Epilepsy

Epilepsy is a condition in which a person has recurrent seizures. A seizure is defined as an abnormal, disorderly discharging of the brain's nerve cells, resulting in a temporary disturbance of motor, sensory, or mental function.

There are many types of seizures, depending primarily on what part of the brain is involved. The term epilepsy says nothing about the type of seizure or cause of the seizure, only that the seizures happen again and again. A stricter definition of the term requires that the seizures have no known underlying cause. This may also be called primary or idiopathic epilepsy.

  • Episodes of abnormal electrical activity within the brain result in seizures.
  • The specific area of the brain affected by the abnormal electrical activity may result in a particular type of seizure.
  • If all areas of the brain are affected by the abnormal electrical activity, a generalized seizure may result. This means that consciousness is lost or impaired. Often all the person's arms and legs stiffen and then jerk rhythmically.
  • One seizure type may evolve into another during the course of the seizure. For example, a seizure may start as a partial, or focal, seizure, involving the face or arm. Then the muscular activity spreads to other areas of the body. In this way, the seizure becomes generalized.
  • Seizures caused by high fevers in children are not considered epilepsy. Also see children's seizures.

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Dr. Anirban Deep Banerjee

Every function in the human body is triggered by messaging systems in our brain. Epilepsy results when this system is disrupted due to faulty electrical activity.

In many cases, the exact cause is not known. Some people have inherited genetic factors that make epilepsy more likely to occur.

Other factors that may increase the risk include:

  • head trauma, for instance, during a car crash
  • brain conditions, including stroke or tumors
  • infectious diseases, for instance, AIDS and viral encephalitis
  • prenatal injury, or brain damage that occurs before birth
  • developmental disorders, for instance, autism or neurofibromatosis

It is most likely to appear in children under 2 years of age, and adults over 65 years.

What a patient with epilepsy experiences during a seizure will depend on which part of the brain is affected, and how widely and quickly it spreads from that area.

The CDC note that the condition "is not well understood." Often, no specific cause can be identified.

Certain factors may increase your risk of epilepsy:

  • Age. The onset of epilepsy is most common in children and older adults, but the condition can occur at any age.
  • Family history. If you have a family history of epilepsy, you may be at an increased risk of developing a seizure disorder.
  • Head injuries. Head injuries are responsible for some cases of epilepsy. You can reduce your risk by wearing a seat belt while riding in a car and by wearing a helmet while bicycling, skiing, riding a motorcycle or engaging in other activities with a high risk of head injury.
  • Stroke and other vascular diseases. Stroke and other blood vessel (vascular) diseases can lead to brain damage that may trigger epilepsy. You can take a number of steps to reduce your risk of these diseases, including limiting your intake of alcohol and avoiding cigarettes, eating a healthy diet, and exercising regularly.
  • Dementia. Dementia can increase the risk of epilepsy in older adults.
  • Brain infections. Infections such as meningitis, which causes inflammation in your brain or spinal cord, can increase your risk.
  • Seizures in childhood. High fevers in childhood can sometimes be associated with seizures. Children who have seizures due to high fevers generally won't develop epilepsy. The risk of epilepsy increases if a child has a long seizure, another nervous system condition or a family history of epilepsy.

Almost any type of behavior that happens repetitively may represent a seizure.

  • Generalized seizures: All areas of the brain (the cortex) are involved in a generalized seizure. Sometimes these are referred to as grand malseizures.
    • To the observer, the person experiencing such a seizure may cry out or make some sound, stiffen for some seconds, then have rhythmic movements of the arms and legs. Often the rhythmic movements slow before stopping.
    • Eyes are generally open.
    • The person may not appear to be breathing. The person is often breathing deeply after an episode.
    • The return to consciousness is gradual and should occur within a few moments.
    • Loss of urine is common.
    • Often people will be confused briefly after a generalized seizure.
  • Partial or focal seizures: Only part of the brain is involved, so only part of the body is affected. Depending on the part of the brain having abnormal electrical activity, symptoms may vary.
    • If the part of the brain controlling movement of the hand is involved, for example, then perhaps only the hand may show rhythmic movements or jerking.
    • If other areas of the brain are involved, symptoms might include strange sensations or small repetitive movements such as picking at clothes or lip smacking.
    • Sometimes the person with a partial seizure appears dazed or confused. This may represent a partial complex seizure. The term "complex" is used by doctors to describe a person who is between being fully alert and unconscious.
  • Absence or petit mal seizures: These are most common in childhood.
    • Impairment of consciousness is present with the person often staring blankly.
    • Repetitive blinking or other small movements may be present.
    • Typically, these seizures are brief, lasting only seconds. Some people may have many of these in a day.
    • Other seizure types exist particularly in very small children.

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. Your evaluation may include:

  • A neurological exam. Your doctor may test your behavior, 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 that 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 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.

