1. Seizures Tutor: Professor V. Wong
Presentation by: Daniel Tsang, Dragon Man, Michele Yuen

2. Outline of Presentation
Some basic terminologies
Brief overview of seizures
Video demonstrations

3. Part 1: Basic Terminologies

4. Some stuff you probably know already…
Epilepsy:
group of syndromes
characterized by paroxysmal transient disturbances of the brain function
Seizure: a single episode of epilepsy

5. Consciousness
Consciousness: awareness or responsiveness to external stimuli
Awareness: contact with events during the period in question
Responsiveness: ability to carry out simple commands or willed movement

6. Drowsiness or somnolence
Drowsiness or somnolence: sleep state from which the patient can be aroused to make appropriate motor and verbal responses
Stupor: state from which the patient can be aroused by painful or other vigorously applied stimuli to make avoidance movements

7. Aura
component of seizure which occurs before consciousness is lost and for which memory is retained afterwards
In seizures that occur without lost of consciousness, the aura is the whole seizure

8. Automatisms
Involuntary motor activity occurring during the state of clouding of consciousness either in the course of, or after an epileptic seizure
Continuation of an activity that was going on when the seizure occurred vs. new activity developed in associated with the ictal impairment of consciousness
Related to discharge in the limbic system
Eating automatisms (chewing and swallowing)
Automatisms of mimicry (expressing the emotional state during the seizure – usu. fear)
Gestural automatisms – crude or elaborate; directed toward either the subject him/herself or the environment
Ambulatory automatisms
Verbal automatisms

9. Types of Automatisms Eating automatisms Automatisms of mimicry
Gestural automatisms
Ambulatory automatisms
Verbal automatisms
→ Absence seizures
Complex partial + absence seizures

10. Part 2: Brief overview of seizures

11. Classification of seizures

12. Partial seizures Consciousness Hemispheric involvement
Simple partial seizure
Intact
Unilateral;
Bilateral involvement rare
Complex partial seizure
Impaired
Primarily unilateral; often bilateral in course of seizure

13. Simple partial seizure
Several types:
With motor signs
With somatosensory or special sensory symptoms
Seizures with autonomic symptoms
With psychic symptoms

14. Simple partial seizures with motor signs
Strictly focal
Spread to contiguous cortical area → sequential involvement of body parts
“Epileptic march” / Jacksonian seizure
Presentations:
Head turns to one side (usually contralateral to discharge)
Speech arrest / vocalization
Epileptic palilalia
Todd’s paralysis
Epilepsia partialis continua

15. Simple partial seizure with somatosensory or special sensory symptoms
“pins-and-needles / numbness
Proprioception or spatial perception disorders
Special sensory
Visual: flashing lights, structured visual halluncinations
Auditory: crude auditory sensations, highly integrated functions (e.g. music)
Olfactory: unpleasant odours
Gustatory: crude (salty, sour, sweet, bitter), sophisticated (‘metallic’)
Vertiginous: falling in space, floating, totatory vertigo

16. Simple partial seizures with autonomic symptoms
Vomiting
Pallor
Flushing
Sweating
Piloerection
Pupil dilatation
Borborygmi
Incontinence

17. Simple partial seizure with psychic symptoms
Dysphasia: motor, sensory, global aphasia
Dysmnesic: distortion of time sense, deja-vu, jamais-vu, deja-entendu, jamais-entendu, panoramic vision
Cognitive disturbances: dreamy state, distortion of time sense, unreality, depersonalization
Affective: extreme pleasure or displeasure, fear, anger, rage
Illusions: objects appear deformed
Structured hallucination

18. Complex partial seizure
Gradual impairment of consciousness (c.f. abrupt impairment in absence seizures)
Presentations:
Limited to impairment of consciousness
With additional psychic, motor and autonomic symptoms

19. Complex partial seizure - Types

20. Generalized seizures

21. Absence seizures
Sudden in onset, interruption of ongoing activities, blank stare
Non-responsive
Vanish in second
Atypical
Can associate with other components
Tonus, clonus, automatism

22. Myoclonic seizures Sudden, brief
Generalized to individual muscle group
Ddx
Spinal cord, brainstem and cortices lesions

23. Clonic seizure Generalized seizure sine tonic component
Postictal phase is usually short
May progress to tonic phase, clonic-tonic-clonic seizure

24. Tonic seizures
Rigid, violent muscular contraction fixing the limbs in some strained position
Deviated eyes, head towards one side, alteration in posture
Pale, flushed and ultimately livid

25. Tonic-clonic seizures
Vague ill-described warning
Tonic phase:
Sudden, sharp, tonic contraction of muscles (+ stridor), cyanosis
Fall on ground, tongue bitten, urine incontinence
Clonic phase:
Grunting
drooling
Deep respiration, all muscle relax, remain unconscious for variable time,
Awake with soreness and drowsiness, deep sleep

26. Atonic seizures Sudden reduction in muscle tone
Head drop, slacking of jaw, dropping of limb or slumping to the ground
Drop attack
Ddx: brainstem ischaemia, narcolepsy

