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TABLE 32.1 Major Seizure Types

Clinical Seizure Type

Key Ictal EEG Manifestations

Major Clinical Manifestations

I. Partial (focal, local) seizures A. Simple partial seizures

B. Complex partial seizures (psychomotor epilepsy, temporal lobe epilepsy)

C. Partial seizures evolving to secondary generalized seizures

II. Generalized seizures

A. Absence seizures (petit mal epilepsy)

B. Myoclonic seizures

C. Clonic seizures

D. Tonic seizures

E. Tonic-clonic seizures (grand mal epilepsy)

F. Atonic seizures (astatic)

Local contralateral discharge

Unilateral or bilateral asynchronous focus, most often in temporal region

3-Hz polyspike and wave

Fast activity (10 Hz or more;

slow waves) Low-voltage, fast activity Fast activity (10 Hz or more) increasing in amplitude during tonic phase; interrupted by slow waves during clonic phase Polyspikes and wave

Seizures may be limited to a single limb or muscle group; may show sequential involvement of body parts (epileptic march);consciousness usually preserved;may be somatosensory (hallucinations, tingling, gustatory sensations); may have autonomic symptoms or signs such as epigastric sensations, sweating, papillary dilation Impairment of consciousness, may have automatisms, flashback (déjà vu, terror);autonomic activity such as pupil dilation, flushing, piloerection May generalize to tonic, clonic, or tonic-clonic

Brief loss of consciousness with or without motor involvement; occurs in childhood with a tendency to disappear following adolescence Sudden, brief, shocklike contractions of musculature (myo-

clonic jerks) Repetitive muscle jerks

Rigid, violent muscular contraction with limbs fixed Loss of consciousness; sudden sharp tonic contractions of muscles, falling to ground, followed by clonic convulsive movements; often postictal depression and incontinence

Sudden diminution in muscle tone affecting isolated muscle groups or loss of all muscle tone; may have extremely brief loss of consciousness

Modified from the International Classification of Epileptic Seizures. Various methods of seizure classification are used by different authors.

drome of individuals physically dependent on CNS depressants.

The therapeutic goal in epilepsy treatment is complete seizure control without excessive side effects. The prognosis depends in part upon the type of seizure disorder, but overall, only about 40 to 60% of patients become totally seizure free with available drugs. These agents are chemically and pharmacologically diverse, having in common only their ability to inhibit seizure activity without impairing consciousness. The choice of drug or drugs used depends on seizure classification, since a particular drug may be more or less specific for a particular type of seizure; patients having a mixture of seizure types present particular therapeutic difficulties. It is not always clear when to treat with one drug (monotherapy) or more than one drug (polytherapy) in a particular patient. Approximately 25% of patients given a single anticon-vulsive agent do not achieve successful seizure control because of an unacceptable level of side effects. Therefore, two or more drugs may be combined in an attempt to provide better seizure control.

Convulsive disorders often begin in childhood, and drug therapy must be continued for decades; therefore, any adverse reaction is especially significant. A knowledge of interactions between anticonvulsants and other drugs is necessary, since the patient usually must continue anticonvulsant medication regardless of the need for other drugs. Since it may be dangerous to withdraw anticonvulsant medication from a pregnant woman with epilepsy, the teratogenic potential of anticonvulsant drugs also is a consideration in the treatment of women of childbearing age.

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