Understanding Epilepsy

 

Epilepsy is not a newly discovered condition but a well-known disorder of the brain, prevalent since ancient times. The ancient people have written about the symptoms and causes of epilepsy about 3,000 years ago. They thought that epilepsy was caused by demons attacking the person. Today, we are aware that epilepsy is a well-known medical condition affecting around 50 million people worldwide.

Let us understand what epilepsy is about a bit more.

What is epilepsy and what is a seizure?

Our brain is a complex organ made up of many specialized brain cells. These brain cells perform electrical activities, which occur in a normal pattern and are responsible for the normal functioning of the brain and the body. Epilepsy is a disorder of the brain cells where there is a recurrent, sudden and episodic burst of excess electrical activity resulting in a change in behaviour of the person with or without jerky movements of limbs, with unconsciousness.

However, a seizure is one single episode of such a change in electrical activity. One single episode of a seizure may or may not be a part of epilepsy. Instead, it can be a symptom of different conditions that can affect the brain, e.g. kidney failure, liver failure, excessive alcohol or illegal drug intake, some medications, change in blood glucose levels, fever etc. Seizures often do not recur in a person, if the above mentioned conditions are controlled. In epilepsy, seizures occur again and again and they are unpredictable.

What are the different types of epilepsy?

Epilepsy is of different types depending upon the pattern of electrical abnormality in the brain. In some cases, the electrical abnormality can start in the small area of the brain, whereas, in some cases it can affect the whole brain.

What are the symptoms or behavioural changes during epileptic attacks?

Different area of the brain control different functions. Depending upon which area of the brain is involved & the type of epilepsy; the behavioural changes happening during an epileptic seizure are different. The symptoms or behavioural changes are unique to every patient. Some important behavioural changes are listed below. It is not implied that every person with epilepsy will experience every symptom described below. \

 
A person with epilepsy is active and normal in-between the seizures.

Seizures or epileptic attacks have a beginning, middle and an end.

Beginning: When an individual is aware of the beginning, it may be thought of as a warning or “aura”. On the other hand, an individual may not be aware of the beginning and, therefore, have no warning. Below are some types of auras experienced by some patients:

 


         Abnormal smell, sound or taste

         Decrease clarity in seeing

         Racing thoughts

         Strange feelings

         Fear/panic/anxiety

         Headache

         Lightheadedness

         Need to vomit


 

Middle: The middle of the seizure may take several different forms depending on the type of epilepsy and the area of brain involved. 

The symptoms can range from:


         Confusion

         Becoming unaware of the surrounding

         Falling down

         Jerking of body

         Difficulty talking

         Drooling of saliva

         Eyes rolling up

         Inability to move

         Loss of control on urine& stool

         Making abnormal sounds

         Teeth clenching/grinding

         Tongue biting

         Twitching movements

         Breathing difficulty

         Heart racing

         Sweating


 

Or the symptoms can range from:


·         Simple staring

·         Eyelids fluttering

·         Unresponsiveness

·         Abnormal movement of tongue and lips

·         Hand waving,

·         Foot stomping

·         Aimlessly wandering


 

End or After-seizure: After the seizure stops, the person may/may not experience the following symptoms for a short while:


·         Memory loss and confusion 

·         Depression and sadness

·         Injuries

·         Difficulty in talking

·         Exhaustion and weakness

·         Headache

·         Wanting to vomit

·         Thirst

·         Shame/embarrassment


 

Does a person who gets only a single seizure have epilepsy?

A single seizure in a person does not mean that he/she has epilepsy. It is estimated that the majority of people who have had an isolated, single seizure will never have another one. On the other hand, persons who are destined to develop epilepsy will have the second seizure after a variable interval, usually within one year of the first one.

 

What causes epilepsy?

The reasons as to why epilepsy occurs are different for people of different ages. But what's true for every age is that the cause is unknown in about half of the people with epilepsy.

However, in some cases, the causes can be traced and could be one of the following:

·         Infection of brain like – tuberculosis, neurocysticercosis

·         Damage to brain nerves due to decreased oxygen at birth

·         Bleeding inside the brain

·         Abnormal blood vessels in the brain

·         Serious head injury or lack of oxygen to the brain

·         Brain tumours

·         Infections of the brain, e.g. brain abscess

·         HIV infection

·         Stroke

·         Abnormal brain development

·         Trauma to the new born during childbirth

·         Family history of epilepsy or genetic factors

·         Alzheimer's disease (disease of old age affecting the memory)etc\

  

What is the frequency of attacks in patients with epilepsy?

