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A seizure is a paroxysmal alteration of neurologic function caused by the excessive, hypersynchronous discharge of neurons in the brain. Epileptic seizure is used to distinguish a seizure caused by abnormal neuronal firing from a nonepileptic event, such as a psychogenic seizure.
Epilepsy is the condition of recurrent, unprovoked seizures. It has numerous causes, each reflecting underlying brain dysfunction (Shorvon et al. 2011).
Epilepsy in the world and in SA
1%-2% of the world has epilepsy. In SA, the data show one in every 100 people.
That’s 50 million people worldwide.
Diagnosis of epilepsy
Diagnosis is based on the clinical assessment, with a detailed history, as well as a collateral account of seizures. Determination to be made that it is a seizure vs syncope, transient ischemic attack, hypoglycaemia, parasomnias or migraine aura, among others.
Look for the recurrence of seizures and an abnormal electroencephalography (EEG) that supports epilepsy. Are seizures provoked and are they recurrent vs single.
Seizure types
- Generalised: Generalised tonic-clonic (usually comes without warning, associated with jerks, comes with confusion), myoclonic (can also occur with just jerks and no loss of consciousness), atonic (loses all body control and falls to the ground)
- Focal (aura): These depend on where in the brain it happens - Visual (visual symptoms), motor (the most common and easiest to diagnose because of the body jerks), sensory (usually on one side of the body), cognitive (impairment of consciousness, impairment in consciousness), autonomic (can be associated with incontinence)
- Non-epileptic seizures (not true seizures in the epileptic sense but are seizure-like events resembling any type of seizure or its own phenomenon, or a psychogenic cause. Some frontal lobe seizures can resemble non-epileptic seizures because of their bizarreness). A video EEG capturing the event as it happens will distinguish the two.
Investigation
An EEG should be done.
Brain imaging should be done in new-onset seizures, even if the person has only had one seizure. It could show a tumour, a stroke, or it could be normal (this doesn’t exclude seizures). A blood investigation should also be done. These tests are often done to look at secondary causes of provoked seizures.
EEG has a lot of terminology. Here is basically what it means: Spike (and/or sharp) and wave (focal or generalised) – are epileptiform terminology. Generalised slowing pertains to encephalopathy and epileleptiform patterns.
Approach to Status Epilepticus
This is a neurological emergency and is a seizure that lasts more than five minutes, or various seizures without the patient gaining consciousness in between.
Typically, it is an ABC approach: Airways, breathing and circulation, and to watch vital signs/glucose of the patient. This approach doesn’t mean immediate intubation, it can be simply turning the patient onto their side.
Understand the history and observe the seizure type. Consider thiamine supplementation and a benzodiazepine. At a certain point, usually after the five minutes, if the benzodiazepine hasn’t abated the seizure, consider intubation, an antiepileptic drug (AED), keeping to the drug that the patient is on if it is a known condition. Brain imaging and ICU may be necessary, especially if the patient was intubated.
Consider EEG monitoring and anaesthetic agents if the patient hasn’t stopped the seizures.
Considerations in Status Epilepticus Is it really Status Epilepticus?
Are these non-epileptic seizures?
Focal Status Epilepticus: This could be in one part of the body where the seizure is ongoing. If the patient is aware during Status Epilepticus the patient isn’t in danger. If the patient isn’t aware, the patient may be in danger and needs to be treated aggressively.
Non-convulsive Status Epilepticus: (10 min). This is often seen in ICU patients (usually in encephalopathy patients). They aren’t clinical features as the patient is non-convulsive, but the EEG shows a sharp wave pattern. Is this epileptic or related to brain injury (encephalopathy)? If it improves on AEDs, it should be understood to be epileptic in nature.
Epilepsy management
The following factors inform the decision in choosing the ideal monotherapy:
- Male vs female
- Seizure type
- Patient’s preferences, potential side effects
- Refractory epilepsy and surgical considerations – risk vs reward
- Vagal nerve stimulation
- Diet (the ketogenic diet has been shown to help, especially in children with refractory epilepsy).
Medication
The following options are available for the management of epilepsy:
- Benzodiazepines – not for chronic treatment, but for seizure control or titrating another medication. Works on generalised/focal seizures, using the GABA pathway
- Phenytoin – one of the older drugs, best for focal seizures but can also help generalised, works on the voltage-gated sodium channel (VGSC)
- Carbamazepine – similar profile but has less long-term side effects than phenytoin, however low sodium can be an issue. For focal/ generalised seizures, works on VGSC
- Valproate – tends to cover all types of epilepsy well. For generalised or focal seizures, works on GABA pathway, however its mechanism of action is not clearly understood
- Lamotrigine – Can be used in generalised or focal seizures (used to be considered as an add-on therapy but can be used as monotherapy, especially in reproductive-aged women). Works in VGSC, glutamate and aspartate pathways in the brain.
- Levetiracetam – Can be used in generalised or focal seizures, works on synaptic vesicle glycoprotein 2A receptors (neuronal conduction)
- Topiramate – Can be used in generalised or focal seizures, works on VGSC, GABA and AMPA receptors
- Perampanel – this is new, can be used for generalised or focal seizures, works on AMPA (postsynaptic pathway).
Women and epilepsy
Be aware of:
- Hormonal contraceptive interactions
- Pregnancy in women with epilepsy - promoted medications to cover this is: levetiracetam, lamotrigine, oxcarbazepine. Being seizure-free for one year prior to pregnancy has been shown to be the safest option for pregnancy
- Breastfeeding and anti-epileptic medication. Studies have shown that in terms of cognition, the drugs didn’t affect breastfed babies, and this is still encouraged.
Driving and epilepsy
What are the risks? In poorly controlled patients, it is out of the question. Epileptic patients on medication can become drowsy at the wheel.
Discuss it with the patient. Patients often want to maintain their independence, but if someone is at a high risk, talk about this issue with their family too.
Conclusions
Epilepsy is an important neurological condition, this is due to its severity and prevalence. The basics are easy in terms of diagnosing a patient: Two seizures or one seizure and an abnormal EEG.
Treatment is AED therapy. However, the art of epilepsy treatment is more difficult in terms of is it a seizure? AEDs have side effects and can cause problems with the patient’s lifestyle, so these issues need to be understood and discussed. If we have the understanding of how to manage it, it can be managed, with the least possible harm to the patient.
