Epilepsy
Seizures and Epilepsy
Seizures are transient or brief alterations in brain function that manifest with motor, sensory or autonomic disturbances. Epilepsy is a term used to describe recurrent seizures or even a single seizure with a high chance of recurrence. Typically seizures are thought to be associated with loss of consciousness with stiffness of shaking of the limbs, eyes rolling back, foaming at the mouth and tongue biting with bladder or bowel incontinence.
However there are many types of seizures. The above description applies to generalized seizures affecting both sides of the brain simultaneously (earlier referred to as grand mal). Seizures can be partial seizures (earlier referred to as petit mal) when only half or less than half of the brain is affected and may be simple partial when awareness is preserved with auras or progression to one sided symptoms, or complex partial when awareness is affected in addition to focal symptoms. These seizures can then spread to the other side of the brain and result in secondarily generalized seizures. Seizures can also be described based on the symptoms of being tonic ( stiffness), clonic ( rhythmic jerking), tonic-clonic, myoclonic( with trunk or limb muscle spasms), atonic or astatic( limpness), or absence ( staring off) in type.
Neurologists and epileptologists (neurologists with epilepsy fellowship training) are trained to differentiate the various types of seizures and decide on further investigations and management options. ( click to find neurologists/epileptologists in your area).
Seizures are injurious for several reasons directly linked to them :
-tongue bites, dislocations, fractures during a seizure.
-SUDEP or sudden unexpected death in epilepsy during sleep due to suffocation, respiratory or cardiac disturbances.
-anoxia or brain injury due to prolonged generalized seizures resulting in lack of oxygen to the brain.
And injuries indirectly linked to them including :
-passing out with falls and head or bodily injury, driving accidents, dropped objects or burn injuries.
-cuts and bruises.
-loss of driving privileges, employment, relationships, depression and social stigma.
Causes of Seizures and Epilepsy
Seizures occur due to various causes (most seizures have an unknown cause) and broadly they can be narrowed down to the below two categories- genetic and secondary causes.
Genetic or idiopathic- family history of seizures with well known genetic syndromes such as :
-febrile seizures ( seizures with fevers during childhood)
-febrile seizures plus ( seizures with and without fevers)
-neonatal and infantile myoclonus ( seizures with truncal and body jerks during the first year of life)
-absence seizures( brief staring spells <12s long usually occurring multiple times a day mostly in the young)
-BECTS or benign epilepsy of childhood with centrotemporal spikes ( usually at around age 4-8yr age, with remission by age 14yrs)
-JME or juvenile myoclonic epilepsy ( associated with morning jerks on awakening, dropping of objects, and seizures induced by sleep deprivation, flashing lights, video games, and alcohol use beginning in the teens)
-Generalized tonic clonic seizures on awakening.
Secondary to known or unknown causes :
-West Syndrome ( seizures with jack knife truncal and arm movements during infancy) due to brain abnormalities
-Lennox Gastaut Syndrome (seizures of multiple types, slow spike and wave noted on EEG and mental retardation)
-Dravetts syndrome ( severe myoclonic seizures)
-Secondary to brain abnormalities including tumors, infection- encephalitis and meningitis, strokes, brain injury, concussions, developmental abnormalities including vascular malformations, and dysplasias, etc.
Differential Diagnosis: Seizures may be confused with the below possibilities:
Fainting episodes or syncope (especially if upright while passed out can be associated with few jerks – convulsive syncope) either due to low blood pressure or cardiac heart related disorders.
Nonepileptic or behavioral spells without EEG changes.
Tremors due to cerebellar or deep brain basal ganglia abnormalities
Myoclonus due to kidney problems (uremia), lack of oxygen or liver problems (high ammonia levels)
Diagnosis :
A diagnosis is usually made by taking a thorough history from witnesses at the scene, and from EMS personnel and evaluation by a neurologist ( please click for neurologists in your area). Various tests including imaging of the brain with CT scan or MRI brain (click to find imaging facilities) (click here to find out the cost of imaging studies), EEG Electroencephalograms usually performed in hospitals or neurology offices (click to find cost). Fainting spells are usually additionally worked up with Carotid Ultrasounds and Echocardiograms (click to find cost). if needed based on history.
