Epilepsy

Epilepsy remains one of the common neurological diseases.
There are 2.5 million people in the United States living with epilepsy. Although epilepsy can be a burden on the individual daily activity, education, social life, and employment, about 70% of people with epilepsy lead normal lives. A number of famous people have or had epilepsy. Historic religious figures, inventors, and writers lived active and productive lives with epilepsy.

Epilepsy is a brain disorder that cause recurrent seizures. Seizure is an electrical disturbance of the brain and is associated with temporary changes in the individual awareness, behavior, or movement (convulsions).  In between seizures, however, the brain function goes back to base line and the seizure symptoms resolve.

Not every convulsion is a seizure and not every seizure is associated with convulsion. Thus, definite diagnosis of epilepsy is crucial. Seizures and certain types of epilepsy share similar symptoms with other medical disorders like syncope, cardiovascular, psychiatric, and sleep disorders. This makes the diagnosis of seizures a challenging task.

The Epilepsy Monitoring Unit (EMU) is the gold standard in the diagnosis and management of epilepsy. This type of monitoring allows the epileptologist to determine the type of epilepsy the patient has and the best long term treatment options. It also helps to determine whether the individual events or symptoms are related to seizures. EMU consist of simultaneous video and EEG monitoring.

The video monitoring is used to observe the clinical and behavioral changes of the individual during a seizure. Simultaneously, the EEG monitoring will record the electrical activity of the brain during a seizure. The EMU allows the physician to adjust the patient medical treatment in the safety of a hospital setting and to provide timely access to both routine and critical medical services.

Epilepsy Types

There are different types of seizures/epilepsies. The two major types are generalized and partial seizures. Among the generalized seizures, the most common type is generalized tonic-clonic seizures (Grand-mal seizures) followed by absence seizures (petit-mal seizures) and myoclonic (recurrent muscle jerks in the extremities) seizures. It is crucial to determine the type of seizures the patient has because different types respond to different medication and some anti-seizure medications may worsen the generalized seizures.

Generalized tonic-clonic seizures (Grand-mal seizures) can be frightening. They are characterized by initial brief grunting noise or gasping followed by generalized rigidity of the body and the extremities (tonic phase). The eyes might roll up and the head might turn to one side. This usually is followed by muscle jerks/convulsions (clonic phase). The person will lose consciousness and usually falls down to the floor. Breathing might be labored and the person might lose bladder or bowel control. The seizure lasts usually between 1-5 minutes followed by a period of lethargy, sleepiness, and confusion (postictal state) which can last from  few minutes to few hours.

The partial seizures are characterized by a blank stare and the person will be unresponsive to verbal stimuli. Repetitive hand movements like picking on the clothes or lip smacking are usually seen with this type of seizures. They might or might not be associated with muscle jerks or convulsions.  Again following the seizure, the person might feel tired and confused.

On the other hand, absence seizures are characterized by a blank stare but they are usually short in duration (20-30 seconds) and are not followed by a period of confusion. Myoclonic seizures cause recurrent muscle jerks in the extremities and they can progress into generalized tonic-clonic (Grand-mal seizure) seizure.

What causes epilepsy?

In about two thirds of the cases of epilepsy the cause is not known.
The most common known causes of epilepsy are: Brain tumor, stroke, meningitis, head trauma (usually associated with loss of consciousness), alcohol and drug abuse, and fetal development problems. Family history of seizures increases the risk of developing seizures.

How can we diagnose seizures?

Seizures are diagnosed by a physician by taking detailed history and neurological examination. Routine electroencephalogram (EEG) which records the brain electrical activity helps in the diagnosis. Brain imaging like CT or MRI of the brain helps in determining the cause of seizures.

What is the treatment of epilepsy?

Taking anti-seizure medications is still the main treatment for epilepsy. More than 13 new anti-seizure medications have been introduced to the market in the past 2 decades (Neurontin, Felbatol, Lamictal, Topamax, Gabitril, Keppra, Trileptal, Zonegran, Lyrica, Banzel, Onfi, Fycompa, Aptiom, and other extended release formulations) . Although about 60- 70% of patients with epilepsy respond well to medical treatment, about 25% of them continue to have seizures.

People who continue to have seizure despite taking medications might benefit from non-medical treatment like:

  • 1-Epilepsy surgery
  • 2- Vagus Nerve Stimulator (VNS)
  • 3- RNS (Responsive Neurostimulation)
  • 4- Diet (Ketogenic or Modified Atkin Diet ).

What is Vagus Nerve Stimulator (VNS)?

Vagus Nerve Stimulator (VNS) is a device that is implanted in the chest under the skin and connected by a wire, also under the skin, to the left vagus nerve at the base of the neck. This helps in controlling the seizures in addition to the medications. The stimulator stimulates the vagus nerve, at regular intervals determined by the physician, 24 hours a day and 7 days a week. The patient will be able to trigger additional stimulations in case of a seizure by passing a magnet across the chest area where the stimulator is implanted. VNS has been in use since 1996.

What is RNS?

RNS is a device implanted in the skull and connected to an electrode strip placed in the subdural space or to a depth electrode in the brain. The device monitors the EEG activity at all times. Whenever, it detects a seizure pattern, then it can deliver a small electric current using the same electrodes to the area involved. This will reduce the frequency and intensity of the seizures. Battery life is 2.5 -3.0 years. The replacement requires minor surgery.  For more information about the device check www.Neuropace.com

Ketogenic Diet

It is a diet high in fat (90%) and contain about 10% of protein and carbohydrate. Many studies showed that it is effective in reducing the frequency of seizures. Certain supplements are recommended for this diet like: Laxatives, Cytra-K, multi-vitamins, Calcium, Vitamin D, Zinc, Selenium and others. For more information: www.charliefoundation.org

Modified Atkins Diet

Unlike Ketogenic diet, no calorie or protein restrictions.  No fasting needed. It does not require admission to the hospital to initiate the diet. Oils and fat intake encouraged. The carbohydrate intake is limited to 15 grams per day for adults. For more information visit www.atkinsforseizures.com and www.charliefoundation.org

What is Epilepsy Surgery?

In many cases of partial epilepsy, the seizures start from one focal area in the brain and it can spread to involve other areas of the brain. Let us assume that the seizures are emanating from the temporal lobe of the brain. Then epilepsy surgery might be indicated to remove part of the temporal lobe that is causing seizures. Epilepsy surgery is not indicated for every person with epilepsy. But, for the appropriate candidates it can be successful and can lead to seizure freedom in up to 80% of the cases. Epilepsy monitoring unit is needed to evaluate patients for epilepsy surgery.

What can trigger a seizure?

There are certain factors that can trigger a seizure in a person who has history of seizures or in a person who is susceptible to have seizures.  Heavy alcohol use and drug abuse, lack of sleep, stress, febrile illness, and not taking the antiepileptic medications can trigger a seizure. In a small percentage of people with generalized epilepsy, strobe lights and certain video displays can trigger a seizure.

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