Ictal

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Ictal refers to a physiologic state or event such as a seizure. The word originates from the Latin ictus, meaning a blow or a stroke. In electroencephalography (EEG), the recording during an actual seizure is said to be "ictal". There are four ictal states which include pre-ictal, ictal, post-ictal, and inter-ictal. Pre-ictal refers to the state immediately before the actual seizure, stroke, or headache, though it's recently come to light that some of characteristics of this stage (such as visual auras) are actually the beginnings of the ictal state. Post-ictal refers to the state shortly after the event. Inter-ictal refers to the period between seizures, or convulsions, that are characteristic of an epilepsy disorder. For most people with epilepsy, the inter-ictal state corresponds to more than 99% of their life. The inter-ictal period is often used by neurologists when diagnosing epilepsy since an EEG trace will often show small inter-ictal spiking and other abnormalities known by neurologists as subclinical seizures. Inter-ictal EEG discharges are those abnormal waveforms not associated with seizure symptoms.

Signs and symptoms in Ictal

Pre-Ictal symptoms

Pre-ictal psychiatric symptoms usually consist of multiple and various symptoms preceding seizures of different duration, which can range from a few minutes up to three days. While these pre-ictal symptoms occur before an epilepsy episode, there are no detectable changes in the electroencephalography(EEG). It is also reported that one-third of the study's participants reported premonitory symptoms, with two of the most prominent symptoms being irritability and mood changes. These symptoms became more severe as the patients got closer to having a seizure.

Ictal symptoms

Ictal symptoms last for a very brief period of time(less than 30 seconds). These symptoms usually include confusion and alteration of consciousness. During these symptoms the EEG is very active because the brain is more electrically active during a seizure. Ictal symptoms depend on where the epileptic seizure originates.

Post-Ictal symptoms

Main article: Post-ictal

Post ictal symptoms are usually split into two categories: the nuclear type, with an established clinical picture and the presence of lucid interval, and the atypical peri-ictal type, usually without the lucid interval and with quite a polymorphic clinical presentation. The former probably represents an indirect aftereffect of seizure activity whereas the latter is a direct manifestation of limbic discharge. The typical clinical phenomenology of post-ictal psychosis which seems to be characterized by grandiose delusions as well as religious delusions with the patient being in a much better mood with the feeling of mystic fusion of the body with the universe. In addition, post-ictal psychoses seem to exhibit few schizophreniform psychotic traits such as perceptual delusions or voices commenting, and well-directed violent and self-destructive behavior.

Depression is the most common symptom that occurs after an epileptic seizure and is more common than postictal psychosis. The most effective therapy done to treat epileptic depression is through electroconvulsive therapy(ECT), although many patients who undergo this therapy are known to have mania for a few days after therapy. Those who undergo ECT receive mixed results; the effectiveness of the therapy depends on the voltage of the electric dose and how much dosage is required to induce a seizure. Suicidal behavior is also prevalent, with the risk of suicide being four to five times higher in people with epilepsy compared to the general population.

Post-Ictal psychosis

Postictal psychosis occurs after an epileptic attack and is where the patient has “lost touch with reality.” This is a very common among persons who’ve had epileptic seizures for more than ten years and tends to appear after clusters of epileptic seizures have occurred. Postictal psychosis is also seen to be more prevalent in persons with seizures originating in the front lobe and the temporal lobe. Doctors also believe that bilateral independent interictal discharges are strongly correlate with postictal psychosis because it was seen in an autopsy that bilateral damage coincides with the onset of postictal psychosis.

Diagnosing Epilepsy using Ictal behaviors

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The EEG cap is used to read the EEG rhythm of the brain.

It has been known for many generations that abnormal behavior is a symptom of an onset or occurrence of an epileptic seizure. But, not until the early 19th century were ictal behaviors correlated to specific areas of the brain. Correlation of certain ictal behaviors and area of the epileptic seizures origin were found through observation of epileptic patients and an examination of the patient’s brain lesions after their death. Eventually with the creation of electroencephalography(EEG), it was found that ictal behavior and brain localization were made with identical accuracy that were found through the use of EEG. Thus doctors now were able to use the EEG to confirm epileptic seizure diagnosis. For further confirmation of using ictal behavior to diagnose seizure origins, researchers also stimulated specific sites in the brain to confirm the source of the seizure.

Ictal behavior originating in the Frontal Lobes

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The four lobes of the brain.

Ictal behavior due to seizures in the frontal lobe are known to be very emotional or sexual in nature. Seizures originating in the frontal lobe may be harder to diagnose because the behavioral change may be silent and would be harder to recognize in patients who do not express as much emotion. It is also harder to recognize because increased sexual behavior may be an increase in urges to have sex instead of outright actions. Some common examples of behavior changes include pelvic thrusting and touching of one’s genital and private areas. Another physical change is that the epileptic patient may have urinary incontinence or loss of bladder control. This feature is not specific to frontal lobe epileptic seizures and is seen in 44% of patients who have non-epileptic psychogenic seizures and the best was to confirm whether the seizure is epileptic or not is to run an EEG on the patient. In most cases an EEG and ictal behavioral analysis will be conducted to confirm if the patient has epilepsy.

