Although individual seizure onsets can appear localized, the location and lateralization are not consistent from one seizure to another. Such bilateral networks can include cortical and subcortical structures, but do not necessarily include the entire cortex. A fundamental distinction of all ILAE classifications is whether tonic-clonic seizures are of generalized or focal onset ( 25 24 04 15 29 28).Īccording to the ILAE definitions, generalized seizures “originate at some point within, and rapidly engage, bilaterally distributed networks. Contributions have been made with video-EEG analysis ( 57 10). These were supplemented by cinematographic or videotaped filming and various other techniques. Their description was based on a large number of combined clinical, EEG, and polygraphic investigations of GTCS in patients with epileptic disorders or induced by Metrazol or electroconvulsive treatment of psychotic patients. However, it was Henri Gastaut and his associates in Marseilles, France who provided us with superb descriptions of the clinical and EEG manifestations of GTCS, which have not been surpassed ( 33). As these become deeper, the muscular contractions become more shock-like in character… Such attacks may commence with tonic spasm, or they may commence by, and sometimes consist only of clonic spasm… Precursory symptoms occasionally precede a fit, sudden jerks of the body or limbs. Gowers gives an excellent description of GTCS ( 38):Īt the onset of the severe fit the spasm is tonic in character, – rigid, violent, muscular contraction, fixing the limbs in some strained position… When the cyanosis has become intense, the fixed tetanic contractions of the muscles can be felt to be vibratory, and the vibrations gradually increase until there are slight visible remissions. A realistic depiction of GTCS, including marked cyanosis, can be seen in the painting The Miracles of St Ignatius of Loyola (1617) by Peter Paul Rubens (1577-1640) ( 79). The manifestations of GTCS are so dramatic that accurate descriptions can be found as early as 1050 BC in the twenty-fifth Babylonian cuneiform tablet devoted to miqtu (a disease in which the person loses consciousness and foams at the mouth) ( 05). ![]() Key points Historical note and terminology In this updated article, the author details the clinical manifestations, pathophysiology, EEG, and neuroimaging of generalized onset tonic-clonic seizures and provides clues for correct diagnosis and optimal management of patients. Treatment is demanding because a significant number of currently available antiepileptic drugs may aggravate generalized seizures. Syncope and psychogenic nonepileptic seizures are frequently misdiagnosed as generalized onset tonic-clonic seizures. Additionally, patients may also suffer from other types of seizures, such as absences and myoclonic jerks. They affect patients of all ages, except neonates. They are often associated with severe complications that may also be fatal. They occur at any time, but mainly on awakening. They are usually spontaneous, but they may also be provoked by external, mainly photic, stimuli. They manifest with violent generalized convulsions, loss of consciousness, and marked autonomic disturbances. Generalized onset tonic-clonic seizures are the most dramatic, severe, and common seizures of mainly syndromes of idiopathic generalized epilepsy.
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