CONVULSIVE DISORDER

.
.





LECTURE BY

H. IBNU
MAS`UD

MEDICAL FACULTY
BRAWIJAYA UNIVERSITY
MALANG 2008

CONVULSIVE DISORDER

HIPPOCRATES:

20 ABAD YG SILAM MELAPORKAN TENTANG PENYAKIT

SERIUS ATAU INSIDENTAL SYMPTOM YANG SIFATNYA
CURABLE DISEASE ie:

PREDISPOSED TO CONVULSIVE SEIZURE IS INFANTS DAN

YOUNG CHILDREN,
PARTICULARLY IN RELATION TO THE ONSET OF AN ACUTE
FEBRILE ILLNESS
IN RESPONSE TO SOME PROFOUND EMOTIONAL OR
METABOLIC DISTURBANCES

THE CAUSE OF TENDENCY IS STILL ENIGMATIC, AND

PROBABLY RELATED WITH:

ABNORMAL FUNCTION OF THE BRAIN TISSUE, THAT WHICH

IN EALRY LIFE AS

GREATER IRRITABILITY OF THE NERVOUS SYSTEM

ITS LACK OF MYELIN

ITS GREATER WATER CONTENT
ITS RAPID METABOLISM

RELATED WITH IMMATURITY IN THE DEVELOPMENT OF THE

CEREBRAL INHIBITORY MECHANISM

IMMATURE DEVELOPMENT IN ASPECT OF THE FUNCTION

PHYSIOLOGICAL HOMEOSTASIS (IS PROGRESSIVELY
STABILIZED WITH INCREASING MATURITY

NEUROPHYSIOLOGY

CLASSIFICATION OF CONVULSIVE DISORDER

IN INFANCY AND CHILDHOOD ACCORDING TO

ETIOLOGY AND PATHOGENESIS

CHARACTER OF THE CONVULSIVE ATTACK 9CLINICAL & EEG)
ANATOMIC LOCATION OF THE POINT OF ORIGIN OF THE SEIZURE
PATIENT`S AGE

CONVULSION ARE FAR MORE COMMON DURING THE FIRST TWO

YEARS THAN AT ANY OTHER PERIODE OF LIFE

THE CAUSED ARE:

CONGINETAL DEFECTS OF THE BRAIN (MOST FREQUENTS IN VERY

YOUNG INFANTS)
ACUTE INFECTION ( INTRACRANIAL OR EXTRA CRANIAL).

INTRACRANIAL BIRTH INJURY (INCLUDING THE EFFECTS OF ANOXIA AND

HEMORRHAGE)

MOST FREQUENT CAUSE IN INFANCY AND EARLY CHILDHOOD ( IN LATER

CHILDHOOD IS CAUSED BY IDIOPATHIC EPILEPSY)

LESS FREQUENT CAUSES OF CONVULSIONS IN INFANTS ARE TETANY,

TRUE EPILEPSY, SPONATNEOUS HYPOGLYCAEMIA, BRAIN TUMOR,
RENAL INSUFFICIENCY, POISONING, ASPHYXIA, SPONTANEOUS
HEMORRHAGE, POSTNATAL TRAUMA.
THE CHIEF CAUSES OF CONVULSIVE SEIZURE IN MIDDLE AND LATER
CHILDHOOD ARE :

INFECTION, IDIOPATHIC EPILEPSY, CONGINETAL DEFECTS OF THE BRAIN,

RESIDUAL CEREBRAL DAMAGE FROM EARLY TRAUMA, LEAD POISONING,
BRAIN TUMOR, ACUTE AND CHRONIC GLOMERULONEPHRITIS,
DEGENERATIVE DISEASE OF THE BRAIN.

