By Dr Harsha Bhatia MBBS, MD, DNB
(Neurology), Specialist - Neurology,
Aster Clinic, Al Hilal
Doha: The theme for International Epilepsy Day – Epilepsy is more than Seizures – highlights the fact that, for many people, the stigma and discrimination faced by people with epilepsy, can be more difficult to overcome than the seizures themselves. Despite the fact at up to 70 percent of people with epilepsy will have their seizures successfully controlled, in the general public there is still fear and ignorance on what epilepsy really is. International Epilepsy Day aims to highlight that:
• Epilepsy still remains a hidden disease due to the stigma attached;
• It is treatable, yet 40 percent of people living with epilepsy in wealthier countries do not receive appropriate treatment. Over 70 percent of those living in low income countries cannot even access epilepsy medication regularly;
• Lack of treatment imposes a huge financial burden on national health systems;
• Research remain key issues in improving the quality of life of persons with epilepsy
Epilepsy is a central nervous system disorder (neurological disorder) in which the nerve cell activity in the brain is disturbed, causing a seizure during which patient experiences abnormal behaviour, abnormal symptoms and sensations, and loss of consciousness.
Seizure symptoms vary. Some people with epilepsy simply stare blankly for a few seconds during a seizure, while others repeatedly twitch their arms or legs. About 1 in 100 may have an unprovoked seizure once in a life. However, a solitary seizure doesn’t mean you have epilepsy. At least two unprovoked seizures are generally required for an epilepsy diagnosis.
Even mild seizures may require treatment because they can be dangerous during activities such as driving or swimming. Treatment, which generally includes medications or sometimes surgery, may eliminate or reduce the frequency and intensity of seizures. Some children with epilepsy even outgrow the condition with age. Since epilepsy is caused by abnormal activity in neurons, seizures can affect any process your brain coordinates.
A seizure can produce symptoms such as:
• Temporary confusion
• A staring spell
• Uncontrollable jerking movements of the arms and legs
• Loss of consciousness or awareness
• Psychic symptoms
Symptoms vary depending on the type of seizure. In most cases, a person with epilepsy will tend to have the same type of seizure each time, so the symptoms will be similar from episode to episode.
When to consult a Neurologist?
If you are experiencing a seizure for the first time, seek medical advice. Seek immediate medical help if any of the following occurs:
• The seizure lasts more than five minutes
• A second seizure follows immediately
• High fever
• Pregnant
• Diabetes
• Injury during the seizure
Causes of Epilepsy
Genetic influence: Researchers have linked some types of epilepsy to specific genes, though it’s estimated that up to 500 genes could be tied to the condition. For most people, genes are only part of the cause of epilepsy. Certain genes may make a person more sensitive to environmental conditions that trigger seizures.
Head trauma: Head trauma that occurs due to a car accident or other traumatic injury can cause epilepsy.
Brain conditions: Damage to the brain, such as brain tumors or strokes, also can cause epilepsy. Stroke is a leading cause of epilepsy in adults older than age 35.
Infectious diseases: Diseases, such as meningitis, AIDS and viral encephalitis, can cause epilepsy.
Prenatal injury: Before birth, babies are sensitive to brain damage that could be caused by several factors, such as an infection in the mother, poor nutrition or oxygen deficiencies. This brain damage can result in epilepsy or cerebral palsy.
Developmental disorders: Epilepsy can sometimes be associated with developmental disorders, such as autism and neurofibromatosis.
Other causes include: Metabolic activity, sleep withdrawal, acute alcohol intoxication and sudden alcohol withdrawal. Certain factors may increase your risk of epilepsy such as age, family history, head injuries, stroke and other vascular diseases, dementia, brain infections and seizures in childhood.
Complications
Having a seizure at certain times can lead to circumstances that are dangerous to yourself or others.
Falling: If you fall during a seizure, you can injure your head or break a bone.
Drowning: If you have epilepsy, you’re 15 to 19 times more likely to drown while swimming or bathing than the rest of the population because of the possibility of having a seizure while in the water.
Car accidents: A seizure that causes either loss of awareness or control can be dangerous if you’re driving a car or operating other equipment.
Pregnancy complications: Seizures during pregnancy pose dangers to both mother and baby, and certain anti-epileptic medications increase the risk of birth defects. If you have epilepsy and you’re considering becoming pregnant, talk to your doctor as you plan your pregnancy.
Emotional health issues: People with epilepsy are more likely to have psychological problems, especially depression, anxiety and, in extreme cases, suicide. Problems may be a result of difficulties from dealing with the condition itself as well as medication side effects.
Status epilepticus: This condition occurs if you’re in a state of continuous seizure activity lasting more than five minutes, or if you have frequent recurrent seizures without regaining full consciousness in between them. People with status epilepticus have an increased risk of permanent brain damage and death.
Sudden unexplained death in epilepsy (SUDEP): People with epilepsy also have a small risk of sudden unexplained death. The cause is unknown, but some research shows it may occur due to heart or respiratory conditions.
