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Type of seizure The patient sometimes senses 60 the approach of a seizure by one of Complex partial several subjective phenomena (a 50 Simple partial prodrome) For some hours, the paPartial, unclassified 40 tient may feel apathetic, depressed, Generalized tonic-clonic 30 irritable, or, very rarely, the oppoAbsence site ecstatic One or more my20 Myoclonic oclonic jerks of the trunk or limbs Generalized, other 10 on awakening may herald a seizure Unknown, multiple 0 later in the day In more than half 0 14 15 34 36 64 >65 the cases, there is some type of Years movement for a few seconds before Figure 16-1 The distribution of the main types of epilepsy by age Apparent is the overrepresentation of absence consciousness is lost (turning of and myoclonic seizures in childhood and of complex partial seizures in older individuals (Adapted from Hauser the head and eyes or whole body or and Annegers and the texts of Engel and of Pedley) intermittent jerking of a limb), although the patient fails to form a turbed, he becomes drowsy and falls asleep, sometimes for several memory of this and such information is obtained only from an hours, then sometimes awakens with a pulsatile headache When observer Abdominal pains or cramps, a sinking, rising, or gripping fully recovered, such a patient has no memory of any part of the feeling in the epigastrium, pallor or redness of the face, throbbing spell but knows that something has happened because of the strange headache, constipation, or diarrhea have also been given prodrosurroundings (in ambulance or hospital); the obvious concern of mal status, but we have not found them consistently enough to be those around him; and a sore, bitten tongue and aching muscles helpful from the violent contractions The latter, if violent enough, may Most often, the seizure strikes out of the blue, ie, without crush a vertebral body or result in a serious injury; a fracture, periwarning, beginning with a sudden loss of consciousness and fall to orbital hemorrhages, subdural hematoma, or burn may have been the ground The initial motor signs are a brief exion of the trunk, sustained in the fall an opening of the mouth and eyelids, and upward deviation of the Each of these phases of the generalized tonic-clonic seizure eyes The arms are elevated and abducted, the elbows semi exed, has its characteristic EEG accompaniment Initially, movement arand the hands pronated These are followed by a more protracted tifacts obscure the EEG changes; sometimes there are repetitive extension (tonic) phase, involving rst the back and neck, then the spikes or spike-wave discharges lasting a few seconds, followed arms and legs There may be a piercing cry as the whole muscuby an approximately 10-s period of 10-Hz spikes As the clonic lature is seized in a spasm and air is forcibly emitted through the phase asserts itself, the spikes become mixed with slow waves and closed vocal cords Since the respiratory muscles are caught up in then the EEG slowly assumes a polyspike-and-wave pattern When the tonic spasm, breathing is suspended, and after some seconds all movements have ceased, the EEG tracing is nearly at for a the skin and mucous membranes may become cyanotic The pupils variable time, and then the brain waves resume their preseizure are dilated and unreactive to light The bladder may empty at this pattern stage or later, during the postictal coma This is the tonic phase of Convulsions of this type ordinarily come singly or in groups the seizure and lasts for 10 to 20 s of two or three and may occur when the patient is awake and active There then occurs a transition from the tonic to the clonic or during sleep, or frequently when falling asleep or awakening phase of the convulsion At rst there is a mild generalized tremor, Some 5 to 8 percent of such patients will at some time have a which is, in effect, a repetitive relaxation of the tonic contraction prolonged series of such seizures without resumption of consciousIt begins at a rate of eight per second and coarsens to four per ness between them; this is called convulsive status epilepticus and second; then it rapidly gives way to brief, violent exor spasms demands urgent treatment Sometimes the rst outburst of seizures that come in rhythmic salvos and agitate the entire body The face takes the form of convulsive status becomes violaceous and contorted by a series of grimaces, and Few clinical states closely simulate a grand mal convulsion, often the tongue is bitten Autonomic signs are prominent: the pulse but several are worthy of mention One is a clonic jerking of the is rapid, blood pressure is elevated, pupils are dilated, and salivaextended limbs (usually less severe than those of a grand mal seition and sweating are abundant; bladder pressure may increase sixzure) that occurs with vasodepressor syncope or a Stokes-Adams fold during this phase The clonic jerks decrease in amplitude and attack In contrast to an epileptic type of EEG, the brain waves are frequency over a period of about 30 s The patient remains apneic slow and at during the jerking movements A rarer phenomenon until the end of the clonic phase, which is marked by a deep inthat may be indistinguishable from a generalized convulsion occurs spiration Instead of the whole dramatic sequence described above, as part of basilar artery occlusion (Ropper) This presumably has the seizures may be abbreviated or limited in scope by anticonits basis in ischemia of the corticospinal tracts in the pons; a similar vulsive medications ischemic mechanism in the cortex has been invoked for limbIn the terminal phase of the seizure, all movements have ended shaking TIAs (transient ischemic attacks), in which there are cloand the patient lies still and limp, in a deep coma The pupils, equal nic movements of one limb or one side of the body during an or unequal, now begin to contract to light Breathing may be quiet episode of cerebral ischemia Hysterical (nonepileptogenic, psyor stertorous This state persists for several minutes, after which chogenic ) seizures, as discussed further on, are often dif cult to the patient opens his eyes, begins to look about, and is obviously distinguish from a true seizure Rarely, in adults, an attack of panic bewildered and confused and may be quite agitated The patient (page 438) or the rare entity of rapid-eye-movement (REM) sleep may speak and later not remember anything that he said UndisPercent of incident cases.

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