and in any woman of childbearing age a pregnancy test an electroc cardiogram or ECG can also be obtained if Syncopy is part of the differential brain Imaging with CT or MRI is only done if a structural lesion is suspected or if no identifiable cause is found on laboratory evaluation if a brain infection like menitis is suspected a lumbar puncture can be obtained if the workup does not reveal an identifiable cause then it's considered an unprovoked seizure and at this point we need to start thinking about epilepsy once again the next step is performing an electroencephalography or EEG which is done by placing electrodes on the scalp and monitoring the brain's activity the EEG tells us whether the epilepsy is generalized or focal additionally it can help with specific diagnosis for example a three Herz spike in wave pattern on EEG is characteristic of absence seizures now the treatment of seizures includes abortive therapy which stops an ongoing seizure episode and anti-epileptic therapy which prevents a future seizure from happening abortive medications are mainly used when the seizure has exceeded 5 minutes in other words status epilepticus the main abortive medications are the benzo diazines like diazapam midazolam and lorazapam as for anti-epileptic medications there are many options like valproic acid fento phenobarbitol and many others a particularly high yield medication is ethos sumide which is specifically used for absence seizures also in cases of eclampsia the medication of choice is magnesium sulf F all right as a quick recap a seizure is a paroxysmal event that happens due to abnormal and excessive electrical discharges in the brain epilepsy is a chronic disorder that predisposes the individual to recurrent seizures and is typically diagnosed when either two or more unprovoked seizures happen seizures can be classified into generalized and focal seizures generalized seizures include tonic clonic tonic clonic myoclonic aonic and absense seizures focal seizures include those that do not alter Consciousness and those that do children are at risk of febr seizures which can be classified as simple or complex when evaluating an individual with seizures it's first important to identify the possible trigger diagnostic tests like CBC electrolytes liver function tests and glucose levels must be done to reveal potential causes an EEG can also be done to assess the type of seizure all right so now back to the patients do due to his age and history of episodes where he briefly loses Consciousness and seems to be daydreaming stepan most likely has episodes of absences now from his friend's description of the event Jacob had a generalized motor seizure and most probably it was a tonic clonic seizure now Megan had a focal seizure with loss of consciousness or a partial complex seizure since the seizure involved only her left foot finally Joanna most likely has episodes of myoclonic seizures which are typically rapid jerking movements that that can be exacerbated by sleep deprivation now a diagnostic workup can be done for all of them in order to find a potential cause for the seizures if the seizure is unprovoked the individual might have epilepsy helping current and future clinicians Focus learn retain and Thrive learn more