TETANY: IS A SYMPTOM COMPLEX OR SYNDROME AND THIS

MANIFESTATION OF WHICH RESULT FROM A STATE OF
INCREASED NEORMUSCULAR IRRITABILTY

CEREBRAL PALSIES IS CAUSED BY LESSIONS OF VARIOUS

PART OF THE BRAIN, FOR EXAMPLE: DISTURBANCES OF A
MOTOR FUNCTIONS OF THE BRAIN, ARE DIVIDED IN THREE
GENERAL GROUPS:

TETANY CAN BE PRODUCE EXPERIMENTALLY IN ANIMAL

BY IV ADMINSTRATION OF KALIUM PHOSPAHTE AND
CALCIUM IS LOWERED AFTER INJECTION GARAM
ALKALIN AND SALT

1/. LESIONS OF THE MOTOR CORTEX ( RESULT

SPASTICITY)
2/. LESIONS OF THE BASE OF THE BRAIN ( ATHETOSIS,
TREMOR, SOME TIME RIGIDITY)
3/. LESIONS OF THE CEREBELLUM ( ATAXIA AND
INCOORDINATION)

PHYSIOLOGICAL SEIZURE

Difinition: paroxysmal events thought to represent abnormal

electrical activity in cerebral neurons
Pathogenesis: usually idiopathic

CEREBRAL PALSY

Definition inclusive term to designate a number of static neuromotor disorders

due to a previous central motor system insult
Pathogenesis often unknown

prenatal insults: genetic, malnutrition, infection, anoxia, toxemia

perinatal insults: prematurity, anoxia, hyperbilirubinemia,

postnatal: infections, trauma, toxins

CLASSIFICATIONS:

Spastic cerebral palsy

associated with lesions of the basal ganglia or

uncontrolled and uncoordinated movements

Ataxic cerebral palsy:

quadriplegia: involves all 4 extremities

hemiplegia: involves both extremities on one side (upper greater than lower)
diplegia: involves all 4 extremities (lower greater than upper)
paraplegia: involves both legs with normal upper extremities

Athetoid cerebral palsy:

spastic
spastic
spastic
spastic

associated with a cerebellar lesion

early hypotonia and decreased tendon reflexes

Mixed cerebral palsy

extrapyramidal tract

EEG PATTERN
EEG recording of a normal brain showing no unusual activity

http://www.epilepsyfoundation.org/answerplace/Medical/treatment/eeg.cfm

DEFINITIONS OF SEIZURE & ITS FEATURES

Seizure: a sudden attack, spasm, or convulsion, as in epilepsy

or another disorder
Epileptic seizure: a transient episode of abnormal and
excessive neuronal activity in the brain that is apparent either to
the subject or an observer.
Epilepsy: a chronic disorder of the brain characterized by
recurrent, unprovoked epileptic seizures.
FEATURES OF EPILEPTIC SEIZURE ARE:

The abnormal neuronal activity during an epileptic seizure may be

manifested as a motor, sensory, autonomic, cognitive, or psychic
disturbance. The neurophysiological basis is inferred on clinical
grounds.
A convulsion is a subtype of seizure in which motor activity occurs.
Can be provoked in individuals who do not have epilepsy

For examples of provoking insults including fever,trauma,

hypoglycaemia and hypoxia)

There are many paroxysmal disturbances that mimic epileptic

seizures.

CLASSIFICATIONS OF EPILEPTIC SEIZURE

Generalized seizures: the first clinical change indicates initial
involvement of both cerebral hemispheres (left & right)
Partial seizures: there is initial activation of pare of one
cerebral hemisphere

INTERNATIONAL CLASSIFICATION OF:

EPILEPTIC SEIZURES:
Partial Seizures
Simple Partial
Complex Partial
Simple or Complex Partial
which generalize
Sensory
Motor
Autonomic

Christopher M. Inglese, M.D.

