The ILAE Commission on Classification and Terminology strives to continually review definitions of seizure types, syndromes, and epilepsy aetiologies, aligned to the latest developments in this field. In 2010 the Commission introduced new concepts into the classification, or as it was termed then organisation, of seizure types and the epilepsies taking a more aetiological approach than previous classifications . This document and a subsequent report, published online, invited comment from the epilepsy community . Debate within the epilepsy community has been well informed and passionate.
The Commission 2013-17 has re-introduced the term classification and charged two Task Forces to further develop the Classification of Seizures and Epilepsies. A Task Force on Classification is developing a framework for classification of the epilepsies and focusing on areas of terminology. This will be presented for comment in the new ILAE journal Epilepsia Open in the near future. The Seizure Type Classification Task Force has focused on developing a clinically-focused seizure type classification which is prese nted below for comment.
Based upon the comments from the epilepsy community, this Seizure Classification expands upon and slightly modifies the seizure classification described in Table 2 of the 2010 proposal . The goal is to establish a final seizure classification scheme accepted by ILAE and the broad epilepsy community. The Commission on Classification & Terminology relies on comments from the wider epilepsy community to ensure that definitions and classifications are conceptually sound, acceptable and clinically meaningful. In addition, they have to translate across the many different languages in which they may be used, and work in a variety of different health care settings and in different media.
Comments are open for 2 months, i.e. until 4 June 2016. Comments will be posted on the web site and will be reviewed by the authors of the classification document prior to its finalization.
15 August 2016
Dear Dr. Fisher and members of the ILAE committee for Seizure classification 2016,
Congratulations on your efforts to propose a new Seizure classification, a much needed step in bringing about uniformity in naming seizures scientifically yet in a simple and reproducible method.
May I suggest a few points:
It would be nice to have these points considered.
10 August 2016
Classifying seizures only gives meaning when the classification has clinical consequences, concerning work-up strategy, prognosis and treatment. To achieve this, at least two aspects have to be known: semiology and EEG. Classifying a seizure merely based on semiology can be misleading. A staring spell can be either a focal seizure with affected consciousness or an absence.
One could consider the following:
Based on the two axes, seizures can be classified as:
Then, seizures can be characterized using the semiological and EEG descriptors.
Hermann Stefan and Sándor Beniczky
1 August 2016
Thank you for the great work in seizure classification. I think this is a really practical classification, different from the 1981 one. So, I have a question: Pre-, post- and ictal bursts of sudden running had been reported initially by French semiologists at least since the 1880s, who called it “procursive seizures.” This is currently named “leaving behavior” (LB), and recently has been reported to be a lateralizing sign in MTLE (Jin and Inoue, 2009). In cases of preictal LB, usually a GCT seizure follows it. I think that this behavior, when it is a seizure, must fit into “HYPERMOTOR” sign category (Am I correct?).
A similar procursive behavior so called “jumping seizure” and “running seizure” is observed in some in vivo models of seizure, notely the audiogenic one, and has been attributed to a focal epileptiform activity in hindbrain (Jobe et al., 1972) arising from deep layers of superior colliculus and integrated in the inferior colliculus (Garcia-Cairasco et al., 1992; Tsutsui et al., 1992; Terra et al., 1992; Dutra Moraes et al., 2000, 2005; Faingold, 2012; Vinogradova et al., 2015, 2016). On the other hand, gelastic crisis is a known focal hindbrain seizure type in humans.
Thereby, the question: Is there evidence that of LB may arise from a focal epileptiform activity in hindbrain structures? This seems probable to me. Although the ictal initiation in many cases may arise in structures out of the brainstem (e.g. in MTLS), it is possible a partial recruitment of brainstem structures in any part of the process.
20 June 2016
May I suggest that the name of focal motor seizures which in the expanded scheme appears as “hypermotor” be replaced by the name “hyperkinetic,” in keeping with the ILAE Glossary of Descriptive Terminology? In addition to that please note that “hypermotor” is highly agrammatical, since “hyper” is derived from Greek whereas “motor” is derived from Latin. The etymologically and grammatically correct form should be either “hyperkinetic” or “supermotor.” “Supermotor” might conjure all manner of inappropriate associations in the public’s mind, so perhaps it would be more appropriate to stick with “hyperkinetic”, the opposite of “hypokinetic.’ Furthermore it is imho not appropriate to adopt “hypermotor,” a term which the arbitrary semiological classification system devised by Dr. Hans Lüders has popularized and which has never been accepted by the ILAE, in an official ILAE scheme.
