Generalized tonic–

clonic seizure

A generalized tonic–clonic seizure,

commonly known as a grand mal seizure
or GTCS,[1] is a type of generalized seizure
that produces bilateral, convulsive tonic
and clonic muscle contractions. Tonic–
clonic seizures are the seizure type most
commonly associated with epilepsy and
seizures in general and the most common
seizure associated with metabolic
imbalances.[2] It is a misconception that
they are the sole type of seizure, as they
are the main seizure type in approximately
10% of those with epilepsy.[2]

Generalized tonic–clonic seizure

Other names Grand mal seizure,

tonic–clonic seizure

Specialty Neurology

These seizures typically initiate abruptly

with either a focal or generalized onset. A
prodrome (a vague sense of impending
seizure) may also be present before the
seizure begins. The seizure itself includes
both tonic and clonic contractions, with
tonic contractions usually preceding clonic
contractions. After these series of
contractions, there is an extended
postictal state where the person is
unresponsive and commonly sleeping with
loud snoring. There is usually pronounced
confusion upon awakening.[3]

Causes
The vast majority of generalized seizures
are idiopathic.[4] Some generalized
seizures start as a smaller seizure that
occurs solely on one side of the brain,
however, and is referred to as a focal (or
partial) seizure. These unilateral seizure
types (formerly known as simple partial
seizure or a complex partial seizure and
now referred to as focal aware seizure and
focal impaired awareness seizure,
respectively[5]) can then spread to both
hemispheres of the brain and cause a
generalized tonic-clonic seizure. This type
of seizure has a specific term called "focal
to bilateral tonic clonic seizure."[5] Other
precipitating factors include chemical and
neurotransmitter imbalances and a
genetically or situationally determined
seizure threshold, both of which have been
implicated. The seizure threshold can be
altered by fatigue, malnutrition, lack of
sleep or rest, hypertension, stress,
diabetes, the presence of strobe-flashes or
simple light/dark patterns, raised estrogen
levels at ovulation, fluorescent lighting,
rapid motion or flight, blood sugar
imbalances, anxiety, antihistamines and
other factors.[6][7] Tonic–clonic seizures
can also be induced deliberately with
electroconvulsive therapy.[8]

In the case of symptomatic epilepsy, the

cause is often determined by MRI or other
neuroimaging techniques showing that
there is some degree of damage to a large
number of neurons.[9] The lesions (i.e.,
scar tissue) caused by the loss of these
neurons can result in groups of neurons
forming a seizure 'focus' area with
episodic abnormal firing that can cause
seizures if the focus is not abolished or
suppressed via anticonvulsant drugs.

Mechanism
Prodrome

Most generalized tonic–clonic seizures

begin without warning and abruptly, but
some epileptic patients describe a
prodrome. The prodrome of a generalized
tonic–clonic seizure is a sort of
premonitory feeling hours before a
seizure. This type of prodrome is distinct
from stereotypic aura of focal seizures
that become generalized seizures.

Phases

A tonic–clonic seizure comprises three

phases: the tonic phase, clonic phase and
postictal phase.

Tonic phase
The tonic phase is usually the first
phase and consciousness will quickly be
lost (though not all generalized tonic–
clonic seizures involve a full loss of
consciousness), and the skeletal
muscles will suddenly tense, often
causing the extremities to be pulled
towards the body or rigidly pushed away
from it, which will cause the patient to
fall if standing or sitting. There may also
be upward deviation of the eyes with the
mouth open.[3] The tonic phase is
usually the shortest part of the seizure,
normally lasting only 10–20 seconds.[2]
The patient may also express brief
vocalizations like a loud moan upon
entering the tonic stage, due to air being
forcefully expelled from the lungs. This
vocalization is commonly referred to as
an "ictal cry." Starting in the tonic phase,
there may also be bluing of the skin
from respiration impairment as well as
pooling of saliva in the back of the
throat. Increased blood pressure,
pupillary size and heart rate
(sympathetic response) may also be
noted with clenching of the jaw possibly
resulting in biting the tongue.[3]
Clonic phase
The clonic phase is an evolution of the
tonic phase and is caused by muscle
relaxations superimposed on the tonic
phase muscle contractions. This phase
is longer than the tonic phase with the
total ictal period usually lasting no
longer than 1 min.[2] Skeletal muscles
will start to contract and relax rapidly,
causing convulsions. These may range
from exaggerated twitches of the limbs
to violent shaking or vibrating of the
stiffened extremities. The patient may
roll and stretch as the seizure spreads.
Initially, these contractions may be high
frequency and low amplitude, which will
progress to decreased frequency and
high amplitude. An eventual decrease in
contraction amplitude just before
seizure cessation is also typical.[2]
Postictal phase
The postictal phase causes are
multifactorial to include alteration of
cerebral blood flow and effects on
multiple neurotransmitters.[10] These
changes after a generalized tonic–
clonic seizure cause a period of
postictal sleep with stertorous
breathing. Confusion and total amnesia
upon regaining consciousness are also
usually experienced and slowly wear off
as the patient becomes gradually aware
that a seizure occurred and remembers
their identity and location. Impaired
consciousness duration can last several
hours after a seizure, especially with a
compounding central nervous system
condition or a prolonged seizure.[2]
Occasionally the patient may vomit or
burst into tears from the experienced
mental trauma. An additional smaller
seizure can also occur several minutes
after the main seizure, particularly if the
 patient's seizure threshold has been
brought unusually low by known factors
or combinations of such. Examples
include: severe hangovers, sleep
deprivation, elevated estrogen at
ovulation, prolonged physical tiredness,
and drug use or abuse (including, but
not limited to, stimulants, alcohol and
caffeine).[11]

