Epilepsy

Symptoms Of 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 (2 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 between individuals vary from mild to severe in form depending upon the type of seizure. Symptoms such as 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:

1. Daydreaming and confusion

Staring at everything and not responding to anything. It is often accompanied by attention blackouts, mumbling, or no response. It is one of the common presentations seen in cases of absence seizures 

2. Uncontrollable jerking movements and twitching of arms and legs

Involuntary movement occurs at the time of seizure leading to nerve damage. It often produces small twitches in the affected muscles. Some involuntary movements include:

• Tardive dyskinesia: A neurological condition that originates in the brain with the use of neuroleptic drugs. A disorder that results in repetitive, involuntary body movement that includes grimacing (the face twists in an ugly way), rapid jerking movements, blinking of the eyes, and protruding tongue. This disorder interferes with normal daily functioning. 

• Myoclonus: It is a quick involuntary muscle jerk. It occurs right before sleeping or waking up. The person might experience an electric shock and rhythmic movements.

• Tremors: It can be a symptom of a seizure. It is an uncontrolled and involuntary movement. Typically a person may experience the following symptoms like uncontrollable nodding head, balance problems, numbness in any part of the body, and stooped posture. 

3. Sudden fear or anger

The abnormal activity in the brain results in seizures. At the time of a seizure, the person experiences change in behavior and automatic responses such as hunger, emotional distress, and fight or flight response. 

4. Sudden falls and frequent stumblings

People with epilepsy tend to have more physical problems such as fractures and bruises related to seizures. Elders are more prone to falls and injury and hurt themselves once and many times a year. 

5. Jacksonian march

Abnormal movements may begin in avery restricted region of limb like fingers and progress gradually over seconds to minutes to involve a large portion of extremity and even involving whole body, eventually culminating into generalized seizures.

6. Todd’s palsy/paralysis

Some of the patients may experience a transient paralysis of the limb or part involved in the seizure, this may last upto minutes to many hours.

• Non-motor symptoms: These are not as common as motor symptoms seen during the episodes of seizures, but can be present in few patients especially those who have atypical presentations.

• Sensory symptoms: Patients may experience sensory symptoms such as numbness, burning sensation, and tingling sensation.

• Autonomic symptoms: Loss of bowel/ bladder control, unregulated increase or decrease in heart rate may be seen.

• Emotional lability: Excessive and unprovoked laughter, crying, anger or sadness may be seen.

Causes Of Epilepsy

There are single established causes of epilepsy or unprovoked seizures. It is likely to be categorized into genetic, structural, infectious, metabolic, immune, and infectious. For example:

• 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 withdrawl

• Febrile seizures

• Illicit drug use/overdose

• Stroke

• Hepatic failure

• Advanced chronic kidney disease 

• Hyponatremia (low levels of sodium)

• Hypoglycemia

Types Of Epilepsy

The signs of the seizure depend on the type of the seizure. Seizures can be broadly classified into two types:

1. Generalized seizures

It affects the entire brain that is both hemispheres of the brain. The seizure begins suddenly, the person loses consciousness and experiences a rigid body, jerking movement of the arms and legs, crying out, and falling on the ground. They are further classified into four types:

• Generalized clonic tonic seizure: During the tonic seizure, the muscle tone is increased greatly in the body. Causing sudden stiffening movements. These seizures last for 1 to 3 minutes. Breathing may decrease producing cyanosis of the lips and nails.

• Myoclonic seizure: They are rapid, brief and shock like a jerk of muscles. They are sudden jerks or clumsiness.   

• Absence seizure: This causes short impairment of consciousness. It is often called blanking out. It usually lasts for no more than a second.

• Atonic seizure: These seizures cause loss of muscle tone. The word means without tone and the muscles become weak. It leads to eyelids drooping, heads to drop and people dropping things.

2. Focal seizures

These are located in one part of the brain and are often called partial seizures. The brain consists of four lobes: frontal, temporal, parietal, and occipital lobes. In focal seizures, only one focused area is affected, depending on the area affected symptoms occur. Seizure in the temporal lobe leads to confusion and staring. Seizure in the occipital lobe tends to cause visual impairment. Location in the parietal lobe leads to numbness. They are further classified into: 

• Simple focal seizure: These seizures affect the small part of the brain. It causes a change in sensation such as strange taste or smell.

• Complex focal seizure: It can make a person confused and the person will not be able to answer questions.

• Secondary generalized seizure: It starts in one part of the brain and spreads in both parts of the brain. 

