Epilepsy

EPILEPSY

You must have seen some patient somewhere, having recurrent involuntary seizure or jerks, with or without impaired consciousness. This may be a case of Epilepsy: You would have noticed people attending to such persons in a very funny manner for observing curiously without helping the person correctly. This chapter deals with the problem: its causes, its correct approach and the myths associated with it. Epilepsy means frequently occurring convulsions or seizures. A single episode of convulsion cannot be called epilepsy. Epilepsy is a disease of the brain in which excessive electrical impulses are produced in the brain for a short period of time resulting in tremors or seizures. One in every hundred persons suffers from epilepsy and thus over l o million people in our country are afflicted with this disease. According to a survey, 4 out of every 100 persons h ave suffered from a convulsion at least once in his lifetime e.g. convulsion during high fever. In 70 to 75% cases of epilepsy the disease is present from childhood. If timely treatment is not given, the patient may suffer from physical and mental damage in future.

If an epileptic patient takes optimum treatment regularly then he/she ‘can lead almost a normal life. 50% of the patients become seizure free permanently only after 2 to 3 years treatment.

The main causes of Epilepsy are as follows :

1.        Trauma during birth of the child or lack of oxygenation perinataly.

2.        Road accidents or any other head injury.Brain Tumor.

3.        Decreased circulation in the brain.

4.        Brain infections or fever of brain (e.g. brain TB).

5.        Hereditary factors.

6.        Hypoglycemia (reduced sugar).

7.        None of the above known causes (e.g. idiopathic).

There are three types of epilepsy :

1.        Generalized seizure.

2.        Partial seizure.

3.        Psychogenic-Hysteria.

These three are further divided as follows :

1. Generalized Seizure :

i.               Grandmal epilepsy or seizure of the entire body: In this type of epilepsy, loss of consciousness, screaming, frothing from the mouth, tremors, tongue biting may occur and sometimes urine and stool are also passed unconsciously. After regaining consciousness, the patient remains in a semiconscious state for some time or goes to sleep He may be paralyzed temporarily.Sometimes a patient may get an inkling of the impending seizure, this is known as Aura.

ii.               Petitmal: In this type of epilepsy the patient suddenly becomes momentarily blank, stunned and blacks out for a few moments.

iii.               Myoclonic seizure: In these cases the person experiences sudden shock like momentary jerks in the limbs and the things held in hand may fall down, but there is no loss of consciousness.

iv.               Besides these there are tonic-clonic and akinetic seizures, which are classified as Generalized seizures.

2. Partial Seizure:

i.               Simple Partial Seizure: The patient remains conscious, but jerking or tingling is felt in one half side of the body.

ii.               Complex Partial Seizure: If the patient loses momentary consciousness along with-* the symptoms of simple partial seizure, it is known as complex partial seizure. In this type, the patient loses consciousness or behaves abnormally for a few moments and immediately becomes normal again.

3. Psychogenic Hysteria :

Hysteria is a disease which resembles epilepsy. It is more common among women. This disease can be cured with proper treatment by a psychiatrist as well as by tackling the underlying socio - economic problem.

Febrile Convulsions :

Sometimes during childhood convulsions may occur due to high fever, which tend to subside automatically after theage of five years. But it is essential to ascertain that no damage has occurred to the brain by these convulsions. In children who get convulsions during fever, it is necessary to ascertain that they do not suffer from fever as far as possible. If fever does occur, Paracetamol or Nimesulide as well as Clobazam should be administered immediately. The medicine called Direc-2 or any other similar kind can be administered rectally if a convulsion seems imminent. It will not only prevent the convulsion, but will also check it midway. This drug can be administered every 12 hours. It is essential to prevent such seizures because frequent attacks can get converted into complex partial seizures or generalized seizures in future.

The following points should be kept in mind during an epileptic attack :

i.               The patient should be made to lie on his side and clothes should be loosened. To prevent an injury to the tongue, a handkerchief or a gauge piece may be placed in the mouth, but one should not insert it forcibly.

ii.               If the patient is hurt or seizures occur repeatedly, it is necessary to take medical advice. If necessary, intravenous administration of Diazepam can be done or the patient may immediately be admitted to a hospital.

An epileptic can lead a normal healthy life, get married, and female patients can also conceive. During pregnancy certain medicines taken for epilepsy do not cause any substantial harm to the Foetus e.g. Carbamazepine. Actually if the drug is stopped and a seizure occurs, the harm to the Foetus due to the lack of oxygen is much greater. Thereforepregnant ladies need to take the medicine regularly. Newer antiepileptic drugs are considered safer in pregnancy.

