Classification of epilepsy Generalized seizures (10%) • Tonic–clonic • Absence Typical Atypical Absence with special features • Myoclonic absence • Eyelid myoclonia • Myoclonic Myoclonic Myoclonic atonic Myoclonic tonic • Clonic • Tonic • Atonic

Classification of epilepsy Focal seizures 80% of adult epilepsies Simple partial seizures Focal motor Focal sensory Complex partial seizure Secondarily generalized seizures Tonic Clonic Tonic–clonic

Classification Partial-onset seizures Repeated, stereotypic occurrence of the same experience focal EEG changes Simple partial seizures Complex partial seizure Secondarily generalized seizures

Partial-onset seizures Simple partial seizures ( normal consciousness) sensory motor autonomic psychic

Somatic motor Jacksonian (focal motor) Masticatory, salivation, speech arrest Simple contraversive Head and eye turning associated with arm movement or athetoid- dystonic postures Prerolandic gyrus Amygdaloid Frontal Supplementary motor cortex

Somatosensory Unformed images, lights, patterns Auditory Vertiginous Olfactory Gustatory Visceral : autonomic Contralateral occipital Heschl gyri Superior temporal Mesial temporal Insula Insular-orbital-frontal cortex

Complex partial seizure Transient loss of the patient ability to maintain normal contact with environment (Temporal and frontal) aura behavioral arrest and is followed by staring consciousness is impaired (60-90 seconds) The patient is unable to respond appropriately. Automatisms (chewing, lip smacking, mumbling, and fumbling with the hands) postictal confusion

Secondarily generalized seizures Generalized tonic clonic convulsion have 1 of the followings Clear history of aura or obvious lateralization Post-ectal todds paralysis Focal EEG record Focal cortical lesion by imaging

Partial-onset seizures

Grand mal seizures 10% of all epilepsy 40% of generalized epilepsy & main epilepsy resulting from metabolic derangements 1. Tonic extension & abrupt loss of consciousness of the extremities (10 – 20 sec) falling heavily if standing and risking facial injury. During this phase, breathing stops and central cyanosis may occur

Grand mal seizures 2. Clonic rhythmic movements ( 1 min ) urinary incontinence and tongue-biting may occur. A bitten, bleeding tongue after an attack of loss of consciousness is pathognomonic of a generalized seizure. 3. Postictal confusion Precipitated by hyperventilation, sleep deprivation or photic stimulation No structural brain abnormality

Grand mal seizures

Absence seizures brief episodes of impaired consciousness ( less than 20 sec) without loss of postural control repetitive blinking Precipitated by hyperventilation or sleep deprivation & fatigue 40-80% develop tonic clonic seizures begin during childhood (4-8 year) or adolescence (10-15 year). 60-70% remit in adulthood

Absence seizures

Atypical absence seizures

Myoclonic seizures (5-10%) Myoclonus is a brief, arrhythmic, jerking, motor movements that last less than a second. predominating in the arms Myoclonus is not always epileptic in origin. (phase I of sleep) In epilepsy, they are more marked in the morning or on awakening from sleep Myoclonic seizures often occur as cluster within a few minutes.

Myoclonus is tend to be provoked by fatigue, alcohol & sleep deprivation The onset of presentation 15-20 years 90% respond to valproate Commonly associated with metabolic disorder degenerative CNS disease anoxic brain injury

Myoclonic seizures

Atonic seizures Brief loss of postural tone (1-2 sec) usually resulting in heavy falls Consciousness is briefly impaired No post ictal confusion Often associated with neurological abnormalities They only occur in the context of epilepsy syndromes that involve other forms of seizure.

Tonic seizures It consist of sudden-onset tonic extension or flexion of the head, trunk, and/or extremities for several seconds with loss of awareness They are often associated with other neurological abnormalities. They are usually seen as part of an epilepsy syndrome and are unlikely to be isolated.

Tonic

Clonic seizures It consist of rhythmic, motor, jerking movements Clonic seizures can have a focal origin with or without impaired consciousness. The ictal EEG correlate consists of bilateral rhythmic epileptiform discharges.

Seizures of uncertain generalized or focal nature occur mainly in infancy. They signify widespread cortical disturbance it take the form of marked contractions of the axial musculature, lasting a fraction of a second but recurring in clusters of 5–50, often on awakening.

Infantile spasm

Pseudoseizures Its tend to occur in the presence of other people, it precipitated by emotional factors, and prolonged for many minutes or hours. Completely asynchronous thrashing of the limbs and repeated side-to-side movements of the head Associated with hand-biting, kicking, trembling, and quivering; pelvic thrusting and opisthotonic arching postures; and screaming or talking during the ictus. lacking tongue-biting, incontinence, hurtful falls, or postictal confusion.

Epilepsy syndromes Many patients with epilepsy fall into specific patterns, depending on: Seizure type Age of onset Responsiveness to treatment Genetic testing demonstrate similarities in molecular pathophysiology.

Epilepsy syndromes Childhood absence epilepsy Age of onset 4–8 yrs Frequent brief absences EEG 3/sec spike and wave complex Treatment: Ethosuximide ,Sodium valproate, Levetiracetam Prognosis: 40% develop GTCS, 80% remit in adulthood

Epilepsy syndromes Juvenile absence epilepsy Age of onset 10–15 yrs Less frequent absences than childhood absence EEG Poly-spike and wave Treatment: Sodium valproate, Levetiracetam Prognosis: 80% develop GTCS, 80% seizure-free in adulthood

Epilepsy syndromes Juvenile myoclonic epilepsy Age of onset 15–20 yrs GTCS. absences, morning myoclonus EEG Poly-spike and wave with photosensitivity Treatment: Sodium valproate or Levetiracetam Prognosis: 90% remit with AEDs but relapse if AED withdrawn

Epilepsy syndromes GTCS on awakening Age of onset 10–25 yrs GTCS, sometimes myoclonus EEG Spike and wave on waking and sleep onset Treatment: Sodium valproate or Levetiracetam Prognosis: 65% controlled with AEDs but relapse if AED withdrawn