Grand mal seizures are also known as generalized tonic clonic seizures. They are the main seizure type in almost 10 percent of all persons with epilepsy. It is also the most common type of seizure resulting from metabolic derangements. The patient experiences an aura followed by a tonic and clonic phase. Aura is a simple partial seizure, consisting of altered vision and hearing, a feeling of discomfort, sense of déjà vu, light headedness and dizziness. It may last for a few minutes to several hours. Some patients may not experience an aura.
Tonic phase: in this phase the patient loses consciousness and the muscles undergo contraction. Tonic contraction of the expiration and larynx produce and ictal cry. There may be pooling of secretions in the pharynx, and cyanosis may develop due to impaired respiration. Contraction of the jaw muscles during a grand mal can cause tongue bite. There is an increase in heart rate, blood pressure and papillary size. In about 10 to 20 seconds the tonic phase evolves into the clonic phase. During this transitory phase there is a relaxation phase of the muscles superimposed during the contraction phase. Thus there is a period of relaxation and contraction alternately which produces convulsions. Incontinence of bladder or bowel may be present. Post ictal phase consists of unresponsiveness, flaccidity of the muscles and excessive salivation. Over minutes to hours the patient may regain consciousness and there may be a phase of confusion and amnesia. Patients may complain of headache, fatigue and muscle ache.
Causes: In most cases, the cause of seizures remains unknown. However the most common causes are low electrolytes like sodium, low calcium or magnesium, low glucose, traumatic head injuries, strokes, brain tumors, brain infections like meningitis, encephalitis, neurocysticercosis, and blood vessels malformations like aneurysms, haemangiomas, drug abuse, alcohol and certain genetic syndromes.
An EEG taken during the tonic phase of a grand mal will show progressive increase in generalized low voltage fast activity followed by generalized high amplitude polyspike discharges. In the clonic phase, the high amplitude activity is interrupted by slow waves to create a spike and wave pattern.
Complications: Persons who are suffering from seizure disorders should take their antiepiletic medications regularly, as irregular treatment can put them at a high risk of suffering from a convulsion. They should avoid swimming, as they can drown if they throw a convulsion while in water. Injuries associated with falling can be produced such as joint dislocations, head injuries or fractures.
Treatment: The cause of the seizures must be tackled first. Electrolyte imbalance, glucose levels, calcium levels must be corrected. Many medications are used in the treatment for epilepsy for e.g. Carbamazepine, Phenytoin, Valproic acid, Oxacarbazepine, Phenobarbital, and Topiramate etc. Mostly the patient is started on a single antiepileptic drug at a low dosage and the dosage may be increased gradually. Most patients have a good seizure control with a single antiepileptic; the others will have to be put on more than one drug.
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