Epilepsy

Q: What is epilepsy?

A: Epilepsy is a brain disorder. It occurs when the electrical signals in the brain are disrupted. This change in the brain leads to a seizure. Seizures can cause brief changes in a person's:

• Body movements

• Awareness

• Emotions

• Senses, such as taste, smell, vision, or hearing People with epilepsy have repeated seizures.

Myth or Fact

Myth #1 --- Epilepsy is rare

Fact --- More than 2.5 million Americans have epilepsy.

Myth #2 --- Epilepsy is contagious

Fact --- You cannot catch epilepsy from another person! Therefore it is not contagious.

Myth or Fact

Myth #3 --- Epilepsy is a psychological condition

Fact --- Epilepsy is a medical condition. Seizures are the result of an excessive and disorderly discharge of electrical energy in the brain.

Myth #4 --- Epilepsy is a form of mental illness

Fact --- Epilepsy is a functional, physical problem, not a mental one. Its an umbrella term that describes about twenty different types of seizure disorders.

Myth or Fact

Myth #5 --- Persons with epilepsy are “epileptics.”

Fact --- Persons with epilepsy are individuals who experience chronic, recurrent seizures and prefer being described as "persons with epilepsy.“

Myth #6 --- You have to be born with epilepsyFact --- Epilepsy often first appears in children and young adults, although anyone can develop epilepsy at any time.

Myth or FactMyth #7 --- Epilepsy is a lifelong disorderFact --- Epilepsy is not necessarily a lifelong disorder. Many persons with epilepsy will not have seizures or require medication all of their lives.

Myth #8 --- You can’t prevent epilepsyFact --- While no specific cause can be pinpointed in a majority of epilepsy cases, some causes, such as severe head injuries experienced in falling from a bicycle or sustained in an automobile accident, have been identified. This is why helmet safety is so important for children as a preventive measure.

Myth or FactMyth #9 --- Epilepsy cannot be treated or

curedFact --- There is no known cure for epilepsy. However, modern treatment methods can achieve full control of seizures in a majority of cases. According to the EFA, 80 percent of those on medication have complete control of seizures. Within the past 15 years, several new drugs have been developed to help control seizures, and surgery is an option for some patients. Many people who have epilepsy lead productive, normal lives. Currently there is no cure, but some children tend to outgrow the condition.

Myth or Fact

Myth #10 --- Epilepsy is a disease

Fact --- Epilepsy is a neurological condition characterized by recurring seizures. Epilepsy is not a disease or a mental illness, and it does not signal emotional instability or lack of intelligence. According to the Epilepsy Foundation of America (EFA), 9 percent of the population will have a seizure at some point in their lives. Of this group, 3 percent will develop epilepsy.

Myth or Fact

Myth #11 --- All seizures are the sameFact --- There are more than 20 forms of seizure disorders. The intensity and duration of the seizure depends on how many and what type of brain cells are affected. Seizures are not painful and range from convulsions to momentary lapses of attention. People with mild seizures may even be unaware they’ve had one. Seizures may occur minutes, days or years apart, depending on how well they are controlled by medication

Incidence

• Over a lifetime, 5-7 percent of us have a seizure

• 30 to 60 per 100,000 persons have epilepsy• Common in very young children• Most common neurological disorder of

adolescence• 60 percent completely controllable; 25

percent can reduce severity

Epileptic Syndromes

• An epileptic disorder characterized by a cluster

of signs and symptoms which occur together

• Factors taken into consideration include seizure

type, etiology, genetics, anatomy, precipitating

factors and the interictal EEG

Proposed by ILAE in 1985, revised in 1989 currently

under revision

Generalized seizures

• Electrical abnormality throughout cerebral cortex

• Grand mal or generalized tonic-clonic seizures

• Absence or petit mal

• Atonic seizures

Generalized Tonic-Clonic Seizures

• Person stiffens, falls, and convulses, losing consciousness

• EEG abnormal in more than 2/3 of cases• Cause in young children due to infection, metabolic

disorder or trauma• In older individuals, usually due to trauma or tumor• Outcome dependent upon age, cause, and ability to

control seizures• Approximately 40 percent retarded

Absence or Petit Mal Seizures

• Temporary lapse of consciousness that starts and ends abruptly

• Brief periods of lack of awareness; may be unusual movements

• Usual age of onset is 4 to 8 years• High genetic predisposition• Over 50 percent go into remission after adolescence• Generally normal IQ; only 5 percent retarded

