Epilepsy

Understanding Epilepsy

Epilepsy, also known as a seizure disorder, is a condition where the brain has recurring seizures. These seizures happen when unusual electrical activity in the brain disrupts normal brain function. While anyone can develop epilepsy, it's more common in children and older adults. Sometimes, the cause is clear, such as a stroke, brain tumor, genetic issues, prior brain infections, birth injuries, or developmental problems. However, in about half of cases, the cause isn't known.

What are the different types of seizures?

Seizures can affect any part of the brain, leading to various symptoms. Often, someone will have the same type of seizure each time, but sometimes they can have different types. Identifying a seizure can be challenging, but common signs include temporary confusion, staring spells, uncontrolled jerking movements, loss of awareness, fear, anxiety, or a feeling of déjà vu.

Seizures are broadly categorized as focal or generalized.

• Focal seizures: These start in one area of the brain. They can happen with or without loss of awareness.

  • Focal seizures with awareness: During these seizures, a person might experience changes in emotions, sensations (like smells, sounds, or tastes), dizziness, tingling, or flashing lights. They might also have involuntary movements, such as jerking of an arm or leg.
  • Focal seizures without awareness: In this type, a person might lose awareness, staring blankly or not responding normally. Activities like hand rubbing, chewing, swallowing, or walking in circles might occur. Since these symptoms overlap with other conditions like migraines, heart problems, or psychiatric issues, proper diagnosis requires medical evaluation.

• Generalized seizures: These occur across the entire brain. Different types of generalized seizures include:

  • Absence seizures: Characterized by staring blankly into space. Blinking and lip smacking may also be present.
  • Tonic seizures: Cause stiffening of the back, arms, and legs.
  • Atonic seizures: Opposite of tonic seizures, causing a sudden loss of muscle control.
  • Clonic seizures: Result in repeated jerking movements, often affecting the neck, face, and arms.
  • Myoclonic seizures: Involve brief, sudden jerks or twitches of the arms.
  • Tonic-clonic seizures: Combine features of both tonic and clonic seizures, including stiffening of the body, shaking, loss of bladder control, and sometimes biting the tongue.

How is epilepsy diagnosed?

Even after one seizure, a diagnosis of epilepsy might not be possible immediately. If someone experiences what seems like a first-time seizure, it's crucial to see a doctor. The doctor will assess motor skills, mental function, and other relevant areas to determine if it's epilepsy. Diagnostic tests may include a neurological exam, blood tests, an EEG (electroencephalogram), CT scan, brain imaging, and sometimes neuropsychological tests. A team of specialists, including neurologists, epileptologists, neurosurgeons, and others, works together to provide the best possible care.

How is epilepsy treated?

Accurate diagnosis is the first step to effective treatment. Epilepsy medications are often highly effective, and more than half of people achieve seizure-free status with medication. However, if medication isn't enough, other treatment options like surgery or brain stimulation may be explored. A specialized epilepsy center can help determine the best course of action for each patient.

It's essential for people undergoing treatment to keep a detailed seizure diary. This diary should record the time, type, and duration of each seizure, along with any potential triggers, such as missed medication, sleep deprivation, stress, or menstrual cycles.

Important facts about epilepsy:

• Epilepsy is common. It's estimated that approximately 1.2% of people in the U.S. have active epilepsy.
• It affects people of all ages, genders, and backgrounds.
• Symptoms vary greatly, ranging from loss of awareness to staring spells to convulsive movements.
• A single seizure doesn't automatically mean epilepsy. A diagnosis requires at least two unprovoked seizures at least 24 hours apart.
• Treatment options, including medication and sometimes surgery, can control seizures for most people. Some people may need lifelong treatment, while for others, seizures may resolve over time, particularly in children.

Different types of seizures have different symptoms. Epilepsy is a condition where unusual electrical activity in the brain causes seizures. Since seizures affect different parts of the brain, they can cause a wide range of symptoms.

