Seizures and Epilepsy (Questions 12-15)
In most situations, the treatment of a seizure disorder lasts for about 2 years. Standard of care suggests treatment for two years after the last seizure. At that point, if the EEG normalizes and there are no brain lesions (detectable on MRI, CT, or physical examination) that may predispose an individual for further seizures, the risk for recurrent seizure events will be as low as 25-30%, which doesn’t require further treatment. If however the EEG stays abnormal the risk for further recurrent events after 2 years of treatment rises to about 50% or more. Under this circumstance, treatment will be continued for at least 1 year.
If a recurrent seizure occurred after 2 years of being seizure free under the effect of anti-epileptic medication, treatment should be resumed for another 2 years. This applies to seizures that are relatively easy to control.
For seizures refractory to the treatment of a single anti-convulsant and those who have multiple recurrent seizure events, treatment for epilepsy may be a life-long requirement. Alternative seizure managements may be an option for those who continue to have frequent seizures, despite the use of different anticonvulsants.
Most children will present with a single seizure and a normal EEG recording. These will not require treatment, just an evaluation that includes a neuro-developmental assessment, an EEG and a MRI of the brain. About 75% of those who have a normal evaluation (as above) will never have another seizure and will continue to lead a normal life. Still, depending on the severity of the seizure and its duration, one may make an exception, especially if dealing with a single seizure that is life threatening in nature. Parents of these children may be prescribed Diastat, a rectal injector containing Valium in a gel form. This may stop a seizure within 3 minutes and continue to protect the child for up to 8 hours from further seizures, which in most situations is a sufficient amount of time to get medical attention.
For children who present with a single seizure, but have abnormal EEG, or for those who have a normal EEG, but a second seizure, the standard of care suggests treatment. The best treatment consists of a single agent, Tegretol (in a slow release form, if possible), Depakote, or Carbatrol, preferably not Dilantin for a prolonged duration of treatment, due to the adverse reactions. Phenobarbital should also be avoided if possible in children older than 2, due to the hyperactivity and learning impairments associated with its use.
Once a medication has been chosen, treatment should start gradually, with a low therapeutic level initially. If seizures recur, the level may be gradually increased until no further seizures occur. If seizures become worse as the medication level is increased, it should be substituted. If the level is high therapeutic and seizures continue, another medication should be used. Whether as a substitute or as an adjunct is dependent on the amount of benefit obtained from the first medication and other considerations (such as the EEG pattern).
More than 2 anti-epileptic medications may be used in combination to attain the best seizure control. This will cover the needs of the majority of the patients. For those 5-10% whose seizures still remain intractable, other options are available, including the Ketogenic diet, epilepsy surgery, and vagus nerve stimulation.
For the most part, the anti-convulsant medications are well tolerated. A serious concern includes the rare (yet possible) potential for the development of a fatal abnormality if the blood cells. Tegretol may affect the white blood cell count, causing an immune deficiency, or affect all the blood cells causing a rare yet fatal aplastic anemia. Dilantin and Depakene may cause similar, but more infrequent difficulties. Depakene also causes a dose related platelet deficiency. The liver may be affected by all the traditional anti-convulsant, but most seriously in children younger than 3 years of age. A frequent 1 in 300 liver disorder may be associated with Depakene use. Allergic reactions may occur, less commonly with Tegretol, a severe Steven Johnson’s reaction may occur. This rash is potentially fatal and may require intensive care unit hospitalization.
The newer anti-convulsants are generally safer except for Felbatol and may cause some specific side effects causing discomfort for the most part.
For specific side effects of the different anticonvulsants, please refer to What are Anti-Epileptic Medications?
Seizures, if left untreated, are associated with a high incidence of injury and may be associated with fatality as well. Treatment with anti-convulsant medications prevents these complications. Other seizures, if left untreated may severely impair the quality of life, such as absence (staring) seizures and some short partial-complex seizures. In adults, other issues, such as driving are of extreme importance.
Even when treated, occasional breakthrough seizures may occur. This is important to remember, because drowning is a common cause of death from epilepsy. For example, people have had seizures while fishing on their own and fallen overboard, there have also been cases of drowning in the bath due to convulsions. The lifestyle of an epileptic should be logically adjusted to prevent such occurrences.