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Epileptology of the first tonic-clonic seizure in adults and prediction of seizure recurrence Volume 20, issue 6, December 2018

TEST YOURSELF

(1) What is an “acute symptomatic seizure”?

(2) What are the most robust clinical criteria to diagnose a tonic-clonic seizure and distinguish it from a convulsive vasovagal syncope (VVS) or a psychogenic non-epileptic seizure (PNES)?

(3) Why might a sleep EEG after partial sleep deprivation (SDEEG) be considered more diagnostic than a routine recording (REEG) in patients with epilepsy?

 

 

 

 

 

 

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Answers

(1) Acute symptomatic seizures are seizures that occur in close temporal relationship with an acute CNS insult, which may be metabolic, toxic, structural, infectious, or due to inflammation. The interval between the insult and the seizure may vary according to the underlying clinical condition. The term “acute symptomatic seizure” should be used instead of “provoked seizure”, “reactive seizure”, or “situation‐related seizure” (Beghi et al., 2010). In contrast to unprovoked seizures, acute symptomatic seizures are unlikely to recur once the underlying acute cause has been treated.

 

(2) Slow recovery with carefully verified postictal confusion and heavy stertorous breathing, based on the accounts of observant witnesses. A statement by the patient “I felt confused as I came round” is likely to be misleading as many mean to say that they simply do not know what actually happened. Of note, recovery may delay for a while in elderly patients with vasovagal syncope, or when a head injury is sustained upon a fall. In their own right, injury and incontinence are rather weak signs, as they can also occur in vasovagal syncope and sometimes in PNES.

PNES may be difficult to clinically diagnose, particularly by inexperienced residents (Q J Med 1989; 71: 507-19 and Neurology 2004; 62: 834-5).

 

(3) The superior diagnostic yield of SDEEG compared to REEG reflects the activation of both focal and generalized spike-wave discharges during sleep. The SDEEG is the examination of choice for patients with suspected nocturnal seizures (as in frontal or some temporal lobe epilepsies), but also for those with suspected GGE. For the latter, generalized discharges are expected to increase, or first appear during sleep, as well as upon awakening particularly during hyperventilation (awakening epilepsies, such as JME and GGE with generalized tonic-clonic seizures only).

 Beghi E, Carpio A, Forsgren L, et al. Recommendation for a definition of acute symptomatic seizure. Epilepsia 2010; 51: 671-5.

 Howell SJ, Owen L, Chadwick DW. Pseudostatus Epilepticus. Q J Med 1989; 71: 507-19.

 Reuber M, Baker GA, Gill R, Smith DF, Chadwick DW. Failure to recognize psychogenic nonepileptic seizures may cause death. Neurology 2004; 62: 834-5.

 

 

 

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