Regional Epilepsy Center
St. Luke's Medical Center
Milwaukee,Wisconsin

EPILEPTIC SEIZURE ~
GENERALIZED:
Absence (typical and atypical)
Myoclonic
Tonic
Clonic
Atonic-astatic

EPILEPTIC SEIZURE ~
UNCLASSIFIED:

Febrile Seizures
Reflex Epilepsies
Status Epilepticus

EEG PATTERN
EEG recording of an absence seizure showing the distinctive
3-per-second spike and wave discharge

http://www.epilepsyfoundation.org/answerplace/Medical/treatment/eeg.cfm

GENERALIZED OF SEIZURES

ABSENCE SEIZURE (PETIT MAL):

MYOCLONIC SEIZURE:

a generalised increase in tone

TONIC-CLONIC SEIZURES (GRAND MAL SEIZURE):

repaid, brief, usually isolated jerks of the limbs, neck or trunk.

TONIC SEIZURES:

brief unawareness lasting a few seconds;

no loss of posture; immediate recovery;
may be very frequent;
associated with automatisms.

tonic phase of rigidity with loss of posture followed by clonic

movements of all four limbs;
loss of consciousness;
duration 2-20minutes;
postictal drowsiness.

ATONIC SEIZURE (ASTATIC):

a trainsient loss of muscle tone caused a sudden fall to the

floor or drop of the head.

GENERALIZED SEIZURE

PARTIAL SEIZURE

SIMPLE PARTIAL SEIZURE (FOCAL SEIZURES):

COMPLEX PARTIAL SEIZURE:

when there is an altered conscious state or confusion due to the

abnormal electrical discharge spreading from the originating site
to become generalised

PARTIAL SEIZURE WITH SECONDARY GENERALIZATION:

when the child will retain awareness with consciousness

unpaired

when there is a focal seizure manifest clinically or on an ictal

EEG followed by a generalised tonic clonic seizure.

CAUSES OF EPILEPTIC SEIZURE

FEBRIL SEIZURES

acute seizure associated with fever in the absence of

intracranial infection or an identifiable neurological disorder
EPILEPSY

chronic disorder of the brain charaterized by recurrent,

unprovoked epileptic seizures

Absence seizures

http://professionals.epilepsy.com/page/generalized_absence.html

Adapted from: Holmes GL. Classification of seizures and the epilepsies. In: Schachter SC, Schomer DL, eds. The
comprehensive evaluation and treatment of epilepsy. San Diego, CA: Academic Press; 1997. p. 1-36.

WHAT CAUSES A SEIZURE?

[K]o = extracellular potassium

AHP = after hyper-polarization
NMDA = N-methyl-D-aspartate
IPSP = inhibitory post-synaptic potential
EC = extracellular
Interictal = between seizures

CONVULSION

convulsion sudden, violent, involuntary contraction of the muscles

of the body, often accompanied by loss of consciousness. It is not
known what causes the abnormal impulses from the brain that
result in convulsive seizures , since the disturbance may arise in
normal brain tissue as well as in diseased or injured tissue.
Convulsions may occur in such conditions as epilepsy, poisoning,
high fever (especially in young children), disturbances of calcium
or phosphorus metabolism, alkalosis, diabetes, oxygen
insufficiency, and a low blood-sugar content, as well as in local
irritation or injury of the brain. Persons undergoing convulsions
should be guarded against self-injury (see epilepsy ). Otherwise,
treatment must be directed to the underlying cause. (The
Columbia Encyclopedia, Sixth Edition. Copyright 2008 Columbia
University Press )
Convulsions are when a person's body shakes rapidly and
uncontrollably. During convulsions, the person's muscles contract
and relax repeatedly.
FEBRILE convulsion is a common medical condition. About ...
aged six months to six years have a convulsion when they have
a fever or high temperature. And the brain is normal . That is
mean:
A febrile convulsion is a seizure occurring in a child aged from six
months to six years, precipitated by a fever arising from infection
outside the nervous system in a child who is otherwise
neurologically normal.

SEIZURE

Definition
A seizure is a sudden change in behavior due to an
excessive electrical activity in the brain.
Seizure: A clinical event in which there is a sudden
disturbance of neurological function in association with an
abnormal or excessive neuronal discharge. (Lissauer,
2002).
There are a wide variety of possible symptoms of seizures,
depending on what parts of the brain are affected.

