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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
  • Epilepsy Behav. 2010 Oct;19(2):96-9. doi: 10.1016/j.yebeh.2010.06.037. Epub 2010 Aug 11. Author information 1 NYU Epilepsy Center, NYU Langone School of Medicine, New York, NY, USA.[ncbi.nlm.nih.gov]
  • Epilepsy Behav. 2010 Oct;19(2):146-50. doi: 10.1016/j.yebeh.2010.06.022. Epub 2010 Aug 14.[ncbi.nlm.nih.gov]
  • Epilepsy Behav. 2010 Oct;19(2):182-5. doi: 10.1016/j.yebeh.2010.06.020. Epub 2010 Aug 17.[ncbi.nlm.nih.gov]
  • Epilepsy Behav. 2010 Oct;19(2):186-7. doi: 10.1016/j.yebeh.2010.06.021. Author information 1 University of South Florida College of Medicine, Tampa, FL 33612, USA.[ncbi.nlm.nih.gov]
  • Epilepsy Behav. 2010 Oct;19(2):127-30. doi: 10.1016/j.yebeh.2010.06.036. Epub 2010 Aug 14.[ncbi.nlm.nih.gov]
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]
  • 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]
  • 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]
  • "Fatigue. Aftereffect of a seizure. Combine cognitive and sensory disorientation with muscle weakness and you get this," Dean said soothingly, leaning over his little brother to wipe hair off his face.[fanfiction.net]
  • 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 in part of all of the body A strong urge to urinate[verywell.com]
Sighing
  • Dean sighed but kept the smile plastered on his face. "It's just a thing..." Dean trailed off. Kevin tilted his head well enough that Dean could see the tacit prompt in his peripheral vision.[fanfiction.net]
Muscle Weakness
  • Combine cognitive and sensory disorientation with muscle weakness and you get this," Dean said soothingly, leaning over his little brother to wipe hair off his face.[fanfiction.net]
Stroke
  • Patients who suffer from structural lesions (caused by a tumor or stroke) seem to be most susceptible.[symptoma.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]
  • YOU MIGHT ALSO LIKE... 22 terms Pharmacology Ch 22 49 terms EMT AAOS Chapter 11 Pharmacology 20 terms EMT Section 4 OTHER SETS BY THIS CREATOR 5 terms Adult Stroke Protocol 12 terms Adult Spinal Motion Restriction Protocol[quizlet.com]
  • Ohtahara Syndrome Information sheet compiled by the National Institute of Neurological Disorders and Stroke. December 7, 2016 at 15:45:07 UTC " Health ... Epilepsy " search on:[dmoztools.net]
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]
  • Nonconvulsive seizure is a rare presentation of altered mental status (AMS) but should always be on the differential of the comatose patient. Electroencephalography (EEG) is the diagnostic modality of choice for identifying these patients.[emedicine.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
  • 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]
  • […] www.efa.org/answerplace/recognition/chart.htm Generalized Tonic-Clonic Seizure Appearance: Sudden cry, fall, rigidity, followed by muscle jerks, shallow breathing or apnea, possible urinary incontinence, typically lasts 1–2 minutes with post-seizure somnolence[ncbi.nlm.nih.gov]
Hyperactivity
  • Sustained cortical hyperactivity in the patients with bilateral cerebral dysfunction and genetic predisposition to psychiatric illness may produce psychosis.[doi.org]
  • Neonatal seizures are a sign of danger, and the risks of subsequent death, cerebral palsy, mental retardation, epilepsy, attention/hyperactivity disorders, behavioral disturbances and other related, CNS-based disorders must be carefully assessed and communicated[ncbi.nlm.nih.gov]
Stupor
  • […] 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]

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. Copyright 2010 Elsevier Inc. All rights reserved.[ncbi.nlm.nih.gov]

Treatment

  • Treatment of postictal states requires recognition of underlying neurological and systemic disorders associated with seizures and delirium such as metabolic disorders and nonconvulsive seizures.[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]
  • 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]
  • Despite a relative lack of biological insight, many key observations were made in an era mostly devoid of treatments for epilepsy. Copyright 2010 Elsevier Inc. All rights reserved.[ncbi.nlm.nih.gov]
  • 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. Copyright 2010 Elsevier Inc. All rights reserved.[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]
  • She worked on the development of markers of consciousness to improve diagnosis, prognosis and treatment of patients with disorders of consciousness.[books.google.ro]
  • 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]

Etiology

  • 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]
  • 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]
  • 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]
  • 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]
  • Etiology Etiologies for seizures include those listed in Table 27-3.[unboundmedicine.com]

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]
  • […] often considered 10 minutes or shorter recurrences without full recovery) NCSE lacks prominent motor features, but may have subtle motor signs (e.g. twitching, blinking, eye movements) NCS and NCSE are likely underdiagnosed, including in the ICU setting Epidemiology[lifeinthefastlane.com]
  • Epidemiology Epilepsy is estimated to affect approximately 70 million people worldwide with the prevalence being twice as high in low-income countries relative to high-income countries.[unboundmedicine.com]
Sex distribution
Age distribution

Pathophysiology

  • Just as the pathophysiology of seizures is complicated, so is that of the PS multifactorial. As a practical issue, it would be very useful to have medications that reduce the morbidity of the PS.[ncbi.nlm.nih.gov]
  • Abstract The neuroanatomical and pathophysiological basis of primary generalised absences is uncertain. Administration of endogenous opioids has been shown to result in absence-like seizures in animal models.[pubmedcentral.nih.gov]
  • 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]
  • Pathophysiology PP is associated with relatively broadly and bilaterally distributed epileptogenic networks as well as genetic determinants of seizures and psychiatric disorders.[doi.org]

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]
  • Deterrence/prevention To date, there have been no data to indicate that any intervention other than medications effectively prevents seizures or SE. Therefore, medication compliance should always be emphasized to every patient.[emedicine.com]
  • 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]
  • Health promotion chapters emphasize principles of wellness and injury prevention for each age group.[books.google.ro]

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: 2019-06-28 12:21