Epilepsy & Seizures 1

Question 1

Definition of seizure

Answer 1

a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain

Question 2

Definition of epilepsy

Answer 2

a disease of the brain defined by any of the following conditions:

1) At least two unprovoked (or reflex) seizures occurring >24h apart
2) 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 **
3) diagnosis of an epilepsy syndrome

** The probability of at least 60% was chosen for this definition because this is the lower limit of the confidence interval for someone with two unprovoked seizures having another seizure within 10 years

Question 3

In the definition of epilepsy, what does the term reflex mean

Answer 3

The condition of recurrent reflex seizures, for instance in response to photic stimuli, represents provoked seizures that are defined as epilepsy.
Even though the seizures are provoked, the tendency to respond repeatedly to such stimuli with seizures meets the conceptual definition of epilepsy, in that reflex epilepsies are associated with an enduring abnormal predisposition to have such seizures

Question 4

Acute symptomatic (provoked) seizure

Answer 4

Acute symptomatic seizure refers to a seizure that occurs at the time of a systemic insult or in close temporal association with a documented brain insult.
Such insults include metabolic derangements, drug or alcohol withdrawal, and acute neurologic disorders such as stroke, encephalitis, or acute head injury.

The time window within which a seizure may be considered acute symptomatic has not been clearly defined and may vary based on the type of insult.
One consensus panel recommendation suggests the following ranges:

● Within one week of stroke, traumatic brain injury, anoxic encephalopathy, or intracranial surgery

● At first identification of subdural hematoma

● During the active phase of a central nervous system infection

● Within 24 hours of a severe metabolic derangement

In population-based studies, acute symptomatic seizures make up 25 to 30 percent of first seizures.

Acute symptomatic seizures may recur during the index illness but generally carry a low risk for future epilepsy compared with unprovoked seizures.
That said, some patients will go on to develop remote symptomatic seizures or epilepsy related to a prior stroke, hemorrhage, or head injury.

Question 5

Management of first provoked seizure

Answer 5

Question 6

When is epilepsy considered to be resolved

Answer 6

Epilepsy is considered to be resolved for individuals:
* who had an age-dependent epilepsy syndrome but are now past the applicable age or
* who have remained seizure-free for the last 10 years, with no seizure medicines for the last 5 years

Question 7

Which are the three levels of epilepsy diagnosis

Answer 7

1) Seizure type
2) Epilepsy type (focal, generalized, combined generalized and focal, unknown)
3) Epilepsy syndrome

Question 8

First level of epilepsy diagnosis

Answer 8

The first level of epilepsy diagnosis is defining the seizure type. This can be either:

1) Focal onset
2) Generalized onset
3) Unknown onset

** Focal seizures originate within a neuronal network limited to one hemisphere that may be discretely localized or more widely distributed, whereas generalized seizures originate at some point within the brain and rapidly engage bilateral distributed networks

Question 9

What kind of seizure types can be seen in focal onset epilepsies

Answer 9

Aware / Impaired awareness as a classifier
and

Motor:
automatisms
atonic
clonic
epileptic spasms
hyperkinetic
myoclonic
tonic

Non motor onset:
autonomic
behaviour arrest
cognitive
emotional
sensory

Question 10

Where does the manifestation in focal seizures come from

Answer 10

Either:

a) the brain region involved in the ictal discharge
b) may originate in silent areas and the manifstation may reflect seizure spread to other brain regions

Question 11

Localization of focal clonic or tonic activity

Answer 11

Usually it originates at the contralateral hemisphere

Question 12

In focal seizures with impaired awareness: 1) Which part of the brain is most commonly responsible 2) which is the most common motor manifestation

Answer 12

1) The most common part of the brain is temproal lobe and then frontal lobe
2) The most common motor manifestations are automatisms

Question 13

Describe focal onset epilepsies with mesial temporal origin

Answer 13

1) Isolated auras:
The most common aura is an epigastric sensation frequently with a rising character (autonomic).
Other auras occur less commonly and include fear, anxiety, and other emotions, déjà vu and jamais vu, nonspecific sensations, and autonomic changes such as palpitation and gooseflesh.
(Olfactory and gustatory auras are uncommon and are more likely with tumoral mesial temporal lobe epilepsy (MTLE)

may be followed by:

2) Automatisms.
Oroalimentary automatisms are the most prevalent. Extremity automatisms also occur and are most commonly manipulative, with picking or fumbling (αδέξια αναζήτηση για κάτι). Nonmanipulative automatisms typically consist of rhythmic movements either distally or proximally.
3) Behavioral arrest
4) Head turning. (Early or late)
5) Autonomic phenomena (pallor, flushing, tachycardia)
6) contralateral upper limb dystonia

Focal onset seizures with impaired awareness of temporal lobe origin usually last between 30 seconds and 3 minutes

Question 14

Characteristics of lateral temporal lobe (neocortical) seizures

Answer 14

less common than those of mesial temporal origin
Auditory auras are the most common auras, usually implying involvement of the Heschl gyrus.
(Other types of auras referable to the lateral temporal cortex are vertigo and complex visual hallucinations (usually posterior temporal)
The focal sensory auditory seizure is usually a basic sound such as buzzing or ringing (rather than formed speech)
If the sound is heard in only one ear it suggests the seizure is in the contralateral hemisphere.
Oroalimentary automatisms and the pattern of contralateral dystonic posturing and ipsilateral extremity automatisms are less common.

Seizures originating in the temporal lobe may have hypermotor semiology characteristic of frontal lobe origin, due to propagation to the frontal lobe (such as contralateral upper limb dystonia, facial twitching or grimacing, and head and eye version may occur)

Question 15

Localizing semiology in temporal lobe epilepsy

Answer 15

1) The contralateral upper extremity is commonly involved in dystonic posturing or milder degrees of posturing and immobility.
This reduces the availability of the contralateral arm for automatisms, so manipulative automatisms tend to be ipsilateral, involving the unaffected upper extremity. Non manipulative automatisms tend to be contralateral, often preceding overt dystonic posturing.

2) Early head turning typically occurs at the same time as dystonic posturing and is most often ipsilateral.
Late head turning most often occurs during evolution to generalized tonic-clonic activity. This is usually contralateral to the side of seizure origin.
3) Ictal speech, spitting, vomiting, drinking, urge to urinate and automatisms with preserved consciousness suggest seizure onset in the non-dominant temporal lobe.
Verbal output may at times be tinged with a fearful tone. However, recollection of conversations is unusual.
4) Postictal aphasia usually in dominant hemisphere seizures
5) Unilateral pupillary dilatation can lateralize the seizure to the ipsilateral hemisphere

Question 16

Which seizures have more tendency for generalization, mesial or lateral temporal lobe seizures?

Answer 16

Seizures of lateral temporal origin tend to be shorter in duration and have a greater tendency to evolve to generalized tonic-clonic activity than seizures of mesial temporal origin.

Question 17

Differences of MTLE and lateral temporal lobe epilepsy

Answer 17

• In comparison to mesial temporal lobe seizures, lateral temporal seizures are of shorter duration, and the onset of impaired awareness is an earlier feature (the initial aware phase is not as prolonged).
• Evolution to a focal to bilateral tonic-clonic seizure is more common than in mesial temporal lobe seizures.
• Neocortical temporal seizures are less frequently associated with visceral sensations and automatisms, and more frequently accompanied by auditory hallucinations

Question 18

Describe focal onset with awareness epilepsies of frontal origin

Answer 18

Many different seizure types can originate in the frontal lobe, depending on site of seizure origin and propagation.
Focal onset seizures with awareness can be motor with localized clonic, tonic or myoclonic activity.
They may exhibit features of a Jacksonian march where unilateral tonic-clonic movements start in one muscle group and spread systematically to adjacent groups reflecting the spread of ictal activity through the motor cortex according to the homunculus.
There may be focal somatosensory features alone, such as unilateral tingling, or in combination with motor features.
Negative motor features such as focal atonic features may also occur (primary sensorimotor cortex)
Asymmetrical tonic seizures or postural seizures are usually related to involvement of the supplementary motor area in the mesial frontal cortex anterior to the motor strip (e,g. the fencing posture in which the contralateral arm is extended and the ipsilateral arm is flexed)
Tonic posturing may involve all four extremities and is occasionally symmetrical.
Subjective focal onset with awareness seizures may also occur with frontal lobe origin (most common being a nonspecific cephalic aura)

