Epilepsy

What is epilepsy?

Epilepsy, sometimes referred to as seizure disorder, refers to a tendency to have recurrent seizures. A seizure is a temporary disturbance in brain function where groups of nerve cells signal abnormally and excessively. During a seizure, disturbances of nerve cell activity produce symptoms that vary depending on which part (and how much) of the brain is affected. Seizures may produce changes in awareness or sensation, involuntary movements, or other changes in behavior.

Types of seizures

There are many types of seizures broadly classified into two groups:

• Primary generalized seizures—seizures begin with involvement of both sides of the brain.
• Partial seizures—seizures begin with involvement of a smaller, localized area of the brain.

Some people have seizures that are hardly noticeable to others. Sometimes, the only clue that a person is having an absence seizure—a type of primary generalized seizure sometimes called petit mal—is rapid blinking or a few seconds of staring into space.

Epilepsy and Seizure are different

In general, seizures do not indicate epilepsy if they only occur as a result of a temporary medical condition such as a high fever, low blood sugar, alcohol or drug withdrawal, or immediately following a brain concussion. In these patients there is usually no need for ongoing treatment for epilepsy, but only a need to treat the underlying medical condition.

Causes of epilepsy

Epilepsy may arise when there are disruptions to the normal connections between nerve cells in the brain. Some of these disruptions, imbalances, and changes may develop early in life, sometimes related to hereditary factors and sometimes related to early exposures and events. Others may be acquired later. Among known conditions and events that may lead to epilepsy are:

• Oxygen deprivation (e.g., during childbirth).
• Infections of brain (e.g., meningitis, encephalitis, cysticercosis, or brain abscess).
• Head injury.
• Stroke (resulting from a block or rupture of a blood vessel in the brain).
• Neurologic diseases.
• Brain tumors.

In few cases of epilepsy, a specific underlying cause is not identified and are labeled as cryptogenic if the cause is unknown, or idiopathic if the epilepsy is not associated with other neurologic disease.

Prevention of epilepsy

Depending on the causes of epilepsy, prevention is possible. Some of the most important preventable causes are:

• Complications of pregnancy and childbirth.
• Infections: Proper immunization (vaccination) against certain diseases. Infections can be prevented through health screening and early treatment as well as proper practices of hygiene.
• Head injuries and Brain injuries.
• Stroke: Reducing risk factors such as physical inactivity, high blood pressure, obesity, diabetes, high cholesterol, and smoking will lessen the likelihood of stroke which may help to reduce the possibility of developing epilepsy later in life.

Diagnosis of Epilepsy

The first step is to in successful treatment of epilepsy is correct diagnosis. This will require a careful review of the person’s medical history and a neurological examination. Other tests may be recommended as well, usually including an electroencephalogram (EEG) and often a brain scan such as computed tomography (CT) or magnetic resonance imaging (MRI). The medical decision about how best to treat the epilepsy is based on this evaluation.

Management of epilepsy

• Antiepileptic drugs are the mainstay of treatment for most people. After starting a medication, close monitoring is required for awhile to assess the effectiveness of the drug as well as possible side effects. Early in treatment, adjustments in dosage are often required. Sometimes, because of continued seizures or significant side effects, it is necessary to change to a different drug. For about two-thirds of people with epilepsy receiving optimum treatment, drugs are successful in fully controlling seizures. For the remainder, although drugs may have a partial benefit, some seizures continue to occur. For some of these people, other treatment options may be considered.
• Surgery: Epilepsy surgery is most commonly performed when a seizure focus is located within the temporal lobe of the brain. With certain types of partial epilepsy, especially when it can be determined that seizures consistently arise from a single area of the brain (the “seizure focus”), surgery to remove that focus may be effective in stopping future seizures or making them much easier to control with medication.
• Other options: These include vagus nerve stimulation, where an electrical device is implanted to intermittently stimulate a large nerve in the neck, and the ketogenic diet, a high fat, low carbohydrate diet with restricted calories.

