Seizure, Postictal State


Article Author:
Waleed Abood


Article Editor:
Susanta Bandyopadhyay


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Grant Goold
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Sandeep Sekhon


Updated:
10/27/2018 12:31:51 PM

Introduction

Postictal state is an abnormal condition that lasts for a period that begins when a seizure subsides and ends when the patient returns to baseline. Marking the termination of a seizure and the return to baseline is straightforward only in a limited number of cases. The difficulty of distinguishing ictal from the postictal period may depend on the type of the seizure. It is easier to determine the end of the seizure and the beginning of the postictal state for a generalized tonic-clonic or a generalized tonic seizure. In absence seizures, focal seizures with impaired awareness and myoclonic seizures, it is harder to distinguish ictal from the postictal state.[1] The practical implication of the postictal state is when it is safe for the patient to return to activity without risking his/hers or other's safety. It may also have a localizing value. An ictal speech arrest followed by an immediate postictal return of speech points to nondominant hemisphere seizure onset. A postictal hemiparesis points to contralateral seizure onset.

Etiology

The underlying process responsible for the postictal state is thought to be related to neuronal exhaustion and hyper-inhibition.

Epidemiology

There is no clear data on the incidence of the postictal state in patients with epilepsy. A study showed that most patients with epilepsy (72%) reported postictal behavioral impairment.[2]

Pathophysiology

A seizure is terminated by a variety of potential mechanisms including depletion of energy substrate, desensitization of receptors to the excitatory neurotransmitter, depolarization block, desynchronization of the neuronal networks, the effect of inhibitory neuromodulators such as endogenous opiate receptor agonists, and various other possible mechanisms. These mechanisms can be classified as[3]:

  • Mechanisms acting at the cellular level: Energy failure, potassium current, ion gradients
  • Mechanisms acting on local networks: Glutamate depletion, glial buffering of glutamate, the role of gap junctions on synchrony, increased GABA-ergic inhibition, effects of neuromodulators (endocannabinoids, adenosine, and neuropeptide Y)
  • Mechanisms acting remotely to limit excitation and seizure spread: Effect of other cortical regions and subcortical nuclei on modifying ictal activity

History and Physical

Different neurological functions are affected by the inhibitory processes in the postictal period. These involve speech, motor, and memory. Patients with left temporal lobe epilepsy develop a more prominent verbal memory deficit in the postictal period while those with right temporal lobe epilepsy suffer from visual memory deficit.[4] The duration of such impairment depends on the pre-ictal cognitive deficit (higher with the higher pre-ictal deficit). The memory is affected in such a way that 30% of the patients do not remember any seizure and only a quarter remember all of their seizures.[5] Postictal motor weakness (Todd’s paresis) has a lateralizing value. It points to seizure onset in the contralateral hemisphere. Automatism is a phenomenon that can be seen both during ictal and postictal states. Other postictal symptoms include postictal coughing, spitting, hypersalivation, nose wiping, psychosis, and mania.

Duration of the postictal state depends on how different mechanisms associated with seizure termination interact with each other. Whether the resolution of postictal state requires the resolution of all the inhibitory processes is a question yet to be answered. Postictal deficits recover at different rates. Postictal deficits in a patient with focal seizure with impaired awareness may resolve in 1 to 2 hours. Todd’s paresis may take up to 1 to 2 days for resolution. Some patients would have cognitive, mood, and change in energy level that may last days.

Evaluation

The decision to intervene during the postictal state depends on the postictal symptoms and the individual patient's epilepsy history. A knowledge of the previous ictal and postictal events is of great importance to determine if all the symptoms can be attributed to the postictal state. A patient with a history of a postictal headache does not require an urgent brain imaging. A patient presenting with a new focal sign (e.g., unilateral weakness) after an unwitnessed but suspected seizure requires brain imaging to rule out alternative etiology like a stroke.

Similarly, a patient presenting with new-onset seizure with prolonged postictal alteration of mental status requires an elaborate workup including cerebrospinal fluid analysis to look for an etiological diagnosis. Nonconvulsive status epilepticus should be in the differential of a patient with prolonged postictal confusion. As already mentioned above, determining the end of a seizure and the beginning of postictal state is often difficult. Electroencephalogram (EEG) is helpful in distinguishing between the two states. Neuroimaging may detect changes in the postictal brain, but its clinical utility is yet to be established and is more a research tool at this time.  