Possible Seizure Symptoms:

• Changes in awareness: This could include temporary confusion, a blank stare, or a loss of consciousness.
• Muscle problems: Stiff muscles, uncontrolled shaking (jerking) of the arms and legs, or loss of muscle control (a sudden fall) can occur.
• Psychological symptoms: Seizures can sometimes lead to feelings like fear, anxiety, or a sense of familiarity (déjà vu). Changes in behavior and even psychosis (loss of contact with reality) are also possible.

Types of Seizures:

Seizures are categorized as either focal or generalized, depending on where the unusual brain activity starts.

Focal Seizures:

These happen when unusual activity begins in a specific area of the brain. Focal seizures are further divided into two types:

• Focal Seizures Without Loss of Awareness (formerly called simple partial seizures): These seizures don't cause a loss of consciousness. They can, however, affect how a person perceives things (e.g., altered senses of sight, smell, touch, taste, or sound). People might experience strange feelings like deja vu, or involuntary jerking of a body part, or sensory symptoms like tingling, dizziness, or flashing lights.

• Focal Seizures With Impaired Awareness (formerly called complex partial seizures): These seizures involve a change or loss of consciousness. A person might seem to be daydreaming or in a trance-like state. They might stare blankly, not respond normally to their surroundings, or repeat simple movements like rubbing their hands, chewing, swallowing, or walking in circles.

Focal seizures can originate in any part of the brain. Examples include:

* **Temporal Lobe Seizures:**  These start in the temporal lobes of the brain, which are important for processing emotions and short-term memory.  People having a temporal lobe seizure may experience an "aura" (warning sign) like a sudden feeling of fear, joy, a strange taste or smell, déjà vu, or a rising sensation in the stomach. During the seizure, they might lose awareness, stare blankly, smack their lips, chew or swallow repeatedly, or have unusual hand movements.

* **Frontal Lobe Seizures:**  Starting in the front of the brain, these seizures affect movement.  People might move their head or eyes to one side, not respond to being spoken to, scream or laugh, extend one arm and flex the other, or make repetitive movements like rocking or pedaling.

* **Occipital Lobe Seizures:**  Beginning in the occipital lobe, which is responsible for vision, these seizures can cause visual hallucinations (seeing things that aren't there) or temporary vision loss.  Eye blinking or eye movements can also occur.

Generalized Seizures:

These seizures involve unusual brain activity that appears to spread throughout both sides of the brain. Examples include:

* **Absence Seizures (formerly petit mal seizures):**  Common in children, these seizures involve staring into space, sometimes with subtle body movements like eye blinking or lip smacking. They last only a few seconds (5-10) and may happen repeatedly throughout the day.

* **Tonic Seizures:**  These seizures cause stiff muscles and may affect consciousness.  The person may fall to the ground, typically involving the back, arms, and legs.

* **Atonic Seizures (drop seizures):**  These seizures cause a sudden loss of muscle control, often resulting in a fall, primarily affecting the legs.

* **Clonic Seizures:**  These seizures involve repeated, rhythmic jerking movements, usually affecting the neck, face, and arms.

* **Myoclonic Seizures:**  These are characterized by sudden, brief jerks or twitches, typically affecting the upper body, arms, and legs.

* **Tonic-Clonic Seizures (formerly grand mal seizures):**  These are the most noticeable seizures.  They involve a sudden loss of consciousness, body stiffening, twitching, and shaking.  Loss of bladder control or biting the tongue can also occur.

When to Seek Immediate Medical Attention:

• A seizure lasting more than five minutes.
• Loss of consciousness or breathing not returning after the seizure ends.
• A second seizure immediately following the first.
• High fever.
• Pregnancy.
• Diabetes.
• Injury during the seizure.
• Seizures continuing despite taking anti-seizure medication.

If you experience a seizure for the first time, it's crucial to seek medical advice.

If you have a seizure, get medical help right away if any of these things happen:

• The seizure lasts longer than five minutes: This is a sign that the seizure might be more serious. A prolonged seizure can cause harm to your body.

• You don't wake up or start breathing again after the seizure stops: This means your body hasn't returned to normal function, and you need immediate medical attention.

