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et al) This suggests that seizures are triggered either by a change in central thalamic rhythm generators or a subtle change in the electrical activity in the region of a focal lesion The clinical utility of this nding has not been determined Even more provocative are the ndings of Litt and colleagues; using complex techniques in a small number of patients, they have detected prolonged bursts of seizure-like activity days before the onset of temporal lobe seizures Their unconventional proposal is that these events cause a cascade of electrophysiologic changes that very gradually culminate in a seizure If unchecked, cortical excitation spreads to the adjacent cortex and to the contralateral cortex via interhemispheric pathways and also to anatomically and functionally related pathways in subcortical nuclei (particularly the basal ganglionic, thalamic, and brainstem reticular nuclei) It is at this time that the clinical manifestations of the seizure begin, the initial signs and symptoms depending on the portion of the brain from which the seizure originates The excitatory activity from the subcortical nuclei is fed back to the original focus and to the other parts of the forebrain, a mechanism that serves to amplify their excitatory activity and to give rise to the characteristic high-voltage polyspike discharge in the EEG There is propagation downward to spinal neurons as well, via corticospinal and reticulospinal pathways, yielding a generalized tonic-clonic convulsion The spread of excitation to the subcortical, thalamic, and brainstem centers is thought to correspond to the tonic phase of the seizure and loss of consciousness as well as to the signs of autonomic nervous system overactivity (salivation, mydriasis, tachycardia, increase in blood pressure) Vital functions may be arrested, but usually for only a few seconds In rare instances, however, death may occur owing to a sustained cessation of respiration, a derangement of cardiac action, or some unknown cause The development of unconsciousness and the generalized tonic contraction of muscles is re ected in the EEG by a diffuse high-voltage discharge pattern appearing simultaneously over the entire cortex Soon after the spread of excitation, a diencephalocortical inhibition begins and intermittently interrupts the seizure discharge, changing it from the persistent discharge of the tonic phase to the intermittent bursts of the clonic phase Electrically, a transition occurs from a continuous polyspike to a spike-and-wave pattern The intermittent clonic bursts become less and less frequent and nally cease altogether, leaving in their wake an exhaustion (paralysis) of the neurons of the epileptogenic focus and a regional increase in permeability of the blood-brain barrier An overshoot of these inhibitory mechanisms is thought to be the basis of Todd s postepileptic paralysis (and of postictal stupor, sensory loss, aphasia, hemianopia, headache, and diffuse slow waves in the EEG, as described earlier) and regional edema in T2-weighted MR images Plum and associates have observed a two- to threefold increase in glucose utilization during seizure discharges and suggested that the paralysis that follows might be due to neuronal depletion of glucose and increase in lactic acid However, inhibition of epileptogenic neurons may occur in the absence of neuronal exhaustion The exact roles played by each of these factors in postictal paralysis of function are not settled Bilaterally synchronous three-per-second high-voltage spikeand-wave discharges and seizures resembling absence attacks have been produced in animals by a number of experimental procedures The spike-and-wave complex, which represents brief excitation followed by slow-wave inhibition, is the type of EEG pattern that. data matrix word 2010 Datamatrix Generator
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