Investigation of Epilepsy :

A detailed description of the seizure should be made for the purpose of investigation. The minutest details of the seizure should be collected from the person who has witnessed the epileptic patient undergoing a seizure. This gives immense information about the type, speed and seriousness of disease to the doctor, apart from telling whether it was a seizure or hysteria or syncope or any other brief event. So interviewing the eye witness is indispensable whenever he or she is available. In order to gather further information about the type of seizure, line of treatment, etc. E.E.G., CT Scan or MRI may be necessary. Blood tests and plain X-Rays of the brain and the chest are also required.

Treatment of Epilepsy :

After investigating the causes of the disease, planning proper treatment is essential. Any precipitating situations, which may aggravate the disease, should be avoided. Thus late nights, tension, fasting or excessive physical or mental stress should be avoided. Proper medication taken for a considerable period of time can definitely control the disease.

Main drugs (Conventional drugs) used for Epilepsy are:

Phenobarbitone: (e.g. Gardenal, Beetal)

 Phenytoin: (e.g. Dilantin, Eptoin)

Carbamazepine :(e.g. Zeptol, Tegrital, Carbatol,Zen, Mazetol)

Valproate:(e.g. Encorate, Valparin, Epilex)

As per the new technology, now slow release formulation drugs are available in Carbamazepine and Valproic acid e.gTegrital - CR, Valtec - CR respectively. This helps to maintain adequate blood level all through out the day, by taking drugs only twice a day. The important side effects of antiepileptic drugs are discussed in chapter No. 23.

Depending on the symptoms and the type of epilepsy, the doctor decides the right drug. In the last few years many new researches have been conducted on this disease and new drugs have been developed for effective control of Epilepsy. The new researches can be classified in two major categories: surgery and medicines.

Newer Drugs :

The second generation anti-epileptic drugs, now being used to treat patients not responding to conventional drugs include Gabapentin, Lamotrigine, Vigabatrine, Felbamate, Topiramate.

These drugs have been approved by the F.D.A. (Federal Drug Authority of USA). Though the newer drugs seem to have less side effects, fewer things require to be monitored (Viz. 2% patients on Topiramate develop kidney stone). Long term results of these drugs are not yet available, but they seem to be safe in pregnancy. Hence, there would be very little risk to the newborn. Therefore, in patients not improving or having side effects with main conventional drugs, newer drugs should definitely be tried.

Recently Introduced Drugs :

These third generation drugs viz. Oxcarbazepine, Levitiracetam, Zonisamide have only recently been introduced and therefore, we have little experience with these drugs, but to date they have proved to be beneficial. Their side effectsare minimal and hence they are likely to replace easily the older drugs (e.g. Oxcarbazepine is likely to replace Carbamazepine).

Refractory Epilepsy :

When the main antiepileptic drugs (AED) have been tried according to the guidelines - (including polytherapy) in optimum dose and for adequate time period and still if seizures cannot be controlled, the diagnosis of refractory seizures can be made. Before doing so we need to confirm certain things.

i.               Confirm diagnosis - Is it Epilepsy? Syncope, Hysterical Fits, Hypoglycemic Spells etc. should be ruled out. The type of Epilepsy or any underlying cause should be evaluated.

ii.               Review treatment - Whether an appropriate drug has been given in appropriate dose. Sometimes an inappropriate drug may worsen seizures (eg. Carbamazepine aggravates myoclonic Epilepsy).

iii.               Assess whether the drug combination is right. Blood level of drugs need to be periodically checked. Finish EEG, CT Scan of the Brain, MRI of the Brain to look for any additional cause of refractoriness.

iv.               Check for patient compliance. Is the patient taking the drugs regularly? Is he on drugs for any other disease? Is there any brain tumor, birth defect etc. If needed, patient should undergo special investigations like video EEG, depth electrode EEG, SI’ECT, MRI.