(seizures originating in the frontal lobe can propagate to the temporal lobe and produce manifestations typical of mesial temporal lobe seizures)

Question 19

Describe focal onset without awareness seizures of frontal origin

Answer 19

Focal onset without awareness seizures of frontal lobe origin tend to be very peculiar (παράξενες).
They may be preceded by a nonspecific aura or they may start abruptly, often out of sleep.
Their most characteristic features are hyperkinetic automatisms with frenzied (ξέφρενος) behavior and agitation (often referred to as hypermotor seizures)
There may be various vocalizations including expletives (βρισιά).
The manifestations can be so bizarre as to suggest a psychiatric origin.
The seizure duration is short, often less than 30 seconds, and postictal manifestations are brief or nonexistent, further adding to the risk of misdiagnosis as psychogenic seizures

** frontal focal impaired awareness seizures can be difficult to distinguish from absence seizures

Question 20

Describe supplementary sensorimotor area seizures (frontal lobe)

Answer 20

Asymmetric posturing of the upper limbs occurs, with extension of the upper limb contralateral to the hemisphere of seizure onset and flexion of the ipsilateral upper limb.
Fencing posture - Ξιφομάχου

Supplementary motor seizures are usually short in duration (10-40 sec), have abrupt onset and offset, frequently arise out of sleep and have minimal postictal confusion.
They tend to occur in clusters and may be preceded by a sensory aura referable to the supplementary sensory cortex.
Loud vocalization or speech arrest can occur at seizure onset.
The head and eyes are often turned to the side contralateral to the hemisphere of seizure onset.
When these seizures originate in the supplementary motor area, consciousness is usually preserved but when they occur as a result of seizure spread to the supplementary motor area from other regions of the brain consciousness is frequently impaired.

Supplementary motor seizures are an important exception to the rule that bilateral motor activity during a seizure should be associated with loss of consciousness

Question 21

Localization of focal onset seizures without awareness of frontal origin

Answer 21

Frontal lobe focal onset without awareness seizures arise predominantly from the orbitofrontal region (κογχομετωπιαίος φλοιός) and from the mesial frontal cingulate region (έλικα του προσαγωγίου).

Question 22

Describe focal onset seizures of occipital origin

Answer 22

The best-recognized occipital lobe seizure semiology is
that of focal onset with awareness seizures with visual manifestations.
The most common are elementary visual hallucinations that are described as flashing colored lights or geometrical figures. These are usually contralateral but may move within the visual field.
Complex visual hallucinations with familiar faces or people may also occur (involvement of supplementary visual cortex).
Negative symptoms may be reported, with loss of vision in one hemifield. Ictal blindness may occur, with loss of vision in the whole visual field.
Objective seizure manifestations include blinking, nystagmoid eye movements, and versive eye and head deviation contralateral to the seizure focus.
This version may occur while the patient is still conscious or could be a component of focal onset without awareness seizures.
Evolution of occipital seizures to secondary generalization is commonly reported

Question 23

Semiology of occipital seizure when spread to a) temporal lobe b) frontal lobe

Answer 23

Seizure manifestations that are related to seizure spread to the temporal or frontal lobe are very common.

a) Temporal lobe: Oroalimentary automatisms
b) Frontal lobe: Asymmetrical tonic posturing
(both types of spread can be seen in the same patient)
Spread to the temporal or frontal lobe is so common with occipital lobe seizures that it is at times reported in the majority of patients.

