The words "epilepsy" and "epileptic" are of Greek origin and have the same root as the verb "epilambanein," which means "to seize" or "to attack." Therefore, epilepsy means seizure, while epileptic means seized. In the modern understanding of epilepsy, it should not be considered a disease. Rather, it is a symptom indicating a medical condition in the brain that causes a potential for recurrent seizures . The condition of epilepsy has many causes and the kinds of seizures that occur can vary widely.
The word epilepsy is actually a descriptive term. It takes into account an individual's risk of recurrent seizures. However, when people are suffering from meningitis and have a seizure, they would not be considered to have epilepsy unless they had a seizure after the meningitis resolved. In this case, these individuals have a risk for recurrent seizures and, hence, epilepsy. If an individual over time does not have any seizures off medications, then it could be said that epilepsy has resolved or gone into remission.
For thousands of years, epilepsy was looked upon differently than most other medical problems. Because of this, epilepsy has been fraught with social stigmas, even up to today. The ancient Greeks knew about the condition that led to a sudden attack upon the unfortunate. Although Hippocrates, in roughly 400 b.c., referred to epilepsy as the sacred disease, he did so to emphasize the general public's superstitious view of the condition. Of course, it certainly was not an affliction sent from a deity, nor was it even a demon. Nevertheless, seizures, which manifest in unusual behaviors, mystified observers who considered this illness, from all others, as coming from another world.
The current understanding of epilepsy is a recent development. Previously, it was not even believed that the brain had electrical properties. It was not until the last few centuries that the brain was considered the seat of the mind; it was the heart or the lungs that were commonly regarded as the organ of thought. Physicians struggled with what to even call a seizure. In general, any behavior that resulted in a loss of consciousness or convulsions was labeled a seizure. It is likely that episodes of fainting were erroneously called seizures.
Finally, in 1873, an adequate definition for the term seizure finally came into existence. The famous English neurologist John Hughlings Jackson explained epilepsy as "a sudden, excessive, and rapid discharge of gray matter of some part of the brain" that would correspond to the patient's experience.
More than 2.5 million Americans suffer from epilepsy, and more than another 50 million worldwide. Epilepsy is more common than Parkinson's disease , multiple sclerosis , cerebral palsy , and muscular dystrophy all combined. The risk of experiencing one seizure in the course of a lifetime, from any cause, is close to 10%. However, there is an approximately 1% chance of developing epilepsy in the general population before the age of 20. The risk increases to 3% by age 75. Of course, depending on the age group being studied, the cause of epilepsy will vary. The incidence of epilepsy is relatively constant among different ethnic groups and similar between genders. However, there may be variation in incidence in underdeveloped countries due to access to care and endemic illness that can cause seizures, such as neurocystercercosis in Latin American countries.
Causes and symptoms
Epilepsy has many causes that, in part, have an affect on the clinical presentation of symptoms. In order for epilepsy to occur, there must be an underlying physical problem in the brain. The problem can be so mild that an individual is perfectly normal other than seizures. The brain has roughly 50–100 billion neurons. Each neuron can have up to 10,000 contacts with neighboring neurons. Hence, trillions of connections exist. However, only a very small area of dysfunctional brain tissue is necessary to create a persistent generator of seizures and, hence, epilepsy. The following are potential causes of epilepsy:
- genetic and/or hereditary
- perinatal neurological insults
- trauma with brain injury
- brain tumors
- infections such as meningitis and encephalitis
- multiple sclerosis
- ideopathic (unknown or genetic)
Any of the above conditions have the potential for causing the brain or a portion of it to be dysfunctional and produce recurrent seizures. Regardless of the exact cause, epilepsy is a paroxysmal (sudden) condition. It involves the synchronous discharging of a population of neurons. This is an abnormal event that, depending on the location in the brain, will correspond to the particular symptoms of a seizure. The International League Against Epilepsy (ILAE) issued a classification of types of seizures. The list gives the kind of seizures that can occur. Individual seizure types are based on the clinical behavior (semiology) and electrophysiological characteristics as seen on an electroencephalogram (EEG). Generalized seizures included in the list are:
- tonic-clonic seizures (includes variations beginning with a clonic or myoclonic phase)
- clonic seizures, including without tonic features and with tonic features
- typical absence seizures
- atypical absence seizures
- myoclonic absence seizures
- tonic seizures
- myoclonic seizures
- eyelid myoclonia, including without absences and with absences
- myoclonic atonic seizures
- negative myoclonus atonic seizures
- reflex seizures in generalized epilepsy syndromes
Focal seizures included in the ILAE list are:
- focal sensory seizures with elementary sensory symptoms (e.g., occipital and parietal lobe seizures) and experiential sensory symptoms (e.g., temporo-parieto-occipital junction seizures)
- focal motor seizures with elementary clonic motor signs, asymmetrical tonic motor seizures (e.g., supplementary motor seizures), typical (temporal lobe) automatisms (e.g., mesial temporal lobe seizures), hyperkinetic automatisms, focal negative myoclonus, and inhibitory motor seizures
- gelastic seizures
- hemiclonic seizures
- secondarily generalized seizures
- reflex seizures in focal epilepsy syndromes
In 1989, the International League Against Epilepsy also issued the following classification of epilepsies and epileptic syndromes:
- benign familial neonatal seizures
- early myoclonic encephalopathy
- Ohtahara syndrome
- migrating partial seizures of infancy (syndrome in development)
- West syndrome
- benign myoclonic epilepsy in infancy
- benign familial and non-familial infantile seizures
- Dravet's syndrome
- HH syndrome
- myoclonic status in nonprogressive encephalopathies (syndrome in development)
- benign childhood epilepsy with centrotemporal spikes
- early onset benign childhood occipital epilepsy (Panayiotopoulos type)
- late-onset childhood occipital epilepsy (Gastaut type)
- epilepsy with myoclonic absences
- epilepsy with myoclonic-astatic seizures
- Lennox-Gastaut syndrome
- Landau-Kleffner syndrome (LKS)
- epilepsy with continuous spike-and-waves during slow-wave sleep (other than LKS)
- childhood absence epilepsy
- progressive myoclonus epilepsies
- idiopathic generalized epilepsies with variable phenotypes include juvenile absence epilepsy, juvenile myoclonic epilepsy, and epilepsy with generalized tonic-clonic seizures only
- reflex epilepsies
- idiopathic photosensitive occipital lobe epilepsy
- other visual sensitive epilepsies
- primary reading epilepsy
- startle epilepsy
- autosomal dominant nocturnal frontal lobe epilepsy
- familial temporal lobe epilepsies
- generalized epilepsies with febrile seizures plus (syndrome in development)
- familial focal epilepsy with variable foci (syndrome in development)
- symptomatic focal epilepsies
- limbic epilepsies
- mesial temporal lobe epilepsy with hippocampal sclerosis
- mesial temporal lobe epilepsy defined by specific etiologies
- neocortical epilepsies
- Rasmussen syndrome
Classifying epilepsy can help in the evaluation and management of patients with seizure disorders. The combination of seizure type(s), etiology (cause), age of onset,
family history, and other medical or neurological conditions can be used to identify an epilepsy syndrome. Classification helps clinicians and researchers understand the broader picture of seizure disorders. On a practical level, syndrome identification can help in planning the management of patients. Syndrome classification schemes are revised periodically as individual components of particular categories are better understood.
The term idiopathic refers to a cause that is suspected to be, if not genetic, then unknown. Cryptogenic is a term that suggests that an underlying cause is suspected, but not yet fully understood. Symptomatic is a term that is applied to epilepsies that are a result of understood underlying pathologies.
