Recovery

As the patient regains consciousness, there is postictal confusion and often headache. Full orientation commonly takes 10–30 minutes—or even longer in patients with status epilepticus (see below) or preexisting structural or metabolic brain disorders.

Physical examination during the postictal state is usually otherwise normal in idiopathic epilepsy or seizures of metabolic origin, except that plantar responses may be transiently extensor (Babinski sign). The pupils always react to light, even when the patient is unconscious. Transient unilateral weakness (hemiparesis) in the postictal period (Todd paralysis) should be sought, because such a finding suggests a focal brain lesion as the cause and calls for further investigation.

*Status epilepticus is defined arbitrarily as seizures that continue for more than 30 minutes without ceasing spontaneously, or which recur so frequently that full consciousness is not restored between successive episodes. Status epilepticus is a medical emergency because it can lead to permanent brain damage—from hyperpyrexia, circulatory collapse, or excitotoxic neuronal damage—if untreated

Absence (petit mal) seizures are genetically transmitted seizures that always begin in childhood and rarely persist into adolescence. The spells are characterized by brief loss of consciousness (for 5–10 seconds) without loss of postural tone.

- Subtle motor manifestations, such as eye blinking or a slight head turning, are common.

- Automatisms are uncommon. - Full orientation immediately follows cessation of the seizure.

There may be as many as several hundred spells daily, leading to impaired school performance and social interactions, so that children may be mistakenly thought to be mentally retarded before the diagnosis of petit mal epilepsy is made. The spells are characteristically inducible by hyperventilation. The electroencephalogram (EEG) shows a characteristic 3/s spike-and-wave

pattern during the seizures (Figure 8–3). In most patients with normal intelligence and normal background activity on EEG, absence spells occur only during childhood; in other cases, however, the attacks continue into adult life, either alone or in association with other types of seizures.

Other Types of Generalized Seizures

These include tonic seizures (not followed by a clonic phase), clonic seizures (not preceded by a tonic phase), and myoclonic seizures.

1. Tonic seizures are characterized by continuing muscle contraction that can lead to fixation of the limbs and axial musculature in flexion or extension and are a cause of drop attacks; the accompanying arrest of ventilatory movements leads to cyanosis. Consciousness is lost, and there is no clonic phase to these seizures.

2. Clonic seizures are characterized by repetitive clonic jerking accompanied by loss of consciousness. There is no initial tonic component.

3. Myoclonic seizures are characterized by sudden, brief, shocklike contractions that may be localized to a few muscles or one or more extremities or that may have a more generalized distribution. Myoclonic seizures may be idiopathic or associated with a variety of rare hereditary neurodegenerative disorders, including Unverricht-Lundborg disease, Lafora body disease, neuronal ceroid lipofuscinosis (late infantile, juvenile, and adult forms), sialidosis, and mitochondrial encephalomyopathy (myoclonus epilepsy with ragged red fibers on skeletal muscle biopsy). Not all myoclonic jerks have an epileptic basis, however, as discussed in Chapter 7.

4. Atonic seizures result from loss of postural tone, sometimes following a myoclonic jerk, leading to a fall or drop attack. They are most common in developmental disorders such as the Lennox-Gastaut syndrome.

1. Simple partial seizures begin with motor, sensory, or autonomic phenomena, depending on the cortical region affected. For example, clonic movements of a single muscle group in the face, a limb, or the pharynx may occur and may be self-limited; they may be recurrent or continuous or may spread to involve contiguous regions of the motor cortex (jacksonian march).

Autonomic symptoms may consist of pallor, flushing, sweating, piloerection, pupillary dilatation, vomiting, borborygmi, and incontinence. Psychic symptoms include dysphasia, distortions of memory (eg, déjà vu, the sensation that a new experience is being repeated), forced thinking or labored thought processes, cognitive deficits, affective disturbances (eg, fear, depression, an inappropriate sense of pleasure), hallucinations, or illusions. During simple partial seizures, consciousness is preserved unless the seizure discharge spreads to other areas of the brain, producing tonic-clonic seizures (secondary generalization). The aura is the portion of the seizure that precedes loss of consciousness and of which the patient retains some memory. The aura is sometimes the sole manifestation of the epileptic discharge.

In the postictal state, a focal neurologic deficit such as hemiparesis (Todd paralysis) that resolves over a period of 1/2–36 hours is a manifestation of an underlying focal brain lesion.

2. Complex partial seizures, formerly called temporal lobe or psychomotor seizures, are partial seizures in which consciousness, responsiveness, or memory is impaired. The seizure discharge usually arises from the temporal lobe or medial frontal lobe but can originate elsewhere. The symptoms take many forms but are usually stereotyped for the individual patient. Episodes may begin with an aura. Epigastric sensations are most common, but affective (fear), cognitive (déjà vu), and sensory (olfactory hallucinations) symptoms also occur. Consciousness is then impaired. Seizures generally persist for less than 30 minutes (on the average, 1–3 minutes). The motor manifestations of complex partial seizures are characterized by coordinated involuntary motor activity, termed automatism, which takes the form of orobuccolingual movements in about 75% of patients

and other facial or neck movements in about 50%. Sitting up or standing, fumbling with objects, and bilateral limb movements are less common. Secondary generalization may occur.