• pts with unexplained posterior headaches
• fever
• AMS

Brudzinski & Kernig

• multiple cranial nerve deficits
• difficulties with higher function, tongue movements, speech, breathing, and chewing

1. meningitis
2. encephalitis
3. meningeal cancer
4. GBS
5. acute demyelinating disorders
6. benign intracranial hypertension
7. seizure
8. stroke
9. polyneuropathy
10. therapy/drug delivery
11. SAH
12. diagnostic injections (myelograms, cisternograms)

• glucose = 2/3 serum glucose
• protein = <35mg/dL
• WBC = <6
• WBC:RBC = 1:500
• pressure = <20mmHg

supine for 6 hours to minimize post-LP headache and potential CSF leak

• caffeine
• fluids
• blood patch
• bed rest for 24 hours

• venous sinueses
• meningeal arteries
• dura
• CN 5, 9, 10
• proximal ICA
• brainstem periaqueductal gray matter
• thalamic sensory nucleus

• skull periosteum
• skin
• subcutaneous tissues, arteries, muscles
• C3-C7
• mucous membranes
• eyes, ears, teeth, sinuses, oropharynx

1. SAH
2. CVD
3. meningitis
4. encephalitis
5. ocular disorders (glaucome, acute iritis)
6. seizures
7. LP
8. hypertensive encephalopathy
9. sudden cold-ice cream
10. coitus

1. GCA-TA
2. intracranial mass (tumor, chronic SDH, abscess)
3. pseudotumor cerebri
4. trigeminal neuralgia
5. glossopharyngeal neuralgia
6. post herpetic neuralgia
7. HTN
8. atypical facial pain
9. use of MAOI plus tyramine

1. migraine
2. tension ha
3. cluster ha
4. cervical spine disease
5. sinusitis
6. dental disease
7. post-concussive ha
8. hemicrania continua
9. chronic daily headache

• unilateral, pulsating, throbbing
• N/V, photo/phonophobia
• auras in 10-15%
• mostly women
• onset- early in life
• FHX common (>80%)
• triggers in 50%-chocolate, hard cheeses, red wine, monosodium glutamate, hormonal changes, exertion, fatigue, stress

• acute vasoconstriction
• artery inflammation and release of peptides

• most common (80-85%)
• prodrome 24 hours before
• lasts 4-72 hours
• b/l or u/l
• pulsating
• moderate to severe intensity
• N/V, photo/phonophobia

• one or more aura sx - CORTICAL BRAIN ACTIVITY
• headache begins within 60 mins of aura
• usually 4-72 hours

• migraine >15 days a month
• tx = dexamethasone

• NSAIDS, ASA, acetaminophen, combinations
• triptans
• ergot derivatives
• opiates-->watch for rebound phenomenon

• BB (propranolol, nadolol)
• CCB (verapamil)
• TCAs
• anticonvulsants (gabapentin, valproic acid, topiramate)
• avoidance of food/drug triggers

• males > females
• onset- 25yo
• brief, severe, unilateral, periorbital, constant, NON-THROBBING headache-tend to pace around room
• 10mins - 2 hrs/ 30-90 mins
• occur at nearly the same time every day
• a/w ipsilateral lacrimation, nasal stuffiness, Horner's Syndrome
• often precipitation by ETOH or vasodilating drugs
• NO n/v, photo/phonophobia

• subQ sumatriptan
• 100% oxygen
• subQ dihydroergotomine
• avoid predcipitating factors

• NSAIDS
• steroids
• lithium
• verapamil
• baclofen
• valproic acid

• H&P
• ESR!!!!!!!! rule out TA
• CBC, CRP, CMP, toxicology
• MRI/MRA/MRV
• CT/CTA/CTV
• angiogram

• NON-THROBBING, bilateral occipital pain
• "like a band around my head"
• aggravated by stress/tension
• muscle contraction thought to be secondary phenomenon
• NO n/v, photo/phono, prodrome, or neuro deficits
• women > men
• tx = NSAIDS, muscle relaxants, TCAs, relaxation techniques

• >50 yo
• headache in 1/3 as presenting sx
• throbbing, often bitemporal, with scalp tenderness
• occasional vision loss
• elevated ESR- >85
• dx- temporal artery biopsy
• tx- steroids 60mg/day with slow taper over several months
• start steroid tx immediately to avoid blindness

