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       What is epilepsy?
         Posted on :16:05:05 Feb 1, 2018
       Last edited on:18:15:31 Feb 1, 2018
         Tags: epilepsy

Epileptic seizures or ‘fits’ in common parlance, refers to the short lasting signs or symptoms that occur due to abnormal and excessive misfiring of brain cells. It can be characterized by brief episodes of involuntary movements that may involve a part of or the entire body, and can be accompanied by loss of consciousness and control of bowel or bladder function. The term epilepsy has a different connotation, pointing to an ongoing predisposition for repeated seizures and also to the ensuing physical, psychological and social consequences of this condition.

Epilepsy: The problem
Latest WHO numbers reveal that about 50 million people are living with epilepsy worldwide with nearly 2.5 million new cases being diagnosed each year. It is a major public health problem and uncontrolled epilepsy can have serious consequences with neurological, psychological and social disabilities that adversely affect the quality of life of the person and their families and even can cause unexpected sudden deaths.

Causes of seizures and epilepsy
There are a number of different causes which trigger the abnormal electrical firing or storms inside the brain network. In the acute setting, medical conditions such low sodium or sugar level, stroke, trauma, alcoholism related, certain infections and inflammations that affect the brain all can cause seizures. A major proportion of childhood, adolescent and even adult onset seizures are consequences of injuries sustained to highly vulnerable fetal brain during and after child birth. There are a group of epilepsies which occur in a particular age with no apparent causes, some of which can have high seizure load, adversely affecting child’s development and can have devastating consequences. Recent research shows that many of such epileptic disorders have a genetic component which need not always run in families.

Types of seizures
Depending on the nature of events that occur during the attacks, seizures can be broadly divided into focal and generalised seizures. In focal seizures, usually one part of the body may be involved but can progress to involve all four limbs wherein they are called generalised seizures. Not all seizures would include dramatic jerking of limbs and body with frothing from mouth. Certain types of seizures may be very subtle and can be easily missed. For instance, in absence seizure, which is a type of generalised seizures seen in childhood, there may be brief spells characterised by blankness- as if relay is lost-along with eye blinks. In certain other cases of focal epilepsies, such as in temporal lobe epilepsy, there might be arrest of activity with chewing and lipsmacking movements along with fumbling hand movements or in frontal lobe epilepsies there might be sudden violent movements or loud screaming, which may be very brief and can occur in sleep. The age, frequency of events, the time of the events all has a bearing on deciphering the type of seizures and the epilepsy syndrome.

What to look out for: from physician’s perspective
The correct identification of the type of seizure and the epilepsy syndrome is of paramount importance and helps the physician to guide a patient’s treatment. The single most important factor that aids this process, is a concise, accurate and articulate history obtained from the patient and bystanders, with queries for information extending as far back as their childhood or even birth. Often, the patient may be unaware of the event and it is the bystander or family members that have witnessed a seizure, who can give a detailed description. Sometimes, the patient himself may be able to elaborate certain warning signals that immediately precede an attack- called “aura” in medical parlance. It can be anything from repeated twitches of one hand or face, tingling sensation of a part of body, visions of bright lights or colours and at times intense emotions such as fear. More often than not the bystanders on witnessing the seizure may panic and may not recollect the details of the event. This is quite natural. But one should bear in mind that a proper description of the event, in sequential order from start to finish leading up till recovery would go a long way in helping your doctor come to a correct diagnosis. It has to be appreciated that many a times, people with good presence of mind has presented to the doctor the video of the captured event, which has proven invaluable to the physician. When consulting the doctor, make sure you provide him with all previous documents, scan films and prescriptions as well as the current medicines, which may save time and can potentially avoid re-investigations. 

Things to do and not to do during seizure
First and foremost do not panic and lose your presence of mind. The sensible actions of the bystanders may at times save the patient from significant injury and can assist in recovery. The falls sustained during seizures can result in serious injuries much more dangerous than the effect of seizures. In case of generalised seizures, protect the patient from injuries by helping them to floor or if in bed take necessary measures to prevent a fall. Gently turn the patient to one side so that whatever froth and saliva that may collect may flow out. One should try to loosen any tight or constricting clothing that may block his or her breathing. Do not press down on the patient in order to subdue the jerks. Unless specifically mentioned by the doctor do not attempt to give any medication or attempt to give drinks until patient is fully conscious and awake. Evidence is lacking whether introduction of any material into the mouth to prevent tongue bite may be beneficial, in fact it may be counterproductive and can injure patient or the helper. There is no scientific evidence that the age old custom of handing metal objects or sniffing objects would abort seizures and is best avoided. Usually most of the seizures would stop by itself in a minute or two. Do not leave the patient unprotected; be with the patient till he or she recovers which usually occurs in ten to fifteen minutes. Post ictally patients may have confusion, headache or vomiting. Gentleness, empathy and reassurance will give them confidence and would assist in recovery.

When to seek urgent medical attention
First seizure, irrespective of age, sex or time of event warrants urgent medical evaluation. In those patients who are suffering from epilepsy, a breakthrough seizure of habitual nature may not warrant an emergency hospital visit, but of course has significance, needs to be noted and communicated to the doctor. Attention must be paid whether seizure occurred due to drug default, change in lifestyle such as decreased sleep, alcohol intake or a particularly stressful time of life. However, clustering of seizures occurring one after another in a brief period of time, prolonged seizure that does not remit even after the routine duration or lasts longer than five minutes or seizure after which patient do not regain normalcy even after the usual period all demand urgent medical attention.

