SEIZURE

Basjiruddin A
Bagian Neurologi FK-Unand

SEIZURE

A seizure is temporary abnormal electrophysiologic phenomenon of the brain,

resulting in abnormal electrical neuronal
activity in the brain
A seizure is a sudden change in behaviour
characterized by changes in sense of feeling
or motor activity (movement) due to an
abnormal firing of nerve cells in the brain
It can manifest as a physical convulsion,
minor physical signs, alteration in mental
state, various psychic symptoms (such as
deja vu or jamais vu)

Type of seizures and symptoms

depend on :
Where the abnormal electrical activity
takes place in the brain
What its cause
Age
General state of health

Seizures can be caused by

head injuries
drug toxicity space-occupying lesions in
the brain (tumor, abscess)
infection (encephalitis, meningitis)
metabolic disturbances
lead poisoning
stroke (embolic, hemorrhage)
mal formation
Half of the patients, no cause can yet be
found

Seizure may be the result of medical

problems :
-

low blood sugar

sudden lack of oxygen
very high fever

NON EPILEPTIC SEIZURES (NES)

NES : Seizures look like epileptic seizures
but have a different cause, not caused by
changes in brain activity
NES: are paroxismal events that mimic
on epileptic seizure, but do not involve
abnormal rhythmic dischange of cortical
neurons

Cause
cause physical reason : such as
fainting/syncope maybe diagnosed
soon
pschological: relating to the mind such as
panic attacks, extreme stress make
finding the cause difficult during attacks,
patient may cry, scream, uncontrol
activity

TYPES

Reflex anoxic seizures : a condition of the

brain where the patient become pale, limp,
cease breathing, recover a short time later
Anoxic seizures: cause by a reflex a systolic
of the heart (vagal responsiveness)
First seizure
Eclampsia

TYPES cont...

Psychogenetic seizures : a need

for attention/stressfull situation
Narcolepsy
Cardiac arrythmia
Taurette syndrome
......they are non epileptic......

Treatment

The first aid for a seizure depend

On the cause and the type of seizure
Anti-epileptic drugs: to stop seizure
Furthermore no need anti-epileptic
medication
Keep patient safe from injury
Medication for anxiety
A seizure longer than five minutes is a
medical emergency

Most seizures last from 30 seconds to 2 minutes,

usually do not cause lasting harm
Emergency medical services immediately need if a
patient with :
-

seizures last longer than 5 minutes

dificulty breathing
turns bluish in color
seems ill
probably fall into a deep sleep
don`t restrain the person

don`t place an object between teeth

don`t attempt to give food or drink until awake :
-

should not try to wake

EPILEPSY

Syndrome of recurrent, unprovoked

seizures is termed epilepsy but some
seizures may occur in people who do not
have epilepsy
The study of seizures is part of neuro
science
Treatment of epilepsy is a subspeciality of
neurology

Epilepsy is one of the commonest chronic

neurological conditions (especially:
childhood)
Its diagnosis is often straight forward but,
on occasion immensely difficult
Misdiagnosis is a significant problem

Definition
Epilepsy is defined as a condition
characterized by recurrent epileptic
seizure. An epileptic seizure is a clinical
manifestation presumed to result from an
abnormal and excessive discharge of a
set of neurones in the brain

Epileptic syndroms have been defined by

the commision on classification and
terminology of the Intern. League
Against Epilepsy (ILAE) 1989 :
A complex of sign and symptoms that
defined a unique epilepsy condition. This
must in value more then just the seizure
type, thus frontal lobe seizure per se, for
instance do not constitute a syndrom

Kelompok studi (POKDI) Epilepsi

PERDOSSI (2007) mendefinisikan
Epilepsi :

Suatu keadaan yang ditandai oleh

bangkitan (seizure) berulang sebagai
akibat dari adanya gangguan fungsi otak
secara intermitten yang disebabkan oleh
lepas muatan listrik abnormal dan
berlebihan di neuron-neuron secara
parokxismal, didasari oleh berbagai faktor
etiologi

Bangkitan epilepsi (epileptic seizure)

adalah manifestasi klinik dari bangkitan
serupa (stereotipik), berlangsung secara
mendadak dan sementara dengan atau
tanpa perubahan kesadaran, disebabkan
oleh hiperaktivitas listrik sekelompok sel
saraf diotak, bukan disebabkan oleh suatu
penyakit otak akut (unprovoked)

Sindrom epilepsi

adalah sekumpulan gejala dan tanda klinik

epilepsi yang terjadi secara bersama-sama
yang berhubungan dengan etiologi, umur,
awitan (onset), jenis bangkitan, faktor
pencetus dan kronisitas