• progressive/reoccuring headache
• follows regular use of headache abortive meds
• >15 days/month for >3 months
• NSAIDS, opioids, triptans, ergotomine
• tx- discontinue

• throbbing, bilateral, occipital, or nuchal
• increased with SITTING UPRIGHT, head movement, or maneuvers that increase ICP
• photophobia common
• LETHARGY/CONFUSION common
• fever
• nuchal rigidity (kernigh or brudzinski sign)
• dx- LP

• increased ICP causing headache, papilledema, decreased visual acuity
• can have CN 6 palsy
• usu idiopathic, but can be caused by meds
• women > men
• peaks 3rd decade
• usu self-limited-->need to r/o intracranial mass
• tx- acetazolamide +/- furosemide, possibly LP shunt
• obese > slender
• WORSE SUPINE

• slow growing
• usu benign
• 15% of all brain tumors
• derived from arachnoid
• durally attached
• often calcified/extra-axial
• female 2:1
• dx: CT/MRI
• tx: surgical excision, gamma knife
• usu found incidentally; no sx

• 10% of all intracranial tumors
• microadenomas <10mm
• macroadenomas >10mm
• hormone secreting- prolactinoma, acromegaly, acth
• macroadenomas often press on optic chiasm-->vision loss
• diplopia- CN 2,4,6
• tx prolactinoma- bromocriptine

• vestibular neuroma CN8
• 8-10% of brain tumors
• increased with neurofibromatosis
• common sx- hearing loss, tinnitus, dysequilibrium
• dx: MRI or CT with contrast
• tx: gamma knife, open surgery

• high grade-highly malignant
• most common brain tumor in adults-40% of all tumors
• age 55yo
• sx: headache, AMS, hemiparesis, aphasia, seizures
• dx: MRI with contrast
• tx: surgical debulking, radiation, chemo

***NEW ONSET SEIZURE IN MIDDLE-AGED PERSON IS GBM UNTIL PROVEN OTHERWISE

***BUTTERFLY LESION

• most common neurological disorder in adults
• more common in blacks

• HTN
• atherosclerosis
• both

1. L/R internal carotid
2. L/R vertebral

1. anterior cerebral
2. posterior cerebral
3. middle cerebral

• 150g of glucose
• 72L of oxygen

• arterioles to dilate
• increase cerebral blood flow

• arterioles constrict
• decrease cerebral blood flow

1. atherosclerosis
2. thrombus or emboli
3. hypotension
4. hyperviscous blood products
5. meningitis
6. arthritis
7. dissecting hematomas
8. arthritis compressing vessels
9. vasospasm secondary to SAH

1. end-stage atherosclerosis
2. HTN

1. carotid bifurcation
2. origins of middle and anterior cerebrals
3. origins of vertebrals at subclavian

1. vasodilation of vessel
2. stasis of red cells
3. edema
4. necrosis of brain tissue

• clot
• air
• fat
• neoplasm
• amniotic fluid

• traumatic
• coagulation defect
• degeneration
• HTN
• infection
• AVMs
• amyloid angiopathy
• neoplasm

• half are fatal
• most common site = basal ganglia
• if survival-blood removed by phagocytes

replaced by:

1. connective tissue
2. glia
3. newly formed blood vessels

results in shrunken fluid filled cavity

1. atherothrombus
2. hemorrhage
3. embolism

1. A-fib
2. endocarditis with vascular lesion
3. cardiac thrombus

1. coumadin/heparin/lovenox
2. asa/plavix
3. open heart surgery

1. athersclerosis
2. embolism

1. asa
2. plavix
3. carotid endarterectomy

1. amaurosis fugax
2. circumoral numbness
3. dizziness
4. hemiparesis
5. dysarthria

• convulsive seizures
• neoplasm
• migraine
• menieres disease
• hyperinsulinism/diabetes

• carotid doppler
• MRA
• angiogram
• echo

• age
• previous stroke
• family hx stroke
• male

• atherosclerosis
• A-fib
• HTN
• DM
• hyperlipidemia
• smoking
• birth control
• illicit drug use
• alcohol
• valvular disease
• hypercoagulable state
• cardiomyopathy
• vasculitis

