8
1
1
,2
may linger into the postictal phase . The interictal
phase in epilepsy is the interval between active seizures.
During this seizure-free period, which may last weeks or
months, the EEG of more than 80% of epileptics con-
tinue to show spikes wave pattern. This indicates an on-
going electrical emission from the cerebral hemisphere
which can secondarily excite the autonomic centres thus
causing active sympathetic and parasympathetic mani-
festations without any concomitant motor component.
This phenomenon, which may even carry a risk of sud-
den and unexpected death from cardiorespiratory dys-
Gastrointestinal manifestations
Abdominal pain is a very common complaint in chil-
dren, and may be a forerunner of an impending motor
manifestation. This could be accompanied with nausea,
vomiting and faecal incontinence.
Genitourinary symptoms
Urinary incontinence is frequent in generalised tonic-
clonic fits due to bladder muscle contraction and exter-
nal sphincter relaxation. Erotic feeling, sexual arousal,
erection and orgasm are reported. All these arise as a
consequence of involvement of the limbic system and
the temporal cortex.
3
function, occurs both in adults and children .
The propagation of the hypersynchronized electrical
impulse to autonomic centres can occur in simple par-
tial, complex partial, generalised tonic-clonic, absence
and generalized tonic seizures. Autonomic symptoms
accompany all generalised tonic-clonic seizures and one
Skin, secretory gland and eye involvement
1
third of simple partial seizure . Patients with epilepsy-
have a mortality rate that is 2-3 times that of the general
population which is deaths, largely due to autonomic
involvement .
The autonomic aspect of epilepsy appears to be an area
of minimal interest and emphasis to clinicians hence the
aim of this communication which is to bring to the fore
anin-depth knowledge, particularly the dangers related
to this subject. With this awareness, clinicians will be
expected to holistically evaluate the epileptics under
their care and institute appropriate measures.
During an episode of generalised tonic-clonic seizure,
excessive sweating, salivation and lacrimation can oc-
cur. Flushing, erythema, blanching, pallor and piloerec-
tion can follow complex partial seizure of temporal lobe
origin. Pupillary dysfunction can be bilateral or unilat-
eral manifesting as mydriasis or miosis.
4
Sudden unexpected death in epilepsy (SUDEP)
SUDEP is defined as sudden, unexpected, witnessed or
unwitnessed, nontraumatic and nondrowning death in a
patient with epilepsy, with or without evidence of a sei-
Cardiovascular manifestation in epilepsy
6
zure and excluding status epilepticus . Autopsy in this
condition does not reveal an anatomical or toxicological
With simultaneous EEG and ECG recordings, several
observations have been documented on the cardiac
manifestations of patients with unprovoked seizures.
Palpitations, chest pain, tachycardia, bradycardia, ar-
rhythmia, hypotension, hypertension can be detected.
Seizure related bradycardia followed by tachycardia can
occur in patient with absence and generalised tonic-
clonic attacks. Rhythm and conduction abnormalities
have been reported in patients with partial seizures. This
cardiovascular phenomena are prevalent when the pri-
mary foci is in the mesial temporal region of the brain.
cause of death. This condition is not rare; it contributes
6
8
-17% of deaths in people with epilepsy . The average
age for SUDEP is 28- 35 years but has also been re-
7
,8
ported in children . Various pathophysiologic events
contribute to SUDEP. These include central apnoea,
neurogenic pulmonary oedema and airway obstruction;
others are cardiac arrhythmias leading to acute cardiac
failure and arrest. Cardiac arrhythmias, during the ictal
and interictal periods, leading to acute cardiac failure
may contribute significantly to SUDEP. Death is not
usually as a direct result of a seizure or status epilepticus
but occurs suddenly during normal or benign circum-
stances. In a majority of cases, patients had had a seizure
immediately before death. In all witnessed deaths, sei-
zure had stopped before death, and in many cases, the
patient had even regained full consciousness before
5
Mayer et al recorded tachycardia in 98% of children
suffering from complex partial seizures of temporal lobe
origin. Rhythm aberrations may include atrial fibrilla-
tion, sinus arrhythmias, atrial and ventricular premature
depolarisations, bundle branch block and asystole.
9
,10,11
.
death
Effect on the respiratory system
Evaluation of autonomic cardiovascular reflexes in pa-
tients with epilepsies indicates dysfunction of both the
sympathetic and parasympathetic components. Repeti-
tive exposure to catecholamines during fits is known to
cause myocardial fibrosis. These fibrotic areas act as
foci for cardiac arrhythmias. Autopsies following death
from SUDEP have demonstrated fibro2,s1i3s of the cardiac
Hyperventilation, cough, hypoventilation, apnoea and
cyanosis have been documented during epileptic attacks
of generalised tonic-clonic type and with fits arising
from the temporal lobe. Since the cardiomodulatory cen-
tres and the respiratory control centres are closely linked
at the brainstem level, the cardiac and respiratory im-
pairment can occur simultaneously. It is pertinent to
note that in some patients presenting with recurrent
autonomic events, a seizure may be the underlying pri-
mary pathology. For example, apnoeic attacks, cyanosis
and heart rate variations are well known features of neo-
natal seizures which may not be apparent otherwise.
1
conducting system in some patients. Poor control of
epilepsy, and polytherapy in the management of patients
render some epileptics vulnerable to SUDEP. Frequent
and potentially fatal asystole is an indication for a per-
manent pacemaker insertion to avoid sudden