9 June 2016
Dear commission member of the ILAE Commission for Classification and Terminology,
I have following requests regarding epilepsy classification:
First we try to change name epilepsy as electro-clinical disorder with or without neuropsychiatry sign and symptoms to avoid social stigmas with epilepsy and to reduced treatment gap in seizure patients.
Dr Surendra Khosya
6 June 2016
Summary of points raised in debate at Asian-Oceanian Epilepsy Congress, Hong Kong, May 2016
Focal v generalized (concept)
Focal and Generalized (words)
Focal: Gastaut in 1972 rejected focal “to emphasise that the participating neuronal system may be distributed to a variable extent... It cannot be represented geometrically as a locus, even less a focus”. i.e. network rather than focus. But in 2016, we have gone back to focal.
Generalized: is not generalized (the seizure does not start everywhere at once)
Corresponding focal and generalized seizure types
The desire to provide focal and generalized versions of several seizure types and seizure groupings is helpful. However, myoclonic seizures in JME are often unilateral and this may lead to incorrect diagnosis of focal epilepsy. Having a focal myoclonic (distinct from focal clonic) facilitates that error.
“The motor event could consist of an increase (positive) or decrease (negative) in muscle contraction to produce a movement.”
If we can’t tell if focal or generalized onset:
“…Lack of knowledge about the onset makes a seizure unclassifiable with the 1981 system.” This is incorrect:
Suggestion: Don’t classify what we can’t classify. Remove the unknown onset and unclassified categories and subcategories from the figure.
One hemisphere to Both hemispheres
BUT Using generalized for a focal seizure might confuse?
BUT bilateral tonic-clonic does not say focal onset
Consciousness v Awareness
BUT How do you test “contact with events?”
The elusive term to describe a focal seizure with impaired consciousness
Attempts so far:
Suggestion: Keep thinking!
Suggestion: We already have a word for a generalized non-motor seizure with impaired consciousness i.e. Absence. We can redefine “Absence” as “a non-motor seizure with impaired consciousness.”
A few factual errors
4 June 2016
I greatly appreciate the efforts that have been made to resolve the many issues that were raised during the open discussions of the previous versions, and many of the comments made to date have reflected the appreciation for the efforts made. A number of the correspondents, however, have raised a number of concerns. Although some have focused on the word choice for the new epilepsy lexicon, which will always be debated, a number have also raised questions about the purpose and practical application of this vocabulary throughout the international epilepsy community. It is primarily on these latter issues that I would like to focus.
I have read through the manuscript several times and am still not sure where this classification fits in with those that exist and how it is to be used practically. Perhaps the authors should clearly define the purpose of this classification. Specifically is it a classification/organization of seizure types to align with etiologies and pathophysiology or is it a list of approved terms (which may not translate well into the many languages of our members)? If the former, then strict adherence to a limited list of approved terms becomes less important to the conceptual framework that the authors are trying to create.
Assuming that the goal of this proposal is to categorize a seizure type based on clinical information,, the scheme of basic classification is useful within limits. But the authors may also be trying to help localize or physiology and etiology. As others have already noted, for most clinical settings, especially when the resources are limited, most of the classification is not useful as it requires more information than will be available. Even in systems with more resources, the reality is that a more extensive categorization is not possible, as much of the clinical information will not be available or will be inconclusive. For that reason it might be useful to identify levels of classification clearly (it has been done to some extent with the basic and higher level organizational diagrams, but a clearer explanation about what is considered minimally sufficient is important). As the authors clarify the role of this organization and glossary they should consider whether it is a primary aid to a front line practitioner with limited resources working with a population that may not describe the seizure well or whether it is to be used primarily in epidemiological studies or to define eligibility for prospective trials. If this organization is to be used with different levels of complexity depending on the setting, that variable application of the classification should be made clearer.
If it is to be useful at all levels of resources and complexity greater input from those who work under conditions of limited resources is essential to determine what is really possible (or is simply the identification of epilepsy the most important step?).
Further, it is not clear what advantage the more extensive classification brings to our understanding of the pathophysiology of a seizure type, as many are beyond our current understanding. Overall the classification seems to be at odds with the Newtonian observation that “nature is pleased with simplicity.” Greater organizational and lexical simplicity would no doubt enhance acceptance and utilization.
