Clonic Movements Research Articles

Transient loss of consciousness: The value of the history for distinguishing seizure from syncope

We studied 94 consecutive patients (age 15 or over) to investigate which aspects of the history and clinical findings help to distinguish seizures from syncope and related conditions. Clonic movements or automatism observed by an eyewitness classified an event as a seizure. The seizure group consisted of 41 patients and the syncope group of 53 patients. The likelihood ratio was used to calculate the predictive power of single findings and logistic regression to analyse combinations of findings. The best discriminatory finding was orientation immediately after the event according to the eyewitness and the age of the patient in the absence of an eyewitness report (P less than 0.001). We found a seizure five times more likely than syncope if the patient was disoriented after the event and three times more likely if the patient was less than 45 years of age. Nausea or sweating before the event were useful to exclude a seizure. Incontinence and trauma were not discriminative findings.

Episodic barrel rotations induced by intrastriatal injection of quinolinic acid in rats. Inhibition by anticonvulsants

Unilateral intrastriatal injection of quinolinic acid (2,3 pyridine dicarboxylate; QUIN) in the rat produces episodic barrel rotations and tonic-clonic forepaw movements, lasting for several hours. We investigated whether intraperitoneal postreatment with anticonvulsants could abolish this phenomenon when it is already fully developed, and whether their potency ratio was similar in models of epilepsy. All 8 tested antiepileptics, namely carbamazepine, clonazepam, diazepam, diphenylhydantoin, ethosuximide, flunarizine, phenobarbital and sodium valproate decreased this behaviour in a dose-dependent way. Six other drugs with anticonvulsant properties were also effective: DL-2-amino-7-phosphonoheptanoic acid, desipramine, etomidate, ketamine, meprobamate and sabeluzole. The ED 50-values for having the frequency of the episodes of barrel rotation correlated well with published ED 50-values for inhibition of tonic hindpaw extension in the maximal metrazol seizure test (r s = .95, p<0.001) and with the ED 50-values for having the duration of the forepaw clonus in the rat-kindling model (r s = .93, p<0.001). This quinolinic acid test allows visualization of the onset of action of anticonvulsants, with each animal as its own control. In order to assess whether this test is also sensitive to drugs influencing the symptoms of Huntington's disease, the effect of the dopamine antagonists haloperidol and pimozide, the acetylcholinesterase inhibitor physostigmine and the anticholinergics atropine and dexetimide were investigated as well. The experiments suggested that the barrel rotations and clonic forepaw movements, only 3–6 hours after intrastriatal injection of QUIN respond to anticonvulsants, but are not specifically sensitive to drugs used in the symptomatic treatment of Huntington's disease.

Clinical and electroencephalographic features of simple partial seizures.

The clinical and electroencephalographic features of 87 simple partial seizures in 14 patients were studied with video-EEG telemetry. The patients were able to respond to verbal stimuli during all seizures and, later, could clearly recall ictal events. To determine whether the EEG changes in simple partial seizures could be reliably observed, a reader blindly reviewed four EEGs of equal duration for each seizure. These EEGs consisted of one ictal and three nonictal recordings obtained at predetermined times before the seizure. There were 27 motor seizures (mean duration, 86 seconds; range, 2 to 250 seconds), all involving clonic movements of the head and/or upper extremities; 8 (30%) of these had a sensory component (pain in 6, paresthesia in 2). An EEG change, usually localized spikes or sharp waves over the contralateral or both rolandic regions, was identifiable in nine (33%) of the motor seizures. The 60 nonmotor seizures (mean duration, 63 seconds; range, 8 to 375 seconds) involved a variety of symptoms, including somatosensory/special sensory (3 seizures), autonomic (26 seizures), cognitive (1 seizure), affective (14 seizures), and mixed, or more than one category of nonmotor symptoms (16 seizures). In only nine (15%) of the nonmotor seizures was there an ictal EEG change, usually localized spikes or paroxysmal theta activity over the temporal region. Overall, among the 87 simple partial seizures, only 18 (21%) revealed ictal EEG changes. Thus, a normal EEG is common during simple partial seizures and does not exclude the diagnosis.