TRIGGERS

Diagnosis of epilepsy requires that the

seizures be unprovoked
However, in some epilepsy or epilepsy
syndromes the provocant is obviously
harmful :

reading
hot water on the had
flasthing, flickering lights
tired
hungry
sleep deprivation

Classification
Classification of seizure types and epilepsy syndromes should always
be attempted, as both may have implications for management and
prognosis

Classification of Epileptic Seizures

International League Against Epilepsy : ILAE, 1981)
I. Partial (focal) seizures
A. Simple partial seizures (no loss of consciousness)
1. with motor signs (including Jacksonian)
2. with sensory symptoms (visual, auditory, olfactory)
3. with psychic symptoms (dysphasia, halluciations)
4. with autonomic symptoms (epigastric, flushing, pallor)
B. Complex partial seizures (consciousness is impaired)
1. with partial onset followed by impaires consciousness
2. with impairment of consciousness at onset
3. with automatism
C. Partial seizures evolving to secondarity generalized seizures

II. Generalised seizures of nonfocal origin (convulsive or

nonconvulsive)
A. Absence seizures
1. with impaired consciousness
2. with one or more of the following a tonic.
Component automatism
B. Myoclonic seizures (single or multiple)
C. Tonic clonic seizures
D. Tonic seizures
E. Atonic seizures
III. Unclassified epileptic seizures (usually used when an
adequate description is not available)

Classification of epilepsy syndromes

Many different epilepsy syndrome, presenting
with its own unique combination of seizures
type typical age of onset, EEG finding ets, as
this affects treatment choice, investigation and
prognosis

Modified classification
I. Idiopathic epilepsy syndromes (focal or
generalized)
A. Benign neonatal convulsions
B. Benign childhood epilepsy
C. Childhood absence epilepsy
D. Juvenile myoclonic epilepsy

II. Symptomatic epilepsy syndrom

A. Infantile spasme (west syndrome)
B. Lennox gasfant syndrome
C. Epilepsia partialis continua
D. Temporal lobe epilepsy
E. Frontal lobe epilepsy
F. Post traumatric
III. Other epilepsy syndromes of uncertain
or mixed classification
A. Neonatal seizure
B. Febrile seisures
C. Reflex epilepsy
D. Other unspecified

Etiology
1. Idiopatik : (usually generalized seizures) about half
of all seizures have notknown cause (suggests
genetic abnormalities)
2. Kriptogenik: dianggap simptomatik tapi
penyebabnya belum diketahui, termasuk disini
sindroma west, sindroma lennox gestaut dan
epilepsi mioklonik. Gambaran klinis berupa
ensefalopati difus
3. Simptomatik
Trauma, infeksi, kelainan kongenital, lesi desak
ruang
Gangguan peredaran darah otak, toksik
(alkohol, obat), metabolik, kelainan
neurodegeneratif

Workup

An emergency basis include a determination

of electrolyte, calcium, magnesium and
glucose levels

A CBC and renal function tests, arterial blood

gas analysis, toxicologic screening and
anticonvulsant levels

Blood culture, urinalysis and LP (after Neuro

emergency)

Neuro imagiong, CT Scan deteksi fokal

MRI-deteksi sklerosis, degenerasi tumor, dll

Neuro imaging

EEG

A clear history from the patient and an eyewitness to the

attack give the most important diagnostic information, and
should be the mainstay of diagnosis
Be sure a clinical feature : recurrent unprovoked seizures
EEG (during awake, sleep, hyperventilation and photic
stimulation)

Diagnosis ditegakkan berdasar :

Anamnesis (auto dan aloanamnesa) lengkap

Bentuk, lama, dan, frekuensi serangan
Pencetus, sudah berapa kali serangan, gejala
sebelum dan sesudah serangan
Penyakit penyerta, riwayat kehamilan, persalinan,
obat-obat yang dikonsumsi, riwayat keluarga
Pemeriksaan umum dan neurologis
Pemeriksaan penunjang

EEG
Indikasi :

Membantu mengetahui jenis epilepsi

Menentukan prognosis
Menentukan letak fokus
Pertimbangan bila akan menurunkan obat
Research

Diagnosis pasti : klinis jelas + EEG dengan

rekaman bangun, tidur, hiperventilasi,
stimulasi fotik

Clinical Features
A Simple partial seizures (consciousness not
impaired)
a. Fokal motor manifestation
Motor signs : jerking or spasm of one or more group of
muscle, finger, hand, without or with march to
shoulder jacksonian march

b. Adversive : kepala berpaling kearah sisi yang

kejang
c. Focal sensory menifestation, tingling,
numbness, burning, pain, flashing lights, colours
d. Autonomic manifstation: change skin colour,
blood pressure, heart rate, pupil size

Clinical Features ....

