Seizure discharges have the capacity to spread from their point of origin and excite other structures. When spread occurs to the subcortical structures (thalamus and upper reticular formation) their excitation releases a discharge which spreads back to the cerebral cortex of both hemispheres, resulting in a tonic/clonic seizure. This chain of events is reflected in the electroencephalogram (EEG).
The symptoms before the tonic/clonic convulsion give a clue to the site of the initial discharge (simple partial or complex partial).
An eyewitness account is important because retrograde amnesia may prevent recall of the onset.
Loss of consciousness;
1. Tonic phase (10 seconds)
Arms pronated. Legs extended.
Teeth clenched. Pupils dilated.
Breath held - cyanosis.
Bowel/bladder control may be lost at the end of this phase.
Tremor gives way to violent generalised shaking. Eyes roll backwards and forwards. Tongue may be bitten. Tachycardia develops. Breathing recommences at end of phase.
The patient then sleeps with stertorous respiration and cannot be roused. On regaining consciousness, confusion and headache are present. He may feel exhausted for hours or even days afterwards. Muscles may ache as a result of violent movement and muscle damage occurs with elevation of the muscle enzyme creatinine phosphokinase (CPK). Trauma occurs frequently, either as a result of the fall, or as a result of the movements, e.g. posterior dislocation of the shoulder. Very rarely sudden death may occur from inhalation or an associated cardiac arrhythmia.
The differentiation of these attacks from hysteria will be discussed later.
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