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#EFNS, How do I examine by Mind Map: #EFNS, How do I examine
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#EFNS, How do I examine



Marie Vidailhet Paris, France

Due to copyright issues / patient privacy no images are included, but this session has many nice images / videos

The face

Only partly reported

Not dystonia, hemimasticatory spasm in hemifacial atrophy, Parry Romberg Syndrome, permanent, tonic, unilateral

Odd or complex dystonia, Secondary causes of dystonia may be suspected, Eyelid apraxia w PSP, STN stimulation parkinson, Involvement of lower face, neuro- acanthocytosis, PANK2, Neuroferritinopathies, Wilson's Disease

Practical consequences, If primary dystonia, Botulinum toxin injections, In very severe cases, DBS


classical, young adult, more frequent in women, Symptoms, torticollis, retrocollis, laterocollis, myoclonic cervical dystonia

Dynamic approach, Geste antagoniste, Wrinkles, on the skin may be the signature of muscle contraction and abnormal postures, Muscle hypertrophy, Pain (muscle tenderness or tension), Predominant abnormal posture (splenius, SCM), role of trunk (posture, gait) abnormal trunk posture, etc.

Consierd theneck mobility and posture!

Treatment, physical therapy, Pain treatment, Botulinum toxin, very very severe cases DBS

Secondary causes, Stiff neck, Family history, congenital torticollis, since infancy, Post traumatic, spinal cord lesion, Stiff person, rapid onset, pain, anti GAD Ab, Neuroleptics, Retrocollis, Psychogenic

Amplitude limitation and thin sterno cleido mastoid (fibrosis), no botulinum there's no muscle, surgeon

Writers cramp

examination, write spontaneously: velocity, stop between words, legible or non legible, tremor, presss excessively on the pen, abnormal posture; jumping pen, write with the non dominant hand: dystonia appears on the dominant hand, drawings

Risk of writer's cramp, increasesw time spent writing each day, reference:Roze e, et al, Brain 2009

Pitfall: compensatory posture hides the real pattern of dystonia

Compensation and dystonia, when present the "mirror" phenomenon is most helpful to observe the core of dystonia

Abnormalposture is not always pathological, e.g. in left handed writing

Sensory disturbances, movement appears when eyes are closed, looks like dystonia, it's something else..., clues, myokimia that can be seen in CIDP, lesion in Cervical myelum, myasthenia gravis can exceptionally mimic normal posture when playing piano (intensive)

How do you examine a first seizure


Paul Boon Ghent, Belgium



disease of CNS

disease originating from the brain cortex

characterized by occurence of recurrent seizurs = epilepsy

epileptic seizures, definition


Classification, Focal, Partial, Generalized

Underlying cause

First seizure

99% self-limiting

general practitioner

emergency room


small % not self-limiting --> status epilepticus --> emergency room --> neurologist --> intensive care unit


is of incredible importance

if not observation: clinical history

Was it a seizure?

Differential diagnosis, Syncope, cardiac arrhytmias, hypoglycaemia, carotid sinus hypersensitivity, panic attacks, hyperventilation

a detailed account from patient, witness or proxy, Account on how long the seizure lasted is almost always over estimated by patients/family on a first seizure, Was it really the first seizure?, inrecognised seizures before?, although most epilepsy syndromes begin in childhood or adolescence, a significant number of patients will experience their first seizure on adulthood

Prodromal symptoms, such as typical auras, epigastricsensations, presyncopal symptomas such as light-headedness, unsteady gait, visual disturbances

Tongue biting, not pathognomonic, lateral tongue biting is more specific

Incontinence, may happen w syncope as well

History of stroke

head trauma

family history of epilepsy

provoking factors, alcohol intake or withdrawal, drug abuse, sleep deprivation, exposure to stroboscopic light


2.4-8% of patients have a metabolic underlying cause

Imaging, CT cerebrum, 6-10% of CT are abnormal, 41% of adults have an abnormal CT following first generalisde seizure, Neuroimaging is necessary after first seizure, ACEP, SIGN guidelines, Acute CT scan, reasons to do so.., MRI cerebrum, MRI preferred on CT, mesial temporal sclerosis, cortical dysplasia, vascular malformations, low-grade gliomas, Yield increases with age, cortical atrophy, cerebral infarction, confirming / excluding diagnosis

EEG, Necessary in all young patients presenting w a generalised seizure, May support diagnosis in older patients, EEG cannot exclude epilepsy

LAB, Alcohol abuse, When suspected drug abuse: substance markers


Lumbar puncture, any suspection on CNS infection, CT prior to LP is often wise

Essential diagnositc procedures

clinical examination

assessment of seizure semiology

routine lab tests

LP if necessary

early EEG within 24 hours

MRI if possible

When >1 seizure, AED active against both partial and generalized seizures: valproate, levetiracetam, topiramate, lamotrigine or zonisamide, VPA longest history of effectiveness; LEV fewer drug interactions

Starting AED therapy after 1st unprovoked seizure is controversial, seizure recurrence without AED 25-50%

Immediate AED, focal neurological findings, abnormal brain imaging, epileptiform EEG, Abnormalities, mental reardation, prior neurological condition

Consequences of first seizure

restrictions to drive a motor vehicle

working at heights and with machinery

patients should be advised to tell their employer

etc.. (not complete list)