C.M. is a 60-year-old man that experienced a right cerebrovascular accident 15 months ago, with resultant left hemiplegia. He initially received rehabilitation in an acute inpatient facility for 4 weeks and was transferred to a long-term cognitive rehabilitation facility for approximately 8 weeks. C.M. made significant improvements in his cognitive and speech abilities, but he was still nonambulatory when he was discharged to home. Home health providers felt he had potential for additional functional return and referred him for outpatient physical therapy. C.M. is medically stable living at home with his wife. His medications include escitalopram (antidepressant), pantoprazole (proton pump inhibitor), amlodipine (calcium channel blocker), warfarin (anticoagulant), valproic acid (antiseizure drug), and lamotrigine (antiseizure drug). C.M. told the outpatient physical therapist that he developed a seizure disorder poststroke and was initially treated only with valproic acid. However, he had breakthrough seizures and lamotrigine was added. C.M. reported that he had his blood levels of warfarin and valproic acid checked every 3 months. After 2 months of outpatient therapy, the physical therapist observed that C.M. was much more lethargic on several consecutive sessions. He began to require multiple rest periods during treatment sessions. Communication with the patient was difficult as his speech was soft and muffled. Notably, there were no new sensory or motor neurologic signs that might suggest another stroke.
Epilepsy and seizures are not the same. Epilepsy is a chronic disorder of the brain that is characterized by unpredictable and recurrent seizures. Approximately 1% of the world’s population has epilepsy, making it the fourth most common neurologic disorder after migraine, stroke, and Alzheimer’s disease. Seizures are transient alterations in behavior, sensation, and/or consciousness that result from finite episodes of abnormal, synchronized electrical discharges in the brain. Most seizures are the result of some damage to the brain such as a tumor, head trauma, stroke, infection, or developmental lesion such as a cortical or vascular malformation. In some individuals, the cause of seizures may be due to genetic factors, though a single gene defect is rarely identified.
In 2017, the International League Against Epilepsy (ILAE) revised its classification of seizures types to assist with accurate diagnosis, appropriate pharmacological treatment, and prognosis. Seizures are classified into two broad categories based on how and where they begin in the brain. Focal onset seizures (formerly known as “partial” or “partial onset”) have their onset in a focal or local cortical site. Generalized onset seizures begin in both brain hemispheres. Table 14-1 provides a list of the ILAE’s major seizure types with their corresponding clinical descriptions. Many of the frequently recognized older terms used to describe seizures have been replaced in this new classification.
TABLE 14-1International League Against Epilepsy classification of seizure types.