Confirmation of Babinski-like response in periodic movements in sleep (nocturnal myoclonus)

Periodic movements in sleep (PMS), also called nocturnal myoclonus, is a disorder of unknown etiology (Coleman 1982). It has been reported in association with many sleep disorders and has also been observed in asymptomatic persons (Bixler et al. 1978; Coleman et al. 1980). It is of importance clinically because it is responsible for 12% of all cases of insomnia (Coleman et al. 1982). The foot and leg movements in PMS are characterized by dorsiflexion of the ankle, extension of the great toe, extension and fanning of the small toes, and partial flexion of the knee and hip (Guilleminauh et al. 1975; Coleman et al. 1980; Smith 198.5); clonic movements about the ankle and toes have also been described (Lugaresi et al. 1968; Smith 1985). As these movements closely resemble the clinical Babinski response (Smith 198.5) and as PMS (Coleman 1982) and the normally occurring nocturnal Babinski response (Fujiki et al. 1971) are phenomena of NREM sleep, the author recently proposed that the foot and leg movements of PMS are Babinski-like responses due to changes in the pyramidal tracts during NREM sleep (Smith 1985). The conclusion that these foot and leg move-

Monitoring the occurrence and duration of electroconvulsive fits.

During 100 routine psychiatric hospital electroconvulsive treatments the medical staff administering treatment experienced little difficulty in deciding that a fit had occurred. The judgement was based on simple clinical observation of a succession of clonic bodily movements, and high inter-rater agreement was found for the measurement of fit duration. The cuff technique was also used, but it tended to underestimate fit duration and is not recommended for routine ECT practice.

Non-convulsive Status Epilepticus: A Prospective Study in an Adult General Hospital

A prospective study of non-convulsive status epilepticus was undertaken in order to evaluate the occurrence and characteristics of this condition in adults. The diagnosis was established in 22 of 113 patients (19 per cent) presenting with status epilepticus over a 23-month period. Non-convulsive status was most prevalent in the over 60 age group. Its two subgroups, absence status (18 cases) and complex partial status (four cases) were both manifest clinically by a prolonged alteration of consciousness of variable extent. Absence status presented de novo (six cases) or against a background of epilepsy (12 cases), often with a long seizure-free interval before presentation. Precipitating factors included infection, inadequate anticonvulsant medication and benzodiazepine withdrawal. The clouding of consciousness was usually characterised by confusion, disorientation and partial responsiveness. Myoclonic or clonic movements of the eyes, face or jaw were evident in all but two patients. Automatisms, including ambulatory behaviour (three cases) were less common. Serious psychiatric disorders preceded the status in seven cases, and contributed to the difficulty in diagnosis. Complex partial status was associated with underlying cerebrovascular disease in three of four cases, and is characterised by a more severe and variable clouding of consciousness, less frequent facial clonic movements, episodic adversive head and eye movements, and a more gradual recovery after treatment.