The management and prognosis vary considerably among these differing syndromes. Epilepsies that have a genetic basis can be inherited or occur spontaneously. A detailed family history can often identify other family members who have had seizures. However, because seizures are common, it is possible to have more than one family member with epilepsy, though the etiologies may not be related. To say that a particular type of epilepsy is genetic does not mean that it is necessarily transmitted by heredity. Often, disorders can have a genetic cause, but be spontaneously occurring in only one member of a family. In this case, there may simply be a random mutation in that particular person's genes.
There are several mechanisms in which epilepsies can be inherited. So-called simple Mendelian inheritance occurs with benign familial neonatal convulsions and autosomal dominant nocturnal frontal lobe epilepsy. On the other hand, complex inheritance mechanisms can involve more than one gene, or a gene mutation in combination with environmental or acquired factors such as juvenile myoclonic epilepsy. As the genetics of the epilepsies become better understood, the classification scheme will evolve.
With epilepsy, symptoms vary considerably depending on the type. The common link among the epilepsies is, of course, seizures. The different epilepsies can sometimes be associated with more than one seizure type. This is the case with Lennox-Gastaut syndrome.
Arriving at a diagnosis of epilepsy is relatively straightforward: when people suffer two or more seizures, they would be considered to have epilepsy. However, diagnosing the specific epilepsy syndrome is much more complex. The first step in the evaluation process is to obtain a very detailed history of the illness, not only from the patient but from the family as well. Since seizures can impair consciousness, the patient may not be able to recall the specifics of the attacks. In these cases, family or friends that have witnessed the episodes can fill in the gaps about the particulars of the seizure. The description of the behaviors during a seizure can go a long way to categorizing the type of seizure and help with the overall diagnosis. Moreover, in the initial visit with the physician, the entire history of the patient is obtained. In a child, this would include birth history, complications, if any, maternal history, and developmental milestones. At any age, socalled co-morbidities (other medical problems) are considered. Medications that have been taken or currently being prescribed are documented.
A complete physical examination is performed, especially a neurological exam. Because seizures are an episodic disorder, abnormal neurological findings may not be present. Frequently, people with epilepsy have a normal exam. However, in some, there can be abnormal findings that can provide clues to the underlying cause of epilepsy. For example, if someone has had a stroke that subsequently caused seizures, then the neurological exam can be expected to reveal a focal neurological deficit such as weakness or language difficulties. In some children with seizures, there can be a variety of associated neurologic abnormalities such as mental retardation and cerebral palsy that are themselves non-specific but indicate that the brain has suffered, at some point in development, an injury or malformation. Also, subtle findings on examination can lead to a diagnosis such as in tuberous sclerosis . This is an autosomal dominantly inherited disorder associated with infantile spasms in 25% of cases. On examination, patients have so-called ash-leaf spots and adenoma sebaceum on the skin. There can also be a variety of systemic abnormalities that involve the kidneys, retina, heart, and gums, depending on severity.
In the course of evaluating epilepsy, a number of tests are typically ordered. Usually, magnetic resonance image (MRI ) of the brain is obtained. This is a scan that can help in finding many known causes of epilepsy such as tumors, strokes, trauma, and congenital malformations. However, while MRI can reveal incredible details of the brain, it cannot visualize the presence of abnormalities in the microscopic neuronal environment. Another test that is routinely ordered is an electroencephalogram (EEG). Unlike the MRI scan, this can be considered a functional test of the brain. The EEG measures the electrical activity of the brain. Some seizure disorders or epilepsies have a characteristic EEG with particular abnormalities that can help in diagnosis. Other tests that are frequently ordered are various blood tests that are also ordered in many medical conditions. These blood tests help to screen for abnormalities that can be a factor in the cause of seizures. Occasionally, genetic testing is performed in those instances where a known genetic cause is suspected and can be tested. A major concern in the course of an evaluation of epilepsy is to identify the presence of life-threatening causes such as brain tumors, infections, and cerebrovascular disease. Also, an accurate diagnosis can expedite the most effective treatment plan.
The symptoms of epilepsy are dependent in part on the particular seizures that occur and other medical problems that may be associated. Seizures, themselves, can take on a variety of features. A simple sustained twitching of an extremity could be a focal seizure. If a seizure arises in the occipital lobes of the brains, then a visual experience can occur. Aura is a term often used to describe symptoms that a person may feel prior to the loss of consciousness of a seizure. However, auras are, themselves, small focal seizures that have not spread in the brain to involve consciousness. Smells, well-formed hallucinations, tingling sensations, or nausea have each occurred in auras. The particular sensation can be a clue as to the location in the brain where a seizure starts. Focal seizures can then spread to involve other areas of the brain and lead to an alteration of consciousness, and possibly convulsions. In certain epilepsy syndromes such as Lennox-Gastaut, there can be more than one type of seizure experienced, such as atonic, atypical absence, and tonic-axial seizures.
One challenge in predicting the course of epilepsy is that for any type, there can be a variable response to treatment. Sometimes, seizures may play a rather small role in the manifestation of a medical condition. For example, a severe head injury could result in seizures that readily respond to medication, but severe neurological impairments and disabilities may still be present. On the other hand, a different head injury may result in relatively mild neurological problems, but there may be seizures that are severe and be resistant to medications.
Whatever the case, the ultimate goals when treating epilepsy are to:
- strive for complete freedom from seizures
- have little to no side effects from medications
- be able to follow an easy regimen so that compliance with treatment can be maintained
Up to 60% of patients with epilepsy can be expected to achieve control of seizures with medication(s). However, in the remaining 40%, epilepsy appears to be resistant, to varying degrees, to medications. In these cases, the epilepsy is termed medically intractable.
Generally, the choice of medication is somewhat trial and error. There are, however, a number of considerations that guide the choice of treatment. Each medication has a particular side effect profile and mechanism of action. Some medications seem to be particularly effective for certain epilepsy syndromes. For example, juvenile myoclonic epilepsy responds well to valproic acid. On the other hand, ethosuxamide is primarily used for absence seizures.
As with any medication, individuals can have very different experiences with same drug. Consequently, it is difficult to predict the efficacy of treatment in the beginning. A key concept of treatment is to first strive for monotherapy (or single drug therapy). This simplifies treatment and minimizes the chance of side effects. Sometimes, however, two or more drugs may be necessary to achieve satisfactory control of seizures. As with any treatment, potential side effects can be worse than the disease itself. Moreover, there is little point in controlling seizures if severe side effects limit quality of life. If a seizure disorder is characterized by mild, focal, or brief symptoms that do not interfere with day-to-day life, then aggressive treatments may not be justified. Epilepsy medications do not cure epilepsy; the medications can only control the frequency and severity of seizures. A list of the most commonly used medications in the management of epilepsy includes:
- phenytoin (Dilantin, Phenytek)
- clonazepam (Klonipin)
- ethosuxamide (Zarontin)
- carbamazepine (Tegretol, Carbatrol)
- divalproex sodium (Depakote, Depakene)
- felbamate (Felbatol)
- gabapentin (Neurontin)
- lamotrigine (Lamictal)
- topiramate (Topamax)
- tiagabine (Gabatril)
- zonisamide (Zonegran)
- oxcarbazepine (Trileptal)
- leviteracetam (Keppra)
It has been found that the initial, thoughtfully chosen medication can be expected to make almost 50% of patients seizure free for extended periods of time. If the initial drug fails, another well-chosen drug may make an additional 14% of people seizure free. If that drug fails, then the likelihood of rendering someone with epilepsy seizure free is poor. This does not mean that trying more medications or combinations of them may not be successful, but rather, these statistics give the neurologist and the patient an understanding of the realities of epilepsy treatment. In cases where medications do not fully control epilepsy, it is recommended that a more extensive evaluation at a comprehensive epilepsy center be conducted where an epileptologist (a specialist in epilepsy) will more thoroughly assess the particular aspects of the seizures. When medications are clearly ineffective, the other types of therapy that can be considered are the ketogenic diet, brain surgery, and vagal nerve stimulation.