27. Part 3: Video Demonstrations

28. CS 2
D:\HMR_ROM1\AVI\CS2.AVI
Video 1

29. CS 2: Simple partial seizure with motor signs and march
No loss of consciousness
Rhythmic twitching of the fingers of the left hand, spreading through arm to shoulder
He held his affected hand
Simple partial seizure with motor signs
Focal

30. CS 12
D:\HMR_ROM1\AVI\CS12.AVI
Video 12

31. CS 12: Simple partial seizure with psychic symptoms and dysphasia
With dysphasic symptoms
Clicking of tongue, mumbling incomprehensible words and smiles
Fully understand commands but unable to speak properly

32. CS 15
D:\HMR_ROM1\AVI\CS15.AVI
V 15

33. CS 15: Complex partial seizure, simple partial onset, impairment of consciousness
Slight loss of postural tone
Preserved orientation reflex
Impaired consciousness

34. CS 17 Patient was asked to hyperventilate in the beginning
D:\HMR_ROM1\AVI\CS17.AVI
v17

35. CS 17: Complex partial seizure vs generalized absence
Patient suddenly stopped hyperventilating
Motionless and blank facial expression
Regain consciousness with told nurse her had vague stomach sensation
EEG: localized right frontal activity pre and postictally favours a partial seizure

36. CS 19 Patient with right frontal ganglioglioma
D:\HMR_ROM1\AVI\CS19.AVI
V 19

37. CS 19: Complex partial seizure, impairment of consciousness at onset
Sudden sat up and started to roll about
Lying on his belly
Manipulated his genitals (frontal automatism)
In the past, this must be classified as hysteria
Artifacts in eeg caused by movement

38. CS 20
D:\HMR_ROM1\AVI\CS20.AVI

39. CS 20: Simple partial seizure with secondary generalization
Left arm started jerking
Still responsive
Coarse jerking of arms, stretching of back, tonic contraction of face, open mouth
Loss of consciousness
Twitching of all limbs and head
Relaxation and postictal sleep

40. CS 23
D:\HMR_ROM1\AVI\CS23.AVI

41. CS 23: Typical absence seizure
Slight loss of tone in neck muscle when stop hyperventilation
Seizure started
Mild eyelid clonus
Regain responsiveness later
Next time a pretty girl stares at you and blinks her eyes, don’t think that she is trying to give u “electric shock”…she is just having an absence seizure

42. CS 29
D:\HMR_ROM1\AVI\CS29.AVI

43. CS 29: Generalized atypical absence seizure
Head drop gradually
Not responsive
Later responded to staff and gradually regain upright position

44. CS 30
D:\HMR_ROM1\AVI\CS30.AVI

45. CS 30: Generalized myoclonic seizure
Brief repetitive movements of the limbs

46. CS 32
D:\HMR_ROM1\AVI\CS32.AVI

47. CS 32: Generalized clonic seizure
Opening of eyes and massive myoclonic jerks
Continuous clonic movement of limbs
Repetitive vocalization with clonic movement of the chest

48. CS 33
D:\HMR_ROM1\AVI\CS33.AVI

49. CS 33: Tonic seizure
Gradual elevation of both hands and stopped walking
Took 2 steps and then passed urine
Bent body strongly forward but kept standing
Dropped handkerchief
Usually patients do not walk but keep standing

50. CS 34
D:\HMR_ROM1\AVI\CS34.AVI

51. CS 34: Tonic clonic seizure
Suddenly bent forward with extended arm and legs
Twitching in face and body
Tonic stretching of arms and legs

52. CS 35
D:\HMR_ROM1\AVI\CS35.AVI

53. CS 35: Atonic seizures Sudden relaxation of muscles
Head drop, floppy limbs and slumping to the ground

54. Some more videos if we have time
Otherwise, THE END.

55. CS 27
D:\HMR_ROM1\AVI\CS27.AVI

56. CS 27: Absence seizure With automatism
Not necessarily specific for complex partial seizures

57. D:\HMR_ROM1\AVI\CS24.AVI

58. Absence with mild clonic component

59. D:\HMR_ROM1\AVI\CS26.AVI

60. Absence with tonic component
Head mainly affected

61. CS 3
D:\HMR_ROM1\AVI\CS3.AVI

62. CS 3: Partial seizure with motor signs and march
Complex partial seizure → partial motor seizure with secondary generalization
Not a Jacksonian seizure: consciousness was impaired before the march starts

63. CS 4
D:\HMR_ROM1\AVI\CS4.AVI

64. CS 4: Simple partial seizure with motor signs and versive movements
Sudden start of seizure from sleep
Version of trunk towards the right
Left arm bent at the elbow, fingers forcefully stretched
Right arm beats on arm of chair to warn nurse
Tonic contraction of face and eyes
EEG: not interpretable due to artifacts (pseudospike waves)

65. CS 13
D:\HMR_ROM1\AVI\CS13.AVI

66. CS 13: Simple partial seizure with psychic, dysmnesic and affective symptoms and hallucinations
Happily talking
Deja-vu
Spontaneous hyperventilation
Facial expression of suffering with weeping and crying
No loss of contact; can give age, date and name of objects
Cries and yells; feels very bad and asks for help; weeps – affective sympoms

67. THE END
Questions?