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Updated: Feb 2 2022

Tonic Clonic (Grand Mal)

  • Snapshot
    • A 78-year-old man presents to the emergency department for a headache. He is accompanied by his wife who reports that his headache progressively worsened over the course of weeks. He does not have a history of headaches. Physical examination is normal. A CT head without contrast demonstrates subdural hematomas. Neurosurgery was consulted and determined that the intracranial bleeds were stable but he was admitted to the hospital due to confusion in the setting of a newly found urinary tract infection. After a few days of admission, he had a witnessed generalized-tonic clonic seizure, prompting him to being treated with benzodiazepines.
  • Introduction
    • Definition
      • a seizure presentation characterized by body stiffening (tonic) and rhythmic jerking (clonic) movements
  • Etiology
    • Can begin as a partial seizure that secondarily generalizes
    • Bilateral hemispheric seizures
  • Presentation
    • Symptoms/physical exam
      • tonic phase
        • muscle stiffness
        • abdominal contraction, forcing air through the vocal chords, producing a cry or groan
        • loss of conciousness and falls to the ground
        • tongue or cheek bite may occur
      • clonic phase
        • rhythmic jerking of the extremities
      • these seizures typically last 1-3 minutes and the patient subsequently becomes confused and drowsy (post-ictal)
  • Imaging
    • MRI brain with and without contrast
      • indication
        • to evaluate for structural lesions producing a seizure focus
  • Studies
    • Patients presenting with a first-time seizure should be evaluated with serum electrolytes, complete blood count, glucose, and a urine toxicology screen prior to further testing
    • Electroencephalogram
      • indication
        • part of the initial evaluation of patients presenting with a first seizure
    • Lactate
      • elevated due to muscle contraction => self-resolves
  • Differential
    • Psychogenic nonepileptic seizures (PNES)
      • differentiating factors
        • most seizure episodes are infront of a witness
        • seizures do not occur during sleep
        • variable and asynchronous muscle movement
    • Migraine with aura
      • differentiating factors
        • patients typically have a pulsatile/throbbing headache
  • Treatment
    • Medical
      • antiepileptic drugs (AED)
        • indication
          • started in patients who are at increased risk of seizure recurrence
            • first address treatable causes of seizure (e.g., hypoglycemia)
            • choice of AED depends on a number of factors (e.g., side-effect profile, cost, and comorbid conditions)
      • corticotropin (ACTH)
        • Used in the treatment of West syndrome, a triad of infantile spasms (stereotyped tonic-clonic seizures in infants), hypsarrythmia, and developmental regression.
  • Complications
    • Behavioral and cognitive alterations
    • Aspiration
    • Head strike
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