MSC Neuro 25 p2

Exam Tip:

Generalized = whole brain, always LOC

Focal = localized cortex; consciousness spared or impaired

Secondary generalized = focal that spreads

48.Classification of epilepsy. Structural, genetic, infectious, immune epilepsies. Epilepsy – Classification

Definition

1.Generalized Epilepsy Syndromes (both hemispheres involved at onset → always LOC)

Absence epilepsies:

Childhood absence epilepsy (3–8 yrs, many daily absences)

Juvenile absence epilepsy (9–13 yrs, shorter, less frequent)

Juvenile Myoclonic Epilepsy (Janz syndrome):

13–18 yrs, myoclonic jerks in morning on awakening, + tonic-clonic seizures.

Generalized tonic-clonic epilepsy on awakening: convulsions soon after waking/sleep onset.

Myoclonic/astatic epilepsies: Lennox-Gastaut, epilepsy with myoclonic-astatic seizures.

Infantile epileptic encephalopathies: West syndrome, Lennox-Gastaut syndrome.

2.Focal (Partial) Epilepsy Syndromes

Benign epilepsy with centrotemporal spikes (Rolandic epilepsy):

Onset 2–12 yrs, boys > girls, partial facial + pharyngeal seizures, sometimes generalized.

Epilepsy with occipital paroxysms (childhood).

Jacksonian Epilepsy:

Due to organic lesion (tumor, scar).

Starts in one muscle group → “Jacksonian march.”

Kozhevnikov (Epilepsia partialis continua):

Post-encephalitic (eg. tick-borne encephalitis).

Continuous clonic jerks in one muscle group, with occasional generalized seizures.

3.Undefined / Mixed Epilepsy Syndromes

Neonatal seizures.

Severe myoclonic epilepsy of infancy (Dravet syndrome).

Epilepsy with continuous spike-wave during slow-wave sleep.

Landau-Kleffner syndrome (epileptic aphasia).

4.Special Epilepsy Syndromes

Febrile seizures (common in children) → not always epilepsy if isolated.

Seizures provoked by stress, sleep deprivation, alcohol, drugs.

Single unprovoked seizures.

Chronic progressive epilepsia partialis continua (Kozhevnikov).

III.Idiopathic vs Symptomatic vs Cryptogenic (classic older division)

Idiopathic (Genetic)

No structural brain abnormality, age-related onset, normal development, normal MRI.

EEG: preserved background rhythm.

Examples: childhood absence epilepsy, juvenile myoclonic epilepsy.

Symptomatic (Structural/Metabolic)

Caused by brain lesion: trauma, tumor, infection, malformation.

Often presents as focal seizures, with neurological deficit.

Cryptogenic (Probable Symptomatic but cause unknown)

No lesion identified but clinical suspicion of underlying pathology.

Exam tip:

Use ILAE 2017 etiological classification (Structural, Genetic, Infectious, Immune, Metabolic/Unknown) + clinical syndromic classification (generalized, focal, combined, special syndromes).

Always cite examples — that’s what examiners look for.

49.Differential diagnosis of paroxysmal disorders of consciousness in epilepsy, syncopation, conversion paroxysms, narcolepsy, and paranoia.

Differential Diagnosis – Paroxysmal Disorders of Consciousness

1.Epileptic Seizure

Cause: Paroxysmal cortical neuron discharges.

Onset: Sudden, any time (day, night, rest, activity).

Prodrome: Often aura (sensory, psychic, autonomic).

Skin color: Cyanosis or congestion common.

Falls / Injury: Frequent, due to sudden onset.

Motor activity: Tonic-clonic convulsions, automatisms.

Urinary incontinence: Common.

Duration of LOC: 1–2 minutes (can be longer).

Recovery: Gradual; postictal confusion, drowsiness, headache; may last hours.

EEG: Epileptiform discharges during/after attack.

2.Syncope (Fainting)

Cause: Transient global cerebral hypoperfusion.

Onset: Usually in upright position, triggered by orthostasis, stress, pain.

Prodrome: Lightheadedness, dizziness, nausea, visual blackouts ("tunnel vision"), ringing ears.

Skin color: Pale.

Falls / Injury: Uncommon (but possible).

Motor phenomena: May have brief myoclonic jerks (convulsive syncope), rarely automatisms.

Urinary incontinence: Rare.

Duration of LOC: Seconds (<1 min).

Recovery: Rapid, complete, no confusion.