Toxicity and neuropharmacology of cyclopiazonic acid

Cyclopiazonic acid (CPA) was found to have many pharmacological properties in common with the antipsychotic drugs chlorpromazine and reserpine. Thus, in mice CPA at ip doses of 5–14 mg/kg body weight produced hypokinesia, hypothermia, catalepsy, ptosis, sedation without loss of righting reflex, tremor, gait disturbance, dyspnoea, opisthotonus, atypical convulsion and prolonged barbiturate-induced sleep. The ip LD 50 of CPA was found to be 13 ± 0.05 mg/kg. The tremors induced by near-lethal doses of CPA were associated with voluntary or forced movements (action tremors); they worsened during the days following treatment, but they were weak compared with the exhausting and continuous tremors of the whole body caused by 20 mg tremorine/kg (used for comparison). When death occurred only 24–259 min after administration of CPA (11–14 mg/kg), it was preceded by dypsnoea, cyanosis, opisthotonus and clonic leg movements and tonic extension of hind legs (convulsions). When death was delayed (2–6 days after CPA administration), it was preceded by prostration, ptosis, hypothermia, tremor and cessation of food and water intake resulting in cachexia; convulsions were not seen in this group of mice. CPA did not affect the rate of convulsion or death caused by either maximal electroshock or metrazol administration but it did delay the onset of metrazol-induced seizures. In rabbits, 10 mg CPA/kg body weight initially produced tachycardia, tachypnoea and sedation with an activated electroencephalogram. Of three rabbits given 10 mg CPA/kg one died, and in this rabbit slow delta waves were seen just before and during a brief period with clonic leg movements. In this animal death was accompanied by tonic extension of the hind legs, respiratory arrest and cardiac fibrillation; and epileptiform EEG was not seen at any time. The unexpected EEG activation with sedation in rabbits treated with CPA was similar to the effect of reserpine on EEG.

Relationship of periodic movements in sleep (nocturnal myoclonus) and the Babinski sign.

To obtain a comprehensive clinical description of periodic movements in sleep, the first 11 videotaped movements of nine patients were studied. These leg movements were characterized by active dorsiflexion of the ankle (91%), dorsiflexion and fanning of the small toes (82%), and dorsiflexion of the great toe (72%). Partial flexion of the knee and hip occurred in 28%. Simultaneous dorsiflexion of the ankle and small toe was almost always the initial change, either preceding or occurring simultaneously with extension of the great toe. Knee and hip flexion almost always followed foot movements. Tonic and/or clonic movements, usually about the ankle, occurred in 75%; plantar flexion of the ankle occurred in 21% at the end of a leg movement. Periodic movements in sleep were thus characterized on detailed videographic analysis by movements similar to the Babinski response. Since both the normally occurring nocturnal Babinski response and periodic movements in sleep are also almost entirely NREM related, the author proposes that periodic movements in sleep are due to the NREM loss of supraspinal inhibitory influences on the pyramidal tract and that the characteristic foot and leg movements are Babinski-type responses secondary to this.

Cough syncope mimicking epilepsy in asthmatic children.

Cough syncope is a more common complication of childhood asthma than formerly recognized. We report twelve children with typical cough syncope who were identified in a pediatric clinic over a period spanning seven years. The condition may be confused with epilepsy because of frequently associated brief clonic convulsive movements during the height of the cerebral anoxia. Cough syncope is readily distinguished from epilepsy by a thorough history. The management and prevention of cough syncope is directed at the aggressive control of bronchospasm in children with asthma.

Diagnosis and treatment of absence seizures

Absence seizures are characterized by a brief, blank stare. Such seizures occur suddenly, without an aura, and likewise end suddenly, without mental confusion. They may be associated with mild clonic movements, an increase or decrease in postural tone, or automatisms. The ictal electroencephalogram (EEG) reveals generalized spike-and-wave discharges, usually at 3 Hz, though the interictal EEG is usually normal. Seizures usually begin between five and 15 years of age and usually subside with adulthood. Half the patients have a history of one or more generalized tonic-clonic seizures, which may precede or follow the onset of absence seizures. One third have a family history of seizures. Ethosuximide is the preferred treatment in individuals who have absence seizures alone, while valproic acid is preferred for those with a history of generalized tonic-clonic seizures. Once the dose is adjusted to provide an effective trough drug level, nearly all seizures can be completely (or at least satisfactorily) controlled.

