A generalized tonic–clonic seizure, commonly known as a grand mal seizure or GTCS, is a type of generalized seizure that produces bilateral, convulsive tonic and clonicmuscle 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. It is a misconception that they are the sole type of seizure, however, as they are the main seizure type in only ~10% of those with epilepsy. These seizures typically initiate abruptly with either a focal or generalized onset. A prodrome 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.
Causes
The vast majority of generalized seizures are idiopathic. 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 seizure. These unilateral seizure types can then spread to both hemispheres of the brain and cause a generalized tonic clonic seizure. Of note, this type of seizure has a specific term called "focal to bilateral tonic clonic seizure." 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. Tonic–clonic seizures can also be induced deliberately with electroconvulsive therapy. 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. The lesions 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 anti-convulsant 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
Clonic phase
Postictal phase
Diagnosis
Diagnosis can be made definitively by Electroencephalography, 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." The clonic phase EEG will show "high amplitude activity that is typically interrrupted by slow waves to create a spike-and-slow-wave pattern." 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. 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, as well as not putting anything in a person's mouth as these items can become choking hazards. Long-term therapy may include the use of antiepileptic drugs, surgical therapy, diet therapy, vagus nerve stimulation, or radio surgery.
Terminology
Generalized tonic–clonic seizures can have a focal onset 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.
