Symptoms of a Seizure, Diagnosis, Treatment, Status Epilepticus

A seizure, also known as fits, occurs with abnormal electrical activity in part of the brain or the entire brain. It may be related to trauma and occur as a once-off event while recurrent seizures are seen with a number of diseases particularly of the central nervous system. The brain has a regulating mechanism that controls the level of electrical activity within the organ. When the controlling effects of the inhibitory and excitatory mechanisms fail, and the electrical activity increases to abnormal levels, a seizure may arise. Seizures are usually short-lived, subside spontaneously and a person regains consciousness. However, in certain instances it can persist for prolonged periods. These episodes are known as status epilepticus and can be life threatening.

Symptoms of Seizure

The symptoms depend upon the type of seizure and the part of the brain involved.

Tonic Clonic Seizures

Prior to the seizure, there may be an “aura”. The aura may be a strange feeling in the gut, a sense of déjà vu (a strange sense of familiarity), or hallucinations of smell or vision. The patient may not remember the aura since there may be retrograde amnesia for immediate past events following generalized seizure.

• Rigidity
• Loss of consciousness
• The patient may fall to the ground and may sustain injuries as a result of the fall.
• The patient may appear to have stopped breathing.
• Patient may appear cyanosed or blue.
• After a few seconds, there may be alternate relaxation and rigidity, producing spasms or clonic jerks (convulsions).
• After the rigidity, some patients do not have convulsions but may go into a temporary coma for a few minutes.
• Urinary incontinence (involuntary passing of urine) may occur.
• Tongue-biting is a possibility during the attack.
• Within a few minutes, the patient usually regains consciousness, but may remain confused (post-ictal confusion) and disoriented for some time. This period may last for half an hour or more in some cases.
• Full memory may return after several hours.
• After a generalized seizure, the patient may feel severely unwell, have a headache (post-ictal headache), and may prefer to sleep.
• Not all cases have tonic clonic jerks, cyanosis, or tongue-biting, but post-ictal confusion, headache, and malaise are likely to be present.

Complex Partial Seizures

Prior to an attack, there may be an alteration in mood, memory and perception, indicated by a disturbing sense of familiarity (déjà vu), unreality (jamais vu), hallucinations, emotional and physical discomfort. When these symptoms occur without progressing to the following stages, it is known as a simple partial seizure.

In complex partial seizures, the symptoms likely to follow are:

• Episodes of altered consciousness or blackouts.
• The patient usually does not become unconscious or fall to the ground.
• The patient suddenly stops all activity and stares blankly ahead.
• Patients may display automatism, such as rhythmic smacking movements of the lips or picking at their clothes.
• Usually returns to consciousness within a few minutes but may be confused or drowsy.

Absence Seizures

This type of seizure, known as petit mal epilepsy, presents in childhood and resembles a milder version of complex partial seizure.

• The attacks are shorter but more frequent than complex partial seizures. There may be 20 to 30 seizures in a day.
• There may be a sudden, brief pause (of about 10 seconds) in mid-sentence. The patient then continues the sentence where it was left off.
• Post-ictal confusion is absent.
• The patient does not fall to the ground during an attack.

Partial Motor Seizures

Seizure activity originating in one side of the brain is manifested in the opposite side of the face, limbs, or trunk.

• There may be rhythmical jerking or persistent spasm of the affected part.
• In Jacksonian epilepsy, the episode may start from one point and then spread gradually to affect the whole side.
• Seizures may last from a few seconds to several hours.
• In Todd’s palsy, longer episodes may result in prolonged weakness of the affected arm or leg following a seizure.

Partial Sensory Seizures

These seizures originate in the sensory cortex.

• Usually cause sharp tingling sensations in the face, arms, and legs of the opposite side.
• The sensation may spread as in a Jacksonian seizure but will do so very rapidly.

Versive Seizures

This may start as a focal seizure in the frontal lobe of the brain.

• It can involve the frontal eye field and cause forced deviation of the eyes to the opposite side.
• It usually progresses to a generalized tonic clonic seizure.

Partial Visual Seizures

This is a focal seizure starting in the occipital lobe of the brain.

• Visual hallucinations of light and color usually occur.
• When the focal seizures start in the temporal lobes, hallucinations of faces and scents are likely to occur.

Distinguishing Seizures from Fainting Attacks and Pseudo-Seizures

The history of the patient, with corroboration from a witness, may elicit the following characteristic findings in a seizure patient, which are not likely to be present in case of a fainting attack.