Complex partial seizures (consciousness is

impaired)

Consist of 3 distinct components:

- Aura a few seconds, psychic aura
- Altered consciousness : motionless stare
- Automotism : orofacial movements, chewing,
lip smacking, swallowing, drolling, langhter,
fear, excitment, complex action-undressing,
walking, circling
- Partial seizures evolving to secondarily
genralized seizures. Partial seizures (simple to
complex) spread to become generalized
(usually tonic-clonic)

Generalize Seizures (consciousness is impaired)

1. Tonic clonic (grandmal) : prodromal
irritability, anxiety, dizziness,
tonic phases 0,5-2min, muscle contraction,
upward movement of the eyes
Characteristic vocalization (epileptic cry)
clonic phase, muscular contractions with
alternating period 15-30 sec
Drooling, loss of consciousness during tonicclonic phase
2. Absence seizure (petitmal)
Anresponsiveness and behavioural arrest of
any ongoing activity (3-10 seconds) abnormal
muscular movements of face and eyelids
flicker 3 x / sec
Amnesia
Frequent seizure up untill 100 x/day

3. Clonic seizures: rapid loss of consciousness

with loss of muscle tone, tonic spasm, and
jerks. Muscle become rigid 30 seconds during
the tonic phase and relax during the clonic
phase lasts 30-60 seconds
4. Myoclonic seizures: these are characterized
by rapid muscular contractions accompanied
with jerks in facial, limb and pelvic muscles
(flying saucer syndrom)
5. Atonic seizures : also called drop attacks,
are abrupt, with loss of muscle tone lasting one
to two seconds. Consciousness is usually
impaired could be limited to head and neck
muscles, resulting in head drop, or causing
unexpected falls with physical injury.

Sindrom epilepsi
1. Sindroma west (infantile spasmus)

Terdiri dari trias kombinasi bangkitan epilepsi (spasme

infantil) yang berlangsung beberapa detik, regresi
perkembangan psikomotor dan pola EEG yang karakteristik
hipsaritmia
Terjadi pada usia dibawah 1 tahun

Spasmus infantile (sindroma west)

Serangan fleksi atau ekstensi kelompok otot secara
mendadak pada bayi usia 3-12 bulan, kepala, badan,
tangan dan tungkai terfleksi yang khas ; gambaran EEG
(hypsarritmia)
2. Sindroma lennox gastaut

Bangkitan epilepsi: bangkitan tonik aksial, dan absens atipikal

EEG abnormal ; diffuse slow apike and wafe (SSW) atau petit
mal variant (PMV) pada kondisi sadar, burst of fast rhytms 10
spd pada keadaan tidur
Perkembangan mental yang lambat
Biasanya muncul pada usia 3-5 tahun, lebih banyak pada
perempuan

3. Frontal lobe epilepsy

Seizure types vary but characterized by: brief
duration, abrupt onset, nighttime occurence;
bizarre motor manifestations (e.g., bilateral limb
thrashing); no postictal confusion; minimal EEG
abnormality; history of status epilepticus
4. Post-traumatic sizures
Folow 70% of head injuries in general
population. Injury severe, associated with brain
contusion, intracerebral or intracranial hemtoma,
unconsciousness or amnesia for > 24 hours, or
persistent neurologic signs
5. Epilepsia partialis continue (EPC)
Unremitting motor seizures involving part or all
of one side of body

Treatment
The crucial decision wether or not to
start anti epileptic drug (AED) treatment
must taken into account the relative risk
of recurrent seizures and commitment to
long term medication with potential side
effects
AED should not be given until the
diagnosis of epilepsy has been confirm
To start AED should be made by patient
and physician

Tujuan pengobatan :
Mengontrol gejala secara adekuat dengan
penggunaan AED yang minimal
Prinsip pengobatan
Diberi AED apabila minimum sudah 2 kali
serangan /tahun, utamakan monoterapi,
dimulai dosis rendah mungkin di naikkan
efektif
Monitor kadar obat dalam serum
Gagal ? obat tak teratur ? obat ditukar ?
Penggantian AED : diturunkan dosis AED
yang lama naikan AED yang baru

Pemilihan AED didasarkan atas :

- Jenis bangkitan epilepsi, efek samping,
- Interaksi antara AED
Pemilihan AED berdasar janis bangkitan epilepsi

Type of seizures
and epileptic
syndrome
Simple and
compelx parial
seizures, primary
and secondarily
generalized tonicclonic seizures

