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Epilepsy

Seizure Disorder

Epilepsy is a brain disorder characterized by an enduring predisposition to generate epileptic seizures, the consequences of this condition and the occurrence of at least one seizure. Seizures can be classified as being partial-onset seizures and generalized-onset seizures.

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Presentation

The symptoms of epilepsy usually vary on the basis of underlying pathology. Seizure is the only symptom which is present in all types of epilepsy. However, the associated symptoms may differ on the type of seizures.

Impairment or loss of consciousness is usually a feature of complex partial seizures. The level of consciousness is not affected in simple partial seizures. Atonic and tonic seizures often make the patient fall down.

Abdominal Pain
  • More severe liver injury can cause nausea, vomiting, abdominal pain, fatigue, anorexia, jaundice and/or dark urine.[fda.gov]
  • The individual may also experience intense fear, abdominal pain or discomfort, or an awareness of increased respiration rate or heartbeat. The form of the onset of a seizure is, in most cases, the same from attack to attack.[britannica.com]
Fecal Incontinence
  • Bruno MK reported that the duration of attacks in his clinical criteria was short (less than one minute). 15 No unconsciousness or urinary and fecal incontinence were observed during the attack.[ncbi.nlm.nih.gov]
Cyanosis
  • In addition to the typical features of PTHS, the girl also had paroxysms of tachypnea followed by cyanosis and recurrent seizures.[ncbi.nlm.nih.gov]
Muscle Twitch
  • These seizures produce muscle twitches, convulsions and loss of consciousness. People with this type of epilepsy do not remember having a seizure.[faculty.washington.edu]
  • Convulsions, during which the muscles twitch or jerk, are just one characteristic of seizures. Some seizures cause convulsions, but many do not.[northshore.org]
  • They proposed a definition of the clinical syndrome as “clonic muscle twitching repeated at fairly short intervals in 1 part of the body for a period of days or weeks.”[medlink.com]
  • Stronger seizures can cause spasms and uncontrollable muscle twitches, and can last a few seconds to several minutes. During a stronger seizure, some people become confused or lose consciousness. Afterward you may have no memory of it happening.[healthline.com]
Anxiety Disorder
  • The identification of risk factors such as mood or anxiety disorders in patients with epilepsy should not delay AED treatment as the risks associated with seizures far outweigh the current research evidence for increased AED-related suicide risk.[ncbi.nlm.nih.gov]
  • Summary The identification of risk factors such as mood or anxiety disorders in patients with epilepsy should not delay AED treatment as the risks associated with seizures far outweigh the current research evidence for increased AED-related suicide risk[dx.doi.org]
Panic Attacks
  • As is true for all drugs that treat epilepsy, the most serious risks include thoughts about suicide, attempts to commit suicide, feelings of agitation, new or worsening depression, aggression and panic attacks.[fda.gov]
  • attacks, Schizophreniform Psychosis 13–18 yrs: normal CT-normal A-III-4 25 yrs, 9 mths 11 mths 18 yrs GTCS, A, CPS, H, status, FS 11 mths Mild Panic attacks, tremor 1-11 yrs: generalized and bilateral independent discharges from both anterior and posterior[brain.oxfordjournals.org]
  • attacks; trouble sleeping (insomnia); acting aggressive; being angry or violent; acting on dangerous impulses; an extreme increase in activity and talking (mania); or other unusual changes in behavior or mood.[aptiom.com]
  • A number of other conditions may present very similar signs and symptoms to seizures, including syncope, hyperventilation, migraines, narcolepsy, panic attacks and psychogenic non-epileptic seizures (PNES).[83][84] In particular a syncope can be accompanied[en.wikipedia.org]
  • Frear, Panic Attacks as Ictal Manifestations of Parietal Lobe Seizures, Epilepsia, 36, 8, (824-830), (2005).[oadoi.org]
Visual Hallucination
  • Types of auras include: Vision (visual): Visual auras can be simple, such as seeing bright flashes of light, dark spots, or tunnel vision, or they can be complex or experiential, such as blindness, visual hallucinations, illusions, and distorted scenery[verywell.com]