Treatment:
Fortunately once the diagnosis is made there are many different options to treat epilepsy. A decision to treat or not to treat with anti seizure medications ( anticonvulsants) is made by the managing physician based on whether this was the first episode (only 50% of first time seizures likely to recur) and whether there was an obvious provoking cause that can be avoided in future. If there is a high chance of recurrence ( repeated or recurrent episode, abnormal neurological examination, or abnormal imaging or EEG findings) a trial of anticonvulsants is warranted. There are many seizure medications which are listed below with major side effects (common favored ones listed on the top). Which one to use is based on individual factors and physician based reasoning. All anticonvulsants have a black box warning of minimal increased risk of suicidal ideation which needs reporting to physicians should this arise. In addition to the below side effects allergic reactions are also common.
-Keppra (Levetiracetam) – irritability, asthenia rarely.
-Dilantin ( phenytoin) - one of the older quite effective anticonvulsants, is associated with dizziness, imbalance, and long term side effects such as gum hypertrophy, osteoporosis, neuropathy and coarse facial features. A level is easily available and checked to maintain between 10 and 20. Typical initial doses range from 300-400mg at night.
-Tegretol ( Carbamazepine) - one of the older anticonvulsants and well tolerated. CBC, Liver function tests and periodic levels can be checked to maintain levels between 4-12 (however in many cases levels may not be necessary if the seizures are under control with any particular dose). Typical initial dose ranges between 400-600mg a day.
-Lamictal (Lamotrigine)- steven johnsons rash especially if dose escalation is not as recommended, rare headaches. Is a mood stabilizer and is occasionally used for bipolar disorder.
-Trileptal ( Oxcarbazepine) – can cause low sodium levels. Also a mood stabilizer.
-Zonegran ( zonisamide)- sulfa allergy cross reaction.
-Vimpat ( lacosamide) – nausea, fatigue
-Depakote ( Valproic acid)- Weight gain, liver dysfunction, low platelets, hair loss, tremor, polycystic ovarian disease, and teratogenic. Works well for migraines, and mood stabilization
-Topamax ( topiramate)- weight loss, fogginess, difficulty with word finding, tingling. Works well for migraine.
-Lyrica ( pregabalin)- works well for neuropathic pain
-Neurontin ( Gabapentin) works well for neuropathic pain.
-Felbatol ( felbamate) blood dyscrasias, liver dysfunction. Used only for Lennox Gastaut Syndrome LGS.
-Banzel ( Rufinamide) Used only for Lennox Gastaut Syndrome LGS.
-Klonopin (clonazepam) drowsiness.
-Oxtellar ( Extended release trileptal) has less hyponatremia
-Aptiom ( Esclicarbazapine) once daily and with less hyponatremia.
-Onfi (Clobazam) a newer agent is a benzodiazepine and used for refractory epilepsy.
-Fycompa (Perampanel) typical dose of 2-8mg a day. Used for partial onset seizures or localization related epilepsy.
-Trokendi ( a delayed release topiramate ) is now available and with fewer side effects than topiramate. Kidney stones is a contraindication for its use.
Tips for Epilepsy
Avoid tub baths
Avoid driving until seizure free for 6 months according to state laws
Avoid heights
Avoid swimming without supervision
Avoid diving and sky diving, and other risk activities
Avoid roof top work
Use the inner hotplate and keep the handles of pots turned away to avoid accidental burns from seizure attacks.
Avoid sleep deprivation, flashing lights, alcohol use, substance use and video games.
In refractory epilepsy, evaluation for epilepsy surgery is an option. This consists of inpatient admission for long term Video EEG monitoring in an epilepsy monitoring unit (EMU) for capturing 4-6 seizures on video and EEG recording and assessing if this arising from a single area of the brain ( focal) or from initial simultaneous whole brain involvement (generalized ). If focal in onset then epilepsy resective surgery may be a an option. Otherwise vagal nerve stimulation may be considered in the appropriate setting.