The ketogenic diet is based on high-fat, low-carbo-hydrate, and low-protein meals. The ketogenic diet is named because of the production of ketones by the breakdown of fatty acids. The most common version of the diet involves long-chain triglycerides. These are present in whole cream, butter, and fatty meats.
The ketogenic diet is administered with the support of a nutritionist with experience in this treatment modality. It is mostly used in children with medically intractable epilepsy and whose diet can be controlled. The ketogenic diet can be considered a pharmacologic treatment. As such, there are potential side effects that limit its tolerance. This includes hair thinning, lethargy, weight loss, kidney stones, and possibly cardiac problems. Sugar-free vitamin and mineral supplementation is necessary. The diet may not be appropriate for certain individuals, particularly in children, who may have certain metabolic diseases.
Overall, the diet has been very helpful in the control of seizures in many patients. Roughly 50% of patients can hope to achieve complete control of seizures, 25% of the patients see improvements, and another 25% are non-responders. There are some patients who have an improvement in behavior. If the diet is well tolerated with good results, then it can be maintained for up to two years, followed by a careful gradual transition to regular meals.
Epilepsy surgery is an option in the attempt to either cure or significantly reduce the severity of medically resistant cases. It is thought that up to 100,000 patients in the United States could be potential candidates for a surgical treatment. However, only about 5,000 cases are performed throughout the United States annually. This is likely due to several factors, including the belief that any brain surgery is a last resort, the lack of awareness or understanding of the benefits of surgery, and the false hope that some medication will come along that will be effective.
There are several kinds of surgery that are available depending on the nature of the seizure disorder. A list of operations that are utilized regularly for epilepsy include:
- corpus collosotomy
- multiple subpial transection
The type of surgery that is performed depends on the nature of the individual seizure disorder. If a seizure can be localized to a particular area in the brain, then this abnormal region can potentially be surgically removed. Epileptic brain tissue is abnormal and its removal can provide a chance of a cure. Generally, surgery should be a consideration when the risk and benefits of it outweigh the long-term risks of uncontrolled epilepsy.
The approach taken in any brain surgery for epilepsy is highly individualized and great care is taken to avoid injury to essential brain tissue. The most common epilepsy surgery performed is the temporal lobectomy. Brain tumors are frequently associated with seizures. In many cases, surgery to remove the tumor is planned so that regions that may be causing seizures are removed as well. However, in many cases, epilepsy surgery cannot be done.
Vagus nerve stimulation
Another non-medicinal approach to treating epilepsy is a novel method that became available in July 1997. The Food and Drug Administration (FDA) approved the use of the vagal nerve stimulator (VNS) as add-on therapy in patients who experience seizures of partial onset. The VNS is designed to intermittently deliver small electrical stimulations to a nerve in the neck called the vagus nerve. There are two vagal nerves, one on each side of the neck near the carotid arteries, making a pair of cranial nerves (there are 12 different paired cranial nerves). The vagus nerve carries information from the brain to many parts of the thoracic and abdominal organs. The nerve also carries information from these same organs back to the brain. VNS takes advantage of this fact and, by intermittent stimulation, there is an effect on many brain areas that can be involved in seizures.
About 50% of patients experience at least 50% reduction in the frequency of their seizures. The responses to VNS range from complete control of seizures (less than 10% of patients) to no noticeable improvement. The device is not a substitute for epilepsy surgery and should be considered only after there is an evaluation for epilepsy surgery. The implantation of the device requires relatively minor surgery with two incisions, one in the neck and the other in the left upper chest area.
The battery in the device lasts up to eight to ten years, after which the device can be replaced. Side effects of VNS therapy include voice hoarseness that typically does not impair communication. Like any surgery, there is an initial risk of infection, bleeding, and pain . Recovery takes a few weeks. Individuals can return to their usual activities once the incisions have healed.
The National Institute of Neurological Disorders and Stroke list a number of clinical trials . There are also a number of studies being conducted at a more basic science stage evaluating the role of the following in seizures and epilepsy: neurotransmitters , non-neuronal cells, and genetic factors. Treatment strategies including deep brain stimulation and intracranial early seizure detection devices are being studied at different stages.
The prognosis of epilepsy varies widely depending on the cause, severity, and patient's age. Even individuals with a similar diagnosis may have different experiences with treatment. For example, in benign epilepsy of childhood with centrotemporal spikes (also called benign rolandic epilepsy), the prognosis is excellent with nearly all children experiencing remission by their teens. With childhood absence epilepsy, the prognosis is variable. In this case, the absence seizures become less frequent with time, but almost half of patients may eventually develop generalized tonic-clonic seizures. Overall, the seizures are responsive to an appropriate anticonvulsant. On the other hand, the seizures in Lennox-Gastaut syndrome are very difficult to control. In this case, however, the ketogenic diet can help. In seizures that begin in adulthood, one can expect that medications will control seizures in up to 60–70% of cases. However, in some of the more than 30% of medically intractable cases, epilepsy surgery can improve or even cure the problem.
Overall, most patients have a good chance of controlling seizures with the available options of treatment. The goal of treatment is complete cessation of seizures since a mere reduction in seizure frequency and/or severity may continue to limit patients'quality of life: they may not be able to drive, sustain employment, or be productive in school.
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Roy Sucholeiki, MD
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Sucholeiki, Roy. "Epilepsy." Gale Encyclopedia of Neurological Disorders. 2005. Retrieved May 27, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3435200142.html
Epilepsy is a condition characterized by recurrent seizures that may include repetitive muscle jerking called convulsions. A seizure is a sudden disruption of the brain's normal electrical activity accompanied by altered consciousness and/or other neurological and behavioral manifestations.
Epilepsy affects 1–2% of the population of the United States. Although epilepsy is as common in adults over 60 as in children under 10, 25% of all cases develop before the age of five. One in every two cases develops before the age of 25. About 125,000 new cases of epilepsy are diagnosed each year, and a significant number of children and adults that have not been diagnosed or treated have epilepsy.
Most seizures are benign, but a seizure that lasts a long time can lead to status epilepticus, a life-threatening condition characterized by continuous seizures, sustained loss of consciousness, and respiratory distress. Nonconvulsive epilepsy can impair physical coordination, vision, and other senses. Undiagnosed seizures can lead to conditions that are more serious and more difficult to manage.
Types of seizures
Generalized epileptic seizures occur when electrical abnormalities exist throughout the brain. A partial seizure does not involve the entire brain. A partial seizure begins in an area called an epileptic focus, but may spread to other parts of the brain and cause a generalized seizure. Some people who have epilepsy have more than one type of seizure.
Motor attacks cause parts of the body to jerk repeatedly. A motor attack usually lasts less than an hour and may last only a few minutes. Sensory seizures begin with numbness or tingling in one area. The sensation may move along one side of the body or the back before subsiding.
Visual seizures that affect the area of the brain that controls sight cause people to hallucinate. Auditory seizures affect the part of the brain that controls hearing and cause the patient to imagine hearing voices, music, and other sounds. Other types of seizures can cause confusion, upset stomach, or emotional distress.
