New Classification:
In the 2010 proposal, mode of onset is subdivided into generalized, focal, and unknown, the latter of which includes spasms.
Generalized — Generalized seizures are conceptualized as those that originate at some point within, and rapidly engage bilaterally distributed networks, which can be
subcortical or cortical structures. Generalized seizures do not need to necessarily include the entire cortex, however, and they may be asymmetric. Importantly, a generalized presentation can still arise from a focal lesion, and does not exclude the possibility of a surgical remedy.
Focal — The term focal has replaced partial to describe seizures that originate in
networks limited to one hemisphere [3]. Focal seizures may arise from either subcortical structures or neocortex.
In addition, the terms simple partial, complex partial, and secondarily generalized have been eliminated, since they were difficult to define pragmatically and were often used incorrectly. Instead, the proposal uses various descriptors of focal seizures to describe an event more precisely. Examples of preferred descriptors include:
●Without impairment of consciousness or awareness
●Involving subjective sensory or psychic phenomena
●With impairment of consciousness or awareness, or dyscognitive
●Evolving to a bilateral convulsive seizure
Unknown — The term unknown mode of onset is used for seizure types where it
remains unclear whether onset is focal, generalized, or perhaps either. A key example is epileptic spasms, concerning which there has traditionally been controversy, and
current knowledge is inadequate to specify mode of onset as either focal or generalized.
ILAE Classification of seizures Generalized seizures
Tonic-clonic (in any combination) Absence
Typical Atypical
Absence with special features Myoclonic absence Eyelid myoclonia Myoclonic
Myoclonic Myoclonic atonic Myoclonic tonic Clonic
Tonic Atonic Focal seizures Unknown
Epileptic spasms
ILAE: International League Against Epilepsy.
old classification:
45. 72 yo man episodes loss of consciousness past 2 years. No warming symptons, suddenly
find on the floor. Fracture arm and bruised. During episodes becomes pale and sweaty.
Jerking or twitching movements of the trunk and extremities for several seconds during episode. He recovers completely and is not confused at the end of episodes. Hx of 2 MI.
K. Syncope
Imitators of epilepsy: Nonepileptic paroxysmal disorders Neonates
Abnormal eye movements (eg, spasmus nutans, opsoclonus-myoclonus) Rhythmic movement disorder (head banging)
Children
Periodic limb movements of sleep Sleep starts Rapid eye movement sleep behavior disorder
Differentiation of generalized tonic-clonic seizures from pseudoseizures and syncope Characteristic Generalized seizure
tonic-clonic Pseudoseizure Syncope
Circumstances
Situation Awake or sleep Awake Usually upright; any position if
cardiogenic
Precipitating factors Sleep loss, alcohol withdrawal, flashing
lights Emotion Emotion, injury, heat, crowds; none
if cardiogenic
Presence of others Variable Usual Variable
Motor phenomena
Vocalization At onset, if any During course None
Location of motor
component (if present) Proximal limb Proximal limb None Generalized motor Tonic, then clonic Tonic; flailing; struggling or
thrashing, or both Usually atonic; if syncope lasts
>20 seconds: tonic, then clonic Tonic posture Partial flexion or
straight Opisthotonic -
Head movements To one side or none Side to side -
Clonus/limb jerks Bilaterally synchronous Asynchronous Bilaterally synchronous Purposeful movements Absent Occasional, including
avoidance Absent
Biting Tongue, inside mouth Lips, arms, other people Tongue biting rare
Babinski's sign Present Absent Absent
Autonomic features
Micturition Frequent Rare Occasional
Eyes Open Closed Open
Pupils Dilated or hippus during
attacks Normal Dilated
Colour Cyanotic or grey Rubor or normal Pale
Pulse Rapid, strong Normal
Slow if vasovagal, weak if vasodepressor; that of arrhythmias if cardiogenic
Timing
Usual duration 1 to 5 min 5 to 60 min 1 to 2 min
Onset Sudden Gradual Gradual; possibly sudden if
cardiogenic
Sequence of symptoms Stereotyped Variable Stereotyped
Termination Spontaneous Spontaneous or induced by supraorbital pressure, suggestion
Rapid
Sequelae
Injury Frequent, mild; scalp,
face, common Rare, but multiple bruises
possible; scalp, face, rare If sudden onset
Postictal Tired, confused, sleepy Alert, emotional outburst Regains consciousness in 2 to 3 min; alert but tired
Following the end of a seizure, there is a period of transition from the ictal state back to the individual's normal level of awareness and function. This interval is referred to as
the "postictal period" and signifies the recovery period for the brain. Manifestations typically include confusion and suppressed alertness; focal neurologic deficits may also be present. The postictal state may last from seconds to minutes to hours, depending upon several factors including which part(s) of the brain were affected by the seizure, the length of the seizure, whether the individual was on antiseizure drugs, and age.
As an example, young adults with focal seizures of frontal lobe origin may have postictal states that last only several seconds, while elderly patients with secondarily
generalized seizures may have postictal confusion and sleepiness that persists for as long as several days to a week, particularly if there is underlying brain dysfunction [27]. If a person had a focal seizure with impairment of consciousness or a convulsion, his or her level of awareness gradually improves during the postictal period, much like a person waking up from anesthesia after an operation.
46. 25 yo woman, growths in her lips and tongue for years. Nodules in lips, buccal mucosa, tongue. Café au lait spot in trunk, limbs. Scattered nodules on skin. Greatest risk for?