• Aura
• Cyanosis
• Tongue-biting
• Post-ictal amnesia
• Post-ictal confusion
• Post-ictal headache

Pseudo-seizures or psychogenic non-epileptic attacks may present with dramatic flailing of the arms and legs, and arching of the back but cyanosis and post-ictal confusion are highly unlikely.

When does a Seizure Patient need Medical Care?

Most seizures last from a few seconds to 2 minutes. At times a seizure may last for up to 5 minutes. Patients usually recover spontaneously. However, some situations need immediate medical attention, such as when :

• This is a first seizure.
• There is a change in seizure pattern in a known seizure patient.
• The seizure lasts for more than 5 minutes.
• Multiple seizures occur without full recovery in between.
• There is prolonged confusion after a seizure.
• There is sustained breathing difficulty.
• The person does not regain consciousness soon after a seizure.
• There is injury caused during a seizure.
• Seizure occurring in a pregnant woman.

Investigations

• A thorough history is essential and often a family member, or a bystander can betterdescribe the seizure in detail. Past history of a seizure and other medical conditions should be elicited to determine the cause and decide if it is a case of epilepsy. The type of seizure, whether partial or generalized, may be diagnosed by focusing on the onset of attack. If it starts with focal features, it is a partial seizure.
• Physical examination, including a neurological examination – to assess brain function.
• Developmental, neurological, and behavioral tests – to determine the type of seizure.
• Electroencephalograph (EEG) – to study the electrical activity of the brain. It may indicate the area of origin in the brain of the seizure.
• CT scan or MRI of the head – may help to determine the cause.
• Lumbar puncture – cerebrospinal fluid (CSF) examination may point to the cause.
• Laboratory tests may include complete blood count (CBC), blood sugar, blood biochemistry, liver and kidney function tests, tests to detect specific infections.

Treatment of Seizure

Immediate First Aid

• Call 911 or the local emergency number.
• Most seizures stop spontaneously.
• Try to prevent the patient from falling on a hard surface or a sharp object, but do not attempt to hold the person down during an attack.
• Do not try to force a hard object, such as a spoon, between the teeth during a seizure.
• The person may be allowed to lie on his back if he is breathing normally after an attack. He may be turned on his side if he is vomiting. This will prevent inhalation of the vomit into the lungs.
• If the patient stops breathing or turns blue, the head may be positioned in a chin-up position to prevent blocking of the airway by fall back of the tongue.

Treatment of Seizure

• The main aim of treatment is to prevent recurrence.
• Determining the cause of the seizure and treatment of causes such as infection or injury can prevent recurrence.
• Avoid triggers such as, sleep deprivation, alcohol, and drug abuse – can help to prevent future attacks in a person who has had a single episode of seizure. Anticonvulsants are not prescribed for such patients unless there is an associated risk factor that is likely to cause recurrence.
• Most seizures can be controlled by medication. Anticonvulsants are recommended for patients who have had more than one seizure. The type of anticonvulsant used will depend on the type of seizure. The drugs which may be used are carbamazepine, valproate, benzodiazepines, phenytoin, ethosuximide, gabapentin, ezogabine, topiramate, and lamotrigine.
• When anticonvulsants are not effective, resective surgery may be considered. Lobectomy and lesionectomy are the common types of curative surgery.
• When one type of medication stops working but resective surgery is not possible, the next step is to change the medication or use a combination of drugs, try dietary therapy, vagus nerve stimulation, or palliative surgery. Palliative surgery though previously done extensively, corpus callosotomy is rarely performed nowadays and is usually reserved for patients with severe epilepsy where seizures lead to falls and injuries.
• Vagus nerve stimulation is used more frequently nowadays as palliative surgery.

Until adequate control of seizures has been obtained, certain restrictions should be maintained. Working at heights, near open fires or water should be avoided. Driving, cycling, swimming, boating, and similar activities are discouraged.

Status Epilepticus

Status epilepticus is a potentially life-threatening condition where seizures last for more than 30 minutes or there are repeated seizures without gaining consciousness in between. The longer the duration, the more is the risk of permanent brain damage. Active medical intervention is essential in any seizure lasting more than a few minutes in order to prevent status epilepticus.

Status epilepticus usually occurs in known epileptics and should be treated as a medical emergency. Investigations will aim to look for the cause, such as hypoglycemia, pregnancy (eclampsia), drug abuse, alcohol withdrawal, infection, or any other cause.

Treatment will consist of maintaining the airway, oxygenation, intravenous fluids, and measures to control seizures immediately. This could include intravenous (IV) thiamine if alcoholism is suspected, or other drugs such as IV lorazepam, phenytoin, or diazepam. In case of continuing seizures, ventilation and continuous EEG monitoring in ITU will be necessary.