  • The cortex is the outer layer of the brain, and seizure symptoms can vary from unusual sensations to visual hallucinations, emotional changes, or convulsions.[everydayhealth.com]
  • hallucinations, ictal blindness, vomiting and post-ictal headache; EEG typically shows interictal occipital spikes attenuated by eye opening an epilepsy syndrome with an age of onset of 3–10 years characterised by multiple seizure types (including atonic[pathways.nice.org.uk]
  • Mark Walterfang, Raju Yerra, Francesco Gaillard, Terence O’Brien, Ramon Mocellin and Dennis Velakoulis, Complex visual hallucinations and occipital seizures, Acta Neuropsychiatrica, 19, 6, (376-379), (2007).[doi.org]
Decreased Libido
  • Decreased libido, or impotence, or both: ( Mattson 1985 ; Ramsay 1983 ).[doi.org]
Seizure
  • In some cases, the test shows the area in the brain where the seizures start. The brain may appear normal after a seizure or between seizures.[nlm.nih.gov]
  • This work resulted in the formation of two major classes: partial-onset seizures and generalized-onset seizures. Partial-onset seizures A partial seizure originates in a specific area of the brain.[britannica.com]
  • Three categories of reflex seizures encountered clinically include pure reflex epilepsies, reflex seizures that occur in generalized or focal epilepsy syndromes that are also associated with spontaneous seizures, and isolated reflex seizures occurring[doi.org]
Confusion
  • On 1-year follow-up, patient and family members did not report episodic confusion or any seizure-like activity. RAS constitute a particular entity of seizures and need careful interpretation and management.[ncbi.nlm.nih.gov]
  • Epileptic seizures typically last one to two minutes but can be followed by weakness, confusion, or unresponsiveness.[britannica.com]
  • 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.[emedicinehealth.com]
  • Unfortunately, a great deal of misunderstanding and confusion about seizures still exists, so it is important that your child's friends and teachers become educated about her condition.[healthychildren.org]
Dizziness
  • These 'peaks' may be associated with side effects such as dizziness, drowsiness and lack of coordination.[dx.doi.org]
  • Nevertheless, polytherapy often results in a number of unwanted effects, including neurological disturbances (somnolence, ataxia, dizziness), psychiatric and behavioural symptoms, and metabolic alteration (osteoporosis, inducement or inhibition of hepatic[ncbi.nlm.nih.gov]
Aura
  • The type of aura you have can give clues as to the region of your brain in which your seizure begins. Sometimes, auras occur without any other seizure symptoms. In these cases, the aura is the seizure.[verywell.com]
  • After experiencing the aura, the individual becomes unresponsive but may examine objects closely or walk around.[britannica.com]
  • Here Prince Myshkin describes the onset of a seizure with an ecstatic aura.[charge.org.uk]
  • Aura Stage For some types of seizures, an aura happens before a seizure and may alert a person that a seizure may occur. Auras typically begin seconds before the seizure.[uchospitals.edu]
  • Her habitual seizures were described as sudden behavioral arrest, staring, unresponsiveness, and oral automatisms, with auras of fear and palpitation.[ncbi.nlm.nih.gov]
Febrile Convulsions
  • Suggestion of a major gene for familial febrile convulsions mapping to 8q13-21. J Med Genet. 1996; 33 (4) 308-312 9 Johnson E W, Dubovsky J, Rich S S et al..[doi.org]
  • If your child has had a febrile convulsion, some parents may try controlling the fever using acetaminophen and sponging. However, these approaches do not prevent future febrile seizures, but only make the child more comfortable.[healthychildren.org]
Urinary Incontinence
  • At 14 years old, she experienced an aggravated seizure, manifesting as unconsciousness, hyperventilation, and urinary incontinence.[ncbi.nlm.nih.gov]
  • The tongue may be bitten during involuntary contraction of the jaw muscles, and urinary incontinence may occur. Usually, the entire generalized tonic-clonic seizure is over in less than five minutes.[britannica.com]

Workup

Before the diagnosis of epilepsy is made, the following investigations are used to rule out infections or metabolic causes of seizures.