• You have another seizure right away: Having more than one seizure in a short time is called a seizure series or status epilepticus. This is a serious medical emergency.

• You have a high fever: Fevers can sometimes trigger or worsen seizures.

• You are pregnant: Pregnancy can affect how your body handles seizures.

• You have diabetes: Diabetes can make you more vulnerable to problems during or after a seizure.

• You get hurt during the seizure: Injuries from falling or other movements during a seizure can lead to complications.

• You still have seizures even though you're taking medicine for them: If your seizure medication isn't working, you need to talk to your doctor. This could indicate a change in your condition or the need for a different treatment plan.

If you have a seizure for the first time, it's important to see a doctor to discuss what happened and get advice on how to prevent future seizures.

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Understanding the Causes of Epilepsy

Epilepsy is a neurological condition characterized by seizures. In about half of those with epilepsy, the exact cause isn't known. However, in the other half, various factors can contribute to the development of epilepsy.

1. Genetic Factors:

Many types of epilepsy tend to run in families, suggesting a genetic link. Scientists have identified specific genes associated with some forms of epilepsy. This means that a person's genetic makeup can influence their risk. Crucially, not all genetic epilepsy is inherited. Sometimes, random genetic changes occur in a child, unrelated to their parents' genes.

For most people with epilepsy, genes are only one piece of the puzzle. Certain genes might make a person more susceptible to environmental factors that can trigger seizures. This means a person might be predisposed to seizures, but a specific trigger is still needed.

2. Environmental and Brain-Related Factors:

• Head Injuries: Accidents, falls, or other traumatic head injuries can damage the brain and increase the risk of developing epilepsy.
• Brain Conditions: Brain tumors can disrupt normal brain function and lead to seizures. Problems with blood vessels in the brain, such as arteriovenous malformations (AVMs) or cavernous malformations, can also cause seizures. In adults over 35, stroke is a significant cause of epilepsy.
• Infections: Certain infections, including meningitis, HIV, viral encephalitis, and some parasitic infections, can damage the brain and trigger epilepsy.
• Prenatal Issues: Issues during pregnancy, such as infections, poor nutrition, or insufficient oxygen supply to the developing fetus, can lead to brain damage. This damage can result in epilepsy, cerebral palsy, or other neurological problems.
• Developmental Conditions: Some developmental conditions, like autism, are more prevalent in people with epilepsy. Research suggests a possible link between genes and the co-occurrence of epilepsy and other developmental disorders, such as attention-deficit/hyperactivity disorder (ADHD).

Factors That Can Trigger Seizures (Not Epilepsy Itself):

While these factors don't cause epilepsy, they can trigger seizures in individuals already predisposed:

• Substance Use: Alcohol and illicit drugs can trigger seizures. Incorrect use or skipping doses of anti-seizure medications can also lead to seizures.
• Lifestyle Factors: Lack of sleep, significant stress, hormonal changes during menstruation, and dehydration can increase the likelihood of a seizure.
• Dietary Factors: Skipping meals or experiencing sudden changes in blood sugar levels can trigger seizures.
• Illness: Fever, illness, and infections can all make seizures more likely.
• Environmental Factors: Exposure to flashing lights can trigger seizures in some individuals.

It's essential to remember that not everyone with epilepsy experiences consistent triggers. While some people can identify patterns that seem to increase their risk, seizures can occur unpredictably. If you suspect you might have epilepsy or experience seizures, consult a doctor for proper diagnosis and management.

Some things can make you more likely to get epilepsy.

• Age: Epilepsy often starts in young children or older adults, but it can happen at any time.

• Family history: If someone in your family has epilepsy, you might have a higher chance of getting it too.

• Head injuries: Head injuries can sometimes cause epilepsy. Protecting your head is important. Always wear a seatbelt in cars, and use a helmet when biking, skiing, riding a motorcycle, or doing other activities that could lead to a head injury.

• Stroke and other blood vessel problems: Strokes and problems with your blood vessels can damage your brain. This brain damage can lead to seizures and epilepsy. You can take steps to lower your risk of these problems. This includes limiting alcohol, not smoking, eating a healthy diet, and getting regular exercise.