Ictal behavior originating in the Temporal Lobes

During temporal lobe seizures, patients ictal behavior can be described as a bodily sensation. The sensations are usually located in the abdomen area and with the most common symptoms consisting of “having the butterflies” and the feeling of riding an elevator. Epileptic persons also experience ictal fear when seizures originate in the amygdala. Patients also are known to undergo intense déjà vu, so intense that the person actually believes that he has lived the situation before. Other sensation changes include olfactory changes where things don’t smell as they should. For example a person undergoing seizure originating in the temporal lobe may think that a rose smells like firewood. It is rare but some epileptic patients experience aphasia, this characteristic is also seen in seizures originating in mesial and lateral temporal lobe.

Ictal behavior originating in the Parietal Lobes

Seizures occurring in the parietal lobe are less common than those that occur in the frontal, occipital, or temporal lobe. Since the parietal lobe deals with higher brain function, such as visual object spacing, ictal behaviors and seizures are silent thus are harder to identify and diagnose. A common ictal behavior that occurs is that there is a tingling or numbness sensation that can be felt throughout the body. This occurs when a seizure occurs in the postcentral gyrus. Another sign of seizures occurring in the parietal lobe is the presence of ictal pain. It is severe pain that can occur throughout the body but is mostly centered around the dermatome or the skin above the spine. Pain in the abdomen area is also common. In the case of ictal pain, the seizures are very brief and occur in short spurt rather than in a long epileptic attack.

Ictal behavior originating in the Occipital Lobes

The occipital lobe handles the body’s visual system thus most ictal behaviorial changes that will occur will be of the body’s visual function. Temporary blindness is an often occurrence with seizure originating in the occipital lobe. Temporary blindess may last a few seconds to a few minutes and is never permanent unless the occipital has been too damaged. Usually patients describe their blindness as either a “whiteout” or “blackout.” Coincidently, patients with migraines produced from seizures in the occipital lobe have their visions changed to black and white. This is usually confirmed by an EEG analysis. If seizures arise in the visual association cortex then patients usually have hallucinations that include seeing scenes, people, animals, and inanimate object. These hallucinations are usually uniform and to the patient, are very real. Seizures occurring in the primary visual cortex produce hallucinations of simple shapes and through this observation doctors are able to further distinguish the origination of the epileptic seizure. A rare behavior is when the patient feels as if his/her eyes are being pushed or pulled by an invisible force.

Seizures originating in the deeper structures of the Brain

One main source of seizures occurring in deep brain lesions is mainly due to gelastic seizure which are caused by hypothalamic hamartomas,which is a tumor which is made up by a collection of neurons and glia which collect at the hypothalamus, and is usually benign. Behaviorial changes include involuntary laughter and a sudden feeling of happiness. Gelastic seizures occur for a very short period of time. Removal of the hamartoma can make a patient seizure free.

Distinguishing between Ictal and Non-Ictal behavior

It is important to correctly diagnose specific behavior as epileptic behavior and it is important to find the origination of the seizures because a correct diagnosis may lead to surgical treatment to reduce or completely remove seizure attacks. Also if correctly diagnosed, a non-epileptic patient will not be subject to be considered for epileptic medicine which has many side effects such as mood changes, mania, and depression.

It is difficult to identify the difference between ictal and non-ictal behavior because during and after an epileptic seizure, patients are usually in a state of confusion and may not be able to correctly communicate their mental and physical state. Other phenomena such as epileptic amnesia, which is amnesia induced by an epileptic seizure and may experience amnesia for a few hours to a few days, making it difficult for doctors to record the mental state of the patient. Although performing an EEG is possible for distinguishing between ictal and non-ictal states, many times scalp EEGs cannot detect epileptic activity especially if it the attack occurs in the intracranial part of the brain.

Behavioral seizure control

Those persons with epilepsy are looking for ways to prevent seizures and some researchers think it is possible. In a study it what shown that 10-47% of patients with epilepsy say they are capable of preventing seizures and are capable of stopping a seizure mid-seize. Doctors are trying different behavioral treatments such as positive and negative reinforcement of seizures. For example patients would be positively rewarded for periods with no seizures and negative rewards during seizures. The reinforcement method showed improved results with patients seizing less often but it was also observed that this improvement may be a result of reducing the number of epileptic inducers in the patient’s life. Self-control techniques are another solution to reduce the number of attacks by reducing and avoiding situations that can possibly induce seizures. Patients also work develop strategies to help abort seizures. Psychotherapy is also an option where patients learn to control their EEG rhythm through biofeedback.

Conclusion

Since the first observance of epileptic attacks, major behavioral changes were also noted and observed before and after the onset of a seizure. Studying the ictal of the patients is important to doctors because it helps them localize the area of the seizure and also helps doctors distinguish between epileptic and non-epileptic seizures. But there is a lot of information missing that could help further advance the treatment of epilepsy. Doctors are currently trying to better understand a lot of the mood changes and trying to find ways to prevent seizures either through surgical or therapeutic ways.

See also

• Ictal headache
• Postictal state