Tests and diagnosis
To diagnose your condition, your doctor will review your symptoms and medical history. Your doctor may order several tests to diagnose epilepsy and determine the cause of seizures.
Neurological examination: Your doctor may test your behaviour, motor abilities, mental function and other areas to diagnose your condition and determine the type of epilepsy you may have.
Blood tests: Your doctor may take a blood sample to check for signs of infections, genetic conditions or other conditions which may be associated with seizures.
Your doctor may also suggest tests to detect brain abnormalities, such as:
Electroencephalogram (EEG): This is the most common test used to diagnose epilepsy. In this test, doctors attach electrodes to your scalp with a paste-like substance. The electrodes record the electrical activity of your brain. If you have epilepsy, it’s common to have changes in your normal pattern of brain waves, even when you’re not having a seizure. Your doctor may monitor you on video while conducting an EEG while you’re awake or asleep, to record any seizures you may experience. Recording the seizures may help the doctor determine what kind of seizures you’re having or rule out other conditions.
Your doctor may give you instructions to do something that will cause seizures, such as getting little sleep prior to the test.
Computerised tomography (CT) scan: A CT scan uses X-rays to obtain cross-sectional images of your brain. CT scans can reveal abnormalities in your brain that might be causing your seizures, such as tumors, bleeding and cysts. These anomalies are indicated only during an emergency.
Magnetic resonance imaging (MRI): An MRI uses powerful magnets and radio waves to create a detailed view of your brain. Your doctor may be able to detect lesions or abnormalities in your brain that could be causing your seizures.
Functional MRI (fMRI): A functional MRI measures the changes in blood flow that occur when specific parts of your brain are working. Doctors may use an fMRI before surgery to identify the exact locations of critical functions, such as speech and movement, so that surgeons can avoid injuring those places while operating.
Positron emission tomography (PET): PET scans use a small amount of low-dose radioactive material that’s injected into a vein to help visualize active areas of the brain and detect abnormalities.
Single-photon emission computerised tomography (SPECT): This type of test is used primarily if you’ve had an MRI and EEG that didn’t pinpoint the location in your brain where the seizures are originating.
A SPECT test uses a small amount of low-dose radioactive material that’s injected into a vein to create a detailed, 3-D map of the blood flow activity in your brain during seizures. Doctors also may conduct a form of a SPECT test called subtraction ictal SPECT co-registered to magnetic resonance imaging (SISCOM), which may provide even more detailed results.
Neuropsychological tests: In these tests, doctors assess your thinking, memory and speech skills. The test results help doctors determine which areas of your brain are affected.
Medication and treatments
Most people with epilepsy can become seizure-free by taking one anti-seizure medication, called anti-epileptic medication. Others may be able to decrease the frequency and intensity of their seizures by taking medications. Your doctor will advise you about the appropriate time to stop taking medications.
Your doctor likely will first prescribe a single medication at a relatively low dosage and may increase the dosage gradually until your seizures are well controlled.
Anti-seizure medications may have some side effects. Mild side effects include fatigue, dizziness, weight gain, loss of bone density, skin rashes, loss of coordination, speech problem, memory and thinking problems.
More severe but rare side effects include depression, suicidal thoughts and behaviours, severe rash and inflammation of certain organs, such as your liver.
At least half of all people newly diagnosed with epilepsy will become seizure-free with their first medication. If anti-epileptic medications don’t provide satisfactory results, your doctor may suggest surgery or other therapies. You’ll have regular follow-up appointments with your doctor to evaluate your condition and medications.
Surgery is most commonly done only when tests show that there is lesion in the brain which causes the seizures. Therapies such as vagus nerve stimulation, wherein doctors implant a device called a vagus nerve stimulator, sends bursts of electrical energy through the vagus nerve and to your brain. It’s not clear how this inhibits seizures, but the device can usually reduce seizures by 20 to 40 percent. Most people still need to take anti-epileptic medication, although some people may be able to lower their medication dose. You may experience side effects from vagus nerve stimulation, such as throat pain, hoarse voice, shortness of breath or coughing.
Researchers are studying brain stimulation as a potential treatment for epilepsy. In brain stimulation, surgeons implant electrodes into a specific part of your brain. The electrodes are connected to a generator implanted in your chest or the skull that sends electrical pulses to your brain and may reduce your seizures.
Researchers also study stereotactic radio surgery as a potential treatment for some types of epilepsy. In this procedure, doctors direct radiation at the specific area of your brain that is causing your seizure.
Important pointers
To achieve the best seizure control possible with medication:
• Take medications exactly as prescribed.
• Always call your doctor before switching to a generic version of your medication or taking other prescription medications, over-the-counter drugs or herbal remedies.
• Never stop taking your medication without talking to your doctor.
• Notify your doctor immediately if you notice new or increased feelings of depression, suicidal thoughts, or unusual changes in your mood or behaviours.
• Tell your doctor if you have migraines. Doctors may prescribe one of the anti-epileptic medications that can prevent your migraines and treat epilepsy.
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