SEIZURE & EPILEPSY
Definition of Seizure
Seizure:
Clinical expression of abnormal paroxysmal, excessive or synchronous discharges of neurons residing
primarily in the cerebral cortex—intermittent and self-limited, lasting seconds to few minutes.
Acute symptomatic seizure:
Seizure that occurs in close temporal association with an acute systemic illness or brain insult—
hyponatremia, hypocalcemia, high fever, toxic exposure, intracranial bleeding, or bacterial meningitis.
Not classify as epilepsy unless they become a recurrent process beyond the acute illness.
An unprovoked seizure:
Seizure that occurs in the absence of a potentially responsible clinical condition OR occurs in relation
to a preexisting brain lesion or progressive nervous system disorder beyond the time interval
recognized for acute symptomatic seizure.
Status epilepticus:
Seizures that are prolonged >5 minutes or immediately recurrent without a return of consciousness.
Definition of epilepsy
Epilepsy is a state of an enduring predisposition to recurrent epileptic seizures. It is considered to be a
disease associated with lasting derangement of normal brain function. It may arise from a variety of
genetic, structural, metabolic, immune, infectious, or unknown causes.
An individual is considered to have epilepsy when any of the following exists:
1) At least two unprovoked (or reflex) seizures occurring more than 24 hours apart—evoked by
specific external (eg light flashes) or internal (eg, emotion, thoughts) stimuli
2) One unprovoked (or reflex) seizure and a probability of further seizures that is similar to the
general recurrence risk after two unprovoked seizures (eg, ≥60 percent), occurring over the
next 10 years. This may be the case with remote structural lesions such as stroke, central
nervous system infection, or certain types of TBI.
3) Diagnosis of epilepsy syndrome such as:
a. Lennox-Gastaut syndrome
b. Developmental and epileptic encephalopathy with spike-wave activation in sleep
(DEE-SWAS)
c. Focal epilepsy syndromes of childhood
d. Absence epilepsies
e. Juvenile myoclonic epilepsy
f. Reflex epilepsies
g. Sturge-Weber syndrome
The 2017 International League Against Epilepsy (ILAE) multi-level classification scheme
Based on clinical and EEG data
1) Focal onset
a. Focal aware (simple partial)
b. Focal impaired awareness (complex
awareness)
2) Generalized onset
a. Motor (tonic-clonic seizure)
b. Non-motor (absence seizure)
Etiology factors of seizure
1) Genetic
2) Structural
a. Congenital
b. Acquired—stroke, trauma, infection, immune-based
3) Metabolic—creatine deficiency syndrome, glucose transporter deficiency
4) Immune—SLE
5) Infectious—malaria, tuberculosis, HIV
6) Unknown
Systemic CNS Seizure
Metabolic Toxin/meds Structural Infectious Other mimics
Hyponatremia/ Drug intoxication— Tumor Encephalitis Primary epilepsy Transient
hypernatremia amphetamines, cocaine syndromes ischemic
Intracranial Meningitis
attack (TIA)
Hypocalcemia Drug withdrawal— hemorrhage Alzheimer’s
Tuberculosis
alcohol, BZD —SDH, IPH Migraine
Hypophosphatemia
Brain abscess
Medications— Ischemic Syncope
Hypomagnesemia
antidepressants, stroke Cerebral
Alcohol
Hypoglycemia tramadol, malaria
Vascular withdrawal
diphenhydramine,
Hypoxia malformation tremor
isoniazid
Heat stroke Head trauma Psychogenic
Serotonin syndrome
nonepileptic
Uremia/kidney failure seizure,PNES
Hepatic Panic attack
encephalopathy or anxiety
Generalized onset, Tonic-Clonic Seizure
Prodorome Aura/ early ictal Ictal phase Post-ictal phase
(hours) (sec-mins) (1-3 mins) (10-20 mins)
Irritability Sensory phenomenon Tonic: Somnolence
Anxiety Déjà vu Tensing of muscles, LOC, loss of Confusion
Impending doom postural tone, ictal cry Fatigue
Clonic: Weakness
Rhythmic contraction/relaxation, Headache
incontinence, foamy salivation
Approach to seizure
History
1) Characteristics of the seizure
a. Nature of any involuntary movements
b. Consciousness during the event
c. Bladder/ bowel incontinence
d. Presence and duration of classic pre and post-ictal symptoms
2) Presence of common potential triggers—sleep deprivation, stress, alcohol/drugs
3) The possible etiology factors:
a. Signs and symptoms suggesting CNS infection—fever, headache, neck pain, confusion
OR history of immunosuppression that put pt at risk of opportunistic infection to CNS
b. History of prior stroke, cancer that suggests metastasizing, hemostasis disorders that
predispose to ischemic stroke or intracranial hemorrhage, endocrine disease that
predisposes to hypoglycemia or electrolyte imbalance
c. Drugs or substance use history/ alcohol abuse
d. Travels history—malaria, tuberculosis
Focused physical exam:
1) Neuro exam
2) Meningeal signs—Brudzinski’s, Kernig’s, nuchal rigidity
3) Tongue bites
4) Traumatic injury signs
Tests:
1) Serum glucose (hypoglycemia)
Management of Epilepsy
3 main goals:
1) Controlling seizures
2) Avoiding treatment side effects
3) Maintaining or restoring quality of life
Emergency management of seizure in dental settings:
1) Stop dental treatment and clear dental instruments away from the patient.
2) Place the dental chair in a supported, supine position as near to the floor as possible.
3) Put the patient in a recovery position (on the patient’s left side) to prevent aspiration.
4) Do not restrain the patient or put fingers inside the patient’s mouth.
5) Loosen any tight clothing around their neck and loosen the belt.
6) Check vital signs and capillary plasma glucose.
7) Beware of status epilepticus—seizures that are prolonged >5 minutes or immediately
recurrent without a return of consciousness.
8) Call 999 if:
a. The seizure last longer than 5 minutes OR
b. Repeated seizures OR
c. Pt has any underlying medical problems—heart disease, hypertension, or DM OR
d. Injured OR
e. First episode of seizure
9) Once the seizure is finished, evaluate the level of consciousness during post-ictal phase and
examine intraoral for any injuries.
10) When a patient make full recovery, discharge home or refer to physician if indicated.
