Epilepsy

A seizure is a transient occurrence of signs or symptoms due to abnormal excessive or synchronous neuronal activity in the brain. Epilepsy describes a condition in which a person has a high risk of recurrent (two or more) unprovoked seizures. It is a neurological disorder that affects the normal activities of the brain. The abnormal activity could be due to inherited conditions, trauma to the head, and developmental disorders. The symptoms vary among individuals from mild to severe depending on the type of seizure. Symptoms may include temporary confusion, episodes of staring blankly, uncontrollable jerks and twitching of arms and legs, loss of consciousness or awareness, and psychological symptoms like fear, anxiety, and depression. The common signs and symptoms of epilepsy include:

• Daydreaming and confusion: Staring at everything and not responding to anything, often accompanied by attention blackouts, mumbling, or no response. This is a common presentation seen in cases of absence seizures.
• Uncontrollable jerking movements and twitching of arms and legs: Involuntary movements occur during a seizure, leading to nerve damage. This may produce small twitches in the affected muscles. Some involuntary movements include:
  • Tardive dyskinesia: A neurological condition originating in the brain due to the use of neuroleptic drugs, resulting in repetitive, involuntary body movements such as grimacing, rapid jerking movements, blinking of the eyes, and protruding tongue. This disorder interferes with normal daily functioning.
  • Myoclonus: A quick involuntary muscle jerk occurring right before sleep or upon waking, which may feel like an electric shock accompanied by rhythmic movements.
  • Tremors: An uncontrolled and involuntary movement that can be a symptom of a seizure, typically presenting as uncontrollable nodding of the head, balance problems, numbness in any part of the body, and stooped posture.
• Sudden fear or anger: Abnormal brain activity leads to seizures, during which a person may experience changes in behavior and automatic responses such as hunger, emotional distress, and a fight or flight response.
• Sudden falls and frequent stumblings: Individuals with epilepsy are more prone to physical problems such as fractures and bruises related to seizures. Elders are particularly susceptible to falls and injuries, which may occur multiple times a year.
• Jacksonian march: Abnormal movements may begin in a restricted region of a limb, such as fingers, and progress gradually over seconds to minutes, potentially involving a larger portion of the extremity and even the whole body, culminating in generalized seizures.
• Todd’s palsy/paralysis: Some patients may experience transient paralysis of the limb or part involved in the seizure, lasting from minutes to several hours.

Non-motor symptoms: These are less common than motor symptoms during seizure episodes but can occur in some patients, especially those with atypical presentations.

• Sensory symptoms: Patients may experience sensations such as numbness, burning, and tingling.
• Autonomic symptoms: Loss of bowel or bladder control and unregulated changes in heart rate may be observed.
• Emotional lability: Excessive and unprovoked laughter, crying, anger, or sadness may be seen.

There are several established causes of epilepsy or unprovoked seizures, which can be categorized into genetic, structural, infectious, metabolic, immune, and other factors. Examples include:

• A severe head injury
• Genetic conditions associated with brain malfunction
• Brain tumor or cyst
• Infections of the brain, such as meningitis
• Lack of oxygen to the brain
• Dementia or Alzheimer’s disease
• Maternal drug use, prenatal injury, brain malformation, or lack of oxygen at birth
• Infectious diseases, such as AIDS (HIV infection)
• Scarring on the brain after a brain injury (post-traumatic epilepsy)
• Intracranial hemorrhage
• Drug or alcohol withdrawal
• Febrile seizures
• Illicit drug use or overdose
• Stroke
• Hepatic failure
• Advanced chronic kidney disease
• Hyponatremia (low levels of sodium)
• Hypoglycemia

The risk factors associated with developing epilepsy include:

• Any injury to the brain
• Being born with brain abnormalities
• A family history of seizures
• Many individuals who develop the disease do not have identifiable risk factors

1. Medications

A missed dose of an antiepileptic drug or underdosing of antiepileptic medication is a common issue observed in day-to-day clinical practice.

2. Medical History

Medical history is foundational in the diagnosis of epilepsy. For precise treatment, it is essential to analyze the family history, including any relatives with the same condition. The doctor identifies prenatal and perinatal causes of brain damage, which may include:

• Born with abnormal areas of the brain
• Seizures in the first month of life
• Premature birth

3. Other Health Conditions

Various health conditions, such as autism and growth defects in the brain, can lead to epileptic seizures. Additionally, issues with electrolyte conduction can result in several other diseases, including:

• Cerebral palsy
• Stroke
• Alzheimer’s disease
• Intellectual disabilities

Epilepsy is predicted by diagnosing the type of seizure. Many disorders lead to a change in behavior and can be confused with epilepsy. Diagnosis involves ruling out other psychiatric illnesses and disorders occurring due to chemical disturbances in the brain. Establishing a diagnosis for epilepsy involves the following:

1. Clinical history
   Before confirming the patient is having epilepsy, it is essential to rule out the conditions that may mimic the symptoms of epilepsy. A physician performs a detailed overview checkup, reviewing the patient’s history as well as his/her family history and the onset of symptoms to rule out other potential causes.
2. Lab tests and imaging studies
   The following tests can be done to evaluate overall health conditions and study brain functioning:
   • Computed tomography (CT) scan (head): A CT scan uses an X-ray to view the cross-sectional area of the brain. It can reveal abnormalities in the brain and the cause of the seizure-like tumor, lesions, and bleeding.
   • Magnetic resonance imaging (MRI) brain: An MRI uses powerful magnetic and radio waves to create a detailed image of the brain. The doctor can detect the cause of the seizure by viewing an MRI.
   • PET CT brain with contrast: A PET scan takes a picture of the brain as it works. It can detect any metabolically active lesion, particularly tumors, which may be a cause of seizures.
   • Electroencephalogram (EEG): It measures the activity of the brain. It is useful in patients with epilepsy, especially in diagnosing the type of epilepsy, localizing the lesion in the brain, and helping the physician choose the appropriate drug for further treatment.
     Note: It is most useful to document electrographic seizure activity, but since seizures are infrequent and unpredictable, it is often not possible to obtain an EEG during a clinical event. In such situations, activating procedures may be undertaken by your doctor to provoke abnormalities. These procedures are done under strict medical supervision and may include hyperventilation (3 or 4 minutes).
   • Brain SPECT: It is an imaging procedure done using a tracer dye to create an image of the blood flow in the brain. It helps in locating the origin of epileptic seizures.
   • Comprehensive health checkup: To evaluate the overall health status of a person, this includes tests to check serum electrolytes (sodium, calcium, and potassium), blood glucose, liver function tests, renal function tests, and urinary toxicology to rule out the use of illicit drugs.
3. Neuropsychological test
   A detailed neuropsychological test is designed to measure individual performance in terms of accuracy, memory, language, attention, thoughts, mental status, and patient history, which is essential to diagnose the disease. These tests can help predict whether seizures are affecting psychological functions, including memory, attention, mood, language, emotions, and personality.

An estimated 25% of epilepsy cases are preventable. The most common ways to reduce the risk of seizure are:

• Have a healthy pregnancy. Some problems during pregnancy and childbirth may lead to epilepsy. Follow a prenatal care plan with your healthcare provider to ensure both you and your baby remain healthy.
• Prevent brain injuries, as they lower the chances of stroke and heart disease.
• Stay up-to-date on your vaccinations.
• Wash your hands and prepare food safely to prevent infections such as cysticercosis/neurocysticercosis.
• Follow proper sleep hygiene and avoid loud music or flashy lights that can trigger an attack.

In known cases of epilepsy or seizures, prevention can be achieved by taking antiepileptic drugs in a timely manner and at the appropriate dosage as prescribed by your doctor. Additionally, avoiding known triggers can help lower the risk of experiencing an epileptic attack.

Treatment with antiepileptics or anti-seizure medications can alleviate symptoms. They are a class of drugs primarily used to treat seizures associated with epilepsy. Usually, treatment is started with a single antiepileptic drug, but if your doctor feels it is not sufficient, a combination of drugs may also be used. Other treatment options include vagus nerve stimulators, ketogenic diet, and surgery. However, medication is the first line of treatment.

1. Conventional anti-epileptics or anti-seizure drugs

These drugs decrease the frequency or severity of seizures in people with epilepsy. They treat the symptoms of epilepsy but not the underlying cause. They maximize the quality of life by minimizing seizures. They work by blocking the sodium channel or enhancing GABAergic action. Potential side effects include unsteady walking and poor coordination or balance. Antiepileptic drugs can be further divided into:

• Narrow spectrum: works for specific types of seizures (partial or focal)
• Broad spectrum: effective for a wide range of seizures (partial plus absence myoclonic seizure)

Common examples include:

• Phenytoin
• Phenobarbitone
• Carbamazepine
• Valproic acid
• Levetiracetam
• Felbamate
• Lamotrigine

2. Intravenous and intramuscular injectables

These are essential during emergency conditions (like status epilepticus) when oral administration of drugs is not possible. These formulations provide rapid delivery and complete bioavailability of the drug. Common examples include:

• Diazepam
• Lorazepam
• Clonazepam
• Pentobarbital

These formulations are useful in the treatment of epilepsy and anxiety disorders. They decrease the abnormal and excessive activity of the nerve cells. Common side effects are fatigue, depression, and impaired coordination.

3. Anesthetic drugs

These are used after conventional therapy for seizures has failed. They are commonly used to treat refractory cases of status epilepticus. Common examples include:

• Isoflurane
• Desflurane
• Ketamine

4. Vagus nerve stimulators

This stimulation prevents seizures by sending regular, mild pulses of electrical energy to the vagus nerve. It is approved to treat focal or partial seizures and works on drug-resistant epilepsy. Common side effects include coughing or shortness of breath.