PARTIAL SEIZURES. Simple partial seizures do not spread from the focal area where they arise. Symptoms are determined by the part of the brain affected. The patient usually remains conscious during the seizure and can later describe it in detail.
COMPLEX PARTIAL SEIZURES. A distinctive smell, taste, or other unusual sensation (aura) may signal the start of a complex partial seizure.
Complex partial seizures start as simple partial seizures, but move beyond the focal area and cause loss of consciousness. Complex partial seizures can become major motor seizures. Although a person having a complex partial seizure may not seem to be unconscious, he or she does not know what is happening and may behave inappropriately. He or she will not remember the seizure, but may seem confused or intoxicated for a few minutes after it ends.
Causes & symptoms
The origin of 50–70% of all cases of epilepsy is unknown. Epilepsy sometimes results from trauma at birth. Such causes include insufficient oxygen to the brain; head injury; heavy bleeding or incompatibility between a woman's blood and the blood of her newborn baby; and infection immediately before, after, or at the time of birth.
Other causes of epilepsy include:
- head trauma resulting from a car accident, gunshot wound, or other injury
- brain abscess or inflammation of membranes covering the brain or spinal cord
- phenylketonuria (PKU), a disease that is present at birth, is often characterized by seizures, and can result in mental retardation
- other inherited disorders
- infectious diseases such as measles, mumps , and diphtheria
- degenerative disease
- lead poisoning, mercury poisoning, carbon monoxide poisoning, or ingestion of some other poisonous substance
- genetic factors
Status epilepticus, a condition in which a person suffers from continuous seizures and may have trouble breathing, can be caused by:
- suddenly discontinuing antiseizure medication
- hypoxic or metabolic encephalopathy (brain disease resulting from lack of oxygen or malfunctioning of other physical or chemical processes)
- acute head injury
- infection spread from blood (for example, meningitis or encephalitis) caused by inflammation of the brain or the membranes that cover it
Personal and family medical history, description of seizure activity, and physical and neurological examinations help primary care physicians, neurologists, and epileptologists diagnose this disorder. Doctors rule out conditions that cause symptoms that resemble epilepsy, including small strokes (transient ischemic attacks, or TIAs), fainting (syncope), pseudoseizures, and sleep attacks (narcolepsy ).
Neuropsychological testing uncovers learning or memory problems. Neuroimaging provides views of brain areas involved in seizure activity.
The electroencephalogram (EEG) is the main test used to diagnose epilepsy. EEGs use electrodes placed on or within the skull to record the brain's electrical activity and pinpoint the exact location of abnormal discharges.
The patient may be asked to remain motionless during a short-term EEG or to go about his normal activities during extended monitoring. Some patients are deprived of sleep or exposed to seizure triggers, such as rapid, deep breathing (hyperventilation) or flashing lights (photic stimulation). In some cases, people may be hospitalized for EEG monitorings that can last as long as two weeks. Video EEGs also document what the patient was doing when the seizure occurred and how the seizure changed his or her behavior.
Other techniques used to diagnose epilepsy include:
- Magnetic resonance imaging (MRI), which provides clear, detailed images of the brain. Functional MRI (fMRI), performed while the patient does various tasks, can measure shifts in electrical intensity and blood flow and indicate which brain region each activity affects.
- Positron emission tomography (PET) and single photon emission tomography (SPECT) monitor blood flow and chemical activity in the brain area being tested. PET and SPECT are very effective in locating the brain region where metabolic changes take place between seizures.
Stress increases seizure activity in 30% of people who have epilepsy. Relaxation techniques can provide some sense of control over the disorder, but they should never be used instead of antiseizure medication or without the approval of the patient's doctor. Yoga, meditation , and favorite pastimes help some people relax and manage stress more successfully. Biofeedback can teach adults and older adolescents how to recognize an aura and what to do to stop its spread. Children under 14 usually are not able to understand and apply principles of biofeedback.
Acupuncture treatments (acupuncture needles inserted for a few minutes or left in place for as long as 30 minutes) make some people feel pleasantly relaxed.
Acupressure can have the same effect on children or on adults who dislike needles.
Aromatherapy involves mixing aromatic plant oils into water or other oils and massaging them into the skin or using a special burner to waft their fragrance throughout the room. Aromatherapy oils affect the body and the brain, and undiluted oils should never be applied directly to the skin. Ylang ylang, chamomile , or lavender can create a soothing mood. People who have epilepsy should not use rosemary, hyssop , citrus (such as lemon), sage , or sweet fennel , which seem to stimulate the brain.
KETOGENIC DIET. A special high-fat, low-protein, low-carbohydrate diet is sometimes used to treat patients whose severe seizures have not responded to other treatment. Calculated according to age, height, and weight, the ketogenic diet induces mild starvation and dehydration. This forces the body to create an excessive supply of ketones, natural chemicals with seizure-suppressing properties.
The goal of this controversial approach is to maintain or improve seizure control while reducing medication. The ketogenic diet works best with children between the ages of one and 10. It is introduced over a period of several days, and most children are hospitalized during the early stages of treatment.
If a child following this diet remains seizure-free for at least six months, increased amounts of carbohydrates and protein are gradually added. If the child shows no improvement after three months, the diet is gradually discontinued. A 2003 study of the diet and its effect on growth noted that if used, clinicians should recommend adequate intake of energy and protein and a higher proportion of unsaturated to saturated dietary fats. The report also recommended use of vitamin and mineral supplements with the diet.
Introduced in the 1920s, the ketogenic diet has had limited, short–term success in controlling seizure activity. Its use exposes patients to such potentially harmful side effects as:
- staphylococcal infections
- stunted or delayed growth
- low blood sugar (hypoglycemia)
- excess fat in the blood (hyperlipidemia)
- disease resulting from calcium deposits in the urinary tract (urolithiasis)
- disease of the optic nerve (optic neuropathy)
Homeopathic therapy also can work for people with seizures, especially constitutional homeopathic treatment that acts at the deepest levels to address the needs of the individual person.
The goal of epilepsy treatment is to eliminate seizures or make the symptoms less frequent and less severe. Long-term anticonvulsant drug therapy is the most common form of epilepsy treatment.
A combination of drugs may be needed to control some symptoms, but most patients who have epilepsy take one of the following medications:
- Dilantin (phenytoin)
- Tegretol (carbamazepine)
- Barbita (phenobarbital)
- Mysoline (primidone)
- Depakene (valproic acid, sodium valproate)
- Klonopin (clonazepam)
- Zarontin (ethosuximide)
Dilantin, Tegretol, Barbita, and Mysoline are used to manage or control generalized tonic-clonic and complex partial seizures. Depakene, Klonopin, and Zarontin are prescribed for patients who have absence seizures.
Neurontin (gabapentin), Lamictal (lamotrigine), and topiramate (Topamax) are among medications more recently approved in the United States to treat adults who have partial seizures or partial and grand mal seizures. Another new medication called Levetiracetam (Keppra) has been approved and shows particularly good results in reducing partial seizures among elderly patients with few side effects. This is important, because elderly patients often have other conditions and must take other medications that might interact with seizure medications. In 2003, Keppra's manufacturer was working on a new antiepilectic drug from the same chemical family as Keppra that should be more potent and effective. Available medications frequently change, and the physician will determine the best treatment for an individual patient. A 2003 report found that monotherapy, or using just one medication rather than a combination, works better for most patients. The less complicated the treatment, the more likely the patient will comply and better manager the seizure disorder.
