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associated with a convulsion is long, and if no other explanation for a single seizure is evident, the physician is advised to look up in standard references the side effects of the drugs being given to the patient In a few of our otherwise healthy adult patients, extreme sleep deprivation coupled with ingestion of large doses of antibiotics or adrenergic medications or other remedies that are used indiscriminately for the symptomatic relief of colds has been the only plausible explanation after extensive search for the cause of a single or doublet seizure Global Arrest of Circulation and Cerebrovascular Diseases Cardiac arrest, suffocation or respiratory failure, carbon monoxide poisoning, or other causes of hypoxic encephalopathy tend to induce diffuse myoclonic jerking and generalized seizures as cardiac function is resumed The myoclonic-convulsive phase of this condition may last only a few hours or days, in association with coma, stupor, and confusion; or it may persist inde nitely as an intention myoclonus-convulsive state (Lance-Adams syndrome) Convulsive seizures are uncommon in the acute or evolving phases of an arterial stroke The ischemic convulsive phenomena of a limb-shaking TIA and a burst of generalized clonic motor activity during basilar artery occlusion have been mentioned earlier but are uncommon Only exceptionally will acute embolic infarction of the brain cause a focal t at its onset With these infrequent exceptions, a new seizure should not be attributed to an acute arterial occlusion in the cerebrum More relevant is the fact that embolic infarcts involving the cortex later, after an interval of months or longer, become epileptogenic in almost 10 percent of cases Thrombotic infarcts are almost never convulsive at their onset In contrast, cortical venous thrombosis with underlying ischemia and infarction is highly epileptogenic The same is true for hypertensive encephalopathy and thrombotic thrombocytopenic purpura (TTP), which has a strong tendency to cause nonconvulsive status epilepticus The rupture of a saccular aneurysm is sometimes marked by one or two generalized convulsions Subcortical cerebral hemorrhages, spontaneous or traumatic, occasionally become sources of recurrent focal seizures Seizures with Acute Head Injury It is not uncommon for severe concussion to be followed by one or more brief convulsions (see Chap 35) The appearance is similar in most cases to the clonic twitching and brief tonic phase that accompanies a faint From time to time, a prolonged clonic convulsion occurs The nature of this event, whether originating in the reticular formation as a component of concussion or from some disruption of cortical activity, is not clear Almost invariably in our experience, the EEG recorded hours or a day later is normal, and imaging procedures are likewise normal or show a small contusion There is little to guide one in treatment of these patients; we tend to give a course of anticonvulsant medications lasting several months Another EEG is taken before discontinuing the medications Seizures during Pregnancy Here one contends with two types of problem: one, the woman with epilepsy who becomes pregnant; the other, the woman who has her rst seizure during pregnancy In respect to the rst group, about half of the epileptic women who become pregnant have no change in seizure frequency or severity; in about 25 percent, the frequency increases; and in an equal number, it lessens In a large cohort of such women, there was a slight increase in the number of stillbirths and a doubling in the expected incidence of mental retardation and nonfebrile seizures in their offspring Issues regarding a coagulopathy in the fetus exposed to phenobarbital and certain of the other drugs are well known to obstetricians and pediatric specialists and are treated with the oral ad-.

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ministration of vitamin K 20 mg/day during the eighth month or 10 mg IV 4 h before birth and 1 mg IM to the neonate The conventional anticonvulsants also seem to be safe for the baby during breast-feeding in that only small amounts are excreted in lactated milk For example, carbamazepine in human milk is found to be 40 percent of the mother s serum concentration, and this results in a neonatal blood level that is below the conventionally detectable amount Phenytoin is excreted at 15 percent of maternal serum concentration, and valproate, being highly protein-bound, is virtually absent in breast milk No adverse effects have been attributed to these small amounts of drug The special issue of the teratogenicity of antiepileptic drugs is addressed further on Eclampsia (See also Chap 34) This syndrome appears during the last trimester of pregnancy and may announce itself by hypertension and convulsions; the latter are generalized and tend to occur in clusters The standard practice is to induce labor or perform cesarean section and manage the seizures as one would manage those of hypertensive encephalopathy (of which this is one type) The administration of magnesium sulfate continues to be the favored treatment by obstetricians for the prevention of eclamptic seizures; two randomized trials have re-established its value in preventing seizures in pre-eclamptic women (Lucas et al) and in avoiding a second convulsion once one had occurred (Eclampsia Trial Collaborative Group) Magnesium sulfate, 10 g IM, followed by 5 g every 4 h, proved comparable to standard doses of phenytoin as prophylaxis for seizures Our colleagues use a regimen of 4 g IV over 5 to 10 min followed by a maintenance dose of 5 g every 4 h IM or 1 to 2 g/h IV Whether magnesium is as effective in the management of active convulsions of toxemia remains uncertain In nontoxic gestational epilepsy, about 25 percent of patients are found to have some disease (neoplastic, vascular, or traumatic) that will persist.