Seizures and Epilepsy (Questions 1-7)
A seizure is an abnormal electrical discharge from the brain. It may affect a small focal area of the brain, or the entire brain (generalized). The area affected by the seizure loses its regular ability of function and may react uncontrollably. For example, if an area of the brain that controls an arm has a seizure, the arm may shake repetitively. If a seizure affects the entire brain, all the extremities may shake uncontrollably. Some seizures may present with staring and unresponsiveness. Theoretically, any function of the brain, motor, smell, vision, or emotion may be individually affected by a seizure. The seizure, however, for the most part will always follow the same pattern in a given individual.
Epilepsy or a seizure disorder (same meaning) is defined by having 2 or more seizures. The seizures must be of an unprovoked cause. Meaning that there is no immediate connectable cause for the seizures, such as low blood glucose, exposure to toxins, alcohol withdraw, immediate effect of a trauma, of fever in young children (less than 6 years of age).
Seizures are generally divided into 2 main types:
- Focal: involving a limited brain region
- Generalized: involving the entire brain. Therefore always associated with loss of consciousness.
Focal seizures may spread to the rest of the brain, therefore becoming focal seizures with secondary generalization.
- Partial (focal) seizures
- Simple partial seizures (without loss of consciousness)
- With motor signs (uncontrolled muscle movements)
- With somosensory or special sensory symptoms (smell, vision,…)
- With autonomic symptoms (nausea, blood pressure changes,…)
- With psychic symptoms
- Complex partial seizures (with loss of consciousness)
- Simple partial followed by a loss of consciousness
- Impaired consciousness from the onset
- Partial seizures evolving to generalized seizures
- Simple partial with secondary generalization
- Complex partial with secondary generalization
- Simple to complex to generalized
- Simple partial seizures (without loss of consciousness)
- Generalized seizures
- Typical absence seizures (petit mal): consists of staring for a few seconds then returning to full function, where activity was left at the onset of the seizure, as if nothing occurred. The patient has no recollection of the event. This is unlike most other seizures that will be followed by as after seizure (or postidital) drowsiness and confusion that may be prolonged at times.
- Myoclonic seizures: Usually presents with rapid muscle jerks. These may be caused by:
- Benign (non-epileptic myoclonus): similar to the jerks one has when falling asleep.
- Benign myoclonic epilepsy: A rare disorder that starts between 4 months and 2 years
- Severe myoclonic epilepsy: A disorder that results in chronic progressive brain damage
- Lenox-Glastaut syndrome: A severe epileptic disorder, associated with atypical absence (atonic and myoclonic), slow spike?wave complexes on EEG, and mental retardation.
- Clonic seizures
- Tonic seizures
- Clonic tonic seizures (grand mal)
- Atomic seizures: Loss of muscle tone (drop effects)
- Unclassified epileptic seizures: seizures that do not fit in the above classification, such as neonatal seizures and febrile seizures.
Febrile seizures are convulsive events that are considered benign (not associated with serious difficulties), occurring between 6 months and 6 years of age. The typical febrile seizure is a convulsive event that lasts about one to five minutes. This usually occurs with the rapid rise of the fever and consists of a rhythmic jerking of the extremities, eye rolling, unresponsiveness, sometimes cyanosis (bluish discoloration around the mouth and the tips of the extremities), followed by 30 minutes of drowsiness and confusion. As the temperature normalizes, the child may return to his normal self. An occasion, a febrile seizure may occur differently, non-convulsive (without shaking), presenting a loss of tone and consciousness or with stiffening of the body.
Some children may have complex febrile seizures. Complex features include the following:
- Duration, more than 20 minutes
- Focality when the seizure occurs on one side of the body
- Multiplicity, when more than one seizure occurs during a 24-hour period
The significance of the complex features is that of a higher risk for future epilepsy; the more complex the features, the higher the risk for epilepsy or seizures without fever. Generally if a child has a simple febrile seizure the risk for epilepsy is 2% compared to 1% in the general population. The risk for future febrile seizures is about 30%, or 50% if the first seizure occurred before one year of age. Also, the lower the temperature that provoked the first febrile seizure is, the higher the risk for future febrile seizure events.
Treatment for febrile seizures is usually unnecessary. Lowering of the temperature with Tylenol or Motrin is usually ineffective. Anticonvulsants may be used in unusual situations, usually continuous Phenobarbithal or Depakene (Depakene after 3 years of age). Oral valium as premedication, given intermittently during febrile illnesses is highly effective and does not require continuous medication administration and monitoring. This is my first choice for febrile seizures that require treatment.
Febrile seizures are not considered to cause any damage to the brain. Studies have shown no difference in intelligence between children who suffer from febrile seizures or their siblings (or identical twins) who do not have febrile seizures. Some recent studies even suggest improved memory function in children who have had febrile seizures.
Complications from febrile seizures are rare and are mostly associated with focal and prolonged febrile seizures. Future epilepsy, especially with recurrent focal seizures, was reported. Respiratory compromise is rare and may be caused by prolonged convulsions affecting the respiratory muscles and breathing.
