Epilepsy

Epilepsy is a group of disorders in the central nervous system characterized by symptoms of recurring seizures. Seizures include the classic convulsions, but also include strange sensations, loss of consciousness, twitching of arms and legs, and other symptoms.   

Epilepsy has several causes, and can be caused by medical conditions ranging from stroke to birth defects. Thus, about 1 in 26 people in the United States will have epilepsy in their lifetime. Estimates show that almost 10 percent of the population will have a single unprovoked seizure. 

Seizures occur when a large group of neurons in the brain produces abnormal excessive electrical activity all at the same time. Seizures become epilepsy when it occurs twice or more. 

All kinds of seizures, including mild ones, require treatment because they can become dangerous if you are driving or swimming. 

The good thing is that medications are capable of relieving the majority of seizures, including those caused by epilepsy. With treatment, most individuals with epilepsy can assume a normal life and perform work activities. Children with epilepsy may improve over time.

Seizures are the only visible symptom of epilepsy.

As seizures affect the brain, it may cause variety of signs and symptoms such as:

• Staring spells
• Temporary confusion
• Involuntary jerking movements of arms and legs
• Loss of consciousness
• Loss of awareness to the surroundings
• Having psychic symptoms, or symptoms that seem to trigger emotions or previous experiences. Patients may start having unexplained feelings of fear, anxiety, or déjà vu 

It is common for individuals with epilepsy to have the same symptoms during seizure episodes.  

Seizures are classified into two: generalized and focal. 

Focal seizures

Focal seizures originate from abnormal activity in one part of the brain. Focal seizures are further classified into the following categories:

• Focal seizures with no loss of consciousness – also called simple partial seizures, tend to alter emotions and senses including hearing, smell, taste or feeling. The patient may have involuntary shaking or jerking of a body part like an arm or leg. They also cause spontaneous sensory symptoms like tingling, dizziness, and flashing lights.
• Focal dyscognitive seizures – also called complex partial seizures, may cause change or loss of consciousness or awareness. Symptoms include staring spells, performing repetitive movements like rubbing of hands, chewing, swallowing or walking in circles. 

Focal seizures tend to be similar to symptoms of conditions like migraine, narcolepsy, and other mental disorders. Therefore, focal seizures require thorough examination and tests.

Generalized seizures

Generalized seizures are caused by abnormal activity of all parts of the brain. It is further classified into the following:

• Tonic-clonic seizures – formerly known as grand mal seizures, cause the most dramatic symptoms associated with epilepsy, including abrupt loss of consciousness, violent shaking of the body, loss of bladder control and biting the tongue.
• Clonic seizures – is characterized by rhythmic or repeated jerking movement of muscles in the neck, face or arms.
• Tonic seizure – involves stiffening or tension of the muscles in the back, arms and legs, and often the patient falls to the ground.
• Myoclonic seizures – cause sudden brief jerks or twitching of the arms and legs
• Atonic seizures – is known as drop seizure, as patients just suddenly collapse or falls down. It is caused by loss of muscle control
• Absence seizures – is characterized by having subtle symptoms, like simply staring into space, repeated eye blinking or lip smacking. It is more common in children, and may cause a brief loss of consciousness. It is previously known as petit mal seizures. 

You need to see a doctor and have medical help immediately if:

• Seizure lasts more than 5 minutes
• A second seizure follows immediately or soon after the first one
• The patient has no breathing or consciousness after the seizure stops
• If you are pregnant or have diabetes
• You have fever
• Have heat exhaustion. Symptoms include nausea, dizziness, high body temperature, irritability, headache and excessive sweating
• If you injured yourself during the seizure
• If a seizure happens to you the first time

More than half of epilepsy cases have no identifiable cause. In those who do, epilepsy is often traced to the following factors:

• Brain conditions like stroke and brain tumors. Stroke is the most common cause of epilepsy in adults older than 35 years of age
• Head trauma, like those caused by sports injuries and car accidents, can often lead to repeated seizures and epilepsy
• Injuries to babies before birth called prenatal injury. Babies in the womb are very sensitive to brain damage, which can cause epilepsy or cerebral palsy later in life. The fetus can sustain brain damage when the mother has infections, low oxygen or blood supply, or have poor nutrition.  
• Having infectious diseases such as meningitis, AIDS, and viral encephalitis
• Having congenital developmental disorders such as autism and neurofibromatosis
• A family history of epilepsy, which is caused by inheriting certain genes. However, environmental factors still have more influence on development epilepsy than genetic factors

Diagnosing epilepsy requires a thorough review of your medical history and symptoms. Once that is taken care of, the doctor may order the following to help determine cause of seizures:

• Neurological examination will test your mental functioning, behavior and motor abilities, which is useful in determining the type of epilepsy
• Blood tests are used to check for signs of other illnesses, infections and genetic conditions that may cause seizures

The following tests can further check for abnormalities in the brain:

• Electroencephalogram (EEG) is often used in diagnosing epilepsy, measures the electrical activity of the brain by attaching electrodes to the head. This is accurate because epilepsy tends to cause changes in brain activity, even if there are no seizures. 

         EEG may be done when you are awake or asleep. EEG can be done even if the seizure is taking place, which is even better as it helps the doctor determine the kind of seizures you have. The doctor may instruct you to do something to provoke seizures, like having little sleep before the test. 

• Computerized tomography (CT) scan uses computer-directed x-rays to create detailed images of the inside of your head, which is useful in detecting tumors, bleeding or cysts that may cause seizures.

• Magnetic resonance imaging (MRI) uses powerful magnets and radio waves to visualize your brain, which helps detect abnormalities or lesions that may cause seizures. During brain surgery, doctors may use a variant of MRT called functional MRI, which detects blood flow in the brain that identifies exact locations of critical areas of the brain so they can avoid injuring those places during the operation.

• Positron emission topography (PET) scan injects a very low-dose radioactive material in your bloodstream, which shows up in imaging to visualize active areas of the brain to check for abnormalities.

• Single-photon emission computerized tomography (SPECT) works somewhat like PET scan, and it is mainly used to visualize the blood flow in your brain during seizures. It is used if MRI or EEG fail to reveal the location in your brain where seizures are originating. 

Doctors may also combine a variant of SPECT that also use MRI, called subtraction ictal SPECT coregistered to magnetic resonance imaging (SISCOM), which provides even more detailed imaging of the brain.

• Neuropsychological tests are used by doctors to determine areas of the brain affected by seizures. These tests will check your thinking, memory and speech skills.

Epilepsy treatment starts by administering medications, called anti-epileptic medication, to relieve seizures. Most cases of epilepsy respond to one anti-epileptic medication while others find relief by taking several drugs. 

You will be monitored throughout treatment, and the doctor will tell you the appropriate time to stop taking medications.

In long-term, medications are fairly effective in treating childhood and adult epilepsy, and there is no need to take them for many years. Many patients experience relief from seizures with their first medication. 

Most epileptic children whose medications proved able to control symptoms can discontinue their medications over time and remain seizure-free for life. Adults can also discontinue taking medications once they are seizure-free for two or more years.

Finding the right medication and the effective dosage for you can be complex. The doctor may review factors such as age, body weight, medical history and other medicines you take when prescribing medication. 

The prescription usually starts at a low dose, and dosage is increased until seizures are controlled. There are many kinds of anti-epileptic medications, so if one does not work for you, the doctor may simply change the prescription until one is found that works.

All anti-epileptic medications have side effects, such as:

• Fatigue
• Dizziness
• Weight gain
• Reduced bone density
• Rashes
• Speech problems
• Reduced coordination
• Memory and thinking difficulties

Some of the more severe side effects include:

• Depression
• Suicidal tendencies
• Severe rashes
• Inflammation of organs like the liver

There are certain guidelines in taking anti-epileptic medications:

• Follow the prescription exactly
• Call your doctor first when switching to generics, before taking any new medication or taking supplements
• Do not stop using the medication without asking the doctor
• Call your doctor if you experience migraines because there are anti-epileptic medications that also work for relieving migraines
• Call your doctor immediately if you experience unusual mood changes, depression, suicidal thoughts 

If medications do not work to relieve seizures, your doctor may recommend surgery.