Childhood Absence Epilepsy

• Onset at 3-12 years

– Peak at 6-7 years

– Second peak at 11-12 years

• Females more than males

• Family history in 15-44%

• Risk of generalized TC seizures is 30-40%

• Increased risk if absence seizures begin

after the age of 8 years

Childhood Absence Epilepsy Treatment

• Effective Drugs

– Ethosuximide

– Valproic acid

– Clobazam

– Lamotrigine

– Topiramate

• Ineffective Drugs– Carbamazepine– Phenytoin– Vigabatrin

Juvenile Myoclonic Epilepsy

• A common cause of tonic-clonic seizures

in teenagers and young adults

• Interictal EEG shows normal background

with polyspike-wave bursts

• A photoconvulsive response is common

Juvenile Myoclonic Epilepsy

• Diagnosis often delayed

• Patients rarely report myoclonic jerks

• Absence seizures occur in 25%

• Myoclonic seizures precede tonic-clonic

seizures by 2-3 years

• Tonic-clonic seizures typically occur when

patient reaches 10-17 years

JME - Treatment

• Avoid sleep-deprivation and alcohol

• VPA is treatment of choice

• Clonazepam, Lamotrigine or

Topiramate may be effective

• Discuss teratogenesis for females and

advise folic acid supplementation

Benign Rolandic Epilepsy

• Most common partial epilepsy

• Onset 3-13 years

• M:F 1.5:1

• 10-13% have a single seizure

• 20% have frequent seizures

– 65% nocturnal

– 15% nocturnal or diurnal

– 10-20% waking state only

Interictal discharge

Benign Rolandic Epilepsy

• Most common partial epilepsy

• Onset 3-13 years

• M:F 1.5:1

• 10-13% have a single seizure

• 20% have frequent seizures

– 65% nocturnal

– 15% nocturnal or diurnal

– 10-20% waking state only

Typical Seizure

• Child 5-10 years with episodes:

– On waking, fully conscious, mouth to one side,

salivating and focal twitching of one side of

the face

– Duration 1-2 mins;

– Child may recall a sensation of numbness,

pins and needles or “electricity” in the tongue,

gums or cheeks;

– Secondary generalization may be seen

Atonic seizures

• Sudden loss of muscle tone

• Individual collapses

• No tonic-clonic phases

• Head injury is greater risk

Partial Seizures

• Simple partial, focal, or Jacksonian seizures

• Complex partial seizures

• Generalized partial seizures

Simple partial seizures

• Localized seizure disorder which lasts a few minutes and is characterized by motor or sensory phenomena in a hand, arm or body part

• Includes Jacksonian seizures in which seizure moves sequentially from one area to another on the same side of the body

• Most frequent between 5-15 years of age• 25 percent of post traumatic seizures of this type• Outcome dependent upon where seizure origin is

located; frontal lobe hard to control• Generally normal IQ

Complex partial seizures

• Also called psychomotor or temporal lobe seizures• Individual loses awareness• Repetitive motor behaviors occur• Last 1 to a few minutes• Recovery includes confusion, irritability• Accounts for 2/3 of all epilepsies• Multifactorial causes: Genetic predisposition,

prenatal trauma, brain lesions

Generalized Partial Seizures

• Sometimes partial seizures develop into full body seizures

• Usually this is when they are uncontrollable

Febrile Seizures

• Brief seizure in a child which occurs in conjunction with a high fever

• Occur in about 3 percent of young children• Peak occurrence between 9 to 20 months• Over 65 percent do not have subsequent seizure• If have multiple seizures, or associated with other

anomalies (CP), then likely to have impact on intellect

• Seems to run in families

Neonatal Seizures

• May have a variety of causes: Trauma, metabolic, or infection

• If have multiple neonatal seizures, 40 percent mortality rate

• 35 percent have mental retardation

• If metabolic, especially due to drug withdrawal, outlook is better

Objectives

• How to investigate possible seizures– History of greatest importance

• How to approach epilepsy syndromes

• How to predict seizure recurrence

• How to choose an anti-epileptic drug

An approach to Seizures

natura l h istory

investiga tion

treatm ent

What is the probable cause?

N o

D iagnose and Treat

Yes

Is it symptomatic of an acute illness

Yes N o

Is it a seizure?

Acute Symptomatic Seizures

• Hypoglycemia• Hyponatremia• Hypocalcemia• Trauma • Toxic process

• Meningitis• Encephalitis• Hypoxia-ischemia• Tumor• Vascular lesion

Causes of Epilepsy

• Newborns:– Head Trauma– Infections– Metabolic– Medications

• Children– Head Trauma– Fever– Infection– Toxins (Lead Poisoning)– Medications

Epilepsy in Adolescence

• Most commonly occurring neurological disorder

• Rapid changes associated with puberty may make seizures more common and severe, especially if grand mal type

• Absence seizures may be improved

• Due to psychosocial demands may be more problematic

Epilepsy in Adulthood

• Causes often trauma, or infections

• Genetic predisposition

• Emotional causes also documented

Developmental Effects

• Not an obvious disorder

• Generally no intellectual disability

• Personal psychological reaction of loss of control

• Family’s response to risk of seizure

• Medication is crucial to control of seizures; especially difficult in adolescence

Women with Epilepsy

• Pregnancy alters occurrence of seizures, usually making more frequent

• Rate of major malformations is doubled for these women

• Anti-epileptic drugs are associated with mild teratogenic effects (clefting, digit abnormalities)

• If seizure free for 2-5 years, then drop drugs for 6 months to see if a single drug can control seizures

• Single drug therapy associated with fewer malformations

Causes of Epileptic Seizures in Children

• Genetic

• Congenital Brain Abnormality

• Brain Insult e.g. trauma, meningitis,

• Progressive lesion e.g. tumor, AVM

• Metabolic

Genetic Causes of Epilepsy• Familial neonatal convulsions

• Benign familial convulsions of infancy

• Benign partial seizures of infancy

• Febrile seizures

• Benign Rolandic seizures

• Absence epilepsies

• Juvenile myoclonic epilepsy