First line drug

Second line drug

Carbamazepin Acetazolamide, clobazam,

e, valproate
clonazepam,
and phenytoin ethosuximide*,
felbamate*, gabapentin,
lamotrigine,
levetiracetam*,
oxcarbazepine,
phenobarbital,
primidone*, tiagabine*,
topiramate, vigabatrin

Generalized
absence seizures

Valproat,
Acetazolamide, clobazam,
ethosuximde* clonazepam, lamotrigine,
phenobarbital, primidone*

Atypical absence, Valproate

tonic and clonic
seizures

Acetazolamide,
carbamasepine, clobazam,
felbamate*, ethosuximide*,
lamotrigine, oxcarbazepine,
phenobarbital, phenytoin,
pirimidone*, topiramate

Myoclonoc
seizures

Clobazam, clonazepam,
ethosuximide*, lamotrigine,
phenobarbital, piracetam,
primidone*

Valproate

Dosis pemberian lihat di buku !

Penghentian AED
Minimal setelah 2 tahun bebas bangkitan,
untuk pasien baru (untuk yang sudah
berulang-ulang minimal 3 tahun atau lebih)
EEG membaik/normal
Bertahap, jangka 3-6 bulan
Obat kombinasi : dimulai dengan menurunkan
dosis AED yang pertama, baru yang lainnya
Kemungkinan kambuh lebih besar pada :

Myoklonik
Grand mal sekunder
Riwayat serangan neonatal
Penggunaan obat-obat kombinasi
EEG masih abnormal

Status epilepticus

Status eplepticus is defined as two or more

sequential seizures without full recovery of
consciousness between seizures, or more
than 30 minutes of continuous seizure
activity
Patient who does not regain conciousness
for five minutes or more after a witnessed
seizure should be considered to have status
epilepticus

Classification
Version 1
Generalized (tonic-clonic, myoclonic,
absence) status epil
Partial (single or complex) status epil
Version 2 (divides according to the condition :
Generalized status epileptikus
Nonconvulsive status epileptikus
Version 3 classifying by life stage
Neonatal period, infancy and childhood
adulthood

The Treiman classification :

- Generalized convulsive SE
- Subtle SE
- Non convulsive SE
- Absence SE
- Complex partial SE
- Simple partial SE
The most frequent and potentially dangerous
type of SE is generalized convulsive SE

Causes :
Many patients who present in convulsive SE do not
have a history of seizures
In people with know epilepsy, the most common cause
is a change in medication :
By physician or
Abrupt cessation
Pharmacologic nonadherence is the most common cause
of SE in patients with khown epilepsy
Otther causes include head trauma, stroke, cardiact
arrest, CNS infection, and neoplasma
Age significantly affects etiology of SE
Younger than 16 years, the most common cause was
fever and / or infection
In adults was cerebrovascular disease (25%)
In more recent series of SE, HIV infection

Penanganan
Prinsip :
Stabilisasi pasien dengan prinsip kegawatan
umum (ABC)
Menghentikan bangkitan dan mencari etiologi
secara simultan
Mencegah bangkitan ulang atau mengatasi
penyulit
Mengatasi faktor pencetus
Bila setelah 60 menit belum teratasi (refrakter),
sebaiknya perawatan dilakukan di ICU

Protokol
Penatalaksanaan umum dan terapi anti epilepsi spesifik
pada berbagai stadium status epileptikus
Stage of status

General Measure

Aed treatment

Premonitory
(0-10 minutes)

Asses cardiorespiratory
function
Secure airways
Give oxygen

Diazepam (i.v. bolus or.p.r)

Midazolam (i.m., i.v. bolus, p.r.)
Paraldehyd (i.m., p.r)

Early
(0-30 minutes)

Institute monitoring i.v acces

emergency investigations
give 50% glucose (50ml)
Give thiamine where
appropriate
Treat acidosis
Transfer to intensive care unit

Lorazepam (i.v.bolus)
Diazepam (i.v. bolus)
Second-line :
Lognocaine (i.v. bolus & inf)
Clonazepam (i.v. bolus)
Paraldehyde (i.m)
Phenytoin (i.v. bolus)

Established (3060 / 90 minutes)

Refractory
(> 60 minutes)

Estabilhed aetiology
Identify and treat
medical-complication

Phenobarbitone (i.v.loading & inf)

Phenytoin (i.v. loading & inf)
Chlormethiazole (i.v. loading & inf)

Pressor therapy if
needed

Second-line
Clonazepam (i..v. bolus or inf)
Paraldehyde (i.v. inf)
Diazepam (short inf)
Midazolam (short inf)