Even an epileptic patient whose seizures are well controlled should have regular blood tests to measure levels of antiseizure medication in his or her system and to check to see if the medication is causing any changes in his or her blood or liver. A doctor should be notified if any signs of drug toxicity appear, including uncontrolled eye movements; sluggishness, dizziness , or hyperactivity; inability to see clearly or speak distinctly; nausea or vomiting ; or sleep problems.
Status epilepticus requires emergency treatment, usually with Valium (Ativan), Dilantin, or Barbita. An intravenous dextrose (sugar) solution is given to a patient whose condition is due to low blood sugar, and a vitamin B1 preparation is administered intravenously when status epilepticus results from chronic alcohol withdrawal. Because dextrose and thiamine are essentially harmless and because delay in treatment can be disastrous, these medications are given routinely, as it is usually difficult to obtain an adequate history from a patient suffering from status epilepticus.
Intractable seizures are seizures that cannot be controlled with medication or without sedation or other unacceptable side effects. Surgery may be used to eliminate or control intractable seizures.
Surgery can be used to treat patients whose intractable seizures stem from small focal lesions that can be removed without endangering the patient, changing the patient's personality, dulling the patient's senses, or reducing the patient's ability to function.
A physical examination is conducted to verify that a patient's seizures are caused by epilepsy, and surgery is not used to treat patients with severe psychiatric disturbances or medical problems that raise risk factors to unacceptable levels.
Surgery is never recommended unless:
- The best available antiseizure medications have failed to control the patient's symptoms satisfactorily.
- The origin of the patient's seizures has been precisely located.
- There is good reason to believe that surgery will significantly improve the patient's health and quality of life.
Every patient considering epilepsy surgery is carefully evaluated by one or more neurologists, neurosurgeons, neuropsychologists, and/or social workers. A psychiatrist, chaplain, or other spiritual advisor may help the patient and his family cope with the stresses that occur during and after the selection process.
TYPES OF SURGERY. Surgical techniques used to treat intractable epilepsy include:
- Lesionectomy. Removing the lesion (diseased brain tissue) and some surrounding brain tissue is very effective in controlling seizures. Lesionectomy is generally more successful than surgery performed on patients whose seizures are not caused by clearly defined lesions, but removing only part of the lesion lessens the effectiveness of the procedure.
- Temporal resections. Removing part of the temporal lobe and the part of the brain associated with feelings, memory, and emotions (the hippocampus) provides good or excellent seizure control in 75–80% of properly selected patients with appropriate types of temporal lobe epilepsy. Some patients experience post-operative speech and memory problems.
- Extra-temporal resection. This procedure involves removing some or all of the frontal lobe, the part of the brain directly behind the forehead. The frontal lobe helps regulate movement, planning, judgment, and personality. Special care must be taken to prevent post-operative problems with movement and speech. Extra-temporal resection is most successful in patients whose seizures are not widespread.
- Hemispherectomy. This method of removing brain tissue is restricted to patients with severe epilepsy and abnormal discharges that often extend from one side of the brain to the other. Hemispherectomies are most often performed on infants or young children who have had an extensive brain disease or disorder since birth or from a very young age.
- Corpus callosotomy. This procedure, an alternative to hemispherectomy in patients with congenital hemiplegia, removes some or all of the white matter that separates the two halves of the brain. Corpus callosotomy is performed almost exclusively on children who are frequently injured during falls caused by seizures. If removing two–thirds of the corpus callosum does not produce lasting improvement in the patient's condition, the remaining one-third will be removed during another operation.
- Multiple subpial transection. This procedure is used to control the spread of seizures that originate in or affect the "eloquent" cortex, the area of the brain responsible for complex thought and reasoning.
Other forms of treatment
VAGUS NERVE STIMULATION. Approved for adults and adolescents (over 16 years old) with intractable seizures, vagus nerve stimulation (VNS) uses a pacemaker-like device implanted under the skin in the upper left chest, to provide intermittent stimulation to the vagus nerve. Stretching from the side of the neck into the brain, the vagus nerve affects swallowing, speech, breathing, and many other functions, and VNS may prevent or shorten some seizures.
First aid for seizures
A person with epilepsy having a seizure should not be restrained, but sharp or dangerous objects should be moved out of reach. Anyone having a complex partial seizure can be warned away from danger by someone calling his/her name in a clear, calm voice.
A person with epilepsy having a grand mal seizure should be helped to lie down, and those aiding the patient should contact emergency medical personnel. Tight clothing should be loosened. A soft, flat object like a towel or the palm of a hand should be placed under the person's head. Forcing a hard object into the mouth of someone having a grand mal seizure could cause injuries or breathing problems. If the person's mouth is open, placing a folded cloth or other soft object between his or her teeth will protect the tongue. Turning the patient's head to the side will help with breathing. After a grand mal seizure has ended, the person who had the seizure should be told what has happened and reminded of where he or she is.
People who have epilepsy have a higher than average rate of suicide; sudden, unexplained death; and drowning and other accidental fatalities.
Benign focal epilepsy of childhood and some absence seizures may disappear in time, but remission is unlikely if seizures occur several times a day, several times in a 48-hour period, or more frequently than in the past.
Epilepsy can be partially or completely controlled if the individual takes antiseizure medication according to directions; avoids seizure-inducing sights, sounds, and other triggers; gets enough sleep; and eats regular, balanced meals.
Anyone who has epilepsy should wear a bracelet or necklace identifying the seizure disorder and listing the medication he or she takes.
Eating properly, getting enough sleep, and controlling stress and fevers can help prevent seizures. A person who has epilepsy should be careful not to hyperventilate. Those who experience auras should find a safe place to lie down and stay until the seizure passes. Anticonvulsant medications should not be stopped suddenly and, if other medications are prescribed or discontinued, the doctor treating the seizures should be notified. In some conditions, such as severe head injury, brain surgery, or subarachnoid hemorrhage, anticonvulsant medications may be given to the patient to prevent seizures.
"Seizures." Reader's Digest Guide to Medical Cures & Treatments : A Complete A-to-Z Sourcebook of Medical Treatments, Alternative Opinions, and Home Remedies. Canada: The Reader's Digest Association, Inc., 1996.
Shaw, Michael, ed. Everything You Need to Know about Diseases. Springhouse, PA: Springhouse Corporation, 1996.
Batchelor, Lori, et al. "An Interdisciplinary Approach to Implementing the Ketogenic Diet for the Treatment of Seizures." Pediatric Nursing (September/October 1997): 465–471.
"Data Analysis Shows Keppra Reduced Partial Seizures in Elderly Patients." Clinical Trials Week (April 28, 2003): 26.
Dichter, M.A., and M.J. Brodie. "Drug Therapy: New Antiepileptic Drugs." The New England Journal of Medicine (15 June 1996): 1583-1588.
Dilorio, Colleen, et al. "The Epilelpsy Medication and Treatment Complexity Index: Reliability and Validity Testing." Journal of Neuroscience Nursing (June 2003): 155–158.
"Epilepsy Surgery and Vagus Nerve Stimulation Are Effective When Drugs Fail." Medical Devices & Surgical Technology Week (May 4, 2003): 33.
Finn, Robert. "Partial Seizures Double Risk of Sleep Disturbances (Consider in Diagnosis, Management)." Clinical Psychiatry News (June 2003): 36–41.
Lannox, Susan L. "Epilepsy Surgery for Partial Seizures." Pediatric Nursing (September–October 1997): 453-458.
Liu, Yeou-Mei Christiana, et al. "A Prospetive Study: Growth and Nutritional Status of Children Treated With the Ketogenic Diet." Journal of the American Dietetic Association (June 2003): 707.