Many types of seizures cause loss of consciousness with

twitching or shaking of the body.
However, some seizures consist of staring spells that can easily
go unnoticed.
Occasionally, seizures can cause temporary abnormal
sensations or visual disturbances.

Seizures can generally be classified as either "simple" (no

change in level of consciousness) or "complex" (change in
level of consciousness). Seizures may also be classified as
generalized (whole body affected) or focal (only one part
or side of the body is affected).
Epilepsy is a chronic disorder with recurrent seizures.
Some types of epilepsy are hereditary.

SEIZURE

Any medical condition that irritates brain cells may result in a seizure.
Common medical conditions that commonly cause seizures include:
Hypoglycemia (low blood sugar)
Drug use (especially cocaine or stimulants)
Alcohol withdrawal
Very high fever (fever convulsions in children)

Febrile convulsions occur in young children when there is a rapid

increase in their body temperature. It affects up to 1 in 20 children
between the ages of one and four but can affect children between six
months and about five years old.
The child's risk of febrile convulsion rises if:
they are genetically predisposed to it
They suffer frequent illnesses, which include high temperatures
The first attack of febrile convulsion was accompanied by a
relatively low body temperature - below 39C.
most febrile seizures (fever convulsion) are harmless and do not cause
brain damage

Febrile seizures are convulsions brought on by a fever in infants or

small children. During a febrile seizure,
a child often loses consciousness and shakes,
moving limbs on both sides of the body.
Less commonly, the child becomes rigid or has twitches in only a
portion of the body.
Most febrile seizures last a minute or two; some can be as brief as
a few seconds, while others last for more than 15 minutes.

FEBRILE SEIZURE

FEBRILE SEIZURE (F S):

the most common seizure disorder in children ( infancy & childhood)

associated with a rapidly rising temperature

usually develop when the core temperature reaches 39 C or greater
occur with the diseases out side the CNS and associated with fever
age dependent: 3-6month ( peak age of onset:14-18 month of age) till 5
years of age
With normal CNS structure and function (without evidence intracranial
infection or defined cause)
Without febrile seizure history
Genetic predisposition

CLINICAL MANISFESTATION OF F S

Simple FS:

Occurs in the children: 3 month - 5 yr of age

Typically generalized seizure (tonic-clonic)
Duration: a few seconds to 10-min
Only has once or twice of seizures during a period of disease

Atypical FS
Age of seizure onset: < 6 mont or > 6 years
Seizure persisting for more than 15 min
Repeated convulsions during a febrile period
A focal seizure.
An EEG is indicated for atypical febrile seizures or for the child
at risk for developing epilepsy

FEBRILE SEIZURE

Febrile convulsions are a common paediatric presentation

to A&E departments, occurring in about 3% of children
between the ages of six months and five years. The seizure
usually occurs early on in a viral infection when the
temperature is rising rapidly, and typically lasts less than
five minutes. It is the abrupt rise in temperature rather than
the high level that is important.
The seizures are tonic or tonic-clonic, with loss of
consciousness and muscular rigidity forming the tonic
stage. This may be preceded by a frightened cry from the
child.
Cessation of respiratory movements and incontinence of
urine and faeces may occur during this stage, which lasts
about 30 seconds.
The clonic stage that follows is characterised by repetitive
movements of the limbs and face.

IS IT FS or EPILEPSY?

Febrile seizures are not classified as epilepsy, about 3% of

children with FS go on to develop afebrile recurrent seizures
( epilepsy)
Risk factors for epilepsy include: seizures that are focal,
prolonged (>15mins) or recur in the same illness; firstdegree relative with epilepsy; neurological abnormality
Classification of epilepsies

According to the seizure type

Generalized epilepsies and syndromes

Localization-related epilepsies and syndromes

According to aetiology

Idiopathic ( or primary) ---in which there is no apparent

cause except perhaps for genetic predisposition
Symptomatic---in which the cause is known or suspected

SEIZURE

Seizures can generally be classified as either:

Seizures may also be classified as:

"simple" (no change in level of consciousness) or

"complex" (change in level of consciousness).
generalized (whole body affected) or
Focal (only one part or side of the body is affected).