Similarly, semantic simplicity would also improve acceptance. Although one appreciates the desire for linguistic precision (which as others have noted might be lost in translation), relegating well accepted and used terms to the trash bin of the epilepsy lexicon is counterproductive. The reality is that words can have many meanings that are established by widespread common usage. One just has to consider the word “bomb.” Although one immediately thinks about an explosive device, it can also mean an artistic or financial disaster, extraordinary pulchritude, a tasty confection or little packets or herbals to place in a bath, a junked car, a long pass in American football and an explosive statement among others. Aura has a well-established meaning from years of utilization and may be less intimidating to patients than calling one a simple focal seizure. The “partial” vs. “focal” debate is similar (I have no real preference here). The discussion about preserved awareness has raised numerous issues that may not be resolvable with a single term. One wonders if, practically speaking, it is distinction really worth pursuing. As others suggested, simply describing the effect of the seizure on function may be a useful part of the clinical history, but not add much to our understanding of the pathophysiology. People with seizures of similar origins can have vastly different effects on one’s perception of the world and memory of the event.
It would be good to field test the proposal in the front lines of clinical practice in the many regions and conditions under which this classification will be used. Bring it out of the tower and into the field or clearly indicate that this classification is intended primarily for scientific and clinical research. If the latter, the further discussion can be limited to the academic community.
4 June 2016
1. “Awareness” could be as in page 6: Heading “How to use the classification” or as in page 8 Heading “Reasons for decisions” subheading ”Consciousness and awareness.” Awareness as on “Added terms” “designate degrees of impairment of consciousness?”
However, on Glossary is “an aspect of consciousness pertaining to knowledge of one's surrounding.” It means that in the “Added Terms” awareness is a degree. On the glossary is a content or a quality. The same is back again in the last paragraph of the heading “Reasons for decisions” subheading ”Consciousness and awareness” on page 9. Responsiveness is not a quality of the awareness.
2. Where the “auto motor” (self-motor) seizures can be included?
3. On supportive information the classification is obliged to include EEG with Polygraphic (EMG, other) recording if the “seizures usually can be classified on the basis of behavior.” How gene mutations, imaging, etc are supporting behavior characterization?
4. Why automatisms are outside the motor? Why undressing is different from manual (if the concept is extended) “Dèja vécu” is missed, why? And why “unpleased” is not included?
Comments from PORTO (Portugal) Epilepsy Unit, reported by António Martins da Silva on behalf of a group of epileptologists: Rui Rangel, João Ramalheira, João Chaves, Joel Feitas, Pedro Guimarães, Paulo Coelho, Sara Cavaco.
3 June 2016
On 12-14 May 2016 the 20th Conference of Ukrainian League against Epilepsy took place in Lviv (Ukraine). We were visited by more than 30 foreign participants and in total 388 participants were registered, including 236 members of ULAE.
During my report named “The classification of epileptic seizures and epilepsy:past, present and future” six questions were asked to the audience and interactive voting was held. For each question, there were three possible answers: “yes,” “no” or “undecided," More than 200 ULAE members took part in the voting process. Voting results are shown below.
The Organizing Committee of the Conference hopes that these results will be taken into account by the Task Force during discussion on the final version of the classification of epileptic seizures and epilepsy.
On behalf of the Organizing Committee,
3 June 2016
We welcome the new seizure classification, which in our view represents a positive change. In particular, we appreciate the efforts of the Commission to provide translation of terms from older classifications to the new classification and to support the classification by common descriptors and a comprehensive glossary of terms.
The authors stipulate that the new classification is meant for clinical use. We think it would be a missed opportunity not to encourage its use as well in research. Within the EpiPGX consortium on epilepsy pharmacogenomics, we have phenotyped over 10000 patients with epilepsy, recruited from multiple centers in seven European countries. Based on our experience in dealing with heterogeneity in the collection, storage and interpretation of clinical data within and across centers, we propose a few modifications which in our view would allow application of the new classification in a clinical research context and which would undoubtedly benefit clinical practice as well.
The mapping of terms from previous classifications is useful but seems incomplete. Guidance for translation of some other important terms such as primary generalized tonic-clonic seizures or seizures with psychic symptoms is missing. Some new terms are included in table 2 but not in figure 1 (e.g. onset unknown clonic), generating confusion.
It is not entirely clear on which elements the classification is based. In addition to the text which describes the methods for classifying a seizure, it would be useful to provide decision trees or a flowchart to assist with seizure classification. This decision tree would be based on the core data elements and take into account missing information.
Finally, we encourage the Commission to provide standardized computer-readable codes for each of the phenotype items. These would highly facilitate translation of data across different languages and IT systems. Furthermore, such codes would avoid confusion arising from differences in the order of terms used (e.g. “focal aware tonic seizure” and “focal tonic seizure with preserved awareness”).
We thank the Commission for taking our comments into consideration.
