Congress of Cervical Pathology and Colposcopy (Rome, May 13,
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EPILEPSY OCTET
Anatomy, physiology, and pathology of epilepsy
B. S. MELDRUM
Anatomy
An epileptic seizure is the result of a sudden excessive
discharge of cells in part of the brain. Since the clinical
components of the seizure are determined by the site of
origin and the pattern of spread of the abnormal discharge,
the task of defining the anatomical basis of epilepsy is closely
related to that of differentiating the various clinical
syndromes of epilepsy. The main clinical differentiation is
into focal or partial epilepsies (called localisation-related by
the Commission on Classification and Terminology of the
International League Against Epilepsy) and generalised
epilepsies (see S. Shorvon, this series). However, this
differentiation is not absolute: in many patients seizures
have a focal or regional origin (as judged from clinical signs
and from electroencephalographic [EEG] records) but
progress to generalised seizures (secondarily generalised
seizures) associated with bilaterally synchronous EEG
discharges.! It is therefore reasonable to ask whether all
seizures might have a focal origin, with very rapid
generalisation giving rise to so-called generalised seizures.
Focal cortical seizures and simple partial seizures
The character of these seizures is entirely determined by
their site of origin, and patients may present with motor,
somatosensory, special sensory, autonomic, or psychic
symptoms. Focal motor seizures commonly originate in or
near the primary motor cortex but may involve the
secondary motor area on the medial aspect of the frontal
10. West JH, Marsh G, Hallam N, Harper C, Charnock M. Acceptability to
patients of large loop excision of the transformation zone as an
outpatient treatment under local anaesthesia. Presentation to annual
meeting of British Society of Colposcopy and Cytology (Sheffield,
March 29-31, 1990).
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large loop diathermy. Lancet 1989; ii: 807.
13. McIndoe GAJ, Smith JR, Tidy JA, Yahya A, Mason WP, Anderson
MC. Occult cervical carcinoma revealed by large loop diathermy.
Lancet 1989; ii: 807
14. Byrne PF, Sant Cassia LJ. Occult cervical carcinoma revealed by large
loop diathermy. Lancet 1989; ii: 807.
15. Hallam N, West J, Charnock M, Gray W. Diathermy loop excision and
the cervix. Lancet 1989; ii: 1160.
16. Bellina JM, Wright VC, Varos JI, Ripello MA, Hohenschutz U. Carbon
monoxide laser management of cervical intraepithelial neoplasia. Am J
Obstet Gynecol 1981; 141: 828-31.
17. Baggish MS, Dorsey JH, Adelson M. A ten year experience treating
cervical intraepithelial neoplasia with the CO2 laser. Am J Obstet
Gynecol 1989; 162: 60-68.
lobe. Intracortical spread is mainly via anatomica
connections (horizontal fibres in layer VI are important2). I
the hippocampus contiguous spread via extracellular ioni
changes and local current flow may be substantial. Th
Jacksonian march is associated with a strictly localise
seizure propagating at a speed of mm/s.2 An "inhibitor
surround" due to activation of intrinsic GABAergic neuron
may limit local cortical (and homotopic) spread of seizur
activity.
Activation of basal ganglia, thalamic, and brainste
nuclei accompanies some clinical signs of focal seizur
activity. The transition from clonic to tonic activity ma
reflect a change in the pattern of cortical discharge, but whe
seizure activity becomes more generalised it reflects
sequence of events in the brainstem.
Complex-partial (psychomotor, temporal lobe, limbic)
seizures
Typical complex partial seizures usually originate in on
mesial temporal lobe but may start in other limbic structure
or in cortical areas that project to limbic areas (includin
frontal and occipital cortex). Depth electrode studies b
Wieser3have contributed to the differentiation of severa
types of complex partial seizures in terms of the origin an
spread of electrical discharges-eg, hippocampal o
ADDRESS Department of Neurology, Institute of Psychiatr
London SE5 8AF, UK (Prof B. S Meldrum, MB)