Epileptic attacks can vary in frequency from less than one per year to several per day.This depends upon the type of epilepsy,various trigger factors and the success of the treatment.

What are the trigger factors for an epileptic attack?

Trigger factors are those events or conditions that are responsible for resulting in an epileptic attack. Some of them are noted below:

·         Forgetting to take medicines for seizures

·         Stress

·         Lack of sleep, fasting

·         Menstruation (Monthly hormonal cycle in women)

·         Illnesses both with/without fever

·         Heavy use of alcohol or other drugs which can result in a seizure

 

These triggers can be avoided to prevent epileptic seizures. Some important tips in the “Living with Epilepsy: Some DOs and DON’Ts” section will help you manage your condition better.

How is epilepsy diagnosed?

Epilepsy is diagnosed by a doctor with the help of information aboutthe events that happened before the attack, during the attack and after the attack. The description of such events can be given to the doctor by the patient as well as witnesses of the epileptic attack. The doctor may ask the following questions:


         At what age did the seizures begin?

         What factors resulted in the seizures?

         What is felt before, during and after the seizures?

         How long do the seizures last?

         How frequently do they occur?

         Has there been previous treatment for epilepsy?

         Which medicines have been prescribed and in what dosages?

         Was the treatment effective?

 

 

 


 

Apart from interviewing and examining the patient, the doctor may order a few tests as per his/her discretion in order to confirm the diagnosis, find the cause of the seizures, and decide on further management and monitoring of treatment.

 

Some important tests

A. Electroencephalogram (EEG)

This is a test that is done to trace the electrical activity of the brain. During the test, many wires called electrodes are attached to the patient’s scalp and they pick up the electrical activity of the brain. The information recorded is transferred onto a computer where it is analysed. In a patient with epilepsy, the electrical activities recorded are abnormal (as against the normal electrical activities of a normal brain). Thus, an EEG not only helps to diagnose a seizure, but also to locate from which part of the brain it is arising. Sometimes it helps to find the possible cause.

EEG is showing abnormal electrical discharges present in all leads suggestive of generalized epilepsy.

B. Brain scans

Computerized tomography (CT) & magnetic resonance imaging (MRI) are scans that produce pictures of the brain and may reveal the structural abnormalities in the brain which may be the cause of epilepsy. These may or may not be used by the treating doctor, depending upon the requirement. MRI brain with Epilepsy protocol focusing hippocampal areas and MPGR sequences are most informative.

 

 

C. Blood tests

There are certain blood teststhat the doctor may ask for to confirm the diagnosis. Also, blood tests are important to check drug levels during the treatment, to correlate side effects with the drugs, to know the drug reactions in patients receiving more than one drug for control of their epilepsy and in certain conditions,such as pregnancy orin patients with liver/kidney failure, where the drug levels can change.

How is epilepsy treated?

Epilepsy is a manageable condition. Some important tips are discussed in the “Living with Epilepsy: Some DOs and DON’Ts” section. The mainstay of treatment in epilepsy is medication. The drugs used for treating epilepsy are called anti-epileptic drugs.

The good news is that with any anti-epileptic medicine, 80% of people with epilepsy remain free of attacks at any point of time. There are a variety of anti-epileptic drugs available. The doctor will decide the appropriate medicine, depending upon the type of epilepsy, age and gender of the patient, and any related illnesses.

Depending upon the condition and the extent of control possible overthe epileptic attacks, the doctor may prescribe one drug or multiple drugs. Generally, the drugs are started at lower doses and, gradually, the dose is increased till epilepsy control is achieved. While prescribing the drugs, the doctor will explain the side effects related to the medicines.

In some of the patients seizures are not controlled with antiepileptic medications. These patients require epilepsy surgery after doing proper evaluation.   

 COUNSELLING

 SPORTS

High risk-flying, gliding, skydiving, parachuting, hang gliding, rock climbing, motorcycling, boxing.

 MODERATE RISK

-          Horseback riding, snowmobiling, hockey, swimming, weightlifting, bicycling, fishing.

 LOW RISK

-          Racquet sports, golf, curling, range shooting, ball games, jogging.

 

-          Low risk sports can certainly be attempted with protection such as helmets and padding even if seizure control is not fully completed.

 MARRIAGE

Most epileptics patients’ marital problems are rarely related to the actual seizures but are more frequently due to secondary emotional disorders.