During your initial consultation the doctor may be more interested in your description of the event and physical examination. Accordingly the physician would decide on relevant investigations. These include routine blood tests, Electroencephalogram(EEG) with or without sleep and Magnetic Resonance Imaging(MRI) of the brain with particular focus from epilepsy point of view. These are neither exclusive nor mandatory and are tailored to each patient’s nature of seizure. At times for a better characterisation of the seizures, the doctor may ask for a video EEG, which includes admission and continuous video and EEG recording of the patient including his or her habitual seizures if need be. Vision assessment, speech and language assessment, psychological review all form necessary tools of investigations in select cases.

There are many myths and misconceptions abound regarding pharmacological treatment of epilepsy. Often, it is the unwarranted and unjustified phobia regarding antiepileptic medications, their potential side effects and duration of treatment. Medication side effects can occur with any medicine and with any treatment system and are not restricted to antiepileptic medications. Just like any other drug class, this group of medicine have their own spectrum of side effects, no more, no less. The type of seizure and the epilepsy syndrome would guide the choice of antiepileptic drug and would vary from one patient to another and does not follow one-fit-for-all policy. The diagnosis of seizure do not warrant treatment at all times but when taken, decision is in conjunction with patient’s wishes after discussing all the pros and cons of treatment in detail. Patients are encouraged to clarify all their doubts during each consultation. Physician should be informed about previous side effects or allergies before drug initiation, your future plans of pregnancy or upcoming important events like exams or marriage so that an informed decision can be made. Usually the physician would highlight the potential side effect and may explain what to look out for when starting a medication. If you encounter any side effects that you perceive is to be medication related, please clarify with your doctor rather than discontinuing medicines abruptly which can lead to serious consequences. Nearly 50-60% of patient would have seizure relief on single medications. But at times, in an unfortunate few two or more medications have to be judiciously tried one after other or in combination for a satisfactory seizure control. Equally important as medications are the lifestyle adjustments to prevent seizure recurrence. Certain types of epilepsy tend to have breakthrough seizure with sleep deprivation. Alcohol intake which can have multiple effects on the body, including the drug levels in the body is best avoided.
A vital but simple device which is of immense benefit during follow-up of patient’s with epilepsy is a well maintained seizure diary. Patient and family is advised to maintain a diary with accounts of seizure, including the date and time, duration and any perceived cause such as drug default.  The physician can assess the success or failure of therapy and can envisage future drug modifications based on these accounts which are much more objective records than subjective estimate of seizure number which can be wrought with recollection errors.

Duration of treatment is another factor that is of extreme interest to patient and family and rightly so. The answer, however, is not straightforward and would vary from patient to patient. Generally if patient remains seizure free for an appropriate period of time, after taking into consideration all factors, including patient’s occupation, life circumstances, results of EEG and MRI, an attempt at drug tapering and even complete withdrawal can be made. In many circumstances this may be successful and patient can be completely off medication. The decision for drug tapering is to be made carefully and should never be attempted by the patient. In such situations, relapse of seizures can occur which may not be controlled by the previous medication or at previous dosages at which patient was seizure free.

Surgical management of epilepsy
Despite instituting the correct medicines in their appropriate dose, around 30% of patients would continue to have disabling and debilitating seizures. These patients who continue to exhibit uncontrolled seizures despite maximally tolerated doses of medicines are considered to have medically refractory epilepsy. This group of patients who are unlikely to have significant seizure freedom with drugs could be viable candidates for epilepsy surgery. Studies have shown that appropriate and early epilepsy surgeries can significantly increased chances of total seizure freedom, reduce epilepsy related neuropsychological complications and lead to better quality of life.

Principle of epilepsy surgery
The principle of epilepsy surgery is to find and remove the focus of abnormality in the brain, the surgical removal of which can lead to seizure freedom. Bearing in mind the fact that the brain is the most complex structure in the universe and that each part of brain has its own vital function, utmost care has to be taken in minimising the extent of removal to limit the functional disability. It consists of a multidisciplinary approach with the team consisting of epileptologist, neurosurgeon, radiologist, neuropsychologist, speech and language therapist and occupational therapist with patient and family always being at the epicentre.

Steps in presurgical evaluation
Presurgical evaluation refers to the series of individualised investigations which would include a detailed clinical history and examination, review of the CT/MRI carried out in specialised epilepsy protocol, video EEG monitoring and neuropsychological evaluation, all of which would guide the team in deciding the patient’s candidacy for epilepsy surgery. At the end of the evaluation a collective decision regarding surgery will be taken in a patient management conference. After weighing all the benefits and potential side effects, the decision shall be discussed with the patient and the family in exhaustive detail.

Epilepsy continues to evoke emotions of fear and misunderstandings regarding its treatment still exist in the community. It has to be borne in mind that majority of patients can have seizure freedom with institution of correct medication at correct dose. In those unfortunates in whom medical treatment fails to control seizures adequately, surgical management is a definitive treatment option.  With advances in science, treatment options are available that can help a person with epilepsy lead an essentially normal life. Times are long gone, when people with epilepsy were forced to be marginalised from mainstream of society.

Dr Deepak Menon
Consultant Neurologist
KIMS Hospital, Trivandrum

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