Electro-clinical studies of epileptic seizures in Mongolian gerbils

In 26 seizure-prone gerbils, with chronically implanted electrodes, the electro-clinical relationship of seizures was studied. The results are based on 70 EEG recordings of fully developed seizures resulting from: (1) moving the animal from its home cage to the testing area, i.e., the naturally occurring environmentally precipitated seizures (EPS); (2) electrically induced by stimulation of cortical electrodes (ICS); and (3) electrically induced by stimulation of hippocampal electrodes (IHS). The EPS were categorized into 4 electro-clinical phases: myoclonic, clonic-tonic, tonic, and clonic movements; usually preceded by an incipient period and followed by a post-seizure period. Usually the EPS were preceded by focal single spiking in the posterior part of the hemisphere, during which the animal's behavior was normal. This spiking turned to generalized epileptic discharges (incipient period without epileptic behavior) which were followed by the 4 phases of generalized myoclonic and clonic-tonic seizures. Post-seizure coma-like behavior was associated with EEG depression. The ICS were very similar to the EPS, but of course lacking the incipient phase. In contrast to the EPS and ICS, the IHS were very different both in terms of EEG and clinical manifestations. Moreover, the post-seizure depression was absent or negligible. We conluded that in the EPS in gerbils, the cortex is of primary importance as to the site of origin of the seizure, while the hippocampal involvement is secondary to it.

Neurochemical and behavioral effects of systematic and intranigral administration of N-methyl-4-phenyl-1,2,3,6-tetrahydropyridine in the rat

At doses of 5–10 mg kg −1, N-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (NMPTP) produces in rats acute immobility, retropulsion, straub tail, piloerection, exophthalmos, salivation and clonic movements of the forepaws. It does not produce analgesia as measured by the tail flick test, nor does it produce permanent motor impairment after chronic or intranigral administration. The acute retropulsion and immobilizing effects can be blocked by methysergide. Administered acutely, NMPTP doubles levels of serotonin in the raphe nucleus and substantia nigra. At the same time, levels of dopamine increase in the caudate nucleus and decrease in the substantia nigra. The NMPTP-induced decrease in dopamine content of the substantia nigra persists in chronically treated rats, but there is no significant decrease in striatal dopamine. After chronic administration of NMPTP, striatal levels of dihydroxyphenylacetic acid (DOPAC) and homovanillic acid (HVA) were decreased by about 50%. Intranigral administrations of NMPTP (10 μg daily for 5 days) failed to produce a 6-hydroxydopamine-like lesion in the nigrostriatal system. These results indicate that NMPTP in the rat does not cause selective destruction of dopaminergic neurons, but it does produce acute tryptamine-like effects.

Induction of oral dyskinesias in naive rats by D 1 stimulation

Repetitious opening and closing of the mouth and high frequency clonic jaw movements were observed in rats challenged with dopamine agonists after acute treatment with sulpiride or a low dose of spiroperidol. SKF 38393, a specific D 1 receptor agonist, alone, also induced these behaviors and cis-flupenthixol blocked them, evidence suggesting D 1 dopamine receptor mediation.

Complex partial seizures: clinical characteristics and differential diagnosis.

Videotape analysis of 163 complex partial seizures in 40 patients showed that the mean duration of the attack was 128 seconds. Automatisms occurred in 159 seizures (97%) and involved more than the face and arms in 132 (80%). Most automatisms were simple, stereotypic, or aimless movements. Postural tone increased in 24 seizures and decreased in 62. Clonic movements of the eyelids occurred in 19 attacks, and clonic movements of the extremities in 4. Only nine patients reported auras. Distinct ictal and postictal phases could be distinguished in 132 seizures (80%); in these, the mean ictal duration was 54 seconds and the mean postictal duration 89 seconds. Videotape analysis provides objective criteria by which complex partial seizures may be differentiated from other seizure types.

