2. New Seizure Classification

3. New classification of seizure types
1981 ILAE
2017 ILAE (international league against epilepsy)

4. Reason to revise the classification
“simple partial,” “complex partial,“ “ dyscognitive,” “psychic,”
Hard to determine if patient has impaired consciousness
Some seizure types are missed

5. Simple partial -> focal aware
Grand mal
Generalized tonic clonic (GTC)
Generalized (onset) tonic-clonic
Focal (onset) to bilateral tonic-clonic
Unknown onset tonic-clonic
Petit mal
Absence
Simple partial -> focal aware
Complex partial -> focal impaired awareness

6. The vertical organization of the focal-onset
category is not hierarchical, since naming the level of
awareness is optional

7. First, decide it is focal or generalized onset.
In adult patients w/o prior seizures, majority are focal onset seizures.
So most likely you would see the patient starts having one side of posturing or shaking or head turning , this is clearly focal onset. Many times we missed this part. The seizure then progress to bilateral hemisphere, and cause bilateral tonic clonic seizure that when people notice the patient is seizing. If I only see the second part, the GTC part, I would say unknown onset tonic-clonic seizure
Give examples:
Most common is RN or someone told you the patient is seizing, and when you seizure the patient, the patient is having GTC.

8. Then, we decide the level of awareness.
Awareness is operationally defined as knowledge of self and environment.
If awareness of the event is impaired for any portion of the seizure, then the seizure is classified as a focal
seizure with impaired awareness.
As a practical matter, a focal aware seizure implies the ability of the person having
the seizure to later verify retained awareness.
Awareness is different from responsiveness.

9. Then, we decide the level of awareness.
Awareness is operationally defined as knowledge of self and environment.
If awareness of the event is impaired for any portion of the seizure, then the seizure is classified as a focal
seizure with impaired awareness.
As a practical matter, a focal aware seizure implies the ability of the person having
the seizure to later verify retained awareness.
Awareness is different from responsiveness.

10. The phrase “focal to bilateral tonic–clonic” replaces the older term “secondarily generalized tonic–clonic.”

11. Simple partial -> focal aware
Grand mal
Generalized tonic clonic (GTC)
Generalized (onset) tonic-clonic
Focal (onset) to bilateral tonic-clonic
Unknown onset tonic-clonic
Petite mal
Abscense
Simple partial -> focal aware
Complex partial -> focal impaired awareness

12. Simple partial -> focal aware
Grand mal
Generalized tonic clonic (GTC)
Generalized (onset) tonic-clonic
Focal (onset) to bilateral tonic-clonic
Unknown onset tonic-clonic
Petite mal
Abscense
Simple partial -> focal aware
Complex partial -> focal impaired awareness

13. Simple partial -> focal aware
Grand mal
Generalized tonic clonic (GTC)
Generalized (onset) tonic-clonic
Focal (onset) to bilateral tonic-clonic
Unknown onset tonic-clonic
Petite mal
Abscense
Simple partial -> focal aware
Complex partial -> focal impaired awareness

14. Simple partial -> focal aware
Grand mal
Generalized tonic clonic (GTC)
Generalized (onset) tonic-clonic
Focal (onset) to bilateral tonic-clonic
Unknown onset tonic-clonic
Petite mal
Abscense
Simple partial -> focal aware
Complex partial -> focal impaired awareness

15. A woman awakens to find her husband having a seizure in bed
A woman awakens to find her husband having a seizure in bed. The onset is not witnessed, but she is able to describe bilateral stiffening followed by bilateral shaking. EEG and magnetic resonance imaging (MRI) findings are normal.
Unknown onset tonic-clonic

16. Focal to bilateral tonic-clonic
A woman awakens to find her husband having a seizure in bed. The onset is not witnessed, but she is able to describe bilateral stiffening followed by bilateral shaking. EEG shows a clear right parietal slow-wave focus. MRI shows a parietal region of cortical dysplasia.
Focal to bilateral tonic-clonic
despite the absence of an observed onset, because a focal
etiology has been identified, and the overwhelming like-
lihood is that the seizure had a focal onset. The old clas-
sification would have classified this seizure as partial
onset, secondarily generalized.

17. A child has brief seizures with stiffening of the right arm and leg, during which responsiveness and awareness are retained.
focal aware tonic seizure

18. First Seizure

20. Epilepsy Two unprovoked seizures, >24 hours apart
One unprovoked seizure, and >60% recurrence rate in 10 years
Epilepsy syndrome
One unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years.

21. How to approach first seizure
Is it a seizure?
Maybe it is not a first seizure?
Provoked factors?
Risk factors of seizures?

22. Is it a seizure? Psychogenic Syncope (convulsive syncope) TIA
Migraine with aura

23. Maybe it is not a first seizure?
Seizure at night?
Affect out management.

24. When to treat? MRI shows a brain lesion
Probably treat
Abnormal EEG with epileptiform discharge
treat
Seizure happens during the sleep
Treat
History of CNS infection two years ago
Normal EEG and MRI
May be not
Provoked seizure
Probably not
patient has PRES
Treat, but probably not for long-term
The ILAE provided a revised basic and expanded sei-
zure type classification, with initial division into focal
versus generalized onset or unknown onset seizures •
Focal seizures are optionally subdivided into focal
aware and focal impaired awareness seizures. Specific
motor and nonmotor classifiers may be added
Generalized-onset seizures can be motor: tonic–clo-
nic, clonic, tonic, myoclonic, myoclonic–tonic–clo-
nic, myoclonic–atonic, atonic, and epileptic spasms
Generalized-onset seizures can also be nonmotor (ab-
sence): typical absence, atypical absence, myoclonic
absence, or absence with eyelid myoclonia
Additional descriptors and free text are encouraged to
characterize the seizures. Mapping of old to new terms
can facilitate adoption of the new terminology

25. When to treat? Patient has brain tumor but no seizure
Likely not
Patient has a severe brain trauma, but no seizure
prophylaxis

26. Provoked factors? Drugs/metabolic/medications
Usually generalized onset seizures
Treat as unprovoked seizure if the seizure is focal onset
Tramadol, imipenem, theophylline, bupropion (Wellbutrin)

27. 2015 AAN guideline
Great majority of recurences occurring within the first 1 to 2 years
The greatest risk in the first year (32% at 1 year vs 45% by 5 year)

28. Risk factors of recurrent seizures
Brain lesions includes stroke, trauma, CNS infection, cerebral palsy, cognitive developmental disability. Remote symptomatic seizure

29. Risk factors of recurrent seizures
Prior brain insults
Abnormal EEG (spikes or sharp waves)
Abnormal MRI with relevant lesions
Nocturnal seizures
Brain lesions includes stroke, trauma, CNS infection, cerebral palsy, cognitive developmental disability. Remote symptomatic seizure

30. Does immediate seizure treatment really make a difference ?
Yes and no

31. Immediate treatment (<1 wk from onset) decrease the short-term (<2 yr) recurrent risk

34. Doesn’t affect Longer term prognosis (>3 years)
Doesn’t affect mortality over a 20 year period