• migraine (scotomatas)
• seizure (tonic-clonic)
• vertigo only

• visual/sensory loss
• weakness
• vertigo with other sx

CT

• ischemic-normal then hypodense
• hemorrhagia-hyperdense

• cardiac disorders
• large vessel disease
• small vessel disease
• hematological disorders

• Plavix 75mg
• warfarin (INR 2.0-3.0)

• 15% of all CVAs
• dx: CT

1. HTN
2. aneurysms
3. AVMs
4. coagulopathies
5. tumor
6. cerebral venous occlusive disease

• usually progress over minutes to hours
• mass effect (HA, dec. LOC, seizure)
• dx: CT, cerebral angiogram often necessary

• identify cause
• control BP
• control ICP
• neuro consult

• arteriosclerotic vessel rupture
• aneurysm (congenital, mycotic)
• AVM
• amyloid angiopathy
• trauma

• cerebellum/brainstem
• basal ganglia
• internal capsule
• thalamus

• ABRUPT HEADACHE
• increasing neuro deficits
• hemiparesis
• cerebellar sx
• rapid LOC
• N/V
• generalized and focal seizures
• fatal in >50%
• often permanent deficits that are functional

• dysconjugate eyes
• agonal breathing
• pinpoint pupils
• coma

CT

• same as ischemic EXCEPT no thrombolytics/antiplatelets/anticoagulants
• surgery >3cm
• if deep hemorrhage-NO SURGERY

• collection of blood between dura and arachnoid
• almost always secondary to trauma
• blast injury, post-natal trauma

• VENOUS
• rare from middle meningeal artery/skull fx
• forms membrane-enlarges
• compress brain-herniation

1. acute-within 24 hours-emergency OR
2. chronic-weeks-months-often no hx trauma

• FLUCCUATIONS IN LOC/hemiplegia
• similar to acute hematoma but increase seizure
• often confused with early dementia

• CT
• MRI

• craniotomy
• burr holes

• middle/anterior cerebrals or communicators in C of W
• 40-65 yo most common

• gold standard = ANGIOGRAM
• LP = most sensitive
• CT positive >95% = first test

• rebleeding
• acute hydrocephalus
• VASOSPASM DAY 3-10
• DVT/PE
• seizures
• determining source of bleed
• hypovolemia/hyponatremia

• congenital malformations of tangled, dilated blood vessels
• arterial and venous combination flow
• can cause neuro deficits
• dx: CT, MRI, angiogram
• tx: anticonvulsant, surgery, gamma knife

• neurosurgical emergency
• younger person
• trauma
• middle meningeal artery
• crescent shaped
• lucid interval

• inflammatory, demyelinating process of the CNS
• disease of young people-20-55 yo
• women > men
• incidence increases FURTHER from equator
• decreases life expectancy 6-7 years
• probable environmental influence with autoimmune problem

• PLAQUES-microscopic multifocal areas of mononuclear cell infiltration and demyelination
• infiltrate of lymphocytes and lipid-filled macrophages
• demyelination casues slowing/blocking of conduction in neurons

• brain-periventricular regions

gliotic scars cause axonal loss

• any region of CNS WHITE matter
• initial complaints = focal weakness, numbess, tingling, unsteadiness in a limb, sudden loss or blurring of vision in one eye, diplopia, disequilibrium, bladder fx disturbances
• OPTIC NEURITIS
• occasionally acute, progressive spastic paresis and sensory loss
• may be months or years before sx return

• infection
• fever
• childbirth

• episodic deficits
• stable between attacks
• 4-16 weeks

• gradual progressive course after initial relapsing-remitting form (25 years)

• rare
• continuous progression of disease
• die in early 30s
• incontinent, can't talk
• worst kind

• evidence of 2 different regions of white matter disease affected at 2 different times
• no specific test

• two attacks within 2 clinically separate lesions
• if only one lesion, then electrocerebral evoked responses needed (visual, auditory, sensory)

• MRI-helps support dx
• CSF-mild lymphocytosis, slightly increased protein
• CSF electrophoresis-increase IgG immunoglobulins (oligoclonal bands)
• oligoclonal bands are NOT specific for MS (Lyme, syphilis, sarcoid, vasculitis)

• corticosteroids-acute relapses
• antidepressants-elavil
• bladder dysfunction-ditropan
• fatigue-summetrel, cylert, prozac
• muscle spasm-tegretol, dilantin, neurontin
• spasticity-baclofen, valium, zanaflex