Gas-Producing Escherichia coli Fasciitis in a Patient With the Neuroleptic Malignant Syndrome

To the Editor.— The neuroleptic malignant syndrome (NMS) is an uncommon but potentially fatal reaction to major tranquilizers. It is characterized by hyperpyrexia, muscle rigidity, altered consciousness, and autonomicdysfunction. 1,2 We report a dramatic case of the NMS complicated by bilateral anterior tibial compartment syndromes that were infected by gasproducing Escherichia coli . Report of a Case.— A 29-year-old man was admitted to the Bernalillo County Mental Health Center, Albuquerque, with the diagnosis of acute paranoid schizophrenia. During a 12-hour period, he received 90 mg of haloperidol and 100 mg of chlorpromazine orally. Two hours later, he was comatose, hypotensive, hyperpyrexic (rectal temperature, 41.3 °C), and rigid, with clonic jerking movements, and was transferred to the University of New Mexico Hospital, Albuquerque. His creatine kinase level was 220,000 IU/L, his uric acid level was 25.2 mg/mL, and the scanty urine specimens were positive for myoglobin and initially yellow and then burgundy-colored

A 'Functional Murmur' and Stroke in a Young Adult

A 19-year-old man had a history of a "functional murmur" since birth and transient episodes of hemiparesis that he had ignored. On Feb 16,1979, he collapsed while playing handball. He was noted to grab his neck and fall, with clonic movements of his extremities. Physical examination disclosed a thin man appearing in distress. His BP was 110/70 mm Hg, his pulse rate was 70 beats per minute and regular, and his respirations were 18/min. Positive physical findings included the cardiac examination where the apical impulse was in the fifth left intercostal space at the midclavicular line. S1 was soft, S2 was persistently split but moved physiologically. A 3/6 mid-frequency systolic ejection-type murmur at the second left intercostal space without radiation, and a 2/6 high-frequency holosystolic murmur at the apex radiating to the left sternal border were noted. The results of a neurologic examination were consistent with a right middle cerebral

Position-dependent hemifacial spasm

Hemifacial spasm developed in a 32-year-old man following a brain stem stroke. This stroke followed a self-induced head movement, which is a rare cause of such events. The clonic movements were often related entirely to the position of the head. Carbamazepine was successful in treating the spasm and may be indicated in the medical treatment of this disorder. The differential diagnosis and treatment of hemifacial spasm are discussed.

Stroke, Orthostatic Hypotension, and Focal Seizures

A 75-year-old man had development of left hemiparesis after a cerebral infarction. Nine months later, he was admitted to the hospital after generalized tonic clonic convulsion. In the hospital, he had clonic movement on the left side of the body. Even after acceptable control of orthostatic hypotension, rising from supine to standing position evoked slow waves over the right hemisphere on the EEG tracing. This example of focal seizures with orthostatic hypotension shows that previously compromised cerebral tissue or vessels may be vulnerable to changes in blood pressure. We suggest that convulsive movements associated with hypotension or syncope result from cortical mechanisms rather than brainstem tonic release mechanisms.

Development of the motor behavior during sleep in newborn infants

Body movements during sleep were examined in eight non-eventful preterm babies and two full-term babies using the polygraphic methods including superficial EMG. Typical movements in quiet sleep were startle (St) or generalized phasic movement (GPM) and increased tonic activity in chin muscles. In active sleep, instead of total simultaneous patterns observed in quiet sleep, more un-coordinated and localized movements such as generalized movement (GM), localized tonic movement (LTM), localized phasic movement (LPM) and clonic movement (CM) occurred. Longitudinal study of movements revealed a decrease of St or GPM, GM and LPM. LTM did not decrease with increasing conceptional age. The differences of decreasing tendency among these movements may indicate the differences of maturational changes in the different part of CNS.

Spontaneous generalized spike-wave discharges in the electrocorticograms of albino rats

Generalized epileptiform discharges occur spontaneously in the electrocorticograms of some albino laboratory rats. These discharges occur during periods of quiet wakefulness, are composed of 6–10/sec spike-wave complexes, are accompanied by locomotor arrest and often by mild clonic facial movements. The occurrence of these discharges is unrelated to surgical procedures used to create chronic recording preparations. Similar discharges and behavior have been induced in controls by injections of pentylenetetrazol.