• Dementia: Dementia, especially in older adults, can sometimes increase the risk of epilepsy.

• Brain infections: Infections like meningitis, which inflames the brain and spinal cord, can raise your risk of epilepsy.

• Childhood seizures: Sometimes, high fevers in children can cause seizures. Most children who have seizures from fevers don't go on to develop epilepsy. However, the risk of epilepsy is higher if a child has a long seizure linked to a fever, other nervous system problems, or a family history of epilepsy.

Living with epilepsy can present several challenges and potential dangers. Understanding these risks is crucial for managing the condition effectively and ensuring safety.

Potential Dangers During Seizures:

• Falls: Seizures can cause loss of balance and lead to falls, potentially resulting in head injuries or broken bones. This is important to be aware of and take precautions to prevent falls during a seizure.
• Drowning: People with epilepsy are significantly more likely to drown while swimming or bathing. This heightened risk is due to the possibility of a seizure occurring in the water, leading to loss of consciousness or control. Always be cautious and take extra safety precautions while around water if you have epilepsy.
• Vehicle Accidents: Seizures can disrupt awareness and control, making driving or operating machinery dangerous. This poses a risk not only to the person with epilepsy but also to others on the road. If you have epilepsy, you should discuss driving restrictions with your doctor.

Driving Restrictions:

Many states have rules about driving and epilepsy. These regulations vary, but they typically require a period of seizure-free driving before a person can be cleared to drive again. The duration of this period can be several months or even years, depending on the frequency and severity of seizures. It's crucial to follow these regulations to ensure public safety.

Other Health Concerns:

• Sleep Problems: Some people with epilepsy experience difficulties falling or staying asleep, a condition known as insomnia. This can affect overall health and well-being. If you are having trouble sleeping, speak with your doctor.
• Pregnancy: While most women with epilepsy can have healthy pregnancies, it's essential to work closely with a healthcare team. Adjustments to medications may be necessary during pregnancy, and careful monitoring is crucial for both the mother and the baby's health. If you have epilepsy and are considering pregnancy, talk to your doctor early in the planning process.
• Memory Issues: Some types of epilepsy can affect memory. This can vary from person to person, and it's important to discuss any concerns with your doctor.

Mental Health:

People with epilepsy may experience increased risks of mental health conditions, such as anxiety or thoughts of suicide. This can be a result of living with the condition itself or side effects from medication. Seeking support from mental health professionals is vital, even if epilepsy is well-controlled.

Other Serious Complications:

• Status Epilepticus: This dangerous condition involves a prolonged seizure lasting more than five minutes or a series of seizures without regaining consciousness. It can lead to permanent brain damage and even death. If you experience a seizure lasting more than five minutes, seek immediate medical attention.
• Sudden Unexpected Death in Epilepsy (SUDEP): A rare but serious risk associated with epilepsy is SUDEP. The cause is not fully understood, but it may be linked to heart or breathing problems. People with frequent or poorly controlled seizures have a slightly higher risk of SUDEP.

Important Note: It's crucial to discuss any concerns or potential risks with your doctor. They can provide personalized guidance and support to manage your epilepsy effectively and safely.

Understanding Epilepsy: Frequently Asked Questions

Pediatric neurologist Lily Wong-Kisiel, M.D., answers common questions about epilepsy.

What Tests Diagnose Epilepsy?

Epilepsy isn't a specific disease, but a group of conditions. It's diagnosed based on unusual electrical activity in the brain. Doctors look for the cause of these brainwave abnormalities. Tests might include:

• Brain MRI: This scan looks for structural problems in the brain, like tumors or injuries.
• Electroencephalogram (EEG): An EEG records the brain's electrical activity. It helps pinpoint the type(s) of seizures a person is having.
• Genetic, metabolic, or autoimmune testing: Sometimes, the cause of epilepsy is related to a person's genes, how their body processes nutrients, or their immune system. These tests are done when needed to find these underlying causes.

What's a Seizure Action Plan?