McDonald, Melori E. "Use of the Ketogenic Diet in Treating Children with Seizures." Pediatric Nursing (September-October 1997): 461-463.
"New Drug Candidate Shows Promise." Clinical Trials Week (April 7, 2003): 26.
American Epilepsy Society. 638 Prospect Avenue, Hartford, CT 06105-4298. (205) 232-4825.
Epilepsy Concern International Service Group. 1282 Wynnewood Drive, West Palm Beach, FL 33417. (407) 683–0044.
Epilepsy Foundation of America. 4251 Garden City Drive, Landover, MD 20875-2267. (800) 532-1000.
Epilepsy Information Service. (800) 642-0500.
Bourgeois, Blaise F.D. Epilepsy Surgery in Children. http://www.neuro.wustl.edu/epilepsy/21children.html (3 March 1998).
Cosgrove, G. Rees, and Andrew J. Cole. Surgical Treatment of Epilepsy. http://neurosurgery.mgh.harvard.edu/ep-sxtre.htm (3 March 1998).
Epilepsy. http://www.ninds.nih.gov/healinfo/disorder/epilepsy/epilepfs.htm (28 February 1998).
Epilepsy and Dental Health. http://www.epinet.org.au/efvdent.html (3 March 1998).
Epilepsy Facts and Figures. http://www.efa.org/what/education/FACTS.html (28 February 1998).
Frequently Asked Questions (FAQs) About the Ketogenic Diet. http://www-leland.Stanford.edu/group/ketodiet/FAQ.html (28 February 1998).
Surgery for Epilepsy: NIH Consensus Statement Online. http://neurosurgery.mgh.harvard.edu/epil-nih.htm (3 March 1998).
The USC Vagus Nerve Stimulator Program. http://www.usc.edu/hsc/medicine/neurology/VNS.html (3 March 1998).
Teresa G. Odle
Tran, Mai; Odle, Teresa. "Epilepsy." Gale Encyclopedia of Alternative Medicine. 2005. Encyclopedia.com. (May 27, 2016). http://www.encyclopedia.com/doc/1G2-3435100289.html
Tran, Mai; Odle, Teresa. "Epilepsy." Gale Encyclopedia of Alternative Medicine. 2005. Retrieved May 27, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3435100289.html
Contrary to what has been asserted in the past, recent literature has demonstrated that the incidence of provoked and unprovoked seizures and of epilepsy and the prevalence of epilepsy in older people is high. It is therefore regrettable that seizures in old age are still relatively under-researched. There are reasons for not relying on data obtained from the general adult population when deriving a picture of epilepsy in old age. The presentation, the etiology, the clinical pharmacology, the functional consequences, and the associated core morbidity are all different in old age.
Presentation and diagnosis
Since many older people live alone, there may be an inadequate history and older people may present with a history of recurrent unexplained falls or of being found on the floor. The vast majority of seizures in old age are either partial seizures with, for example, focal motor events such as recurrent jerking of an arm or leg, or secondary generalized seizure that may present either with disturbances of higher level function as in complex partial seizures or with convulsive movements. The list of conditions that may be confused with epilepsy is very long and includes: fainting; low blood sugar; transient ischaemic attacks; recurrent paroxysmal behavioral disturbances, such as clapping or calling out, secondary to dementia; drop attacks and other nonepileptic causes of falls; transient global amnesia; and nonepileptic attack disorder or psychogenic attacks. Conversely, there is an equally long list of conditions that are genuinely epileptic but may be thought to be nonepileptic; partial motor status epilepticus (e.g., persistent involuntary movement of an arm or leg) may be thought to be an extrapyramidal movement disorder such as Parkinson's disease; sensory epilepsy may be thought to be a transient ischaemic attack; complex partial seizures in which a patient may stare or call out can be confused with psychoses; atonic seizures can be confused with drop attacks or hysteria; and Todd's palsy (transient weakness) following a generalized seizure can be confused with a new stroke or a transient ischaemic attack.
The biggest challenge in elderly epileptology is determining whether or not the patient's events are seizures or fainting (syncope). Differentiating the two conditions may be extremely difficult in the absence of an eyewitness report. Moreover, the usual features that differentiate the two conditions may not apply to older people. For example, whereas syncope is not usually associated with either incontinence (loss of bladder and/or bowel control) or post-event confusion, an elderly person who is already incontinent or has background confusion may be incontinent or confused in association with a syncope attack. Even so, the history remains the most powerful diagnostic tool. Investigations will be guided by the history and the findings on examination. The EEG will rarely be useful in making a diagnosis of epilepsy and certainly should not be used to make up for the shortfalls in history taking. The indications for neuroimaging are not well defined and depend at least in part on the availability of radiological services. Strong indications for neuroimaging include unexplained focal neurological signs, progressive or new neurological symptoms, especially those of raised intracranial pressure, progressive or new neurological signs or poor control of fits not attributable to poor compliance, or continued exposure to precipitants such as alcohol.
The most common cause of seizures in old age is cerebrovascular disease: seizures may be a harbinger of future manifestations of cerebrovascular disease; late onset seizures are associated with a higher level of occult cerebral ischaemia; and overt strokes may trigger seizures either acutely or subsequently. Any patient who develops a seizure for the first time in old age when there was no obvious cause should be thoroughly investigated for cardiovascular risk factors and possibly placed on low dose aspirin, so long as there is no contraindication. Other cerebral causes of seizures include tumor, which may account for 10 to 15 percent of elderly onset cases. However, the proportion of these cases in which seizure is the only manifestation and the proportion in which any underlying tumor found is benign and/or resectable is not known. Seizures may occur in nonvascular cerebral degenerative disease, such as Alzheimer's disease. Non-cerebral causes of seizures include those which are secondary to cerebral anoxia as in prolonged syncopal attacks due, for example, to cardiac arythymias. Seizures may also be triggered by a wide variety of drugs that have proconvulsant side effects, notably tricyclic antidepressants, phenothiazines, and aminophylline. The role of alcohol in triggering seizures in older people or in interfering with control must not be forgotten.
Reassurance, education, and information are of paramount importance in the management of elderly patients with seizures as in any other age group. Guidance on driving regulations, reasonable risk-taking, and the avoidance of precipitants of seizures should be covered. The mainstay of treatment is drug therapy. This should not be undertaken lightly and a so-called therapeutic trial of antiepileptic drugs in patients whose episodes are of uncertain nature is usually undesirable, unless the events are occurring with such frequency that the response to drugs can be assessed very quickly. It must be remembered that the adverse impact of drugs may outweigh the episodic discomfort of an occasional seizure. Drug treatment is usually started in patients who have more than one unprovoked generalized seizure or a single major seizure where there is a continuing underlying cause as in the case of a patient who has had a cerebral infarct in the past. The evidence that early treatment prevents recurrent epilepsy from becoming chronic (the notion that "fits breed fits") is poor. Patients with minor seizures that are not in any way interfering with their life may, if the episodes are infrequent, reasonably elect not to have drug treatment.