Who treats epilepsy?

Often primary care doctors are the first to diagnose epilepsy, patients may be referred to a neurologist or pediatric neurologist for consultation or continuing care. Some neurologists with advanced training further specialize in the diagnosis and treatment of epilepsy, a subspecialty called epileptology. People whose seizures are difficult to control or who need specialized or intensive care for epilepsy may be referred to epileptologists or to specialized epilepsy centers like KIMS Hospitals. Epilepsy centers have advanced diagnostic and treatment capabilities and are staffed by epileptologists and other physicians, psychologists, nurses, and technicians specializing in epilepsy care.

Unique issues unique for women with epilepsy

Women with epilepsy can experience difficulties arising from hormonal changes during their reproductive cycle. Pregnancy brings some special considerations for women with epilepsy, because seizure occurrence and certain drugs taken during this time may sometimes carry a risk of harm to the developing fetus. Usually these risks can be minimized by several precautions women can take before and during pregnancy. Please consult our epileptologist for further details.

Women With Epilepsy Can Have Children

Most women with epilepsy can become pregnant and have healthy children. Planning for the pregnancy is the best thing you can do to help ensure that you have a healthy baby. Because of the effects of seizures and/or anti-epileptic medications, there is a mild increase in the risk of birth defects in children born to mothers with epilepsy. The amount and kinds of risk depend upon the medication(s) you are taking, and you should ask your doctor about your own situation.

Can epilepsy be fatal?

Most people with epilepsy live a full life span. Nevertheless, the risk of premature death is increased for some, depending on factors like:

• People with some types of epilepsy who continue to have major seizures can experience injuries during a seizure from falling or hurting their head that may occasionally be life-threatening.
• Very prolonged seizures or seizures in rapid succession, a condition called status epilepticus, can also be life-threatening. Status epilepticus can sometimes occur when seizure medication use is stopped suddenly.

Can people who have epilepsy drive?

Physician’s recommendation is mandatory and may allow a person who has seizures that don’t impair consciousness, occur only during sleep, or have long auras or other warning signs that allow the person to avoid driving when a seizure is likely to occur.

Can’t people with epilepsy lead a normal life?

In general, most people who have seizures can lead normal and active lives — with only a few restrictions.

• Driving is prohibited in people with uncontrolled seizures.
• You should avoid working from heights or around dangerous machinery and under water.
• Showers are safer than tub bathing because of the risk of drowning during a seizure.

Can I Drink Alcohol?

In some people, alcohol can increase the risk of seizures. In others, alcohol and anticonvulsants can combine to make them less alert.

The major risk of birth defects occur during the first three months of pregnancy. Therefore, your doctor may want to adjust or change your medication before you become pregnant. It usually is a good idea to begin taking at least 400 micrograms a day of folic acid before becoming pregnant; you should speak with your doctor about whether you may need a higher dose. Ideally you should start taking folic acid months before conception. Anticonvulsant medication does not seem to increase the risk of birth defects in the children of men with epilepsy.

How Can I Take Care Of a Person Who Is Having a Seizure?

For a tonic-clonic seizure (grand mal, convulsion):

• Help the person to a lying position and turn him or her onto one side.
• Place something soft under the head.
• Loosen tight clothing. Do not restrain the arms or legs.
• Do not put anything into the mouth.
• Forcing something in to the mouth may cause more harm than good.

The seizure itself should last less than one to two minutes. Afterwards the person may be very sleepy and confused and should be talked to in a calm and quiet manner

Seek medical attention when:

• The patient does not completely return to his or her normal state following the seizure (which generally lasts less than 30 to 60 minutes).
• The seizure itself lasts for more than a few minutes.
• The patient experiences multiple seizures. or
• Any injury was sustained during the seizure.
• Remain with the person, talk calmly, and protect him or her from self-injury.
• Do not restrain.