EEG

The transition from ictal to postictal EEG can be classified either by rate or location; some seizures end abruptly, while others have gradual termination. In terms of location, some seizures terminate in all involved regions of the brain at the same time while others terminate at various regions at various times. Postictal EEG typically shows attenuation or slowing (usually in delta frequency range) or a combination of both.[6] As further recovery ensues, delta slowing transitions to theta frequencies before background rhythms return. Some patients enter sleep in the course of recovery. Brain regions involved in postictal attenuation/slowing may be of localizing value. The EEG changes tend to be more pronounced with prolonged seizures but has less lateralizing value in such cases[7]. A retrospective study showed that the average time for EEG to return to baseline was 120 minutes with a maximum of 420 minutes in adults.[8] Postictal slowing was found to match with the site of surgery in 96% of the times in temporal lobe epilepsy.[9]

Neuroimaging

Positron emission tomography (PET) scan of brain can be used to study the changes in neurotransmitters and receptors in the postictal state. In one study,[8] it was found that opioid receptors were upregulated in the postictal period in a patient with temporal lobe epilepsy in the epileptogenic side. PET scan also showed that benzodiazepine receptor levels vary with the duration of the postictal period. The shorter the duration, the lower is the levels of benzodiazepine receptors.[10] Perfusion MRI is used to detect variation in cerebral blood flow (CBF) in the postictal state. One study showed that CBF, ipsilateral to the focus, doubles within 5 minutes of a seizure and drops below average after 1 hour.[11] Diffusion-weighted imaging also shows diffusion restriction postictally.

Treatment / Management

Postictal deficits, once alternative causes are ruled out, only require supportive care and monitoring. Postictal delirium typically lasts for hours but may continue up to 1 to 2 days. It is usually of the hypoactive type, but some may evolve to hyperactive type. Supportive care is usually enough unless the patient gets agitated; medications should be avoided unless the patient is extremely agitated.

Differential Diagnosis

  • Ongoing seizure
  • CNS secondary causes, e.g., stroke
  • Systemic causes:
    • Infection
    • Metabolic
    • Drug/Toxin

Enhancing Healthcare Team Outcomes

Caring for a patient with seizure requires a team aware of the common complications of seizures and understands the natural course of seizures. The team should include physicians, nurses, and other supporting staff. Proper education and training of the staff involved and coordination among the team members are crucial for optimum care.


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Seizure, Postictal State - Questions

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Which of the following conditions is unlikely to be a postictal state?



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What is the most appropriate nursing action during the postictal period of a seizure?



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A 57-year-old male with a past medical history of left middle cerebral artery territory stroke presents to the emergency department with right-sided weakness. A code stroke alert is activated. Emergency medical services (EMS) personnel states that the patient had a witnessed generalized tonic-clonic seizure 5 hours ago that lasted for 2 minutes. The patient has a history of epilepsy secondary to his stroke. His medications are levetiracetam 750 mg twice daily for epilepsy, lisinopril 20 mg daily for hypertension, atorvastatin 20 mg daily for hyperlipidemia, and aspirin 81 mg daily for history of stroke. The EMS personnel also states that the patient's right-sided deficit has improved from complete paralysis to some movement. In the emergency department, the physical examination shows a drowsy gentleman who is oriented and following commands. His motor examination shows grade 2/5 right-sided weakness in the upper and lower extremities. The patient does not remember what happened. He said that he is compliant with all medications and that his last seizure was three years ago. A CT scan of the head and a CT angiogram of the head and neck do not reveal any acute changes. What is the appropriate management of this patient?



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What does the return of a patient's ability to speak almost immediately after a focal seizure with speech arrest most likely suggest?



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Which is not true regarding postictal EEG?



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Seizure, Postictal State - References

References

Fisher RS,Engel JJ Jr, Definition of the postictal state: when does it start and end? Epilepsy     [PubMed]
Lado FA,Moshé SL, How do seizures stop? Epilepsia. 2008 Oct     [PubMed]
Helmstaedter C,Elger CE,Lendt M, Postictal courses of cognitive deficits in focal epilepsies. Epilepsia. 1994 Sep-Oct     [PubMed]
Blum DE,Eskola J,Bortz JJ,Fisher RS, Patient awareness of seizures. Neurology. 1996 Jul     [PubMed]
So NK,Blume WT, The postictal EEG. Epilepsy     [PubMed]
Kaibara M,Blume WT, The postictal electroencephalogram. Electroencephalography and clinical neurophysiology. 1988 Aug     [PubMed]
Arkilo D,Wang S,Thiele EA, Time interval required for return to baseline of the background rhythm on electroencephalogram after recorded electrographic seizures. Epilepsy research. 2013 Sep     [PubMed]
Jan MM,Sadler M,Rahey SR, Lateralized postictal EEG delta predicts the side of seizure surgery in temporal lobe epilepsy. Epilepsia. 2001 Mar     [PubMed]
Bouvard S,Costes N,Bonnefoi F,Lavenne F,Mauguière F,Delforge J,Ryvlin P, Seizure-related short-term plasticity of benzodiazepine receptors in partial epilepsy: a [11C]flumazenil-PET study. Brain : a journal of neurology. 2005 Jun     [PubMed]
Weinand ME,Carter LP,Patton DD,Oommen KJ,Labiner DM,Talwar D, Long-term surface cortical cerebral blood flow monitoring in temporal lobe epilepsy. Neurosurgery. 1994 Oct     [PubMed]
Josephson CB,Engbers JD,Sajobi TT,Jette N,Agha-Khani Y,Federico P,Murphy W,Pillay N,Wiebe S, An investigation into the psychosocial effects of the postictal state. Neurology. 2016 Feb 23     [PubMed]

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