Diagnosis
Diagnosis can be made definitively by
Electroencephalography (EEG), which
records the electrical activity of the brain.
This is typically done after a seizure
episode in a clinical setting with an
attempt to "capture" a seizure while it
happens. According to "Harrisons Manual
of Medicine," the EEG during the tonic
phase will show a "progressive increase in
low-voltage fast wave activity, followed by
generalized high-amplitude, poly spike
discharges."[2] The clonic phase EEG will
show "high amplitude activity that is
typically interrupted by slow waves to
create a spike-and-slow-wave pattern."[2]
Additionally, the postictal phase will show
suppression of all brain activity, then
slowing that gradually recovers as the
patient awakens.

Management
For a person experiencing a tonic–clonic
seizure, first-aid treatment includes rolling
the person over into the recovery position,
which can prevent asphyxiation by
preventing fluid from entering the lungs.[12]
Other general actions to take as
recommended by the Epilepsy Foundation
include staying with a person until a
seizure is over, paying attention to length
of seizure as a possible indication for
status epilepticus and/or indication to give
rescue medication and call for emergency
help, moving close objects out of the way
to prevent injury. It is also not
recommended to hold a person down that
is having a seizure, as that can lead to
injury. Nor should anything be put in a
person's mouth, as these items can
become choking hazards and, depending
on what is put in, can potentially break the
person's teeth.[13] Long-term therapy may
include the use of antiepileptic drugs,
surgical therapy, diet therapy (ketogenic
diet), vagus nerve stimulation, or radio
surgery.[3]

Terminology
Generalized tonic–clonic seizures can
have a focal onset (described above) that
progresses into a generalized seizure or be
a generalized seizure at onset. The term
"Grand Mal" is nonspecific, referring to
generalized tonic–clonic seizures with
either a focal or generalized onset. Due to
this lack of specificity in describing the
onset of a seizure and being considered
an archaic term, it is not typically used by
medical professionals.[3]

See also
Focal seizure
Absence seizure
Epileptic seizure
Non-epileptic seizure
Tonic (physiology)
 Clonus
Postictal state
ictal
Electroencephalography

References
1. MayoClinic.org
2. Herausgeber., Kasper, Dennis L.,
Herausgeber. Fauci, Anthony S.,
Herausgeber. Hauser, Stephen L.,
Herausgeber. Longo, Dan L., 1949–
Herausgeber. Jameson, J. Larry,
Herausgeber. Loscalzo, Joseph (2016-05-
27). Harrisons manual of medicine.
ISBN 978-0071828529. OCLC 956960804 .
3. Abou-Khalil, Bassel W.; Gallagher, Martin J.;
Macdonald, Robert L. (2012), "Epilepsies",
Neurology in Clinical Practice, Elsevier,
pp. 1583–1633, doi:10.1016/b978-1-4377-
0434-1.00092-x , ISBN 9781437704341
4. David Y Ko (5 April 2007). "Tonic–Clonic
Seizures" . eMedicine. Retrieved
2008-03-19.
5. "2017 Revised Classification of Seizures" .
Epilepsy Foundation. Retrieved 2018-12-04.
. "Seizure Mechanisms and Threshold" .
Epilepsy Foundation. Retrieved 2015-11-13.
7. "Triggers of Seizures" . Epilepsy
Foundation. Retrieved 2017-09-30.
. "Electroconvulsive therapy-Electroshock
(ECT)" . Retrieved 25 November 2018.
 9. Ruben Kuzniecky, M.D. (16 April 2004).
"Looking at the Brain" . epilepsy.com.
Epilepsy Therapy Project. Archived from the
original on 2007-10-12. Retrieved
2008-03-19.
10. Fisher, Robert S.; Schachter, Steven C.
(2000). "The Postictal State: A Neglected
Entity in the Management of Epilepsy".
Epilepsy & Behavior. 1 (1): 52–59.
doi:10.1006/ebeh.2000.0023 . ISSN 1525-
5050 . PMID 12609127 .
11. "Triggers of Seizures" . Epilepsy
Foundation. Retrieved 2018-12-07.
12. Michael, Glen E.; o'Connor, Robert E. (2011-
02-01). "The Diagnosis and Management of
Seizures and Status Epilepticus in the
Prehospital Setting". Emergency Medicine
Clinics of North America. 29 (1): 29–39.
doi:10.1016/j.emc.2010.08.003 .
ISSN 0733-8627 . PMID 21109100 .
13. "General First Aid Steps" . Epilepsy
Foundation. Retrieved 2018-12-14.

External links
Classification ICD-10: G40.3 • D

ICD-9-CM: 345.3 •

MeSH: D004830

External resources MedlinePlus:

000695 •

eMedicine:
neuro/376

Generalized tonic–clonic seizure at

Curlie

Retrieved from
"https://en.wikipedia.org/w/index.php?
title=Generalized_tonic–
clonic_seizure&oldid=1018140786"
 Last edited 15 days ago by Mfhulskemper

Content is available under CC BY-SA 3.0 unless

otherwise noted.