TONIC-CLONIC SEIZURES: SYMPTOMS, CAUSES, AND TREATMENT - NEUROPSYCHOLOGY - 2024

The tonic clonic seizures, formerly called "grand mal seizure" are a type of generalized crisis. That is, it is an imbalance in brain activity that involves both hemispheres of the brain.

This causes people who suffer from them to lose consciousness and experience very strong muscle contractions, since abnormal electrical signals cause manifestations that affect the nerves, muscles or glands.

Most clonic tonic seizures have an unknown cause or appear spontaneously (called idiopathic), although they occur frequently in people with epilepsy.

On the other hand, they can also occur from a high fever, low blood sugar, or any brain injury. Drug or alcohol abuse is one factor that makes a person more prone to tonic-clonic seizures, especially if they have a family history of seizures.

Some people may have tonic-clonic seizures once in their life, and never experience them again. Instead, in others it may be part of a more serious condition that needs to be treated, such as epilepsy. In this case, the patient must follow certain recommendations and may need anticonvulsant drugs.

Phases and symptoms of tonic-clonic seizures

Tonic-clonic seizures are named for the 2 phases that occur in their development (tonic and clonic). However, prior to these, another stage known as "aura" may appear. Each of them is explained below:

Aura phase

In this previous phase, the person suddenly experiences a strange sensation. Feelings of sadness, happiness, anger, or fear often arise for no apparent reason, which can cause the person to involuntarily scream or cry.

Similarly, there are alterations in the senses such as visual, tactile, auditory, taste or olfactory hallucinations, as well as a distorted spatial sensation, seeing objects larger or smaller than normal.

There may also be difficulties speaking and a feeling of unreality or disconnection with the environment.

Another very typical sign of the aura is "déjà vu", that is, feeling as if you had previously experienced a new situation. Like the jamais vu, which means a feeling of strangeness in a normal situation.

Tonic phase

The tonic phase of tonic-clonic seizures is characterized by severe muscle stiffness and loss of consciousness. This lasts around 15 to 30 seconds, and usually does not last more than a minute.

At this stage, the back and neck are arched. The chest muscles also contract, so there is great difficulty in breathing. This causes a choking sensation, and can also cause the skin on the face and lips to turn bluish.

The "epileptic scream" can also occur, which arises when the diaphragm and vocal cords contract, expelling air from the lungs outward.

There is a misconception that the person during tonic-clonic seizures could “swallow their own tongue”. So it is thought that you should put something in your mouth to avoid it.

However, swallowing the tongue is impossible, and attempting to open the jaw when it is being clenched tightly can do more harm than good.

The real reason why a handkerchief or other object that can bite can be placed in the mouth is to avoid that in the next phase (clonic phase), it bites its own tongue or the dental cheek.

Clonic phase

The last stage of tonic-clonic seizures is the clonic phase. It is characterized by rapid muscle spasms and contractions.

The muscles in the legs, head, and elbows flex and then slowly relax. The frequency of spasms at first is very high, but as time passes it gradually decreases.

As the crisis passes, the person may breathe deep sighs, as they gradually return to a normal breathing rate.

The total duration of seizures can be 1 to 3 minutes. If it lasts more than 5 minutes, it is a medical emergency and urgent health intervention is necessary.

During this period the person does not react to stimuli and is likely to remain unconscious for another few minutes. In these minutes, another phase called the “postictal period” can be defined. During this, the brain is very active trying to stop the neural impulses to stop the crisis and return to normal.

Gradually the person will wake up during the next 10 to 30 minutes. Later, she may appear sleepy and confused. They also tend to feel very weak or tired, and have headaches and muscle aches for the next 24 hours.

Causes

Nerve cells in the brain (called neurons) communicate with each other by sending electrical and chemical signals. The location of these signals tells us what the brain is doing; like thinking, hearing, seeing, feeling or controlling the movement of muscles.

In people who have seizures, the electrical activity of the brain is abnormally synchronized. During seizures, it becomes much more intense than normal.

This can occur in an isolated area of ​​the brain or as a whole. When it happens throughout the brain, it is called a generalized seizure. On the other hand, when it appears in a localized area, they are called focal or partial seizures. Tonic-clonic seizures are a type of generalized seizure.

In most cases, the cause of tonic-clonic seizures is unknown. When this happens, they are called idiopathic seizures. However, in other cases, tonic-clonic seizures can appear as a consequence of other conditions.

However, it is important to note that seizures are more likely if the person has a genetic predisposition to them. Each of us is more or less likely to have seizures. In some people they are much more easily triggered, while others do not suffer them at any time in their lives.

Some conditions that can lead to tonic-clonic seizures are:

Problems affecting the brain

Seizures can be the consequence of head injuries, strokes, tumors… As well as infections that involve the central nervous system such as encephalitis, meningitis or brain abscess.

Serious imbalances of substances in the blood or disturbances in metabolism

For example, imbalances in sodium, calcium, magnesium or glucose levels (having more or less sugar in the blood than normal, as occurs in diabetes.)

Congenital anomalies

For example, there are genetic syndromes where tonic-clonic seizures such as Batten's disease appear. Another hereditary syndrome that presents them is juvenile myoclonic epilepsy.

They are also facilitated by malformations in the blood vessels that can cause a stroke.

Reactions to certain medications and drugs

For example, side effects of certain anesthetic drugs, penicillin, anticancer drugs or asthma drugs. Like they can appear by overdose of illegal drugs such as cocaine or amphetamines.

