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Postictal State

Postseizure State

The postictal state is defined as an abnormal state at the end of an epileptic seizure and it is characterized by motor, behavioral and neuropsychological symptoms. Depending on the type of seizure and other factors, the postictal state may last from minutes to hours, which is why the diagnosis is based on patient history and clinical criteria supported by electroencephalographic studies.


Presentation

Numerous signs and symptoms may appear in a postictal state, with some variations depending on the underlying type of epilepsy. For example, the duration of symptoms is significantly shorter if seizures originate from the temporal and frontal lobes (about 90 seconds), while tonic-clonic seizures may be followed by a postictal state lasting for hours [1] [2]. Additionally, a prolonged duration of seizures, age extremes (elderly and children) and seizures of the dominant hemisphere are established risk factors for a prolonged postictal state [1] [3]. Regardless of the duration, the following symptoms are encountered [1] [2] [3] [4] [5] [6] [7]:

  • Behavioral changes - Postictal psychosis is one of the most important behavioral manifestations of the postictal state, distinguished by auditory and visual hallucinations, delusions, paranoia, mood disorders, aggression and disorders of thought [1] [3]. A rapidly resolving delirium is another important feature, but a severe and prolonged form is seen in more than a third of cases, presenting as alterations in the sleep-wake cycle, attention deficits, and increased autonomic activity [3] [6].
  • Alterations in motor function - Weakness and/or paralysis, usually unilateral and contralateral to the seizure focus, can last for minutes or even hours, depending on the extent of brain damage after seizures. Patients who suffer from structural lesions (caused by a tumor or stroke) seem to be most susceptible [1].
  • Cognitive and visual symptoms - Dysphasia, homonymous hemianopias or blindness, respectively, are also encountered during the postictal state, and they seem to be more common during childhood and when seizures stem from the occipital or occipitotemporal lobes [1].

Severe, potentially recurrent headaches after seizures may also be reported by some individuals, and they are frequently misdiagnosed as migraines [3], while epilepsy occurring exclusively during sleep can induce confusion or sleepwalking, which could be the only symptoms of a postictal state in such circumstances [5].

Epilepsy
  • Numerous signs and symptoms may appear in a postictal state, with some variations depending on the underlying type of epilepsy.[symptoma.com]
  • Clinical epilepsy". Clinical Epilepsy . American Epilepsy Society. Absence ... seizures begin and end suddenly. There is no warning before the seizure, and immediately afterward the person is alert and attentive.[en.wikipedia.org]
  • The annual cost of treating epilepsy in the United States is an estimated 12.5 billion, according to a report issued January 2000 by The Epilepsy Foundation. The Foundation also reports that more than 180,000 Americans develop epilepsy each year.[books.google.com]
  • […] and surgery on behavior Pediatric and adolescent epilepsy Disorders associated with epilepsy that impact behavior And much more[books.google.com]
  • Featuring expert authors from major epilepsy centers, this seminal work reviews all current procedures and applications for monitoring adults and children with epilepsy in the Epilepsy Monitoring Unit and the ICU.[books.google.com]
Fatigue
  • He or she may be able to help you find out what's causing your fatigue and recommend ways to relieve it. Read more on MedlinePlus.gov.[treato.com]
  • It is the period following a seizure, which sometimes includes a headache , confusion, soreness or fatigue.[omicsonline.org]
  • Postictal phase : Fatigue, lethargy, and exhaustion follow the pain phase for migraine and the seizure phase for and epilepsy. This is the stage that’s often called a migraine hangover.[theraspecs.com]
  • Postictal symptoms can effect changes in behavior, thinking, mood, and motor function, including: Fatigue Headache Nausea Sleepiness Memory loss Mental confusion or fogginess Feeling thirsty Weakness on part of all of the body A strong urge to urinate[verywell.com]
  • Related to Physical Agents 397 Injury and Poisoning 404 Care of Acute Lacerations 421 Selected Injuries 435 Care of the Athlete 444 Athletic Injuries 453 Common Clinical Problems 465 Care of the Patient with Dysequilibrium 471 Care of the Patient with Fatigue[books.google.ro]
Dentist
  • This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts.[statpearls.com]
Stroke
  • Patients who suffer from structural lesions (caused by a tumor or stroke) seem to be most susceptible.[symptoma.com]
  • The patient has a history of epilepsy secondary to his stroke.[statpearls.com]
  • The following chapters cover the therapy of seizures when they develop after traumatic brain injury or stroke, and the treatment of concomitant depression and anxiety in patients with epilepsy.[books.google.com]
  • It refers to a patient who remains in coma after a stroke or grand mal. Regards Or "...estado pos t ictal..." .[forum.wordreference.com]
Altered Mental Status
  • If a patient remains confused for longer than 20 minutes after a seizure, consider another cause of altered mental status [4].[ems1.com]
  • Alcohol withdrawal Patients that present with seizures from alcohol withdrawal (delirium tremens) may present with anxiety, tremulousness, and altered mental status.[cdemcurriculum.com]
  • mental status in whom no other cause is available to explain the altered sensorium Paradoxical response (improved alertness) in a patient with altered sensorium who receives anti-epileptic therapy (e.g. benzodiazepine, propofol) RISK FACTORS Systemic[lifeinthefastlane.com]
Somnolence
  • Excessive daytime somnolence - eg, due to a sleep apnoea or narcolepsy . Periodic limb movement disorder. Tardive dyskinesia. Panic attacks .[patient.info]
  • Postictal patients may also be confused or combative, especially as they transition from somnolent to awake. The postictal phase may last a few minutes to several hours, but patients usually fully recover after 20 minutes.[ems1.com]
  • , somnolent? if so, for how long?). Physical Examination Vital signs and blood sugar should be obtained immediately on all patients. As discussed previously, empiric thiamine should be given when treating hypoglycemia.[unboundmedicine.com]
  • Side effects: nystagmus, dizziness, somnolence, drowsiness. D. Promote physical and emotional health. Establish regular routines for eating, sleeping, and physical activity. Avoid alcohol, stress, and excessive fatigue.[brilliantnurse.com]
Stupor
  • Stupor and "twitching" Case #5 A 56-year-old man who was previously well was admitted to the hospital in a stupor with clonic twitching of his left extremities and face.[dartmouth.edu]
  • […] twitching or blinking or other eye movement signs and/or fluctuating mental status Patients in whom no other cause is available to explain the altered sensorium, especially in those who have a history of a previous seizure, even if remote Unexplained stupor[lifeinthefastlane.com]
  • It is terminated by inhibitory transmitters that result in postictal period of dense stupor or coma. 22-6. What is a petit mal (absence) seizure? 22-6.[dartmouth.edu]
Slurred Speech
  • Symptoms of Todd’s paralysis include: weakness of a limb, such as your hand, arm, or leg numbness slurred speech disorientation Symptoms begin during the postictal state, which is a period of time after a seizure when you transition back to a normal state[healthline.com]