Recent meta-analyses have made the choice of anticonvulsant a little easier. There is evidence that carbamazepine has some advantages over the other first-line drugs (phenytoin or sodium valproate) for the generality of elderly people who have partial or secondary generalized seizures. However, there may be a case for using other drugs for first-line treatment in patients with specific problems. Where compliance demands that patients receive medication once daily, there may be a case for phenytoin, although this may predispose to bone demineralization as well as having the neuropsychiatric effects shared with other anticonvulsants. Carbamazepine may predispose to hyponatraemia (low sodium in the blood or less than 130 mmol/l), particularly in patients on diuretics or who have recurrent chest infections. Sodium valproate may be the drug of choice for patients who cannot tolerate either phenytoin or carbamazepine or in the small number of patients who have primary generalized seizures. There is relatively little evidence about the newer generation of anticonvulsants but lamotragine appears to be at least as effective as carbamazepine and may have fewer side effects, although it is expensive; and gabapentin has the advantage of not interacting with other drugs as well as being relatively non-toxic, although it may also be relatively less effect in controlling seizures. There are no recommended doses of anticonvulsants for older people. Overall, the retrospective analysis of a Veterans Administration's study of the effect of age on epilepsy and its treatment showed that older patients' seizures were better controlled and they were on lower doses of anticonvulsants than were younger patients. However, there is enormous variation between older people. Anti-epileptic drug monitoring may be particularly useful in the case of phenytoin and carbamazepine. The prognosis for control is at least as good as, or possibly better than, in the general adult population. There is little evidence about the appropriateness of withdrawal of anticonvulsants as studies have not been done in older people. Presently, an elderly person who has been started appropriately on an anticonvulsant may have to remain on it for the rest of his or her life.
Services for elderly people with epilepsy are often poorly developed: such patients fall between geriatrics and neurology services. There is a case for developing specialized epilepsy services for older people that can address both management of seizures and other concurrent problems and associated disabilities. A key element of that service would be a specialist epilepsy nurse.
Raymond C. Tallis
See also Balance and Mobility; Dementia; Disease Presentation; Drugs and Aging; Fainting; Stroke.
KrÄmer, G. Epilepsy in the Elderly—Clinical Aspects and Pharmacology. Stuttgart: Georg Thieme Verlag, 1999.
Rowan, J. A., and Ramsey, R. E. Seizures and Epilepsy in the Elderly. Newton, Mass.: Butter-worth-Heinemann, 1997.
Tallis, R. C. Epilepsy in Elderly People. London: Martin Dunitz, 1995.
See Andropause; Menopause; Sexuality
Tallis, Raymond C.. "Epilepsy." Encyclopedia of Aging. 2002. Encyclopedia.com. (May 27, 2016). http://www.encyclopedia.com/doc/1G2-3402200133.html
Tallis, Raymond C.. "Epilepsy." Encyclopedia of Aging. 2002. Retrieved May 27, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3402200133.html
Further, Hippocrates argued that the disease was inherited and was caused by a disturbance in the brain, and thus firmly fixed epilepsy as a natural disease, treatable by doctors and not by priests, an important development for both market and medical practices. This view was long held by learned doctors: the influential physician Alexander of Tralles (525–605), however, recommended treatments that included making the nail of a wrecked ship into a bracelet, which was to be decorated with ‘the bone of a stag's heart taken from its body whilst alive’, adding that this should be worn on the left arm, for ‘astonishing results’. Somewhat earlier, the Roman physician Pliny (c.23–79) had also reported that epileptic patients could be cured by drinking blood, especially of gladiators. Throughout the Middle Ages, the view that epilepsy was a medical problem continued to coexist with causative theories of demonic possession and spiritual imbalances. Treatments including Christian prayer (St Christopher was drafted in as a patron saint with special responsibility), pagan ritual, and humoral medicine all emerged. A prominent medieval surgeon, Guy de Chauliac (1298–1368), prescribed magic and prayer for epileptics — they were to write the names of the Three Wise Men in their own blood on parchment, and daily recite three Pater Nosters and Ave Marias for three months. It was at this time that mistletoe acquired a special association with epilepsy — mistletoe was hung around children's necks in Central Europe as a protective against seizures, and in Scandinavia knife handles were cut from oak mistletoe, for the same purpose. By the sixteenth century epileptics could be branded as witches, and little medical progress had been made. In the middle of the seventeenth century, Robert Boyle, a founder member of the Royal Society of London, was still advocating crushed mistletoe to be taken during the days of a full moon.
Gradually however, some effort was made to classify the different types of seizures, and by the beginning of the nineteenth century epileptics were often hospitalized. One advance occurred in 1838, when epileptic children in Paris were provided with education, rather than being completely hospitalized, although often epileptics were separated from the insane because of the growing belief that epilepsy was infectious. Thus epileptics were increasingly confined in separate wards, and soon in separate institutions.
By 1860 special hospitals for epileptics had been founded in Germany, France, and Britain. One of these was the Hospital for Epilepsy and Paralysis in Queen Square, London (later the National Hospital for Nervous Diseases). This meant that epileptics were increasingly seen and treated by physicians attached to such institutions, who became particularly experienced in the diagnosis and treatment of the disease. This led in particular to a more detailed differentiation and classification of epilepsy, including terms still in use today, such as grand mal, petit mal, absence seizures, and status epilepticus. By the latter part of the nineteenth century, the theories of the British neurologist, John Hughlings Jackson (1835–1911), and his French counterpart Jean Charcot (1825–93) began to define the neurological basis of the disease and its complex symptomatology. W. R. Gowers (1845–1915) authoritatively described the ‘aura’ that preceded a grand mal attack (although Hippocrates had not been ignorant of it).
In terms of treatment, bromides were the first successful medicine for epilepsy, from the 1850s onwards, abolishing attacks in some, and diminishing them in number or violence in most others; they started to be displaced only after the introduction of phenobarbital, first prescribed in 1912. Barbiturates continue to be one of the effective treatments, although further understanding of the underlying mechanisms have led to the development of alternative modern anticonvulsant drugs: those that potentiate or imitate the inhibitory neurotransmitter GABA, or stabilize the neuronal cell membrane, and thus prevent excessive firing.
It may seem obvious in the present day that the origin of the convulsions that characterize epilepsy lies in the brain — but this was not in fact established until the latter half of the nineteenth century. Indeed, there had been at that time a belief that they originated as abnormal reflexes from the spinal cord. This, together with the notion that there was not any localization of function in the cerebral cortex, was based on faulty interpretation of experimental studies. Broca initiated the concept of localization in the 1860s, with his description of the part of the left hemisphere responsible for speech function, followed by Hughlings Jackson's conclusion from his studies that convulsions on one side of the body are due to discharge from certain convolutions of the cortex on the opposite side of the brain. ( Hippocrates had noted this association somewhat earlier in his writings on injuries to the head, but the knowledge had been submerged.) Studies on electrical stimulation of the brain of animals in the 1870s supported Hughling Jackson's suppositions. Anaesthesia and antisepsis followed by asepsis allowed the beginnings of modern brain surgery, and another historic event was in 1886, when Victor Horsley in London operated on the brain and cured a young man's fits by removing scarring resulting from a head injury in childhood.
The next landmark in the history of epilepsy was the electroencephalogram (EEG) — the first demonstration in the late 1920s that the electrical activity of the brain could be recorded through the intact skull, and that abnormal patterns appeared during an epileptic attack. In subsequent decades, electroencephalography advanced the diagnosis of epilepsy, and the localization of its site of origin in the brain. Meanwhile, exploration of the effects of electrical stimulation of the human brain, with relevance to the site of onset of focal seizures, culminated in the detailed mapping of functional localization of the parts of the body in the motor and sensory regions of the cortex, by the Canadian neurosurgeon Wilder Penfield and his colleagues in the 1930s.