Chantal Depondt, Roland Krause, Holger Lerche, Pasquale Striano, Ley Sander, Graeme Sills, John Craig, Sanjay Sisodiya
2 June 2016
I would like to thank the Task Force for its work to improve and clarify nomenclature in epileptology. I have two comments.
First, the Task Force acknowledges that impairment of mental functions is an important part of the seizure classification. The case for changing consciousness to awareness is not entirely convincing, though. In “How to use the classification,” impairment of awareness is suggested as a shorthand for the presence of an impairment in any of awareness, responsiveness, recall, or consciousness (or, equivalently, that the patient is aware if all these are intact). There are some problems with this definition; 1) it is circular, 2) it is contradicted further on in the manuscript, where it is noted that a patient may be aware but unresponsive during a seizure, and 3) it will be almost impossible to ascertain that a patient is aware during a seizure (or, according to the slightly peculiar abbreviated terminology, “has an aware seizure”) without knowing the status for all the factors awareness, responsiveness, recall, and consciousness. Of course, consciousness is an ambiguous entity, but that could also turned into an advantage, since consciousness can through its subjective and objective aspects be ascertained in a number of ways (asking a patient afterwards if she recalls what happened during the seizure, asking her to follow commands during the seizure, apply painful stimuli during the postictal phase, etc.).
Second, the proposal aims for feasibility for professionals and laypersons alike. However, the terminology for the type of seizures commonly called tonic-clonic seizures is slightly confusing. According to the proposal, we have generalized tonic-clonic seizures, focal to bilateral tonic-clonic seizures, and (generalized) clonic-to-tonic-clonic seizures. This terminology makes it difficult to name these types of seizures, especially since the exact classification often is not known. Also, it is difficult to group them together, which would make sense when discussing the risk for SUDEP, convulsive status epilepticus, etc. May I suggest the term tonic-clonic seizure (TCS), which may be subclassified into focal to TCS, generalized TCS, and (generalized) clonic to TCS.
1 June 2016
Dear Prof.Robert Fisher and all members of the ILAE Commission for Classification and Terminology,
I think highly of your attempts to develop an operational (practical) classification on seizure type.
According to the new document your mentioned, many important clincial epileptic seizure type, such as (focal) versive, which is commonly recognized as the vital localized sign, could not be included in the below of focal category.
Moreover, it is well known that an epileptic seizure with epileptic patient may always present a sequence of signs and symptoms during an ictal seizure, such as aura( epigastric aura), hand fumbling, unwareness, followed by head versive, sGTCS etc, how can we classify so many signs and symptoms?
26 May 2016
I would like to thank the ILAE Commission for Classification and Terminology for putting this document in public domain and asking comments or suggestions from the epilepsy professionals.
In my opinion, there are many cons in this “operational” classification. There are no major changes from 2010 classification, so a new classification may not be required just after 5 years and in view of lack of enough evidence. The suggestions made in this document could have been put in some other format e.g. a commentary article.
Here are few points, which I want to highlight regarding the proposed classification and terminologies:
1. The ommision of “auras” from the proposed classification is not a good idea as there are so many patients with epilepsy who present only with aura especially after surgery. This classification does not offer any place to such patients.
2. I do not agree with the term “aware” being used as a classifier. The phrases “focal aware seizures” and “focal unaware seizures” seem very trivial and they simply do not convey the intented message!! In order to fullfill the goal to make the classification understandable by patients and families and broadly applicable to all ages, the underlying scientific gist should not go away.
3. The new classification extended scheme is very confusing because of the following reasons:
4. In the new seizure classifying terms, absence seizures have been renamed as generalized absence seizures. This gives a wrong impression that there are focal absence seizures also!!
5. There are many confusions in the glossary of terms e.g. definition of emotional seizures, confusion between definitions of hypomotor and activity arrest etc.
The consideration of ICD classification in the ILAE classification is a welcome step and should be sought. It is my humble request to the ILAE that there should be a proper representation of all the geographical areas in the committiee so that there is a greater understanding and wider acceptability of the recommendations.
19 May 2016
Dear members of the ILAE Commission for Classification and Terminology,
Congratulations for trying to make the classification more simple. I have two comments to make.
18 May 2016
I read with interest the new operational classification of seizure types. I am happy with the rationale for change and the proposed modifications. However, for the sake of clarity, I would like you to address the following points:
1. If research is one of the possible indications for the classification, a problem arises when the level of accuracy is dependent on supportive information; only for the purposes of research, it should be made clear if a seizure was classified based on clinical findings alone or with the support of laboratory/instrumental findings;
2. It is unclear why epidemiologists are mentioned as a category separate from researchers;
3. Figure 1: "automatisms" are not contemplated among focal, non-motor seizures;
4. ICD9, 10, 11, 12: I suggest changing " … even though ICD10 is just being introducted into US systems" into " … even though ICD10 is just being introducted into US systems and is still unavailable in other countries;" then I wonder whether we should mention ICD12 when ICD11 is still in development.