• well-balanced diet
• no smoking
• avoid alcohol
• patient education
• exercise-PT

• usually at least partial recovery
• next relapse-unknown/unpredictable
• FAVORABALE-FEMALE <40, INITIAL SX VISUAL OR SENSORY VS. PYRAMIDAL OR CEREBELLAR
• most pts only mildly to moderatelyy disabled after 10 years

• an acquired, generalized and usually progressive impairment of cognitive function that affects the CONTENT but not the level of consciousness
• memory is also impaired
• it must also include one of the following: aphasia, agnosia, apraxia, personality change, or trouble with organizational skills

• increases with age and doubles every 5 years
• 1% at 65yo
• 50% at 90yo

• most common form
• steady progressive memory loss and other cognitive deficits
• typically begins during 6th and 7th decades of life
• 6% at 65yo and 15-20% >80yo
• slowly progressive- 7-10 years til death
• complex heterogenous disorder
• multiple genes involved

• advanced age
• positive family history
• female
• hx head trauma
• small head circumference
• low intelligence

• NO CURE!!!!!
• donepezil (aricept)-cholinesterase inhibitor
• NSAIDs- may slow progression
• gingko biloba- helps with memory deficits

• 2nd most common dementia
• variable attention, alertness, cognition, visual hallucinations, and motor features of parkinsons
• falls, syncope, delusions, LOC

• men > women
• abrupt onset with rapid progression
• visual hallucinations and psychotic sx
• tx same as Alzheimers

• from multi-infarct
• strategic infarcts
• small-vessel disease
• hypoperfusion
• hemorrhage
• tx same as Alzheimers

1. DEMENTIA
2. GAIT DISTURBANCE
3. URINARY INCONTINENCE

• unknown etiology (after infection, SAH, trauma)
• enlargement of lateral ventricles with compression of cerebral cortex

• degeneration of frontal and temporal lobes
• behavioral and language problems
• inappropriate social behavior and apathetic
• example = Pick Disease

• most new cases are <5yo, lower in 20-50yo, ad higher again in older
• male > female (slightly)
• chronic seizures begin before age 20
• usually then lifelong
• THE LATER THE ONEST OF SEIZURES, THE HIGHER THE PROBABILITY THEY ARE A RESULT OF A BRAIN STRUCTURAL LESION
• long-term survival in chronic seizure patients is lower than normal
• greatest increase in mortality is among those with abnormal neurologic fuction at birth

PAROXYSMAL DEPOLARIZATION SHIFT (universal phenomenon and intrinsic  property of neuron)

• correction of biochemical abnormalities delated
• irreversible changes
• systemic factors contribute to permanent brain damage of status epilepticus

1. hypoxia
2. lactic acidosis
3. metabolic change
4. hypotension

1. impaired membrane influences of ion flux's
2. abnormal synaptic transmission

• most common type
• 2 types-simple, comples

• no LOC
• partial motor-jacksonian march (sequential body part involvement)
• todd paralysis- localized paralysis/weakness for minutes to days (probable underlying lesion)
• somatosensory attacks- numbess, visual, auditory, olfactory sensations; often the 'aura' of complex partial seizures or tonic clonic seizures
• psychic seizures- deja vu, flashback, intense fear, distortions of sound, outside the body sensation

• usual begin with AURA
• next, they become unresponsive even while doing purposeful activity (picking at clothes, walking around aimlessly)
• often resist efforts to restrain
• lasts 1-3 minutes
• usually complete amnesia except aura
• TEMPORAL LOBE, but can be from others

• absence seizures:

brief interruptions of consciousness (3-15 secs)

no aura

few to hundreds per day

flickering eyelids, rubbing nose, chewing, swallowing

no loss of muscle tone

patient immediately clear again

petit mal

• bilateral cerebral structures involved
• lasts 3-5 minutes
• complete LOC/falling

1. involuntary contraction of laryngeal and respiratory muscles (stop breathing, turn blue)
2. generalized tonic contraction of axial and limb muscles (stiffen up)-often asymmetric, respirations stop during tonic phase
3. jerking/clonic movement in all limbs
4. pt. becomes confused/sleepy or uncooperative, amnesia of event

• benign
• 6 months - 4 years old
• normal EEG within one week
• no clinical signs of brain damage
• no atypical features