Risk Factors For Epilepsy

The risk factors associated with developing epilepsy are any injury to the brain, being born with brain abnormalities, a family history of seizures, and many people developing disease don’t have the risk factor.

1. Medications

Missed dose of antiepileptic drug or underdosing of antiepileptic is a common cause seen in day to day clinical practice.

2. Medical history

Medical history is the foundation in the diagnosis of epilepsy. For a precise treatment to analyze the family history, any patient in the family background for the same disease. The doctor identifies the prenatal and perinatal causes brain damage, before birth and after birth like:

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

3. Other health conditions

Many health conditions like autism and growth defects in the brain can lead to epileptic seizures. Any problem in the electrolyte conduction can cause many other diseases like:

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

Diagnosis Of Epilepsy

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 test can be done to evaluate the overall health conditions and study brain functioning. 

1. Computed tomography (CT) scan (head): A CT scan uses an X-ray to view the cross-sectional area of the brain. It can reveal the abnormalities in the brain and the cause of the seizure-like tumor, lesions, and bleeding. 

2. Magnetic resonance imaging (MRI) brain: A MRI uses powerful magnetic and radio waves to create a detailed image of the brain. The doctor by viewing an MRI can detect the cause of the seizure.

3. 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 tumor, which may be a cause of seizures. 

4. Electroencephalogram (EEG): It measures the activity of the brain. It is useful in patients with epilepsy especially in the diagnosis of the type of epilepsy, in localizing the lesion in the brain, and helps the physician in choosing the appropriate drug for further treatment. 

Note: It is most useful to document electrographic seizure activity but the seizures are infrequent and unpredictable so it is often not possible to obtain 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).

5. Brain spect: It is an imaging procedure done by using a tracer dye to create an image of the blood flow in the brain. It helps in locating the origin of epileptic seizures. 

6. Comprehensive health checkup: To evaluate the overall health status of a person. This includes tests to check serum electrolytes (sodium, calcium & potassium), blood glucose, liver function tests, renal function tests and urinary toxicology to rule out use of illicit drugs.

3. Neuropsychological test

A detailed neuropsychologists test is designed to measure the individual performance in terms of accuracy, memory, language, attention, thoughts, mental status and patient’s history is essential to diagnose the disease. 

These tests can help to predict whether seizures are affecting your psychological functions including memory, attention, mood, language, emotions, and personality.

Prevention Of Epilepsy

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

1. Have a healthy pregnancy. Some problems during pregnancy and childbirth may lead to epilepsy. Follow a prenatal care plan with your healthcare provider to keep you and your baby healthy.

2. Prevent brain injuries as it lowers the chances of stroke and heart disease.

3. Be up-to-date on your vaccinations.

4. Wash your hands and prepare food safely to prevent infections such as cysticercosis/neurocysticercosis. 

5. Follow proper sleep hygiene & avoidance of loud music/flashy lights which can trigger an attack

In a known case of epilepsy/seizures, prevention can be done by taking antiepileptic drugs in a timely manner and appropriate dose as prescribed by your doctor. Also, prevention of triggers can help lower the risk of getting an epileptic attack.

Specialist To Visit

Patients exhibiting the symptoms of epilepsy are not capable enough to take their decisions on their own. Thus, the family or caregivers are the primary ones to decide and they must approach the healthcare physician if they suspect any abnormal activities of the brain through scans and tests which are lasting for a prolonged time.

In an acute episode of status epilepticus an emergency physician might be helpful. The healthcare physician can thus refer the patient to the specialist’s doctor for better evaluation and treatment. These patients can be referred to:

• Neurologist

• Psychiatrist

• Psychologist

Treatment Of Epilepsy

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 the treatment is started with a single antiepileptic drug, but if your doctor feels it is not sufficient then a combination of drugs may also be used. The other treatment options include vagus nerve stimulator, ketogenic diet, and surgery. But, 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. These drugs treat the symptoms of epilepsy and not the underlying cause of epilepsy. They maximize the quality of life by minimizing seizures. They work by blocking the sodium channel or enhancing GABAergic action. They can potentially cause unsteady walking and poor coordination or balance. Antiepileptic drugs can be further divided into a narrow spectrum that works for specific types of seizures (partial or focus) and a broad spectrum that has effectiveness for a wide range of seizures (partial plus absence myoclonic seizure). 

Some of the common examples include: 

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

2. Intravenous and intramuscular injectables

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

Common examples are:

• Diazepam
• Lorazepam 
• Clonazepam
• Pentobarbital

3. Anesthetic drugs

These are used after the conventional therapy for seizures has failed to terminate seizures. They are commonly used to treat refractory cases of status epilepticus.