  • High-density EEG. In a variation of an EEG test, your doctor may recommend high-density EEG, which spaces electrodes more closely than conventional EEG — about a half a centimeter apart. High-density EEG may help your doctor more precisely determine which areas of your brain are affected by seizures.
  • Computerized 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.
  • 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 computerized 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 coregistered to MRI (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.

Along with your test results, your doctor may use a combination of analysis techniques to help pinpoint where in the brain seizures start:

  • Statistical parametric mapping (SPM). SPM is a method of comparing areas of the brain that have increased metabolism during seizures to normal brains, which can give doctors an idea of where seizures begin.
  • Curry analysis. Curry analysis is a technique that takes EEG data and projects it onto an MRI of the brain to show doctors where seizures are occurring.
  • Magnetoencephalography (MEG). MEG measures the magnetic fields produced by brain activity to identify potential areas of seizure onset.

Accurate diagnosis of your seizure type and where seizures begin gives you the best chance for finding an effective treatment.

Doctors generally begin by treating epilepsy with medication. If medications don't treat the condition, doctors may propose surgery or another type of treatment.

Medication

Most people with epilepsy can become seizure-free by taking one anti-seizure medication, which is also called anti-epileptic medication. Others may be able to decrease the frequency and intensity of their seizures by taking a combination of medications.

Many children with epilepsy who aren't experiencing epilepsy symptoms can eventually discontinue medications and live a seizure-free life. Many adults can discontinue medications after two or more years without seizures. Your doctor will advise you about the appropriate time to stop taking medications.

Finding the right medication and dosage can be complex. Your doctor will consider your condition, frequency of seizures, your age and other factors when choosing which medication to prescribe. Your doctor will also review any other medications you may be taking, to ensure the anti-epileptic medications won't interact with them.

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 problems
  • Memory and thinking problems

More-severe but rare side effects include:

  • Depression
  • Suicidal thoughts and behaviors
  • Severe rash
  • Inflammation of certain organs, such as your liver

To achieve the best seizure control possible with medication, follow these steps:

  • 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 behaviors.
  • Tell your doctor if you have migraines. Doctors may prescribe one of the anti-epileptic medications that can prevent your migraines and treat epilepsy.

At least half the 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

When medications fail to provide adequate control over seizures, surgery may be an option. With epilepsy surgery, a surgeon removes the area of your brain that's causing seizures.

Doctors usually perform surgery when tests show that:

  • Your seizures originate in a small, well-defined area of your brain
  • The area in your brain to be operated on doesn't interfere with vital functions such as speech, language, motor function, vision or hearing

Although many people continue to need some medication to help prevent seizures after successful surgery, you may be able to take fewer drugs and reduce your dosages.

In a small number of cases, surgery for epilepsy can cause complications such as permanently altering your thinking (cognitive) abilities. Talk to your surgeon about his or her experience, success rates, and complication rates with the procedure you're considering.

Therapies

Apart from medications and surgery, these potential therapies offer an alternative for treating epilepsy:

  • Vagus nerve stimulation. In vagus nerve stimulation, doctors implant a device called a vagus nerve stimulator underneath the skin of your chest, similar to a heart pacemaker. Wires from the stimulator are connected to the vagus nerve in your neck.

The battery-powered device 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.

  • Ketogenic diet. Some children with epilepsy have been able to reduce their seizures by following a strict diet that's high in fats and low in carbohydrates.

In this diet, called a ketogenic diet, the body breaks down fats instead of carbohydrates for energy. After a few years, some children may be able to stop the ketogenic diet — under close supervision of their doctors — and remain seizure-free.

Consult a doctor if you or your child is considering a ketogenic diet. It's important to make sure that your child doesn't become malnourished when following the diet.

Side effects of a ketogenic diet may include dehydration, constipation, slowed growth because of nutritional deficiencies and a buildup of uric acid in the blood, which can cause kidney stones. These side effects are uncommon if the diet is properly and medically supervised.

Following a ketogenic diet can be a challenge. Low-glycemic index and modified Atkins diets offer less restrictive alternatives that may still provide some benefit for seizure control.

  • Deep brain stimulation. In deep brain stimulation, surgeons implant electrodes into a specific part of your brain, typically your thalamus. The electrodes are connected to a generator implanted in your chest or your skull that sends electrical pulses to your brain and may reduce your seizures.

If the seizures are related to another medical condition, identification and treatment of that medical condition is the key to prevention. If anticonvulsant medication is prescribed, taking the medication on the recommended schedule and not missing medication is important.

  • Some people with epilepsy are quite sensitive to alcohol. If this pattern develops, avoid alcohol. Others may have seizures only after ceasing heavy alcohol intake. The key to prevention is avoidance of alcohol.
  • Sleep deprivation and stress certainly may increase the frequency of seizures in some people with epilepsy.

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