If all these issues have been looked into and the relevant problems addressed, most of the seizures can be controlled.However, if despite having tried two different. drugs as mono therapy ( for at least 6 months each) and at least one (or two) combination therapy, patient has one/two fits every month for two years, then the patient is said to have refractory epilepsy. About 15 to 22% of all the patients of epilepsy, are thus having refractory epilepsy. However the diagnosis needs to be individualized taking into consideration the patient’s age and his physical and mental condition and his social and financial background. For such patients the following steps can be taken.

i.               New drugs can be tried as add-ons to the.conventional drugs. Occasionally new drugs -can be instituted as first line of treatment.

ii.               Surgery :When drugs fail to control seizures andthe cause of seizures is an electrical focus which may be localized to a structure, then seizures can be controlled after appropriate surgery. During the last decade, there has been satisfactory progress in this field. Hence, in refractory cases where a focus can be defined as a cause of epilepsy, surgery can fully control seizures in 30 to 35 % patients. In another 30 to 35 % cases, seizures are fairly reduced after surgery. The facilities for these surgeries are available in our Country and they do not carry much risk. The cost of surgery comes to Rs. 50,000 to 2,00,000 approximately. A team of experienced Neurosurgeon - Neurophysician can decide as to which of the following surgeries would be beneficial to the patient.

(a) ResectiveSurgery  (b) Functional Surgery

(a) Resective Surgery

Microscopic Dissection

Temporal Lobe Surgery

Extra Temporal Surgery

Lesionectomy

Lobectomy

Multi Lobar Surgery

Hemispherectomy

(b)Functional- Nonresective Surgery

Corpus Callosotomy

Multiple SubpialTransection

Stereotactic Procedure

Ionising Radiation

Comissurotomy

(c) Stimulation

Vagus Nerve Stimulation

Thalamic Stimulation

Cerebellar Stimulation Vagus Nerve Stimulation :

In 1980 Joseph zarbara proposed this therapy. This surgical procedure costing about Rs.8-10 lacs entails stimulation of vagus nerve with a computerized system. This can reduce the frequency of seizures to less than 50%. One can continue anti-epileptic drugs with this therapy. If a patient has aura, he can stimulate the electrode and abort the oncoming fit. This is a safe and hence increasingly popular mode of treatment. The parameters can be changed: For those patients who are not appropriate candidates for surgery, in whom a focus is not dependable or those who are awaiting surgery this method is beneficial, specially when anti-epileptic drugs have not worked.

KetogenicDiet :

This mode of treatment came into vogue after the observation that substituting 80% fat in diet significantly reduces the frequency of seizures. This mode of treatment may help in the cases of refractory seizures. About 30% children have improved after this treatment. This form of treatment may sound difficult for children initially but slowly they adapt to this diet. This should be continued for 1 to 2 years under supervision. Parents also have an important role to play and this therapy is not expensive. Initiation of this form of treatment may be done in hospital.

It is beyond doubt that the novel approaches (eg. Targeted drug delivery), newer surgical techniques will ensure brighter future for epileptic patients.Since Epilepsyis a very common disease, I have dealt with the topic atlength. However in view of the ever changing concepts and advances in the field of medicine, this discussion should be adequate; if not complete.

Misconceptions :

Unfortunately a lot of misconceptions are still prevailing about Epilepsy; therefore it has been observed that the patients do not get the correct treatment.

1.        “Epilepsy is a mental disease.” This is not true.

2.        “During seizure attack, an iron piece should be put in his palm or he should be made to smell an onion or a shoe”. All these beliefs are misconceptions.Actually the seizure usually subsides automatically within 1 to 5 minutes.

3.        “Epilepsy is a hereditary disease.” Epilepsy is nota hereditary disease, but if any of the parents is suffering from epilepsy, the possibilities of the offspring having epilepsy are slightly higher.

4.        “Vitamins or Tonics are good for patients suffering from epilepsy”. This is another misconception.

5.        “Once an epileptic always an epileptic”.This is nottrue. 60 to 75% patients are cured completely with the help of proper medication It may so happen that a person gets a seizure only once in a lifetime.

Even after recovering from epilepsy it is advisable to stay away from fire and not drive or swim for some years.

Epileptic patients should be considered as normal; one should not have a biased attitude towards them. They should not be considered handicapped.

Julius Cesar, Napoleon, Alfred Nobel, Vincent Van Gaugh, Jhonty Rhodes, and many other great personalities suffered from epilepsy, but still managed to excel in their respective professions. Thus, epilepsy is not a barrier to excellence in social life or business activities.

To help the epileptic patients “The Indian EpilepsyAssociation and Society” have been very active in severalcities. They provide detailed information on epilepsy and also arrange various group programmes. Various activities are carried out to provide moral support to the patient and family members, and to help patients gain acceptance in the society. Society should support such noble activities.