12 May 2016
We highly appreciate the attempt of the Commission to develop an operational (practical) classification.
Our major concerns:
Sándor Beniczky and Guido Rubboli, on behalf of the Danish Epilepsy Society
5 May 2016
Dear members of the ILAE Commission for Classification and Terminology,
Congratulations to the team for trying to make the classification more and more simple and user friendly. I have two comments to make.
1. Epileptic spasms with focal onset or nonfocal onset
2. I agree with the comment of Dr S Jain that Video clippings brought by the parents/attendants be added to the description of the seizure.
3 May 2016
Dear members of the ILAE Commission for Classification and Terminology,
The new operational classification of seizure types by ILAE has made steady progres s as compared to the previous proposal. I would be grateful if my following minor comments are considered.
1. In Table 2, drop attack is replaced by generalized/focal/onset unknown atonic.
2. Generalized myoclonic seizures can occur in isolation or in conjunction with tonic or atonic activity. Myoclonus differs from clonus by being briefer and not regularly repetitive.
3. Focal epileptic spasms shown in Example 9
3 May 2016
Dear Sirs and Madams,
I have the following minor comments/requests regarding the seizure classification:
With best wishes and many thanks,
2 May 2016
Dear members of the ILAE Commission for Classification and Terminology,
First of all, thanks for this work that is a major achievement for the community. Here are the very minor points that might be considered:
1. The section on "Aura" gives a clear overview of the problem of using the term "Aura." The way to write this paragraph directly describes directly the risk to a misunderstanding related to the use of the term "aura." I would suggest to discuss if the paragraph should start by a statement that an aura is a seizure type.
2. As mentioned by others, it is difficult to classify Eyelid myoclonia under the absence seizures. Using the basic scheme, this seizure type would be most likely to be in the motor generalized. Based on the most usual duration and usual level of awareness without EEG recording (not done or not available), Eyelid myoclonia are more characterized by the motor component than an "absence" component.
26 April 2016
Dear Commission members,
First of all thanks for your continued effort on this complicated matter and for giving the opportunity to comment.
Mutatis mutandis: this proposal does not change too much the things. A few comments:
25 April 2016
I write in regard to the new clinically-focused seizure type classification created by the Seizure Type Classification Task Force. My comments are as follows:
1. The Task Force defines an operational seizure type as a useful grouping of seizure characteristics “for purposes of communication in clinical care, teaching and research by stakeholders that include patients, families, medical professionals, researchers, epidemiologists, medical educators, clinical trialists, insurance payers, regulatory agencies, advocacy groups, and medical reporters.”
The Task Force Members are very well known and some of the most outstanding epileptologists and researchers and have done a wonderful job of the very difficult task allocated to them. An important aspect, however, has been overlooked since the Task Force has no representation from parts of the world where almost 80% of PWE live today. The conditions at the grass root level, social and cultural sensibilities of the “unrepresented part of the world” are totally different and deserve to be addressed in an appropriate manner. Any recommendation by such a task force is going to affect the clinical care; teaching and research involving various stakeholders in the unrepresented part of the world to a much greater extent since majority of PWE live there today!!
2. An example highlighting the different social and cultural sensibilities being the classification of focal seizures as “Focal Aware” and “Focal Unaware.” This is confusing and can be misleading to most people in the “unrepresented” part of the world. “Focal Aware” could be understood as “being aware that the seizure is focal” and “Focal Unaware” as “being unaware that seizure is focal.” These should be classified as “Focal with intact awareness” and “Focal with impaired awareness.” Descriptive terms need not be made too short at the risk of sacrificing their main purpose.
3. In an emerging economy like India (with a population of approximately 1.2 billion), it is estimated that there are about 1027.17 million cell phone users (as of February 2016). An estimated 9 million cell phone users are added every month1, 2. Very often family members bring a video recording of a seizure when they come for the evaluation in the hospital or a clinic. Even if they don’t get it the first time, they can be told to record a seizure and bring it on the next visit. Video recording of seizure at home on a cell phone needs to be encouraged and included in the list of supportive evidence that can help in any seizure type classification scheme.