 EMPLOYMENT

If the seizures are not completely controlled and if they occur during working hours

- should not seek jobs which would place them or their co-workers at riskj. Eg pilot, driving, swimming

-Avoid working at height and near fire

 PREGNANCY

During pregnancy seizures frequency is variable and antiepileptic should be continued during pregnancy.

-          Most of anti epileptics drugs can cause fatal malformation around but benefits of medication are much more in controlling seizures than small risk (around 3-7 percent)

Consult your neurologist to optimize the medication for seizures during pregnancy
LACTATION

During lactation anti epileptics should be continued.

 PRECAUTIONS

1-    No driving around minimum 6 months (single seizures) but preferably 2 yrs seizures free period

2-    No swimming

3-    Normal sleep of 6-8 hrs

4-    Watching TV should be avoided, distance must be maintained

5-    Avoid video games

6-    Avoid working on computer for long period prefer to use LCD or Laptop and antiglare screen

7-    No fasting

8-    No missing of the drug

 

 If you have Epilepsy, you can hold a driver license or learner permit as long as your seizures are well controlled

Guidelines for commercial truck, taxi and bus licenses are stricter than those for private licenses

In most cases, if you have had any form of epileptic seizure (apart from some childhood seizures), you will not be permitted to drive commercial vehicles.

The period that you must be free from seizures before driving depends upon your type of epilepsy and the circumstances surrounding the seizure.

 Single seizure on withdrawal of medication

On medical advice 1 month

Seizure due to sleep deprivation;

Generalise epilepsy syndromes;

Seizure following illness or other health problems 3 months isolated seizure(s);

Recent diagnosis;

Partial epilepsy syndromes 3-6 months

Any seizures while driving;

Temporal lobectomy;

Sleep epilepsy (seizure during normal walking periods) 1 year

Non compliant patients;

Chronic epilepsy 2 years

Under some circumstances a restricted license may be possible e.g. a person with nocturnal seizures may be granted a license to drive during daylight hours only. In every case, individual circumstances apply.

 WHAT IS TO BE DONE DURING SEIZURES

-          Make patient lie down one side position

-          Noting to be given by mouth

-          Remove all sharp articles around patient

-          Maintain airway of patient and proper ventilation of room

-          Midaspray or insend nasal spray as advices by doctor. (8-10 puffs in each nostril in adults and 4 puffs in each nostril in children) modifiable according to weight

-          OR Tab Midazolam (Lobazem MD 10 mg SOS – mouth dispersible immediately after completion of seizure)

-          If seizure lasting more than 10 minutes then go to nearby hospital or inform to treating neurologist for injectable medications.

                                              

                       

It is very essential to adhere to the treatment and avoid missing doses in order to achieve control over the epileptic attacks.

As mentioned above, most cases of epilepsy get controlled with medicines alone. However, in some cases, depending upon the cause of the epilepsy, and after thorough examination the doctor may recommend surgery as a treatment for epilepsy if required.  Surgery is attempted to remove the area of the brain which is responsible for the epileptic attacks. The success of the surgery is very variable and depends on various factors which should be discussed with your treating doctor.

Does anti-epileptic treatment have to be continued for life?

The anti-epileptic treatment may or may not be continued for life. The criterion for stopping the treatment is very variable. It depends on the type of epilepsy, the age of onset of symptoms, and the extent and duration of control over the epileptic attacks when under treatment. In most of the patients the treatment may be stopped if the patient remains seizure-free for a period of 2—5 years. This decision is made by the treating doctor who will make the decision after analysing different aspects of the situation. However, there are chances that the seizure may occur again after stopping treatment and the treatment might have to be started again.

Never stop the treatment, unless the doctor advises to do so.

Can epilepsy be cured?

Epilepsy can be cured in most of the patients. Epilepsy is a disease like hypertension, asthma and diabetes. Seizures can be totally controlled in almost 75-80% of epilepsy cases with medications alone. In some people, especially children, the seizures never recur after stopping their anti-epileptic treatment;these people can be considered to be cured of their epilepsy.    

DR. PUNEET AGARWAL
M.D, D.M(Neurology), FCCN(UCLA,USA)
Ex Asst. Prof Neurology, AIIMS, N.Delhi
HEAD OF NEUROLOGY

Max Superspeciality Hospital
Saket, N.Delhi
Ph: 011-66116666(O), 9971545666(m),