Epilepsy is a chronic disorder with recurrent seizures. Some

types of epilepsy are hereditary.
Causes of seizure: Any condition that results in abnormal
electrical excitation of the brain may result in a seizure,
including:

Epilepsy
Injury or trauma to the head
Infection (brain abscess, meningitis)
Brain tumor
Stroke

CAUSES OF EPILEPSY

Fever
36%
Medication change
20%
Unknown
9%
Metabolic
8%
Congenital
7%
Anoxic
5%
Other(trauma, vascular, infection, tumor, drugs) 15%
DeLorenzoRJ.Epilepsia1992;33Suppl4:S1525

Basal

nuclei: gray matter yg

letaknya didalam (within)
white matter td: Corpus
striatum:
Caudate

nucleus.
Lentiform nucleus
Functions: memperbaiki gerakan
motor sadar menjadi lebih baik (in
the refinement of voluntary
movements.)
Parkinsons: penyebabnya adalah
degeneration of neurons yg
menghubungkan substantia
nigra ( midbrain) ke caudate
nucleus.
Hilangnya kendali GB terhadap
aktivitas cortex motor yg
berlebihan menyebabkan rentetan
rangsngan pada bagian otot tubuh
yg berlebihan dan timbul seizure
Kejang sesuai rangsangan dari
bagian cortex yg mana?kaki,
lengan dan bisa menyeluruh.
F:doc.aging immunity/8brainM.ppt/Lt.ibnu/2005

BAGIAN DALAM OTAK:

BASAL NUCLEI

MALIGNANT HYPERTHERMIA

Sensory input to
the CNS comes
from receptors of
many different
types situated
throughout the
body. From the
sensory cortex
to the motor
cortex etc and
produce a body
movement. But
the cortex motor
can stimulate by
some terrible
stimulant ie:
infection, fever
or poison etc.

Stimulation by fever,
poison, drugs or
infection

Nervous system conveys highspeed electrical signals along

neurons such rapid
messages control the
movement of body parts in
response to sudden
environmental changes
Receptor (sensor) detects a
stimulus and sends information
to control center
Control center = compares
the incoming info to a set
point (desired value) and
sends out a signal that
directs an effector to
respond
Example. ~ a change in
blood calcium level
Repetitive stimulation from the
motor cortex conveys more
electrical signal to the part of
body and make a convulsion.
Why? Control center fail to
regulate set point & signal that
directs stimulation to the
effector repetitively

Somatosensory and Motor

cortex
Both of their neurons are
distributed according to
the part of the body that
generates the sensory
input or receives the
motor commands
Primary Motor Cortex helps
issue commands that consist
of action potentials
produced by neurons
[located: rear of frontal lobe,
adjacent to the primary
somatosensory cortex]
Action potentials travel
along axons to brainstem
& spinal cord excite
motor neurons excite
skeletal muscle cells
What happen when
stimulation repetitively &
uncontrollable to the
primary motor cortex?

Management of the fitting febrile child:

Clothing should be removed and the child covered with a sheet.
The child should be placed on its side, or prone with its head to one
side, since vomiting with aspiration is a hazard.
Rectal diazepam is the drug of choice, producing an effective blood
concentration of anticonvulsant within ten minutes.
All children with a first febrile convulsion should be admitted to
hospital to a) exclude meningitis and b) educate the parents.
A urine specimen should be taken to exclude infection, and a blood
glucose level should be taken.
A lumbar puncture may be performed if the child is less than eighteen
months old shows signs of meningitis or sepsis.
Treatment of the febrile child:
Fever should be treated to promote the comfort of the child and to
prevent dehydration. Paracetamol is the preferred anti-pyretic and fluid
levels should be maintained. Ibuprofen can be given if the fever does
not respond to paracetamol.
Rectal diazepam should be administered as soon as possible after the
start of the convulsion, and should not be given after the convulsion
has stopped.