  • Blood Chemistry Panel
  • Serum urea, creatinine and electrolytes
  • Random blood sugar
  • Serum calcium and magnesium
  • Liver function tests
  • Lumbar puncture

Other investigations that will help diagnose epilepsy include the following.

  • Electroencephalography: Electroencephalography may help establish and characterize the type of epilepsy by demonstrating abnormal electrical activity in the brain.
  • Compuerized Tomography (CT) or Magnetic Resonance Imaging (MRI) scan: CT or MRI brain scanning is often useful in defining or excluding structural causes for seizures e.g. tumors and infections.
  • Position Emission Tomography (PET) and Single Photon Emission Computed Tomography (SPECT): PET and SPECT are also used to evaluate certain patients of seizures who do not respond to medical therapy.
Epileptiform Activity
  • It remains unclear whether seizures and epileptiform activity on the EEG are causative or comorbid. It is also uncertain if focal epileptiform EEG abnormalities may be associated with stable cognitive impairment.[ncbi.nlm.nih.gov]
  • Her EEG at 2 years was reported as showing frequent left central epileptiform activity. At 4 years, the EEG was more abnormal with the background predominantly comprising bilateral delta rhythms most prominent over the right central region.[brain.oxfordjournals.org]
EEG Suppression
  • Loparo, Automated Detection of Postictal Generalized EEG Suppression, IEEE Transactions on Biomedical Engineering, 65, 2, (371), (2018).[doi.org]
  • Kalitzin, Dynamics of convulsive seizure termination and postictal generalized EEG suppression, Brain, 10.1093/brain/aww322, (aww322), (2017).[oadoi.org]
Periodic Lateralized Epileptiform Discharges
3 Hz Spikes
  • Epilepsy Other names Seizure disorder Generalized 3 Hz spike-and-wave discharges on an electroencephalogram Specialty Neurology Symptoms Periods of vigorous shaking, nearly undetectable spells[1] Duration Long term[1] Causes Unknown, brain injury, stroke[en.wikipedia.org]
  • Wong, Co-existence of Rolandic and 3 Hz Spike-Wave Discharges on EEG in Children with Epilepsy, Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques, 10.1017/cjn.2018.364, (1-7), (2018).[doi.org]
Focal Epileptiform Discharges
  • The cellular neurophysiologic correlate of an interictal focal epileptiform discharge in single cortical neurons is the paroxysmal depolarization shift (PDS).[emedicine.medscape.com]

Treatment

Immediate care of seizures:

Little can be done for a person having a major seizure. Supportive treatment includes first aid, maintenance of airway, provision of oxygen and administration of intravenous anticonvulsants.

Anti-convulsant drug therapy:

If the cause of epilepsy is treatable promptly, drug therapy is not necessary. Drug therapy is required when the cause is not immediately treatable and and the patient is at a risk of having further seizures. There are various anticonvulsant drugs with different mechanism of actions. They can be divided into the following large groups [6]. 

Surgical choices

The type of epilepsy surgery depends on the location in the brain causing the seizures. Anterior temporal lobectomy is the most common surgical choice in adults [7]. In children, the surgical choices include corpus callosotomy and hemispherectomy [8] [9].

Prognosis

If epilepsy is properly controlled via medications, the lifespan of the patients is completely normal.

Even without treatment, sudden death in the patients suffering from epilepsy is very uncommon. Those suffering from tonic-clonic seizures may suffer from accidents and traumas. Mortality is also higher in the patients whose seizures are associated with loss of consciousness.

Etiology

The etiology of epilepsy varies with age group.

In neonates, developmental insufficiency or brain injury are the most common causes for the development of epilepsy.

In the infantile age group, the principal congenital malformations, perinatal injury and metabolic disorders are the principal causes of epilepsy.

In children and adolescents, epilepsy usually results from genetic causes.

In adults, in addition to genetic causes, cerebral neoplasms, drugs, alcohol withdrawal, brain trauma, stroke, infection and surgery are the predisposing conditions that lead to the development of epilepsy.

The genetic syndromes that cause seizures include Angelman syndrome, Rett syndrome, Pitt Hopkin’s syndrome, tuberous sclerosis, Prader Willi syndrome and Struge Weber syndrome [1][2].