4. The new classification mentions that “as part of the diagnostic process, a clinician will commonly use supportive evidence to help to classify a seizure, even though that evidence is not part of the classification scheme. Such evidence may include EEG patterns, lesions detected by neuroimaging, laboratory results such as detection of anti-neuronal antibodies, gene mutations, or presence of an epilepsy syndrome known to be associated with either focal or generalized seizures.” Most often, clinicians working in the developing world have no access to any technology when they first examine the patient. The seizures have to be classified on the basis of the subjective and objective description that is available. It is correctly mentioned that, where supportive information is available, it should be used to secure the most accurate classification. The classification of a seizure type may change drastically from the first evaluation based on the descriptive account alone as compared to the “final impression” based on the varying level of supportive evidence(s) available in different parts of the world (on most occasions no supportive evidence is available in developing countries). This aspect of the classification procedure depending upon the variable degree of availability of supportive evidence deserves discussion in the form of a separate paragraph.
5. In the ILAE Seizure Classification 2016 basic scheme, “Generalized” category has two sub-types – Motor and Absence (presumably representing non-motor type). Further, in the ILAE Seizure Classification 2016 expanded scheme, there are Absences with myoclonic jerks and eyelid myoclonias. Both myoclonic jerks and eyelid myoclonias have a motor component. This is confusing and contradictory.
6. The previous classification of seizures that are generalized from the onset into “generalized tonic-clonic seizure” and those having “partial onset seizures getting secondarily generalized” was perhaps based not only on the seizures being focal at onset versus those being “primarily generalized”. There was a hint to the possible etiology in that classification – most focal seizures being secondary to a focal abnormality in the brain while the “primarily generalized” having a possible genetic etiology. This hint toward the underlying etiological possibility appears to get lost in the revised proposal of “focal to bilateral tonic-clonic” that seems to reflect merely a propagation pattern of a seizure.
7. As per the proposed classification, the use of one of the oldest terminology in human epilepsy – the “aura” - has been discontinued mainly because “the aura itself represents a type of seizure, but it often is considered a prelude to a seizure rather than a seizure itself. This may not be obvious to patients, who may, for example, decide to discontinue medicines because they believe themselves to be seizure-free when they only experience auras”. It has been suggested that the use of term “aura” should be replaced with “focal aware”. In comparison to “aura”, the suggested term “focal aware” is very vague, non-descriptive term that has been used to classify many other types of focal seizures. Any term like “aura” that describes in a very captivating manner what the patients experience and is as historical as “epilepsy” itself, needs to be preserved by the “connoisseurs” as part of the “epilepsy heritage”. It was in 1981 that the term “focal” was replaced by “partial”, only to make a strong comeback now as being “more understandable” within a few decades. In case “aura” as a descriptive term is allowed to be condemned, the “romance” in descriptive epileptology will be lost forever!!
1. Telecommunications statistics in India: https://en.wikipedia.org/wiki/Telecommunications_statistics_in_India
25 April 2016
Kudos to the committee for their outstanding effort on a challenging subject.
21 April 2016
Thanks for opportunity of comment. We can classify as seizure
20 April 2016
We should thank the commission for their work in this difficult area, clarifying the seizure classification and maintaining clinical relevance, which will aid applicability and adoption in the wide range of circumstances across the world.
Use of simple terminology in focal seizures aware vs unaware is helpful, particularly in training those new to these concepts and are more intuitive compared to complex partial (the meaning of which gets students confused with complex febrile seizures – complex for an entirely different reason)
Inclusion of epileptic spasms is welcome.
Regarding the subclassification of focal seizures, would it be helpful to specify the main subgroups as focal motor onset or non-motor onset i.e., clarify the temporal relationship? This is to avoid value judgements on which aspect is the main component of the seizure, since there will be subjective variation in perception e.g. is it to be based on duration, intensity, extent etc…
Use of the term “to bilateral tonic clonic” is very specific and, in situations where observers do not identify both tonic and clonic components, may lead to (a.) inability to classify as such or (b.) over-designation of tonic clonic secondary generalized semiology. Perhaps retention of “secondary generalization” would continue to serve well in this respect.
Thank you for your kind consideration.
20 April 2016
This is an excellent proposal and a clearly written document that is going to be very useful when accepted. I only have a couple of comments:
16 April 2016
The basal scheme this new approach is suggesting to follow is nicely simple and certainly easy to use.
In one particular field I feel oversimplification and loss, i.e introducing "focal nonmotor aware" to include all the seizure-states well-known as aurae. The new term in my view does not mirror the richness and complexity of auras. Many of them are multimodal (comparable to Jackson's dreamy states) combining sensory-autonomic-cognitive facets.