Question 24

Describe focal onset seizures of parietal origin

Answer 24

The best-recognized seizure type that originates in the
parietal lobe is focal seizure with somatosensory manifestations.
The somatosensory experience can be described as tingling, pins and needles, numbness, burning, or pain.
The presence of a sensory march is most suggestive of involvement of the primary sensory cortex.
Other auras of parietal lobe origin are a sensation of movement in an extremity, a feeling of the body bending forward or swaying or twisting or turning, or even a feeling of an extremity being absent.
Some patients may complain of inability to move a limb.
Vertigo has been reported, as well as visual illusions of objects going away or coming closer or looking larger.
Some patients may have initial auras suggesting spread to the occipital or temporal lobe.

Question 25

Semiology of parietal seizure when spread to a) frontal lobe b) temporal lobe

Answer 25

a) Frontal lobe: Motor manifestations tend to reflect seizure spread to the frontal lobe. These include tonic posturing of the extremities, focal motor clonic activity, and version of the head and eyes. Negative motor manifestations may occur, with ictal paralysis
b) Temporal lobe: oroalimentary or extremity automatisms

Question 26

Localization in focal onset parietal epilepsy

Answer 26

Somatosensory auras tend to be contralateral to the hemisphere of seizure origin, but they may be bilateral or ipsilateral when arising from the second or supplementary sensory regions
Seizures involving the dominant parietal lobe may produce aphasic manifestations.

Question 27

Describe focal onset seizures of insular origin

Answer 27

Insular epilepsy is uncommon and also frequently unrecognized because of the inability to record directly from the insula with scalp electrodes.
Subjective symptoms that should suggest seizure origin in the insula include laryngeal discomfort, possibly preceded or followed by a sensation in the chest or abdomen, shortness of breath, and paresthesias around the mouth or also involving other contralateral body parts.
Objective seizure manifestations include dysarthria/dysphonia, sometimes evolving to complete muteness.
With seizure progression in some patients, tonic spasm of the face and upper limb, head and eye rotation, and at times generalized dystonia occur.
Hypersalivation is also very common and can be impressive. Insular-onset seizures may spread to other brain regions and can be disguised as temporal lobe, parietal lobe, or frontal lobe epilepsy

Question 28

What kind of seizure types can be seen in generalized onset epilepsies

Answer 28

Motor:
tonic-clonic
clonic
tonic
myoclonic
myoclonic-tonic-clonic
myoclonic-atonic
atonic
epileptic spasms

Non motor (absense):
typical
atypical
myoclonic
eyelid myoclonia

Question 29

Describe generalized tonic-clonic seizures

Answer 29

Generalized tonic-clonic seizures do not have an aura, but they may be preceded by a prodrome—the vague sense a seizure will occur—lasting up to hours.
Seizure onset is abrupt, most often with loss of consciousness and a generalized tonic contraction
Generalized tonic-clonic seizures rarely last more than 2 minutes

The tonic phase: may have asymmetrical movements, and these often change from seizure to seizure.
One such commonly encountered asymmetry is versive head turning, which is not evidence of a focal onset.
The tonic phase includes an upward eye deviation with eyes half open and the mouth open.
Involvement of the respiratory muscles usually produces a forced expiration that produces a loud guttural vocalization, often referred to as the epileptic cry.
Cyanosis may occur during the tonic phase in association with apnea. The tongue may also be bitten during this phase and most often affects the side of the tongue

The clonic phase: The transition can be with initially highfrequency and low-amplitude motion, often referred to as a vibratory phase.
With seizure progression, the frequency of clonic jerks decreases, and the amplitude may initially increase but later decreases just before the seizure stops.
Incontinence of urine is common, and incontinence of stool may also occur.

Question 30

Describe postictal state in generalized tonic-clonic seizures

Answer 30

In the immediate postictal state the individual is limp and unresponsive.
Respiration is loud and snoring in character (stertorous).
The postictal state is often followed by sleep, although the individual may awaken briefly with postictal confusion.
After awakening, patients often have a pronounced headache and generalized muscle soreness.
The postictal state seems to correlate with severity and duration

Question 31

Describe typical absence seizures

Answer 31

Typical absence seizures are characterized by a sudden blank stare with motor arrest, usually lasting less than 15 seconds.
The individual is usually unresponsive and unaware.
The seizure ends as abruptly as it starts, and the patient returns immediately to a baseline level of function with no postictal confusion but may have missed conversation and seems confused as a result.
If the only manifestation is altered responsiveness and awareness, with no associated motor component, the absence seizure is classified as simple absence.

