Generalized Tonic Clonic Seizure

Aka: Generalized Tonic Clonic Seizure, Grand Mal Seizure, Generalized Tonic Clonic Epilepsy, Major Motor Seizure, GTCS, Generalized Epilepsy, Generalized Seizure

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II. Types: Generalized Seizures

  1. Generalized Tonic-Clonic Seizure (Simple Seizure)
    1. Generalized movements with unresponsiveness reflecting excessive synchronous cortical electrical activity
  2. Myoclonic Seizure
    1. Rhythmic jerking of arms (may involve head and neck)
  3. Atonic Seizure (e.g. drop attack)
    1. Sudden, brief loss of Muscle tone
  4. Tonic Seizure
    1. Brief (<1 minute), bilateral increased extremity motor tone
  5. Absence Seizure
    1. Non-motor Seizure

III. Cause

  1. Idiopathic
  2. Congenital cerebral lesion
  3. Posttraumatic cerebral scar
  4. Brain Tumor

IV. Symptoms: Aura (may precede Seizure)

  1. Irritability
  2. Apathy
  3. Giddiness
  4. Headache
  5. Scintillating scotomata
  6. Nausea
  7. Choking Sensation
  8. Paresthesia
  9. Myalgia

V. Signs: Generalized Tonic-Clonic Seizure

  1. Sudden Loss of consciousness
  2. Tonic Phase
    1. Muscular rigidity with Opisthotonos
    2. Adduction and flexion of arms
    3. Extension of legs
  3. Clonic Phase
    1. Generalized body musculature jerking
  4. Flaccid coma
    1. Loss of postural tone
    2. Loss of Deep Tendon Reflexes
    3. Unconsciousness
    4. Apnea, Cyanosis
  5. Associated findings
    1. Tongue or lip biting
    2. Urinary or Fecal Incontinence on awakening

VI. Labs

  1. Complete Blood Count (CBC)
    1. Postictal Leukocytosis in peripheral blood
  2. Prolactin
    1. Elevated following Seizure

VII. Diagnosis

  1. Electroencephalogram (EEG)
    1. Paroxysmal diffuse outbursts of high voltage
    2. Many spikes in fast rhythm

VIII. Management: Prophylaxis of Generalized Tonic-Clonic Seizures in Children (age <16 years)

  1. Level C evidence
    1. Carbamazepine (Tegretol)
    2. Phenobarbital
    3. Phenytoin (Dilantin)
    4. Topiramate (Topamax) - also Level D evidence for use in Myoclonic Seizures
    5. Valproic Acid (Depakene) - also Level D evidence for use in Myoclonic Seizures
  2. Level D evidence
    1. Oxcarbazepine (Trileptal)

IX. Management: Prophylaxis for both GTCS and Myoclonic Seizures in Younger Adults (age >16 years)

  1. Level C evidence
    1. Carbamazepine (Tegretol)
    2. Lamotrigine (Lamictal)
    3. Oxcarbazepine (Trileptal)
    4. Phenobarbital
    5. Phenytoin (Dilantin)
    6. Topiramate (Topamax)
    7. Valproic Acid (Depakene)
  2. Level D evidence
    1. Gabapentin (Neurontin)
    2. Levetiracetam (Keppra)
    3. Vigabatrin (Sabril)

X. References

  1. Liu (2017) Am Fam Physician 96(2): 87-96 [PubMed]

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