Other

-Diseases such as high fever, high blood pressure (hypertension), eclampsia (seizures or coma during pregnancy), liver failure, kidney failure, lupus, among others.

- Abstinence from alcohol or drugs.

- Other causes that facilitate tonic-clonic seizures are sleep deprivation, high fever, flashing lights, and intermittent noises.

Diagnosis

There are several steps in making the diagnosis of tonic-clonic seizures:

Medical record

The doctor will have an interview with the patient about other previous seizures or previous medical conditions. Information from the people who were there during the seizures may also be needed to describe what happened.

It can also be very helpful for the doctor to know what the person was doing before the seizure. This will help you to know the reason that triggered them.

Neurological examination

It consists of certain tests to check balance, reflexes and coordination. Muscle tone and strength will also need to be assessed.

This test also includes tests to detect abnormalities in memory, attention, or executive functions.

Blood test

This test is necessary to find other medical causes of seizures. For example, it is recommended if diabetes or unevenness in certain substances present in the body is suspected.

Electroencephalogram (EEG) or magnetic resonance imaging (MRI)

These are scans that reflect possible abnormalities in the functioning of the brain. It is used to observe the electrical patterns of the brain in detail, as well as to obtain images of certain areas of the brain.

Circumstances

Other circumstances must also be taken into account when diagnosing the patient. For example:

- Having hyperventilation or electrolyte imbalances (which are chemical substances in the body such as calcium, magnesium, potassium or sodium).

- Long QT syndrome (abnormality in potassium and sodium that reaches the heart, which can cause arrhythmias).

- Sleep apnea.

- Simple fainting spells.

- Spasms of sobbing or emotional apnea. The latter refers to episodes that occur in children where breathing is suddenly stopped after intense emotion.

- Dystonias (continuous muscle contraction for neurological reasons).

- It is also necessary to make a differential diagnosis that allows to rule out tonic-clonic seizures from other conditions, such as: complex partial seizures, confusional states, acute memory disorders, dizziness or vertigo, migraine variants, narcolepsy, syncope, among others.

Forecast

As mentioned above, having a single tonic-clonic seizure from a single trigger does not usually have long-term effects. However, if there is a second attack, the risk of a third is 80%. Doctors usually consider a second seizure a sign of epilepsy.

People with tonic-clonic seizures can lead normal lives if they are treated properly. For example, by controlling electrical or chemical imbalances in the brain or other underlying conditions, the problem may disappear.

Certain complications may arise from tonic-clonic seizures. The most commons are:

- Injuries to the head, tongue and lips.

- Vertebral fractures.

- Aspiration pneumonia.

- Cardiac arrhythmia.

- Sudden death.

The death rate for seizures is low, but may be higher in epilepsies accompanied by tonic-clonic seizures.

The incidence of sudden death in people with epilepsy is 24 times higher than in the general population. In these cases, there are certain risk factors. For example, the high frequency of seizures, a younger age, psychopathological problems or combination therapy (use of two or more drugs for the treatment of epilepsy).

It should be noted that people affected by seizures should avoid driving vehicles. As well as avoiding handling dangerous equipment, swimming alone or bathing without anyone at home to help them.

Treatment

There is no single treatment method for tonic-clonic seizures. Each treatment must be tailored to the patient according to their diagnosis and symptoms.

Many of the people are treated effectively through anticonvulsant drugs. It starts with a low dose that can be progressively increased according to medical indications. Although some patients need more than one medicine to treat seizures.

Some of the most commonly used medications are carbamazepine, phenytoin, ocarbazepine, lamotrigine, phenobarbital, and lorazepam.

It should be taken into account that some of these medications may interact with other drugs. For example, with oral contraceptives. Therefore, it is important to know what other medications the patient follows.

Neurofeedback

There are other effective treatments as well. One of them that is beginning to be used and that gives very good results is neurofeedback. Through this technique, brain electrical activity is regulated with reinforcing visual and / or auditory stimuli.

In this way, when the person has a more desirable electrical brain activity, sounds or videos appear that “reward” said activity.

Surgery

In severe cases that resist treatment, surgery may be necessary. Although research indicates that surgery is more recommended for partial seizures, that is, those that affect only one part of the brain.

Another method that has had positive results is the stimulation of the vagus nerve by placing an electrical device that stimulates it automatically.

Lifestyle

On the other hand, to control seizures it is recommended not to consume alcohol or drugs. In addition to following a ketogenic diet, that is, one high in protein and fat, and low in carbohydrates.

The ratio of protein and fat to carbohydrates should be 4: 1. Studies have shown that it is effective in reducing seizures in 50% of patients.

The ketogenic diet is generally used for intractable epilepsy, especially in children. It is prescribed less frequently in adults, because being a very restrictive diet is difficult to comply with.

Prevention

Certain simple actions in daily life can prevent the onset of tonic-clonic seizures or their complications, for example:

- Take all the necessary precautions for driving vehicles. That is, the use of helmets on motorcycles, as well as seat belts and airbags.

- Handle food properly to avoid parasitic infections that can cause epilepsy.

- Reduce risk factors such as alcohol, drug, or tobacco use. Maintain a healthy life avoiding sedentary lifestyle and controlling blood pressure and cholesterol.

- Get adequate rest, as sleep deprivation and stress can trigger seizures.

References

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