Most often, generalized absence seizures include mild motor components and are classified as complex absence.
The most common motor components are automatisms such as licking the lips or playing with an object that was held in the hand before the seizure.
Other motor components include clonic, tonic, atonic, and autonomic manifestations.
Clonic activity may affect the eyelids or the mouth.
An atonic component may manifest with dropping an object or slight head drop or drooping of the shoulders or trunk
Tonic components may manifest with slight increase in tone
Absence seizures may evolve to generalized tonic-clonic activity

Question 32

How is EEG in absence seizures

Answer 32

The EEG hallmark of a typical generalized absence seizure is generalized 2.5- to 4-Hz spike-and-wave activity with a normal interictal background.
Atypical absence seizures are diagnosed primarily based on a slower (<2.5 Hz) frequency of the EEG spike-and-wave activity

Question 33

Which are the 4 types of absence seizures (describe)

Answer 33

1) typical absence
2) atypical absence
usually occur in individuals with impaired cognitive function. Affected individuals usually have associated seizure types such as generalized tonic, generalized atonic, and generalized tonic-clonic seizures.
Less important distinctions are that the onset and termination of an atypical absence seizure may be less abrupt and the motor components a bit more pronounced than seen with typical absence seizures.
3) myoclonic absence
The key manifestation of these seizures is a prominent rhythmic myoclonus predominantly affecting the limbs
4) absence with eyelid myoclonia
The eyelid myoclonia consists of pronounced rhythmic jerking of the eyelids, usually associated with an upward deviation of the eyes and retropulsion of the head.
There may or may not be associated generalized spike-and-wave activity on EEG.

Question 34

Describe myoclonic seizures

Answer 34

Myoclonic seizures are muscle contractions lasting a fraction of a second ( <250 msec), in association with an ictal EEG discharge.
The myoclonic jerk can be generalized, affecting the whole body, or could affect just the upper extremities or (rarely) the head or trunk, or even the diaphragm.
The myoclonic jerks may affect one side of the body at one time, but typically the other side is affected at other times. The jerks can be single or could occur in an arrhythmic cluster.
Epileptic myoclonus is generated in the cerebral cortex and is usually associated with a single or brief serial spike-and-wave or polyspike-and-wave activity.
Negative myoclonic seizures consist of a very brief pause in muscle activity rather than a brief muscle contraction.
Just as with positive myoclonus, negative myoclonus can be generalized, bilateral with limited distribution, or even focal, typically with shifting lateralization.
Generalized myoclonic seizures may cluster just before a generalized tonic clonic seizure occurrence.

Question 35

Describe a) myoclonic-atonic and b) myoclonic-tonic seizures

Answer 35

a) Myoclonic seizures may be immediately followed by a loss of tone. The seizure type is called myoclonic-atonic. Historically it was called myoclonic-astatic.
The seizures are brief (1 second or less) but may be associated with falls and injuries.
The EEG shows generalized spike-and-wave or polyspike-and-wave discharge.
The slow wave is prolonged and associated with the electromyographic silence characteristic of the atonic phase
b) Myoclonic seizures may precede a more sustained tonic contraction, and the resultant seizures may be referred to as myoclonic-tonic seizures

Question 36

Is myoclonus always epileptic

Answer 36

Myoclonus is not always epileptic

(Myoclonus can be generated anywhere along the central nervous system)

Question 37

1) Describe generalized clonic seizures
2) Where are they most commonly seen

Answer 37

1) a seizure with bilateral, sustained rhythmic jerking and loss of consciousness

2) Generalized clonic seizures are uncommon and particularly rare in adults.
They are more frequently seen in certain epileptic syndromes of infancy and childhood.
For example, clonic seizures are a common seizure of Dravet syndrome.
Clonic seizures are also noted in progressive myoclonic epilepsies