Epidemiology

The annual incidence of epilepsy in Minnesota was demonstrated by a study to be around a 100 cases per 100,000 persons aged between 0 to 1 years; 40 cases per 100,000 persons aged 38 to 40 years and 140 cases per 100,000 persons aged 79-80 years.

Overall, the total incidence of epilepsy is 3400 per 100,000 men (3.4%) and 2800 per 100,000 women (2.8%) by the age of 75 years [3].

Sex distribution
Age distribution

Pathophysiology

Seizures result from a sudden imbalance between the excitatory and inhibitory mechanisms in the brain [4].

Partial seizures are those in which the seizure activity is restricted to one part of the cerebrum; i.e. the focus of increased electrical activity is in one hemisphere.

On the other hand, in generalized seizures, diffuse regions of both the hemispheres are involved simultaneously and sunchronously.

If any seizure remains for 60 minutes, irreversible brain damage occurs. Cell death occurs from excessively increased metabolic demands of the continuously discharging neurons.

Prevention

Since the cause of epilepsy is not exactly known, it is not possible to prevent it. However, head injury being the most important cause, if avoided can prevent the development of epilepsy [10]. Wearing seat belts, following traffic rules and avoiding accidents is helpful in reducing the risk of head trauma.
Epileptics sensitive to alcohol must prevent alcohol intake.

Summary

A seizure or convulsion is a paroxysmal involuntary disturbance of brain function that may be manifested as an impairment or loss of consciousness, abnormal motor activity, behavioral abnormalities, sensory disturbances or autonomic dysfunction.
Epilepsy is defined as a brain disorder that is characterized by recurrent seizures unrelated to fever or to an acute cerebral etiology.

Patient Information

Epilepsy is a group of disorders characterized by seizures in association with loss of consciousness and psychic abnormalities. The patients of epilepsy may belong to any age group. Early diagnosis and proper management of the disease improves the outcome. Treatment may be done through anti-seizure drugs or brain surgery.

References

Article

  1. Steffenburg U, Hagberg G, Hagberg B. Epilepsy in a representative series of Rett syndrome. Acta paediatrica. Jan 2001;90(1):34-39.
  2. Whalen S, Heron D, Gaillon T, et al. Novel comprehensive diagnostic strategy in Pitt-Hopkins syndrome: clinical score and further delineation of the TCF4 mutational spectrum. Human mutation. Jan 2012;33(1):64-72.
  3. Hauser WA, Annegers JF, Rocca WA. Descriptive epidemiology of epilepsy: contributions of population-based studies from Rochester, Minnesota. Mayo Clinic proceedings. Jun 1996;71(6):576-586.
  4. Engelborghs S, D'Hooge R, De Deyn PP. Pathophysiology of epilepsy. Acta neurologica Belgica. Dec 2000;100(4):201-213.
  5. Tharyan P. Prolactin levels in epilepsy. The Journal of the Association of Physicians of India. Jun 1991;39(6):505-506.
  6. Goldenberg MM. Overview of drugs used for epilepsy and seizures: etiology, diagnosis, and treatment. P & T : a peer-reviewed journal for formulary management. Jul 2010;35(7):392-415.
  7. Matsuura M. Indication for anterior temporal lobectomy in patients with temporal lobe epilepsy and psychopathology. Epilepsia. 2000;41 Suppl 9:39-42.
  8. Gonzalez-Martinez JA, Gupta A, Kotagal P, et al. Hemispherectomy for catastrophic epilepsy in infants. Epilepsia. Sep 2005;46(9):1518-1525.
  9. Rahimi SY, Park YD, Witcher MR, Lee KH, Marrufo M, Lee MR. Corpus callosotomy for treatment of pediatric epilepsy in the modern era. Pediatric neurosurgery. 2007;43(3):202-208.
  10. Pitkanen A, Bolkvadze T. Head Trauma and Epilepsy. In: Noebels JL, Avoli M, Rogawski MA, Olsen RW, Delgado-Escueta AV, eds. Jasper's Basic Mechanisms of the Epilepsies. 4th ed. Bethesda (MD)2012.

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Last updated: 2019-07-11 22:47