Workup

To confirm the diagnosis of a postictal state and to confirm its symptoms as being a consequence of epilepsy, a thorough patient history, and a detailed physical examination must be conducted, as various conditions may mimic the clinical presentation [3]. Firstly, details regarding prior treatment with antipsychotic medications, alcohol abuse, use of antiepileptic therapy that can exert side-effects, and recent exposure to illicit drugs must be noted, in order to exclude iatrogenic causes of delirium and psychosis [3] [6]. A complete neurological examination should follow, during which weakness, paralysis or other pathological phenomena can be encountered. If clinical evidence suggests that patients fall into a postictal state, further workup must include electroencephalography (EEG). A nonconvulsive status while symptoms are still present, is considered to be a diagnostic hallmark of the postictal state, but interictal spikes and spike-waves may be present as a remnant of a seizure [7]. Because imaging studies, such as computed tomography (CT) and magnetic resonance imaging (MRI) are of limited use, the diagnosis of a postictal state relies on excluding other causes through patient history, clinical criteria and EEG studies.

Kluver-Bucy Syndrome
  • Case reports of post ictal Kluver Bucy Syndrome and Capgas Syndrome have been reported after resective epilepsy surgery as well.[ncbi.nlm.nih.gov]

Treatment

  • There is incomplete information about the causes and optimal treatments for seizure-related psychosis, however, postictal behaviors can usually be managed safely.[ncbi.nlm.nih.gov]
  • Despite a relative lack of biological insight, many key observations were made in an era mostly devoid of treatments for epilepsy.[ncbi.nlm.nih.gov]
  • The final chapters discuss emerging topics in epilepsy: the treatment of the postictal state, technologies to predict and detect seizures, strategies for closing the treatment gap and sudden unexpected death in epilepsy.[books.google.com]
  • Awareness of the various manifestations of sleep disorders, seizures, and postictal phenomena during sleep is critical to optimal diagnosis and treatment of patients with epilepsy.[ncbi.nlm.nih.gov]
  • Here we review different behavioral, neuropsychological, and EEG phenomena of the postictal state and discuss several semiological features of the postictal period with respect to patient characteristics, seizure duration, influences of drug treatment[ncbi.nlm.nih.gov]

Prognosis

  • […] recordings of 955 spasms in children with cryptogenic and symptomatic West syndrome (WS) were reviewed to define the relation between a clinical manifestation of a spasm and its EEG pattern, and to examine whether these features reflect the etiology and prognosis[moh-it.pure.elsevier.com]
  • Prognosis The prognosis of Todd's paralysis is excellent, with full recovery to be anticipated. Resources BOOKS Pedley, Timothy A. "The Epilepsies." Cecil Textbook of Internal Medicine , edited by Lee Goldman, et al. Philadelphia: W.B.[encyclopedia.com]
  • Implications of NCSE are poorly defined associated with poorer prognosis, however the underlying cause is typically the major determinant of mortality Patients with pre-existing epilepsy have a lower mortality (3%) than where NCSE is due to acute medical[lifeinthefastlane.com]
  • PROGNOSIS The long-term impact of seizures is small for most children, especially if there are no underlying abnormalities in the child's brain. Many children with epilepsy have normal development and a good chance for a normal life.[uptodate.com]
  • She worked on the development of markers of consciousness to improve diagnosis, prognosis and treatment of patients with disorders of consciousness.[books.google.ro]