Question 38

Describe generalized tonic seizures

Answer 38

A generalized tonic seizure involves bilaterally increased tone of the limbs typically lasting seconds to a minute.
Their onset may be gradual or abrupt.
They may be initiated with a myoclonic jerk.
They can vary in severity from subtle, with slight increase in neck tone with upward deviation of the eyes, to massive, with involvement of the axial muscles and extremities.
Proximal muscles are the most affected.
Most commonly there is neck and trunk flexion as well as abduction of the shoulders and flexion of the hips. However extension may also occur.
Tonic seizures may be asymmetrical, which could result in turning to one side.
The pattern of muscle involvement may change over time so that there may be a change in the position of the limbs over the course of the seizure.
Autonomic changes may occur, with tachycardia, pupil dilation, and flushing
Involvement of respiratory muscles could cause apnea and cyanosis.
The tonic contraction may end with one or more pauses that result in a few clonic jerks
A postictal state with confusion may occur, but recovery is usually rapid.
However, tonic seizures may be followed by atypical absence, resulting in what appears to be a more prolonged postictal state.
This has been referred to as tonic-absence seizure
Generalized tonic seizures occur most often out of sleep and drowsiness

Question 39

Describe generalized atonic seizures

Answer 39

Generalized atonic seizures are associated with very brief, sudden loss of tone and vary from extremely subtle, manifesting with only a head drop, to generalized loss of tone and falling.
Atonic seizures may result in falling if the person is standing (drop attack)
However, drop attacks may be the result of both generalized atonic and generalized tonic seizures.
There is a very brief loss of consciousness and brief postictal confusion. Seizures are usually very brief, lasting 1 second to a few seconds.
They may be preceded by a brief myoclonic jerk, in which case the seizure type is called myoclonic-atonic.
Despite their brief duration, generalized atonic seizures can result in serious injury and are an important cause of morbidity in epilepsy

Question 40

Describe epileptic spasms

Answer 40

An epileptic spasm is a sudden flexion, extension or mixed flexion-extension of proximal and truncal muscles, lasting 1-2 seconds i.e. longer than a myoclonic jerk (which lasts milliseconds) but not as long as a tonic seizure (which lasts > 2 seconds).
The pattern of contraction is “diamond-shaped,” with intensity of contraction maximal in the middle of the spasm and less at the beginning and end.
Epileptic spasms are also called infantile spasms and salaam attacks.
Because their occurrence is not restricted to infants, the preferred current term is epileptic spasms.
The classic epileptic spasm involves neck and trunk flexion and arm abduction with a jackknife pattern, but extension may be seen.
Epileptic spasms typically occur in clusters recurring every 5 to 40 seconds (if singular, consider other seizure types). In a cluster, the initial spasms may be subtle or mild, increase in intensity as the cluster progresses, and decrease in intensity again toward the end of the cluster

Question 41

Characteristic manifestations of focal onset bilateral seizure (former term partial onset seizure with secondary generalization)

Answer 41

1) versive head turning in a direction contralateral to the hemisphere of seizure onset (rarely ipsilateral), and focal or lateralized tonic or clonic motor activity
2) figure-of-4

Question 42

What is figure-of-4 posturing

Answer 42

A characteristic asymmetrical tonic phase with flexion on one side and extension on the other
It is sually seen in transition from focal to bilateral activity.
The sign lateralizes seizure activity contralaterally to the extended upper extremity (left hemisphere on the left, right hemisphere on the right)

Question 43

1) Describe focal to bilateral seizures 2) Differential diagnosis from generalized tonic-clonic

Answer 43

1)
- Consciousness is impaired
- Motor components in such a situation include tonic and clonic features.
- This type of seizure may follow after other focal seizures types, such as focal motor seizures, focal cognitive seizures, focal sensory seizures or focal impaired awareness seizures. Alternatively, the spread in brain networks may be so rapid that no preceding focal seizure type is identified