Then, how to fit in the classic "epigastric aura" into your scheme? Where to put the ecstatic sensation? In addition, many auras neither do correspond to aware nor unaware, they are somehow inbetween; thus can you really classify/designate any of them as "aware?"
Aurae are classic, they are known ever since, the term transfers much of the fascinating nature of epilepsy (an important part of it). Of course there's a need to use it correctly (e.g contrasting prodromi). Of course, many patients do not know about auras as themselves representing seizures (until you explain and teach them…) However: the term "aura" grasps that it happens in the subjective sphere of the patient's experience. "Focal non-motor aware" is a very technical, cold term - but we're not talking about mechanical clockworks.
Why do you sacrifice the "aura?"BS Kasper
16 April 2016
Thank you for the opportunity to comment.
Do we really need another overhaul of the operational classification scheme? Particularly without any major new contributions from underlying neurobiology. The current scheme whilst imperfect serves well clinical, research and teaching needs.
My initial thoughts on this paper are:
11 April 2016
I like the new seizure classification. I read it too quickly so apologies if my comments are redundant.
There is still an unresolved issue, with respect to “unresponsive stares” a.k.a. “dialeptic seizures”. I agree that absence seizures still require generalised spike and wave or polyspike wave, but we need a term for the unresponsive stare semiology, when we do not know yet if it is an absence seizure. I think “unresponsive stare” is the best term, and it could be added to the list of focal sxs. Sometimes a frontal lobe onset seizure becomes an absence seizure with generalised spike and wave during the unresponsive stare i.e. an absence. This is then a secondarily generalised absence seizure. However if the “secondarily generalised” terminology is to be abandoned… I suppose we can call them frontal lobe onset absence seizures.
If revising the seizure classification, I think presenting the electroclinical seizure classification / terminology with ictal EEG correlates, and a parallel semiology classification / terminology without ictal EEG criteria would be a great help, as many still get muddled, e.g. calling unresponsive stares “absences” even when there is no generalised spike wave / polyspike wave accompanying them.
It is good to include epileptic spasm in generalised and focal and unknown onset groups. Perhaps for the next revision of the epilepsy terminology, it would help to abandon “infantile spasms” as an epilepsy name, (use West syndrome), and use “infantile epileptic spasms” for the epileptic spasms of West syndrome. Epileptic spasms are also important seizure types in older children.
11 April 2016
This is a noble effort to make the classification of seizure types more accessible to more people, who are not necessarily familiar with former terms. There is one glaring omission, and that is subclinical seizure discharges, often prolonged and/or frequent, that might or might not impair awareness in adults. These adults have what is called "idiopathic generalized epilepsy," and they are a distinct group who usually have their first generalized tonic-clonic seizure around age 20 or later (Marini et al., J Neurol Neurosurg Psychiat 2003;74:192-196; Fujikawa et al., Epilepsy Behav 2012;25:442-448). They have EEG discharges of varying duration (2-3 Hz bilaterally synchronous spike and/or polyspike and slow-wave discharges) often without clinical signs. They are not simply a form of juvenile myoclonic epilepsy (JME), first, because they may or may not have myoclonic seizures (or absence-like seizures), and secondly, because their discharges are generally 2-3 Hz and not faster discharges, as occur in JME.
Denson G. Fujikawa
8 April 2016
Bravo – this is major step forward in clarity and respects the previous classifications. It looks easy to use and the terms are intuitively obvious.
7 April 2016
I welcome the further clarification and proposed amendments in the new seizure classification. The revised approach, whilst retaining the scientific and philosophical rationale of the 2010 document (albeit in a rapidly changing area), will I think be more readily accessible to non-specialists and thus more likely to be implemented over time but doctors and patients alike. As well as being fundamental to support research and improvements in care, this is important given that the majority of people with epilepsy worldwide will never have access to an epilepsy subspecialist, and even in developed countries access can be patchy. Furthermore – patients and carers are the individuals we communicate with most regularly about their seizures, so having a terminology that they can readily understand is clearly desirable. To improve the care of people with epilepsy we all need to speak the same language (in our different languages!) – to benefit the individual and the epilepsy society.
As is highlighted it is already compatible with ICD11, again of importance for many reasons worldwide. Whilst status epilepticus is a different condition, that there are some parallels in approach between this document and the ILAE Taskforce on Classification of Status Epilepticus (Trinka et al, Epilepsia 2015) in relation to motor, non-motor, and awareness/consciousness will also likely support more harmonized communication with non-specialists.