5. Surgery

In the most severe cases, the affected area of the brain is surgically treated to improve the symptoms and condition of the patient. Most commonly performed surgical procedures include:

• Temporal lobectomy
• Corpus callosectomy
• Lesionectomy

6. Transcranial magnetic stimulation (TMS)

This is a form of focal, noninvasive cortical stimulation in which a focal electric current is induced in the cerebral cortex by a fluctuating extracranial magnetic field generated, most commonly, by a handheld electromagnet. It is useful for cases refractory to conventional medical therapy.

First-aid for epilepsy

The major precautions one should take to help someone who is having an epileptic seizure include:

• Ease the person and remain calm.
• Turn the person onto one side to help them breathe.
• Remove all harmful objects from close proximity.
• Put something soft underneath the person's head.
• Loosen all clothing and anything around the neck to facilitate breathing.
• If the seizure lasts for more than 5 minutes, contact a doctor and stay with them until they are awake.

Living with someone who has epilepsy can be challenging for the family and caregivers. The patient requires support and care at each stage. Epilepsy can vary from person to person, so the care can vary greatly. Some individuals with epilepsy need extensive care, while others may require assistance only during a seizure. However, the following tips can aid in caring for someone with this condition.

Understanding the Condition

Understanding the condition of the person is the first step in managing the disease. Caregiving may involve several skills, including:

• Emotional support
• Dealing with medical equipment
• Recognizing warning signs if the condition worsens

Stay Focused on Therapy

The therapy goals vary for each person and are adjusted to meet the patient's needs. Encourage your loved ones to adapt to their therapy and practice self-management strategies. This will help them take responsibility for their goals. One of the most common causes of seizure recurrence is missed doses or under-dosage of antiepileptic drugs; therefore, it is crucial for the patient to maintain a regular dosing schedule, preferably at the same time each day.

Keep Patient Away from Tobacco, Alcohol, and Substance Abuse

Alcohol and other drugs can exacerbate the symptoms of epilepsy. Families should ensure that the patient avoids these substances. Professional help should be sought for patients who are already struggling with alcohol or drug addiction, as abrupt cessation may lead to withdrawal symptoms, which can trigger seizures.

Try Stress Management Techniques

Being a caregiver can be exhausting, and emotions such as anger, resentment, guilt, and helplessness are common. Learning relaxation and stress management techniques can assist in coping with the challenges of the disease.

Join Epilepsy Support Groups

Connecting with others facing similar challenges can provide support and boost morale. Several organizations in India assist individuals with mental illness and encourage them to engage with other patients in a safe and supportive environment.

Note: Epilepsy symptoms and conditions can change over time. The level of care needed by the patient may also evolve, as can the condition of the caregiver.

If left untreated, epilepsy may severely hamper a patient’s life and can cause various complications such as:

• Impaired mental function
• Lack of motor coordination
• Depression
• Anxiety disorders
• Physiological symptoms, fear and anxiety
• Aggressive behavior

If it worsens, the patient might require long-term hospitalization.

1. Relaxation therapy

Massage and aromatherapy are often used to reduce stress and tension. They can help alleviate poor sleeping patterns. Some individuals practice yoga and meditation to relax and enhance mindfulness. These techniques have been shown to ease tension and reduce stress related to seizures.

2. Cognitive behavioral therapy (CBT)

This psycho-social intervention aims to improve mental health by helping patients change their perceptions of specific situations. It assists in managing feelings and altering actions, which further helps in modifying their reactions.

3. Electroconvulsive therapy

For adults who do not respond to drug therapy, electroconvulsive therapy may be considered. This psychiatric treatment involves inducing seizures to manage refractory mental disorders. A small amount of electric current is passed through the brain to regulate its activity.

4. Deep brain stimulation (DBS)

This surgical procedure involves implanting a device that sends electrical signals to the brain. Electrodes are implanted in the patient's brain area, generating mild electrical impulses that regulate abnormal brain activity and improve symptoms.

5. Ayurveda in epilepsy

Ayurveda treatment for epilepsy follows an integrated approach, combining natural medicine, a ketogenic diet, and lifestyle regulation. In some cases, ayurvedic herbs have been found beneficial when used alongside antipsychotic medication. However, there is insufficient evidence to support the effectiveness of ayurvedic treatment for managing epilepsy.

• Learn about your condition
• Take medicines as recommended by your doctor
• Talk to your doctor if you have any questions
• Manage your stress levels with yoga and meditation
• Get enough sleep and maintain a sleep schedule
• Maintain a seizure diary by noting the time and day of an epileptic attack, triggers or aura before it, chronic medications, and liver function test readings