2)
- The focal to bilateral tonic-clonic seizure may be differentiated from the generalised tonic-clonic seizure on the basis of other evidence that supports a focal epilepsy/etiology, or
- there may be asymmetry seen in the focal to bilateral tonic-clonic seizure (such as head/eye version to one side, asymmetric amplitude to the motor features), and this asymmetry is seen consistently from seizure to seizure

Question 44

Which are the most common cases were a seizure type is classified as of unknown onset

Answer 44

1) the patient was asleep
2) the patient was alone
3) observers were too distracted by the manifestations of the seizure to notice the presence of focal features

Question 45

Describe hyperkinetic seizures (former term hypermotor)

Answer 45

Hyperkinetic activity comprises agitated thrashing or leg pedaling movements
Hyperkinetic seizures belong to focal onset seizures

Question 46

1) Describe automatisms
2) Where are they seen

Answer 46

1) Automatism is a more or less coordinated motor activity usually occurring when cognition is impaired and for which the subject is usually (but not always) amnesic afterward.
This often resembles a voluntary movement and may consist of an inappropriate continuation of preictal motor activity

2) Automatisms may be seen in focal seizures and in absence seizures

Question 47

Describe focal onset autonomic seizures

Answer 47

Focal autonomic seizures present with gastrointestinal sensations, a sense of heat or cold, flushing, piloerection (goosebumps), palpitations, sexual arousal, respiratory changes, or other autonomic effects

Question 48

1) Describe behavior arrest
2) Where is it seen
3) When is a seizure considered as behavior arrest

Answer 48

1) Arrest (pause) of activities, freezing, immobilization. Clinical symptoms include a blank stare and cessation from talking or moving
2) Behavior arrest occurs in focal impaired awareness seizures and absence seizures
3) Because brief behavioral arrest at the start of many seizures is common and difficult to identify, a focal behavioral arrest seizure should comprise behavioral arrest as the predominant aspect of the entire seizure

Question 49

Describe cognitive seizures (former term psychic)

Answer 49

Cognitive seizures pertain to thinking and higher cortical functions, such as language, spatial perception, memory, and praxis.
Cognitive seizures also imply impaired positive features such as deja vu, hallucinations or illusions

Question 50

Describe emotional seizures

Answer 50

Focal emotional seizures present with emotional changes, including fear, anxiety, agitation, anger, paranoia, pleasure, joy, ecstasy, laughing (gelastic), or crying (dacrystic).
Some of these phenomena are subjective and must be recalled and reported by the patient or caregiver.
Emotional symptoms comprise a subjective component, whereas, affective signs may or may not be accompanied by subjective emotionality

Question 51

Describe sensory seizures

Answer 51

A focal sensory seizure can produce somatosensory, olfactory, visual, auditory, gustatory, hot–cold sense, or vestibular sensations

Question 52

Types of seizures that can result in a drop attack

Answer 52

1) Myoclonic-atonic
2) myoclonic (especially in younger children)
3) tonic
4) atonic seizures

Question 53

Clues to a focal rather than generlized origin of epileptic spasms (seizure type)

Answer 53

1) asymmetry of the motor features (especially in initial spasms in the cluster)
2) lateral head/eye version
3) focal emphasis to the interictal or ictal EEG
4) presence of focal structural brain abnormality

Question 54

Which features distinguish myoclonic status epilepticus from generalised clonic status epilepticus

Answer 54

Myoclonic status epilepticus is characterized by ongoing (> 30 minutes) irregular jerking, often with partially retained awareness.
These two features distinguish a myoclonic status epilepticus from a generalized clonic seizure, where consciousness is lost and the jerking is sustained and rhythmic

Question 55

What is the risk of another seizure after:

1) one unprovoked seizure
2) two unprovoked seizures (in the next 4 years)

Answer 55

1) 40-52%
2) 60-90%

Question 56

Which are the four subgroups of Genetic Generalized Epilepsy (former and still acceptable term Idiopathic Generalized Epilepsy)

Answer 56

Childhood Absence Epilepsy
Juvenile Absence Epilepsy
Juvenile Myoclonic Epilepsy
and Generalized Tonic–Clonic Seizures Alone