Mesial temporal sclerosis, or scarring of the inner part of the temporal lobe, called the hippocampus, is a condition thought-to-be-caused by recurrent focal febrile seizures. The hippocampus, if damaged, is highly epileptogenic (causing seizures). If mesial temporal sclerosis develops, this is associated with a form of epilepsy (partial complex seizures), difficult to control. This, however, is a rare and questionable complication of febrile seizures.
In an individual who suffers from seizures, one of the most important things to avoid is drowning. Drowning is one of the most common causes of death from Epilepsy. It is very important to ensure that a person with seizures will not be left alone in the water; (bathtub, Jacuzzi or pool) without supervision. Also people with Epilepsy should not go on a small boat without a partner in order to avoid falling overboard during a seizure and drowning.
The other thing to avoid is unnecessary head trauma. A person with Epilepsy should try to avoid engaging in sports that predispose one to repeated head injury (such as boxing). The question is less clear when it comes to other sports. In principle, one would like to lead a regular (as normal as possible) life style, not to be crippled incessantly by the disease. To date, there are no clear guidelines of the American Academy of Neurology that pertain to each sport specifically such as football, soccer and basketball. What I generally suggest is to use common sense and avoid head trauma without creating unnecessary hardships. This involves judgment that has to take into account the severity of Epilepsy.
Other precautions involve avoiding situations that predispose one to a higher risk of seizures, such as staying up late and disrupting the structured daily routine, (circadian rhythm). One must slow the level of security when an intercurrent illness or fever are present and control fever with Tylenol (acetaminophen). Some parents make the mistake of stopping the antiepileptic drugs when Tylenol and antibiotics are given for fever. Unfortunately, this is the riskiest time for seizures, and antiepileptic drug administration must be continuous and uninterrupted.
Some people are sensitive to flickering lights, strobe lights, and other photic stimulations. A person with epilepsy should avoid such situations as disco light exposure or sitting on the sunny side of a car when trees block the light intermittently and create an intermittent photic stimulation.
Eating well, sleeping well, and using common sense is potentially life saving and could allow a person with Epilepsy to live a full, happy life without unreasonable of excessive limitations.
The first most important rule for any stressful situation is DO NOT PANIC!! Keep yourself as calm as possible under the circumstances. A seizure is a scary sight, especially if it is prolonged. As in any medical emergency, the first step is the ABC’s of emergencies. (A), for airway, (B) for breathing and (C), for circulation.
In a case of a seizure the airway is the main concern. Protecting the airway is the most important action an observer can take. Positioning the individual on his or her side, leaning the head against the forearm so that the face and the mouth point downwards, this will enable gravity to clear the oral secretions and push the tongue outwards. This action is sufficient in most circumstances to protect the patient from harm during the duration of the epileptic convulsion. Do not attempt to prop the mouth open, pull out the tongue, or place the person on his back during the convulsion. All these actions may cause further bleeding into the airway or cause regurgitation or secretion/tongue obstructing the airway. In most instances, the seizure will be over in 1-5 minutes. That is when the position may be adjusted, and the situation reassessed. Call 911 as soon as possible if a high degree of concern exists. Children who have frequent daily short seizures, however, whose parents are familiar with the situation do not require a hospital visit for each seizure. In these circumstances, the parents must exercise common sense but should not take any unnecessary risks.
In a situation where breathing has stopped, on extremely rare occasions, (B), Breathing assistance may be required. Parents of children with a known tendency to stop breathing should be trained in CPR and have an ambo-bag as well as an oxygen tank handy at home. (C), Circulatory assistance is hardly ever required and is reserved for the hospital emergency department.
Measures to be taken during a seizure include: administration of Diastat, rectal Valium gel that helps stop the seizure within a few minutes. For those who have an implanted VNS (Vagal Nerve Stimulator), swiping the magnet will deliver an immediate electrical impulse that may shorten the seizure significantly as well. Following a seizure, the caregiver must assess the situation. If in doubt, call 911 or your physician in order to plan the next step, which includes future superior protection against further recurrent seizures. This may include remembering to administer the medications (anticonvulsants), as prescribed, making sure that the child keeps the medicine down, shaking the bottle of liquid medications (especially Dilantin, which tends to sediment at the bottom on the container), going to sleep on time, increasing the dose of the medications, or changing the medication regimen for better seizure control. Compliance with the prescribed medication regimen and keeping your physician informed of any mishaps is the best recipe for good seizure control. If poor seizure control is present for an extended period of time, obtaining a second opinion may be helpful.
The causes for seizures include the immediate causes for acute seizures and the chronic causes for epilepsy or a seizure disorder. The acute causes include hypoglycemia (low blood sugar, hypocalcemia (low blood calcium), meningitis, bacterial toxins (such as shigella), alcohol withdrawal, environmental toxins, electrical shock, and side effects of medication. Penicillin overdose may also cause a seizure. Chronic causes for epilepsy include genetic epilepsy (benign rolandic, absence and juvenile myoclonic epilepsies are some examples), congenital brain malformation associated with some neurocutaneous disorders (tuberous sclerosis, neurofibromatosis), migrational defects (where gray matter migrates to the wrong brain region during early development. Other causes include chronic effects of trauma or infection that did cause brain damage or damaged an area called the hippocampus in the front central temporal lobe that if damaged, becomes highly epileptogenic.