EEG: Generalized slowing (hypoperfusion).

ECG: Often shows brady/tachycardia, arrhythmia.

3.Conversion (Psychogenic non-epileptic seizures – PNES)

Cause: Psychogenic / functional disorder.

Onset: Often in stressful situations, with witnesses.

Movements: Asynchronous, exaggerated thrashing, pelvic thrusting (not stereotypical tonic-clonic).

Eyes: Often tightly closed (epileptic seizures = open, with gaze deviation).

Injury/Incontinence: Rare.

Duration: Long (minutes to hours).

Recovery: No true postictal state.

EEG: Normal during attack.

4.Narcolepsy

Cause: Dysfunction in orexin/hypocretin pathways (sleep-wake regulation).

Features: Excessive daytime sleepiness, cataplexy (sudden loss of tone, triggered by emotions), hypnagogic hallucinations, sleep paralysis.

LOC: Not sudden convulsion – patient “falls asleep.”

Duration: Minutes.

Recovery: Sleep refreshed but recurrence possible.

5.Parasomnias

Examples: Sleepwalking, night terrors, REM sleep behavior disorder.

Timing: Occurs during sleep phases (NREM or REM).

Features: Complex motor behaviors, crying, shouting, walking; no convulsions.

Consciousness: Not true LOC but altered arousal; patient often amnestic for episode.

Recovery: Returns to normal sleep; no postictal state.

EEG: Parasomnia-related changes, not epileptiform.

MemoryTip:

Grey face (cyanosis, chewing tongue, confused long after) → seizure

Pale face, quick recovery → syncope

Over-dramatized “seizure” with normal EEG → psychogenic

Day sleep attacks/cataplexy → narcolepsy

During sleep, walking/talking → parasomnia

50.Principles of epilepsy treatment. Epileptic status: definition, types, treatment. Principles of Epilepsy Treatment

1. Primary Goal: long-term seizure freedom with minimal side effects. 2. Main principles:

1.Prevention of seizures with antiepileptic drugs (AEDs):

Monotherapy preferred (Carbamazepine, Valproate, Phenytoin, Lamotrigine, Levetiracetam, etc., depending on seizure type).

Individualized choice (seizure type, patient age, comorbidity, drug interactions).

2.Elimination of provoking factors:

Sleep deprivation, alcohol, bright flashes, stress, fever, neurotoxic substances.

3.Social rehabilitation:

Assist patient in education, employment, and social integration.

4.Family counseling:

Educate family/friends about nature of seizures, importance of drug compliance, and basic first aid.

5.Special measures:

Surgery (refractory focal epilepsy),Vagus nerve stimulation, Ketogenic diet (especially in children).

Key: Monotherapy, avoid triggers, compliance, psychosocial support.

Status Epilepticus (SE)

Definition

Acondition of continuous seizures lasting >5 minutes OR ≥2 seizures without recovery of consciousness in between.

Medical emergency – risk of neuronal death, systemic complications, mortality.

Types of Status Epilepticus

1.Generalized SE

Convulsive: tonic-clonic (most common, life-threatening), tonic, clonic, myoclonic.

Non-convulsive: absence status, complex partial status.

2.Partial SE

Simple partial (somatomotor/Jacksonian, somatosensory, aphasic).

Complex partial (psychomotor).

Etiology (Causes)

Epilepsy (poorAED compliance, sudden withdrawal).

Traumatic brain injury.

Stroke (ischemic or hemorrhagic).

CNS infections: meningitis, encephalitis.

Brain tumors.

Metabolic disorders: hypoglycemia, uremia, hepatic failure, porphyria, alcohol/drug withdrawal, eclampsia.

Poisoning, systemic infections with hyperthermia.

Clinical Picture

Recurrent or continuous seizures.

No full recovery of consciousness between attacks.

Vital dysfunction: respiratory depression, arrhythmias, hypertension, cerebral edema, metabolic acidosis.

Management of Status Epilepticus (Emergency Protocol)

FirstAid (pre-hospital):

Call ambulance.

Position on side (prevent aspiration).

Remove dentures, clear airway secretions.

Ensure breathing and circulation.

In Hospital (Standard Protocol):

Step 1 (0–5 min): Airway, Breathing, Circulation

Oxygen, IV access, monitor ECG, BP, O saturation.

Blood sample (glucose, electrolytes,AED levels).

Give IVglucose + thiamine if hypoglycemia suspected. Step 2 (First-line drug – immediate seizure suppression):