Who is suitable for epilepsy surgery?

Epilepsy surgery is appropriate for few patients with medically refractory seizures where:

• The seizures must consistently arise from the same location in the brain.
• There must be only one seizure focus.
• The seizure focus must be in a location of the brain that can be removed while preserving important function like language, memory, movement and vision.

What tests/investigations are done before surgery?

At KIMS Hospitals, patients undergo extensive testing as part of the pre-surgical workup. The following tests are standard procedure:

• Clinical evaluation by an epileptologist.
• Video-EEG monitoring of a patient during seizures to identify the seizure focus.
• High-resolution MRI taken of the abnormal regions that could be causing seizures
• Few patients may need noninvasive tests such as magnetoencephalography (MEG), used to identify speech and motor control areas to make surgery safer.
• Neuropsychological tests of brain function and memory, done before and after surgery
• A Wada test (intracarotid angiography) is performed to test language and memory on each side of the brain.
• Presurgical visit with the anesthesiologist and neurosurgeon

My doctor said I may be awake during part of the surgery?

To make sure that language areas are protected during the surgery, patients with a seizure focus in the language dominant side of the brain (usually the left side) may undergo intraoperative language testing. In such cases, the anesthesiologist will wake you and may ask you to count, talk or name items in pictures while the surgeon tests for areas of language function. The procedure is not painful as local anesthesia is used throughout the procedure. After language areas are identified, the patient is put back to sleep with general anesthesia for the rest of the procedure.

Will I be Seizure-free after surgery?

Outcome of epilepsy surgery at KIMS are comparable to the best centers in the world. Of all patients who have temporal lobe epilepsy surgery, 80 percent are seizure-free after surgery and usually continue on medication. The remainder are significantly better, but not seizure-free. Certain features may improve or reduce the chances of success for a particular patient.

How long will I be in the hospital? How much time will I need to recover?

Most patients are discharged from the hospital within 3 – 5 days of surgery. Recovery is gradual and step-wise like easing back into their school, work or home activities over the next few months. You may need more or less time depending on your general health.

What are the risks of epilepsy surgery?

Any operation of brain carries a small risk of a major complication like intraoperative bleeding, stroke or even death. Epilepsy surgery at KIMS Hospital is carefully planned and carried out under optimal circumstances to spare parts of the brain necessary for everyday functions.

After surgery there may be swelling around the eye on the side of surgery. Few patients complaint of jaw pain or limited jaw movement or head-aches and/ or earache. These problems tend to resolve in a matter of weeks.

Some patients may have a small “blind spot” in their upper visual field, which is seldom noticeable. Results of neuropsychological testing before and after surgery are satisfying. Most people experience no change in overall IQ. The presurgical neuropsychologic and psychiatric testing and Wada tests are very important in screening for patients that might have behavioral or memory problems after surgery.

At KIMS hospitals, every effort is made to select only those patients who have a very good chance of improvement, and for whom the benefits appear to outweigh the risks of surgery. Every case is unique and is evaluated with a great deal of care and consideration by the entire epilepsy team.

Will I need to take anti-epileptic medications after surgery?

Yes. We recommend continuing the medication as advised by our epileptologist for at least three years even if you are completely seizure-free before attempting to wean off them completely.

Will I be able to drive after the surgery?

Patients who have never driven or patients who have not driven for many years, are advised to begin with a driver training course and proceed slowly as advised by our epileptologist.Is there an age limit for epilepsy surgery?

There is little to gain by waiting. Not only age, attitudes, lifestyle, family support and educational background all enter into the equation. Though average age at the time of surgery is 20 – 40 years; the ideal age may be younger still. Patients less than one year of age and patients 60 and older have been operated on successfully at KIMS Hospitals.

What else should I know?

If you wish to meet with a person who has already undergone epilepsy surgery, this can be arranged. Be sure to ask questions and remember that communication with your doctors is essential.