Surgery

The doctor may recommend surgery if you did not experience relief from medications, and if imaging tests show that your seizures originate from a small, well-localized area of your brain that does not affect vital functions like speech, cognition, motor function, vision or hearing. 

Surgery for epilepsy involves removing an area of the brain that causes seizures. Some surgical procedures require you to remain awake and answer questions. 

In case seizures come from a part of the brain that cannot be removed, the surgeon may recommend a procedure where cuts are made (multiple subpial transection) in the brain.  This prevents seizures from spreading to other areas of the brain. 

Most patients experience success in surgery and have reduced seizures. You must still take medications to prevent seizures, but with fewer drugs and at reduced dosages. 

Surgery for epilepsy has complications such as permanently altered thinking or cognition. You can discuss this with your surgeon, and make sure to ask for his or her experience in treating similar conditions, success rates, and complication rates.

Therapies

Here are the therapies designed to treat epilepsy:

• Vagus nerve stimulation – this involves planting a battery-powered device called nerve stimulator connected to the vagus nerve. The device is implanted underneath the skin of the chest, where it sends bursts of electricity to the vagus nerve and to the brain. 

         The mechanism of how it works to reduce seizures is still unclear, but it reduces it by 20 to 40 percent. It enables patients to lower dose of their medication. Side effects include throat pain, hoarse voice, shortness of breath or coughing.

• Ketogenic diet – is a restrictive diet high in fats and very low in carbohydrates. This causes the body to get energy from fats, which increases ketones in the body. The exact manner on how ketones control seizures are still unknown, but it works in reducing seizures in children. 

         Few years of ketogenic diet may be able to stop seizures completely. However, ketogenic diet is more restrictive than Atkins diet, and it requires doctor’s supervision to make sure the child does not suffer from malnutrition and reduce the likelihood of side effects. Side effects include constipation, slowed growth because of nutritional deficiencies and buildup of uric acid in the blood, which can cause kidney stones. 

Potential future treatments

In the near future, chronic or recurrent epilepsy may be addressed by implanting devices in the brain. A treatment called deep brain stimulation involves implanting electrodes to specific areas of the brain, which sends precise electrical pulses to reduce seizures. 

Another such device is like a pacemaker that continuously analyzes brain activity patterns to detect developing seizures, which then delivers an electrical charge or drug to stop a seizure. 

Development of new surgical techniques like MRI-guided laser ablation and stereotactic radiosurgery may pose fewer risks to patients than traditional open brain surgery. MRI-guided laser ablation uses the detailed imaging power of MRI to guide a laser to precisely destroy brain areas that are causing seizures while stereotactic radiosurgery uses direct radiation to do the same objective. 

The risk of having epilepsy is increased in individuals with the following:

• Sustaining head injuries, which can cause damage to areas of the brain that can result in seizures
• Having stroke and other blood vessel conditions that can lead to brain damage
• Infections in the central nervous system like meningitis
• Having seizures during childhood, particularly if the patient has histories of extended seizures and other central nervous system disorders
• Dementia may increase risk of seizures in elderly
• Young children and older adults 60 years of age and above are more prone to epilepsy

Seizures are dangerous when they occur in circumstances like when you are driving, swimming or operating machinery. Falls can also occur during seizures, which can cause fractures and head injuries. Some cases of epilepsy may result in status epilepticus or prolonged seizure, which can cause permanent brain damage or death. 

Individuals with epilepsy also face a very small risk of having the condition called sudden unexplained death in epilepsy (SUDEP), especially if they have frequent tonic-clonic seizures or whose seizures are uncontrolled by medication.

Seizures are also a significant problem during pregnancy because anti-seizure medications may cause problems to the fetus. Pregnant mothers suffering from seizure episodes or have epilepsy can still have a healthy baby if their condition is carefully monitored and medications adjusted by the doctor. 

Epilepsy also has a significant emotional impact and may cause the patient to suffer from depression, anxiety, or even suicide.