As someone who does a lot of undergraduate teaching, and having sometimes struggled to adequately convey changing classifications in this context, I can also see how much more readily this new proposal would be understandable to a relatively uninformed, but scientifically inclined audience and look forward to hopefully using it.
Congratulations to the taskforce.
Dr Hannah Cock
6 April 2016
Can I overall compliment the committee on this important work. I recognise the difficulty in getting agreement across a disparate community of epileptologists, and the importance of having a seizure classification system that works across different languages.
However, I have a couple of concerns, mainly around the use of "focal" to describe seizure types perviously regarded as 'generalised.'
Dr John Archer, FRACP, PhD
6 April 2016
Thanks for all your efforts. I have a few comments.
The terms focal myoclonic and focal atonic might be confusing and difficult to ascertain. Many patients with myoclonic seizures including JME (a generalized epilepsy syndrome), have asymmetrical, at times one sides jerks and existence of this terminology may lead some people to wrongly classify patients that may lead to wrong management.
Focal semiologic and electroencephalographic features in patients with juvenile myoclonic epilepsy.
Also, epileptic spasms are often a result of a focal pathology, but may be a consequence of a generalized process (e.g., in genetic or metabolic causes). If it is included in focal, it should also be included in generalized.
Also, what happens to the classification of patients with focal epilepsy and manual automatism or dystonic posture? These are motor phenomena, but none of the focal motor classifications, which are included in the proposal, cover them, specially for nonhypermotor manual automatisms.
Within generalized classification, what is the advantage of having both tonic-clonic and clonic-tonic-clonic? We know that CTC seizures are more in favor of generalized syndromes compared with TC seizures, but within the generalized group having CTC vs TC does not offer any diagnostic or therapeutic advantages. Yes, it exists, but is it really necessary? More subgroups would make future studies more difficult.
Thanks again for all your efforts.
6 April 2016
The new seizure proposal unfortunately does not take into account my mother language at all. No wonder since nobody from the German language region was considered to be educated enough to participate,. The result is that nobody will be able to translate the term awareness properly and usably into German. Dyscognitive was understandable and appropriate, awareness as a distinction and as a term is not. Therefore this classification will simply not be used in the second biggest chapter of the ILAE.
Second comment: It is not acceptable to use the term “cognitive” seizure. This is semantic suicide. Nobody in the world will use this term for an epileptic seizure.
6 April 2016
Thank you very much for your continuous hard work on further organizing this. Your classification seems or appears to make more emphasis in what is in the adults with epilepsy, despite the presence of several pediatric epileptologist on your team.
I would replace “UNKNOWN” Epileptic Spasms. All seizures are unknown on presentation despite they could suggest either focal or generalized ONSET. You suggest to use either – after imaging – either focal or generalized, as you state in your example. I urge you to change to FOCAL OR GENERALIZED OR EITHER or BOTH.
Second, NOT all seizures that evolve bilaterally are TONIC-CLONIC. Clinical experience as documented on video-EEG clearly has revealed focal seizures can evolve BILATERALLY – even to status – without any tonic activity, I would clarify or extend this.
Please see below
6 April 2016
The very first item I wondered about when reading through the proposed classification was "awareness." There have been many attempts so far to optimize the term describing what happens during this kind of seizures. Whether told by the patient, a lay witness, or professional observer, several terms have been/are in use to characterize what happens, but each is emphasizing a different facet.
To me, impaired awareness, again is not optimal to catch the core issue. There are patients who are aware of themselves having had/having a seizure albeit conciousness, responsiveness, memory … has been significantly to severely impaired. Others again don't notice their own seizures at all, i.e are not aware of them. Thus, while appreciating that awareness can be reduced to abolished during certain seizures, there's this other meaning of awareness (which i think is very helpful)
6 April 2016
Congratulations, nice message about epilepsy. Further problem is when translation in countries not english speaker, create a variation in terms that otherwise, had been coined by using, is important each nation and so federation and so, work in the important isue of translation.
Thank you anyway,
6 April 2016
To whom it may concern:
Neurologists and pediatricians have been calling laughing seizures "gelastic" in order to emphasize that these involuntary bursts of laughter are typically not induced or accompanied by an appropriate affect like mirth, amusement or happiness. This detail of seizure semiology is crucial for parents and carers to understand and interpret the patient's seizures correctly. Thus, it seems misleading to re-classify them as "focal emotional" seizures. (In very rare cases of temporal epileptogenesis, gelastic seizures can indeed be accompanied by mirth, but these are exceptions.)
Accordingly, as a behavioural descriptor (Table 1) "gelastic" should be classified under "Automatism" rather than "Emotional or affective."