Some of the common examples include:

• Isoflurane
• Desflurane
• Ketamine

4. Vagus nerve stimulators 

This stimulation prevents seizure by sending regular, mild pulses of electrical energy to the vagus nerve. It is approved to treat focal or partial seizures. Vagus nerve stimulators work 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 the condition of the patient. Most commonly performed surgical procedures are:

• Temporal lobectomy

• Corpus callosectomy

• Lesionectomy

6. Transcranial magnetic stimulation (TMS)

It 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 epilespy

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

1. Ease the person and remain calm.

2. Turn the person onto one side, this will help them to breathe. 

3. Remove all the harmful objects from close proximity.

4. Put something soft underneath the head of the person.

5. Lose all the clothes and anything around the neck to make the person breathe properly.

6. If the seizure lasts for more than 5 minutes, contact the doctor and stay with them until awake.

Home-care For Epilepsy

Living with someone who has epilepsy can be challenging for the family and the caregivers. The patient requires support and care at each stage. Epilepsy can vary from person to person so the care can vary greatly. Some people with epilepsy need a lot of care while others need only at the time of seizure. However, there are a few tips that can help to take care of someone with the condition.

Understanding the condition

Understanding the condition of the person is the first step in managing the disease. Caring can involve several skills such as emotional support, dealing with medical equipment, and recognizing the warning signs, if the disease worsens.

Stay focused on therapy 

The therapy goal varies for a person and is adjusted to suit the requirement of the patient. Help your loved ones to adjust to the therapy and encourage them to practice self-management strategies. This will help them to take responsibility for their goals.

One of the most common causes for seizure recurrence is missed dose or under dosage of antiepileptic drugs, hence it is of paramount importance for the patient to maintain a regular dose schedule and preferably at the same time.  

Keep patient away from tobacco, alcohol, and substance abuse

Alcohol and other drugs worsen the symptoms of epilepsy. Hence, the family should ensure that the patient does not indulge in such activities. 

Professional help should be taken for patients already alcoholic or suffering from drug addiction as abrupt and sudden cessation may lead to withdrawal symptoms which may lead on to seizures.

Try stress management techniques 

Being a caretaker for a patient can be exhausting and emotions such as anger, resentment, guilt, and helplessness can be common. Learning relaxation and stress management techniques will help in coping with the disease. 

Join epilepsy support groups

Connecting with other people facing the same challenges may help the person and boost morale. Few societies in India help people with mental illness and encourage them to take advantage to engage with other patients in a safe and supportive environment. 

Note: Epilepsy symptoms and conditions can change over time. The amount of care needed by the patient can also change with time and even the condition of the person caring can also change. 

Complications Of Epilepsy

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

• Impaired mental function

• Lack of motor coordination

• Depression

• Anxiety disorders

• Physiological symptoms fear and anxiety

• Aggressive behavior

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

Alternative Therapies For Epilepsy

1. Relaxation therapy 

These days massage and aromatherapy are often used to reduce stress and tension. They can help get rid of poor sleeping patterns. Some people use yoga and meditation to relax and practice mindfulness. It has been found out that these techniques can ease tension and reduce stress related to seizures.

2. Cognitive behavioral therapy (CBT)

It is a psycho-social intervention that aims to improve mental health. This helps the patient to change what they think about a particular situation. It helps manage feelings and change the actions which further helps them to change the reaction.

3. Electroconvulsive therapy

For adults who do not respond to drug therapy, electroconvulsive therapy may be considered. It is a psychiatric treatment where seizures are induced to manage refractory mental disorders. A small amount of electric current is passed through the brain to regulate activity in the brain.

4. Deep brain stimulation (DBS)

This is a type of surgical procedure involving the implantation of a device to send electrical signals to the brain. Some electrodes are implanted in the patient’s brain area. These electrodes generate mild electrical impulses which regulate abnormal brain activity and improve the symptoms. 

5. Ayurveda in epilepsy

Ayurveda treatment for epilepsy follows an integrated approach, combining natural medicine, ketogenic diet, and lifestyle regulation. In some cases, ayurvedic herbs were found to be beneficial when used in adjuvant with antipsychotic medication. However, there has been no such evidence to prove the effectiveness of ayurvedic treatment to treat or manage epilepsy.

Living With Epilepsy

Self management can help in taking care of yourself. 

• 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 & maintain a sleep schedule

• Maintain a seizure dairy by noting the time and day of an epileptic attcak, trigger or aura before it, chronic medicines, and liver function test reading