GRAND MAL EPILEPSY
(Major epilepsy, Tonic clonic seizure)
Age: Usually after 2 years upto 20 years of age.
Exciting factors
1. Pyrexia.
2. Overwork.
3. Fatigue.
4. Menstruation.
5. Hunger.
6. Excitement.
7. Lack of sleep.
8. Drugs (MAO inhibitors, Phenothiazines, Amphetamine, Tricyclic antidepressants, Nalidixic acid, Lignocaine).
9. Alcohol (excess/withdrawal).
10. Metabolic changes (uraemia, hepatic failure, porphyria, O2 lack, hyponatraemia, hypocalcaemia, hypoglycaemia, etc.).
11. Trauma.
12. Photosensitivity and other exogenous stimuli, e.g. flashing of light or flicking Television set (Photosensitive epilepsy).
Premonitary symptoms
There may be a change of mood or behaviour for few days prior to the attack.
Onset
Anytime but usually when the patient just falls asleep or gets up from bed.
Attack
This consists of several stages:
Aura
This is a symptom due to early epileptic discharge perceived by the patient. This consists of various sensory symptoms, e.g. psychic, visual, auditory, olfactory, gustatory and cutaneous hallucination or sometimes a peculiar epigastric sensation. Child becomes afraid of something going to happen soon and runs towards the mother’s lap.
Tonic phase
This phase lasts for about half a minute. Different muscles of the body undergo spasmodic contraction including voluntary and involuntary muscles. Whole body becomes stiff, respiration ceases, cyanosis develops and sudden contraction of the respiratory and glottic muscles are responsible for the “epileptic cry” which is a characteristic feature. It is an unearthly, peculiar hollow sound which cannot be expressed in language but who has heard it once can recognise it immediately. Patient loses consciousness. The arms are adducted, elbows and wrists are flexed. The lower limbs and feet are extended.
Clonic phase
This lasts for about a minute. Maximum 2-3 minutes. This consists of short jerky movements of different muscles with relaxation in between. Due to simultaneous contraction of the muscles of the jaw and tongue there may be tongue bite. Contraction of the intestinal and vesical muscles may lead to involuntary evacuation of faeces and urine respectively. Due to contraction of the muscles of the glottis there may be formation of froth which may come out of the mouth. Breathing starts and cyanosis gradually clears up.
Flaccid coma and sleep
Steady relaxation of different muscle groups starts, patient takes deep and stertorous breathing and remains unconscious for about few minutes to half an hour. Jerks are sluggish, plantar reflexes become extensor and corneal reflex is lost. Some patients may regain consciousness or may have headache and drowsiness. Some patients fall asleep immediately after the attack. This sleep may continue for hours. After waking from sleep these patients cannot remember the occurrence of fit.
Post epileptic automatism
Some patients may develop this state after an attack. They may do some unsocial work, e.g., undressing, stealing things etc. which consists of series of complex activities.
Past epileptic Todd’s paralysis
This may develop after convulsion is over due to exhaustion of cerebral neurons and may last for as long as 24 hours. Usually monoplegia occurs, rarely hemiplegia may develop with extensor plantar response.
Serial Seizure
After the attack is over and consciousness is regained once again patient may develop convulsion and this is called serial seizure.
Status Epilepticus
When attacks of grand mal epilepsy occur successively without any intervening period of consciousness or remission the condition is called Status epilepticus. If this is continued for long time, patient gets exhausted and may die out of circulatory failure. Sometimes hyperpyrexia develops in such cases.
The stages Post epileptic automatism, Todd’s paralysis serial seizure and status epilepticus are not actually stages of Grand Mal epilepsy; they are not usually seen in every cases.