Neurologic Problems in the Athlete

Epilepsy and Seizure Activity in Athletes


  • Seizure: A transient disruption of brain function from abnormal, excessive, synchronous neuronal activity in the brain; its clinical manifestation depends on the specific region and extent of the brain involved, which may include altered motor function, sensation, alertness, perception, and autonomic function.

  • Epilepsy: An enduring predisposition to generate recurrent, unprovoked epileptic seizures; worldwide prevalence is approximately 8.2 per 1000 individuals; 75% of epileptics experience their first seizure before the third decade of their life.


Seizures can be systematically classified as focal or generalized.


  • Overview: Seizures involve both cerebral hemispheres, are of abrupt onset, and involve alteration in consciousness.

  • Tonic-clonic (grand mal): Occurs at all ages; may have a prodromal phase lasting hours to days. Typically starts with a tonic phase (rigid extension) lasting up to 20 seconds, followed by a clonic phase (synchronous muscle jerking) lasting 1–2 minutes; most last for <1 minute. Characteristics include loss of consciousness, convulsions, muscle rigidity, and urinary but not fecal incontinence; may progress to generalized status epilepticus; a postictal phase (confusion, headache, and fatigue) is common. May be followed by focal weakness or paralysis, including vision and speech function, reflecting postictal depression of the epileptogenic cortical area; this phenomenon, known as Todd paralysis , is reversible and usually resolves within 48 hours.

  • Absence (petit mal): Occurs generally in children; no prodromal or postictal phase reported.

    • Typical: Onset is acute, as is recovery, with seizure activity lasting <10 seconds.

    • Atypical: Lasts for >10 seconds, with more gradual onset and recovery; sudden loss of awareness with associated staring, rhythmic blinking, and possibly clonic jerks.

  • Generalized status epilepticus: Defined as a continuous seizure activity lasting 30 minutes or as two or more discrete seizures between which consciousness is not fully regained. Seizures lasting >5 minutes have a high likelihood of progressing to status epilepticus and should be treated aggressively. This is a medical emergency. Activate emergency medical services (EMS). Ensure adequate airway, breathing, and circulation. Attempt to obtain intravenous (IV) access and to prevent aspiration. Benzodiazepines are the drugs of choice for initial treatment because they are fast acting and effective. Lorazepam at a dose of 0.1 mg/kg IV over 2 minutes is considered first-line treatment. Consider metabolic etiologies. Complications include dysrhythmias, metabolic abnormalities, hyperthermia, pulmonary edema, rhabdomyolysis, and pulmonary aspiration.


  • Overview: Originate in a localized region of the brain and cause symptoms specific to the part of the cortex wherein they originate; partial seizures may become secondarily generalized.

Broad Types

  • Simple focal: May include motor, sensory, autonomic, or psychic symptoms; no alteration of consciousness occurs; may be isolated or progress to complex focal or generalized seizures; associated with Todd paralysis (see “Tonic-Clonic Seizures”).

  • Complex focal: Most common type of seizure in epileptic adults; characterized by focal repetitive, purposeless, and complex movements (e.g., chewing, gesturing, lip smacking, and finger snapping) with alteration of consciousness; associated with auras that represent sensory and psychoillusory phenomena; most originate in the temporal lobe; typically last for <90 seconds and are associated with the postictal phase; amnesia specific to the event is common.

Posttraumatic Seizures

  • Description: Provoked seizures after traumatic brain injury (TBI); classified by timing of the seizure activity

  • Immediate (concussive convulsions): Occurs within the first 24 hours after TBI; about one-half of seizures occur during the first 24 hours and one-quarter during the first hour; controversial classification, as they are not felt to represent a true seizure, but rather a fairly benign phenomenon that occurs immediately after a concussion; usually do not require anticonvulsant therapy

  • Early: Occurs within 1 week of TBI; risk factors include young age, severity of injury, alcoholism, and intracerebral or subdural hematoma. Incidence is approximately 6%–10% but higher in patients with marked head injury. Seizure activity is usually tonic-clonic within the first 24 hours, progressing to more focal symptoms thereafter. A computed tomography (CT) scan of the head is indicated, considering the higher incidence of intracranial bleeding; not felt to represent epilepsy but often treated with prophylactic antiepileptic medication to minimize the risk of status epilepticus and secondary injury; treatment with antiepileptic medications does not affect the risk of posttraumatic epilepsy.

  • Late: Occurs over 1 week after TBI, with most occurring before 2 years after injury.

    • Risk factors: Early posttraumatic seizures, severity of injury, age >65 years, alcoholism, brain contusion, and intracerebral or subdural hematoma. Overall incidence is approximately 2% but is strongly correlated with severity of TBI. Seizures are also associated with underlying brain pathology. They may recur in up to 70% of cases and often require long-term anticonvulsant medication.

Precipitating Factors for Seizure

Idiopathic, new-onset epilepsy, stress, sleep deprivation, fatigue, prenatal or perinatal brain injury, hyperthermia, metabolic (dehydration, hypoglycemia, hyponatremia, etc.), infectious (e.g., meningitis), trauma, drugs/alcohol (intoxication and withdrawal), febrile (usually occur between 6 months and 5 years of age), and intracranial lesions (mass, hematoma, etc.)

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