Etiology

  • A patient presenting with a new focal sign (e.g., unilateral weakness) after an unwitnessed but suspected seizure requires brain imaging to rule out alternative etiology like a stroke.[statpearls.com]
  • Although it was independent from the etiology of the spasms, persisting hypsarrhythmia during a cluster of spasms appeared to be an EEG pattern that correlated with a favorable outcome.[moh-it.pure.elsevier.com]
  • Adult first generalized seizure: etiology, biological tests, EEG, CT scan, in an ED. Am J Emerg Med. Jan 1995;13(1):1-5.[cdemcurriculum.com]
  • Postictal migraine headaches are a major complaint among persons with epilepsy , and can have a variety of etiologies. One possible cause of these migraines is high intracranial pressure resulting from postictal cerebral edema .[en.wikipedia.org]
  • The presumed etiology was due to diverse causes, but a withdrawal state was the most common. EEG demonstrated continuous or nearly continuous generalized ictal discharges of variable morphology.[neurology.org]

Epidemiology

  • Causes of epilepsy: contributions of the Rochester epidemiology project. Mayo Clin Proc. 1996;71(6):570–5. PubMed CrossRef Google Scholar 2. Hildebrand J, Lecaille C, Perennes J, et al.[link.springer.com]
  • These epidemiological results were first reported and stressed by Verrotti et al. [ 15 – 17 ], which conducted in pediatric age.[thejournalofheadacheandpain.springeropen.com]
  • He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education.[lifeinthefastlane.com]
  • Epidemiology There is no clear data on the incidence of the postictal state in patients with epilepsy.[statpearls.com]
Sex distribution
Age distribution

Pathophysiology

  • A consistent format for each care plan allows faster lookup of topics, with headings for Overview/Pathophysiology, Health Care Setting, Assessment, Diagnostic Tests, Nursing Diagnoses, Desired Outcomes, Interventions with Rationales, and Patient-Family[books.google.ro]
  • The pathophysiologic mechanism of PIP is unknown. One hypothesis is that PIP represents a psychic Todd's paralysis [ 15 , 18 ].[annals-general-psychiatry.biomedcentral.com]
  • A study showed that most patients with epilepsy (72%) reported postictal behavioral impairment. [2] Pathophysiology A seizure is terminated by a variety of potential mechanisms including depletion of energy substrate, desensitization of receptors to the[statpearls.com]
  • Concerning the pathophysiological mechanisms of postictal hemiparesis, the two major theories propounded by Jackson and Gowers are still under discussion [8].[jle.com]
  • According to our literature review, the possible mechanisms reported for the pathophysiology of TP include neuronal exhaustion from hypoxia or energy and/or substrate depletion due to a possible damage or seizure activity in a localized brain region or[jneuro.com]

Prevention

  • […] to prevent these from happening in the future. No ER visit. No seizure drugs. No EEG etc. To get the diagnosis wrong—either way—would be to treat the patient inappropriately and perhaps even to harm the patient. So, accurate diagnosis is paramount.[jailmedicine.com]
  • Prevent infection. High risk of meningitis, abscess, osteomyelitis, particularly in presence of rhinorrhea, otorrhea. Maintain strict asepsis. I. Prevent complications of immobility. Continue range-of-motion activities. Prevent contractures. J.[brilliantnurse.com]
  • Sheldon R, Connolly S, Rose S et al (2006) Prevention of Syncope Trial (POST): a randomized, placebo-controlled study of metoprolol in the prevention of vasovagal syncope. Circulation 113:1164–1170 CrossRef PubMed 51.[springermedizin.de]
  • Prevention In some cases, a febrile seizure may be the first indication that a child is ill. Prevention is, therefore, not always possible.[healthofchildren.com]
  • Similarly, deep brain stimulation (DBS) prevents seizures to spread throughout the brain and stops them from becoming clinically relevant.[uchospitals.edu]

References

Article

  1. Theodore WH. Effects of age and underlying brain dysfunction on the postictal state. Epilepsy Behav. 2010;19(2):118-120.
  2. Bromfield EB, Cavazos JE, Sirven JI, editors. An Introduction to Epilepsy [Internet]. West Hartford (CT): American Epilepsy Society; 2006. Chapter 2, Clinical Epilepsy.
  3. Krauss G, Theodore WH. Treatment strategies in the postictal state. Epilepsy Behav. 2010;19(2):188-190.
  4. Rémi J, Noachtar S. Clinical features of the postictal state: correlation with seizure variables. Epilepsy Behav. 2010;19(2):114-117.
  5. Bazil CW. Effects of sleep on the postictal state. Epilepsy Behav. 2010 Oct;19(2):146-50
  6. Devinsky O. Postictal Psychosis: Common, Dangerous, and Treatable. Epilepsy Currents. 2008;8(2):31-34.
  7. Fisher RS, Engel JJ Jr. Definition of the postictal state: when does it start and end? Epilepsy Behav. 2010;19(2):100-104.

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Last updated: 2018-06-22 09:28