EEG monitoring
Monitoring seizure EEG
and cerebral function
Intracranial pressure
monitoring if
appropriate

Thiopentone (i.v. bolus & inf)

Propofol (i.v. bolus & inf)
Second-line
Phenobarbitone (i.v. bolus & inf)
Isoflurane (inhalation)
Etomidate (i.v. bolus & inf)

References

Adams RD. Principles of neurology 6th ed Mc Graw Hill 1997

Harsono, Buku Ajar Neurologi, Bab II

Harsono, Kapita selekta neurologi, Bab II

Samuel MA. Manual of Neurology 4th ed (1997)

Scotish Intercolleagiate guidelines Network(SIGN). Diagnosis and

Management of Epilepsy in Adult. Royal colleage of physicians
Edinbergh. 2003. www.sign.oc.uk

Scotish Intercolleagiate guidelines Network (SIGN). Diagnosis and

Management of Epilepsy in Children. Royal colleage of physicians
Edinbergh .2005

Shorvon SD. Handbook of epilepsy Treatment. Blackwell Science Ltd.

London.2000

POKDI Epilepsi PERDOSSI. Pedoman Tatalaksana Epilepsi 2006

Mazzoni.P.Merritts`s Neurology Handbook. 2nd ed Dresden. Lippincott

William & Wilkins. 2006

Definiti Definition of Status Epilepticus

Recurrent seizures without complete recovery of
consciousness between attacks or continuous
seizure activity for more than 30 minutes, with or
without impairment of consciousness.

Includes generalized convulsive seizures,

nonconvulsive seizures (absence status, complex
partial status) and continuous focal motor seizure
activity
Nonconvulsive or partial motor status is not
associated with the same severity of sequelae or
urgency of treatment as generalized convulsive
status, but if sustained may still result in permanent
damage.
Generalized myoclonic status epilepticus occurs in
children with myoclonic epilepsies

Most seizures in childhood stop within five minutes,

therefore in practice treatment should start if the seizure
has not spontaneously terminated after 5 minutes. Seizures
of longer duration are more difficult to terminate, prolonged
seizures (>30 min) can cause neuronal death.

Convulsive status epilepticus is a life-threatening

condition, and may result in serious neurological
sequelae. Refractory status occurs in 9-31% of patients
and is associated with high morbidity and mortality, the
major aetiology in children is infection with fever.

Aim of Guidelines
To prevent seizure-induced brain damage by
limiting the duration of generalized convulsive
status.
Use of Guidelines

Applicable to the Emergency Department, clinical wards or

in the intensive care unit
Most appropriately applied to generalized convulsive
status, in which prompt aggressive treatment is required
Children with simple partial motor status with maintained
awareness should not be treated with coma-inducing
drugs such as thiopental
Absence status may require EEG confirmation, and should
be treated with benzodiazepines followed by sodium
valproate. Phenytoin and phenobarbitone should be
avoided as these agents may aggravate absence status
Lennox-Gastaut and other myoclonic epilepsies of
childhood may be associated with continuous tonic,
myoclonic or atypical absence seizures. The most
appropriate therapy for these children is sodium valproate

Potential Complications of Prolonged Status

Epilepticus
Permanent Brain Damage
Chronic epilepsy
Blood Glucose - initial hyperglycaemia, later
hypoglycaemia
Cerebral Oedema - prevent hyponatraemia.
Maintenance fluids should be 0.9%NaCl with
dextrose as required. Avoid fluid overload.
Hyperkalaemia
Renal Failure - from rhabdomyolysis
Disseminated Intravascular Coagulopathy
Pulmonary Oedema

Outcomes of Status Epilepticus

Mortality in children low compared to

adults (3-8% vs 22%) but still significant.
Children are more likely to have recurrent
status.
Refractory status is associated with
significant risk of long-term neurodisability and epilepsy.

Initial Assessment
(see also flow diagram opposite page 4 4)

Resuscitate:
A - support Airway, assume recovery position
B - administer 100% oxygen, assess Breathing
C - Circulation: check pulses & blood pressure, ECG
monitor
D - check blood glucose urgently, replace with
Dextrose if low
E - Establish IV access
Investigations: glucose, electrolytes, calcium, magnesium,
FBC

Consider cultures, blood gas, anticonvulsant levels, toxicology

screen, insulin & cortisol if
hypoglycaemic

Acute Management of Status Epilepticus

The times of drug administration in the guidelines are from time of seizure onset, or
if historically unclear, time of arrival in the emergency department.

Refractory Status Epilepticus: Ongoing Guidelines after Acute

Presentation
Management should occur in PICU unless agreed otherwise by PICU and
Neurology senior staff.