It is defined as changes in behavior after a tonic-clonic seizure.
An epileptic seizure is caused by over-activity of nerve cells in the brain .
Often when the seizure is over, these cells are depleted and require time to recover.
An epileptic seizure is also called a stroke , so the postictal state refers to any dysfunction that occurs after a seizure while the brain is recovering from the stroke.
During the postictal state, the individual possesses a state of disturbed consciousness, which allows him to fully understand the environment.
The postictal state lasts between 5 and 30 minutes. However, it is possible that an individual may experience this state for a longer period.
It can consist of agitation, confusion, aggressive behavior, or unresponsiveness and can last up to 24 to 72 hours.
Later it is possible that the individual experiences exhaustion, both mentally and physically.
Post fatigue can occur for a maximum time of two days.
Causes of postictal state
The postictal state is a consequence of epilepsy. The causes of the postictal state should not be attributed to seizures associated with complications of antiepileptic drug therapy such as valproic acid-induced hyperammonemia and overdose.
They are also not related to structural, metabolic and endocrine alterations, thus excluding iatrogenic causes of delirium and psychosis.
Signs and symptoms of the postictal state
Posttictal state behaviors and symptoms often require special evaluation and treatment.
For generalized tonic-clonic seizures, where the whole brain is ultimately involved, the postictal state may consist of a complete lack of response with gradual recovery associated with confusion and other symptoms that can last for hours, while brief absences have no postictal symptom.
Dysfunction can occur after focal seizures, and the characteristic of posttictal symptoms depends on the area of the brain involved in the seizure.
After seizures, most patients have “hypoactive” forms of delirium with confusion and withdrawn behavior.
These can occasionally evolve into a “hyperactive” form of postictal delirium with agitated or unusual behaviors.
More often, focal motor seizures, for example, involving clonic movements of one hand and one arm, can be followed by weakness of the same hand and arm for minutes or sometimes a day or more.
Postictal visual impairments and memory problems also often occur.
The types of posttictal symptoms experienced by patients with epilepsy are as varied as the seizures themselves, and for some patients, disability may be caused more by posttictal symptoms than seizures.
In general the symptoms are:
- State of confusion.
- Inability to think properly.
- Posttictal migraines.
- Short-term memory loss.
- Decreased concentration levels.
- Motor function disability.
- Auditory and visual hallucinations.
- Paranoia, aggression and delusions.
- Decrease in interactive skills.
- Temporary loss of hearing, vision, and numbness.
- Other cognitive impairments.
Thus, once the seizures are over, the individual remains in a confused state for a period during which he experiences symptoms, and then gradually regains consciousness and returns to a normal state.
Diagnosis of postictal status
To confirm the diagnosis of a postictal condition and to confirm its symptoms as a consequence of epilepsy, a complete history of the patient and a detailed physical examination should be performed, as several conditions can mimic the clinical presentation.
First, details about previous antipsychotic drug treatment, alcohol abuse, use of antiepileptic therapy that can exert side effects, and recent exposure to illicit drugs should be noted to exclude iatrogenic causes of delirium and psychosis.
The type of evaluation may depend on the baseline diagnostic data available. When patients are in prolonged confusion and do not return to their pre-ictal function, there may be a non-convulsive state.
A complete neurological examination should be performed, during which weakness, paralysis, or other pathological phenomena may be found. If clinical evidence suggests that patients fall into a postictal state, further study should include electroencephalography.
A non-convulsive state while symptoms are still present is considered a diagnostic hallmark of the postictal state, but interictal spikes and wave spikes may be present as a remnant of an attack.
New metabolic disorders may have occurred, and clinical chemistry studies are important. Patients with initial seizures and prolonged confusion require extensive evaluations, usually with cerebrospinal fluid examinations to exclude infections and inflammatory disorders.
Because imaging studies such as computed tomography and magnetic resonance imaging have limited use, the diagnosis of a postictal condition is based on the exclusion of other causes through the patient’s history, clinical criteria, and studies of an EEG.
Whether specific intervention is necessary (or possible) depends not only on the symptoms themselves, but also on their place in the general context of the patient’s epileptic syndrome.
Treatment of postictal states requires recognition of underlying neurological and systemic disorders associated with seizures and delirium, such as metabolic disorders and non-convulsive seizures.
Treatment of the postictal state should be based on technologies to predict and detect seizures, strategies to close the treatment gap, and sudden unexpected death in epilepsy.
Knowledge of the various manifestations of sleep disorders, seizures, and postictal phenomena during sleep is essential for the optimal diagnosis and treatment of patients with epilepsy.
Most patients with postictal delirium do not require specific treatments, but simply need to be protected while their postictal confusion is resolved. Patients need supportive care to avoid injury.
Risk factors for postictal delirium and psychosis and management of agitated and confused behaviors in patients after seizures should be reviewed.
Family members require careful training to control behaviors associated with postictal delirium and psychosis to protect patients while their confusion is resolved.
Behavioral syndromes, although generally brief, can pose special challenges in patient management.