A seizure action plan is a guide for teachers and other caregivers to follow if a child has a seizure at school. It details the type of seizure, what it looks like in that child, and what steps to take (e.g., medication during a seizure to potentially shorten it, or how to contact the family). It's a safety plan to help care for the child during a seizure.

How Harmful Are Seizures?

Most seizures are short. For example, absence seizures last only a few seconds, while generalized tonic-clonic seizures might last a couple of minutes. These short seizures usually don't affect a child's growth or development. However, prolonged seizures (lasting more than 5 minutes) or multiple seizures (more than 3 in an hour) are a concern, and a doctor will discuss a seizure action plan in these cases.

How Are Seizures Monitored?

Monitoring depends on the type of seizure:

• Absence seizures (brief staring spells): Monitoring often relies on parents noting how often they occur.
• More complex seizures: Video EEG monitoring, where a video camera records brain activity along with an EEG, can be helpful for subtle or nighttime seizures that are hard to spot. For seizures involving body movements (like generalized tonic-clonic seizures), wearable devices designed for this purpose can detect the movements associated with those seizures.

What is Medically Refractory Epilepsy?

About one-third of people with epilepsy have seizures that can't be controlled with medicine. In these cases, surgery might be an option. Surgery is usually considered for focal epilepsy (seizures originating in a specific part of the brain) where that area can be safely removed. It's also an option for some types of generalized epilepsy.

How Can I Be a Good Partner to My Epilepsy Team?

To help doctors and other care providers, be prepared for appointments:

• Be prepared with detailed information: Note the different types of seizures you've observed, how long they last, and keep a seizure calendar to track the frequency.

Diagnosing Epilepsy: A Range of Tests

To diagnose epilepsy, healthcare professionals use a combination of methods:

• Medical History and Physical Exam: The doctor will ask about symptoms and review the child's medical history. A physical exam checks for any signs that might suggest a cause.
• Blood Tests: These can detect infections, genetic problems, or other conditions that might be linked to seizures.
• Genetic Testing: This is often done in children to look for genetic causes of epilepsy.
• Brain Imaging Tests: These provide images of the brain to look for structural abnormalities:
  • Electroencephalogram (EEG): This common test records the brain's electrical activity. Changes in brainwave patterns can indicate epilepsy, even when no seizure is happening. Sometimes, video EEG monitoring (using a camera to record the child's behavior alongside EEG activity) is used to capture seizures. EEG can be done in a doctor's office or at home (ambulatory EEG) for longer monitoring periods. Sometimes, a doctor might ask the child to do something that might trigger a seizure before the test to better understand their brain activity.
  • High-density EEG: This variation uses more electrodes for a more detailed recording of brain activity.
  • Computed Tomography (CT) Scan: This uses X-rays to create detailed images of the brain, helping detect brain tumors, bleeding, or other structural problems.
  • Magnetic Resonance Imaging (MRI): This powerful technique creates detailed images of the brain's structure, looking for potential causes of seizures.
  • Functional MRI (fMRI): This advanced test measures blood flow in the brain, helping pinpoint areas of the brain involved in specific functions like speech or movement.
  • Positron Emission Tomography (PET) Scan: This test uses a small amount of radioactive material to visualize brain activity. Areas with less activity might be connected to seizure locations.
  • Single-photon Emission Computed Tomography (SPECT) Scan: This test helps visualize blood flow in the brain, particularly during seizures. A special type of SPECT, called subtraction ictal SPECT coregistered to MRI, combines SPECT results with MRI images for a more precise view.
• Neuropsychological Tests: These evaluate thinking, memory, and language skills to understand how seizures might be affecting these areas.

Additional techniques to pinpoint seizure locations include:

• Statistical Parametric Mapping (SPM): This technique compares brain activity during seizures to normal brain activity.
• Electrical Source Imaging (ESI): This uses EEG data alongside MRI images to pinpoint seizure areas.
• Magnetoencephalography (MEG): This measures magnetic fields from brain activity, providing more precise information about seizure locations.

These tests help determine the type and location of seizures, allowing for a more effective treatment plan.