1. eliminate factors that may cause seizures
2. anti-convulsant drugs
3. maintaining mental/physical health
4. surgery to eliminate focal seizure origins

• adequate ventilation
• IV line
• routine labs/drug levels
• 25-50g glucose with 100mg thiamine
• large dose anticonvulsant

• remove epileptic foci
• when medical therapy unsuccessful
• needs to be a single foci

• poor coordination
• ataxia
• intention tremors

• all ethnic groups
• male and female equally

1. tremor
2. hypokinesia
3. rigidity
4. abnormal gait

• loss of pigmentation and cells in substantia nigra
• cell loss in putamen and globus pallidus
• lewy bodies in basal ganglia, brain stem, and spinal cord
• ABNORMAL BALANCE OF ACH AND DOPAMINE
• usually DOPAMINE IS LOW
• NE IS LOW

• tremor-usually at rest, worse with stress, better with voluntary movements, pill rolling
• rigidity- increase tone and resistance to passive movement, flexed posture, uniform ROM, cogwheel rigidity
• hypokinesia- slow voluntary movements, mask like facies, hypophonia, poor/fine coordinated movements, small tremulous handwriting
• abnormal gait- small shuffling steps, chronic flexed posture, no arm swing, walks fast to prevent falling

sinemet (levodopa/carbidopa)

*reduce N/V and orthostatic hypotension

• most common- "on/off" states, motor fluccuations
• falls
• sleep disturbances- low levodopa
• cognitive difficulty-dementia
• psychiatric-hallucinations, psychosis, depression, anxiety
• last resort-thalamotomy, pallidotomy, deep brain stimulation

• equal males and females
• peak 2-6 decades
• usually HANDS
• also have other movement disorder
• inherited
• postural tremor-worse with voluntary movement
• usually symmetric
• ETOH DECREASES TREMOR
• tx = inderal, botox

• tics- motor and phonic

brief intermittent movements and sounds

paroxysmal and occur abruptly

tend to be repetitive

induced by inner sensory stimulus

relieved by movement

• tourette syndrome-combination of simple and complex motor and vocal tics

• most don't require tx
• only if interfere with daily living-prolixin, haldol

• hereditary disorder of CNS
• autosomal dominant-short arm of chromosome 4
• 30-50yo
• clinical sx- dementia, chorea
• CT- cerebral atrophy, atrophy of caudate nucleus
• MRI/PET-decreased glucose metabolism
• no cure (fatal after 10-20 years)
• no specific tx

• autosomal dominant
• disorder of copper metabolism
• occurs in childhood to young adult
• occular-KAYSER-FLEISCHER RINGS
• tremors, choreiform movements, facial grimacing, seizures, abnormal postures, dementia

• elevated LFTs
• low serum copper
• increased urine copper

• occurs usually with antipsychotic drugs
• abnormal chorea-like movements esp. in face and mouth
• chronic tx = resirpine
• acute tx = benadryl

• disease of peripheral nervous system
• many of the cells at lease lie partially in CNS- due to axon length

1. axonal degeneration
2. damage to schwann cells or myelin

• most symmetric
• most are distal in nature
• most caused by axonal degeneration
• weakness = axonal loss
• sensory loss = stocking glove
• large fiber loss = pins and needles
• small fiber loss = burning, stinging cold

• mononeuropathy multiplex problem
• radiculopathy
• entrapment neuropathy
• demyelinating problem

• EMG/NCS-examines large myelinated fibers, so "normal" with small fiber process

• nerve biopsy-sural nerve-always have numbness

• most common form in western world
• causes significant M&M

generalized sensorimotor

• dx of exclusion
• stocking glove
• paresthesias in feet
• major RF for foot ulcers

• multiple organs affected-pupillary light response poor-trouble with dim light
• poor vagal tone-increased resting HR and ortho hypo
• gastroparesis, diarrhea, constipation
• decreased bladder sensation and impotence
• decrease in sweating- stocking glove

• hypotension-high salt diet, increase fluids, HOB up, compression stockings
• gastroparesis-eat small meals, metaclopramide and cisapride
• diarrhea-tetra, erythro, cholestyramine, clonidine
• constipation-hydration, psyllium

• asymmetric-usu L2-L4
• c/o severe back, hip, buttock, anterior thigh pain, weakness in legs, atrophy
• EMG/MRI-needed to r/o other dx

• compression/entrapment-median, ulnar, peroneal, lateral femoral cutaneous nerves
• CN 3,4,6
• CN 3-periorbital pain, ptosis, decreased pupil light response

• ETOH abuse
• malabsorption
• abnormal diet
• decreased B12-low IF
• B1- beriberi
• vitamin B2/ribaflavin-burning feet

• elavil, tagamet, antabuse, gold, INH, flagyl, dilantin
• chemo agents- taxol, cisplatin, vincristine, paclitaxel

• vasculitic-commonly caused by polyarteritis nodosa and RA
• Sjorgren Syndrome- female with sensory, clumsiness, ataxic gait

• monoglobinopathies-increased IgM proteins
• indicators of multiple myeloma and amyloidosis (urine for bence jones proteins with mm)

• herpes zoster
• leprosy
• lyme disease
• syphilis
• HIV

• acute inflammatory demyelinating polyneuropathy
• ascending muscle weakness
• areflexic/hyporeflexic
• cardiac arrhythmias, hypertension, hypotension, respiratory failure
• tx: plasma exchange and immunoglobulin
• dx: CSF with increased protein/rare cells

• compression of median nerve
• causes: repetitive movement, DM, pregnancy, RA, amyloid
• PE: positive tinel and phalen sign
• dx: EMG
• tx: NSAIDs, splint, steroid injection, surgery

• lateral femoral cutaneous nerve
• parasthesias, sensory loss, but no motor involvement

• EMG
• muscle biopsy (biceps, triceps, quadriceps)

• inherited
• progressive muscle weakness
• loss of muscle BULK
• duchenne md-most severe with high mortality

• autosomal dominant
• multiple systemic problems
• ptosis, facial, distal limb weakness
• cardiac arrhythmias, conduction defects, pneumonia (aspiration)
• dx: clinical feataures, family hx, muscle biopsy, EMG

• females > males
• blue-violet rash on eyelids
• red scaly rash on knuckles, face, trunk
• rash usually precedes muscle weakness

• dx of exclusion
• often a/w systemic AI dz (crohns, lupus, celiac)

corticosteroids-high dose

methotrexate

azathioprine

cyclophosphamide

PT

• most common disorder of neuromuscular junction-ACH receptor
• "fatigable weakness"
• AI
• bulbar muscles-chewing, speaking, swallowing, EOM, proximal limb muscles
• sx progress as day goes-improve with rest
• normal sensation, no reflex changes
• ophthalmoplegia-ptosis/diplopia

• mestinon
• acetylcholinesterase (edrophonium)

• physical stress
• fever
• pregnancy
• heat
• antibiotics
• lithium
• CCB
• antiarrhythmics

• most common motor neuron disease
• affects both upper and motor neurons
• tests- hexosaminidase A
• tx- riluzole

• rare since vaccine
• post polio syndrome
• fatigue, myalgias, arthralgias, weakness, cold intolerance, sleep apnea, depression
• tx: specific for sx

• intracellular neurofibrillary tangles
• extracellular neuritic plaques

• chronic impairment in muscle tone, strength, coordination, or movements
• believed to be result of birth trauma

• spasticity
• ataxia
• seizure disorders
• mental retardation
• disorders of speech, hearing, vision, sensory perception

• hyperreflexia
• microcephaly
• limb length discrepancies
• cataracts
• retinopathy
• congenital heart defects

• unilateral facial muscle weakness is noted without evidence of other neurologic disease and without apparent cause
• more than 60% of cases occur on RIGHT side
• seen more frequently in pregnant women and diabetics
• often a/w trauma, infection, neoplasm, toxins

• facial muscle weakness
• paralysis of forhead and lower face
• cannot close the eye
• cannot raise the eyebrow
• cannot smile on affected side
• pain about ipsilateral ear often precedes facial weakness

1. inflammation
2. increased ICP
3. tissue necrosis

• step pneumo
• neisseria meningitidis
• group B strep (infants)

• turbid, grossly purulent
• pressure elevated
• WBC >1,000, >10,000 with increased neutrophils
• protein >100-500
• glucose <40

• opening pressure normal
• lympocytes and monocytes
• WBC < 1,000
• protein, glucose, serum blood counts normal

• a/w postural obtundation and confusion lasting minutes to hours
• grand mal
• tonic clonic

• a/w only mild activity, such as blinking
• absence