Deliberate induction of epileptic seizures was used during the twentieth century in attempts to treat mental illness. Camphor, which had been observed to precipitate attacks in epileptic patients, was introduced to induce shocks, but it produced such violent convulsions that bones were broken, and symptoms remained unaffected. Insulin shock therapy inducing seizures by the lowering of blood sugar was used with some success in schizophrenics. Electroconvulsive therapy (ECT), first applied in the late 1930s, and nowadays performed under anaesthesia, remains in use and is effective in the treatment of depressive illness.
Epilepsy would now be defined as a paroxysmal and transitory disturbance of the functions of the brain, involving repetitive discharges in large groups of brain cells, and commonly causing convulsions. The disturbance develops suddenly, ceases spontaneously, and is subject to recurrence. The current understanding of epileptiform activity in the brain, its types, nature, and mechanisms, is described under ‘convulsions’.
E. M. Tansey, and Sheila Jennett
See also convulsions; craniotomy; EEG; magnetic brain stimulation.
COLIN BLAKEMORE and SHELIA JENNETT. "epilepsy." The Oxford Companion to the Body. 2001. Encyclopedia.com. (May 27, 2016). http://www.encyclopedia.com/doc/1O128-epilepsy.html
COLIN BLAKEMORE and SHELIA JENNETT. "epilepsy." The Oxford Companion to the Body. 2001. Retrieved May 27, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O128-epilepsy.html
A condition affecting people regardless of age, sex, or race, where a pattern of recurring malfunctioning of the brain is present.
Epilepsy, from the Greek word for seizure, is a recurrent demonstration of a brain malfunction. The outward signs of epilepsy may range from only a slight smacking of the lips or staring into space to a generalized convulsion. It is a condition that can affect anyone of any age, sex, or race.
The number of people with epilepsy is not known. Some authorities say that up to 0.5% of the population are epileptic, but others believe this estimate is too low. Many cases of epilepsy, particularly those with very subtle symptoms, are not reported. The most serious form of epilepsy is not considered an inherited condition, though parents with epilepsy are more prone to have children with the disease. On the other hand, an epileptic child may have parents who show no sign of the condition, though they will have some abnormal brain waves.
Though the cause of epilepsy remains unknown, the manner in which the condition is demonstrated indicates the area of the brain that is affected. Jacksonian seizures, for example, which are localized twitching of muscles, originate in the frontal lobe of the brain in the motor cortex. A localized numbness or tingling indicates an origin in the parietal lobe on the side of the brain in the sensory cortex.
The recurrent symptoms, then, are the result of localized, excessive activity of brain cells or neurons. These can be seen on the standard brain test called the electroencephalogram (EEG). For this test electrodes are applied to specific areas of the head to pick up the electrical waves generated by the brain. If the patient experiences an epileptic episode while wired to the EEG, the abnormal brain waves can easily be seen and the determination made as to their origin in the brain. Usually the patient does not experience a seizure and no abnormalities are found.
Grand mal seizures are those that are most characteristic of epilepsy. Immediately prior to the seizure, the patient may have some indication that a seizure is imminent. This feeling is called an aura. Very soon after experiencing the aura the patient will lapse into unconsciousness and experience clonic seizures, which are generalized muscle contractions that may distort the body position. Thrashing movements of the limbs shortly ensue and are caused by opposing sets of muscles alternating in contractions (hence, the other name for grand mal seizures: tonic-clonic seizures). The patient may also
lose bladder control. When the seizures cease, usually after three to five minutes, the patient may remain unconscious for up to half an hour. Upon waking, he or she may not remember having had a seizure and may be confused for a time.
In contrast to the drama of the grand mal seizure, the petit mal may seem inconsequential. The patient interrupts whatever he or she is doing and for up to about 30 seconds may show subtle outward signs such as blinking eyes, staring into space, or pausing in conversation. After the seizure previous activities are resumed. Petit mal seizures are associated with heredity , and they never occur in people over the age of 20 years. Oddly, though the seizures may occur several times a day, they do so usually when the patient is quiet and not during periods of activity. After puberty these seizures may disappear or they may be replaced by the grand mal type of seizure.
A serious form of seizure, status epilepticus, indicates a state in which grand mal seizures occur in rapid succession with no period of recovery between them. This can be a life-threatening event because the patient has difficulty breathing and may experience a dangerous rise in blood pressure. This form of seizure is very rare, but it can be brought on if someone abruptly stops taking medication prescribed for the epilepsy. It may also occur during alcohol withdrawal.
A number of drugs are available for the treatment of epilepsy. The oldest is phenobarbital, which has the unfortunate side effect of being addictive. Other commonly used drugs include phenytoin, carbamazepine, and sodium valproate. All have the possibility of causing such undesirable side effects as drowsiness, nausea, or dizziness. Several new drugs are being studied to determine their efficacy and safety.
The epileptic patient needs to be protected from self-injury during an attack. Usually for the patient having a petit mal seizure, little needs to be done. Occasionally these individuals may lose their balance and need to be helped to the ground to avoid hitting their heads, but otherwise need little attention. The individual in a grand mal seizure should not be restrained, but may need some help to avoid striking his limbs or head on the floor or nearby obstruction. If possible, the patient should be rolled onto his side. This will maintain an open airway for breathing by allowing the tongue to fall to one side.
Epilepsy can be a recurrent, lifelong condition. Medication can control seizures in a substantial percentage of patients, perhaps up to 85% of those with grand mal manifestations. Some patients will experience seizures even with maximum dosages of medication, and these individuals need to wear an identification bracelet to let others know of their condition.
Glanz, J. "Do Chaos-Control Techniques Offer Hope for Epilepsy?" Science 265, (August 26, 1994): 1174.
American Epilepsy Foundation. 638 Prospect Avenue, Hartford, CT 06105–2498, (203) 232–4825.
Epilepsy Foundation of America. 4351 Garden City Drive, Landover, MD 20785, (800) 332–1000.
"Epilepsy." Gale Encyclopedia of Psychology. 2001. Encyclopedia.com. (May 27, 2016). http://www.encyclopedia.com/doc/1G2-3406000227.html
"Epilepsy." Gale Encyclopedia of Psychology. 2001. Retrieved May 27, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3406000227.html
Epilepsy is a neurological disorder, usually characterized by either recurrent or sporadic seizures. Epilepsy presents a particular challenge for forensic scientists because sudden, unexplained death may occur in people with epilepsy, and up to 30% of individuals with epilepsy have no demonstrable cause of death at the time of autopsy .
Known as both sudden unexplained death syndrome (SUDS) and sudden unexpected death in epilepsy (SUDEP), the condition is often under-recognized. Deaths are sometimes attributed to other causes in people with epilepsy, such as drowning, when in fact, a seizure precipitated events leading to death. One study conducted in Australia in 2003 showed that SUDEP occurs in approximately one person per 200 people with epilepsy per year. Usually, a person with (SUDEP) dies in their sleep. With awareness of the condition growing and funding for research increasing, forensic scientists are assisting in collecting data and other research into unraveling the mystery of SUDEP.
Epileptic seizures are usually convulsive, affecting autonomic reflexes, as well as motor, sensory, and cognitive neuronal (nerve cell) functions. They are caused by the synchronous hyper-excitation of isolated groups of nerve cells in one of the brain cortical areas. Seizures can last from a few seconds up to minutes, depending on the intensity of neuronal excitability.
Epilepsy may be the result of inherited gene mutations, metabolic diseases, or brain malformation, or may constitute a major symptom of a neurological disease. When the epilepsy results from an identified cerebral condition, such as cerebral concussion or brain tumor, or is a clinical manifestation of a hereditary neurodegenerative syndrome, it is classified as symptomatic. Non-symptomatic epilepsies are those occurring in persons who do not present brain abnormalities or neurological disorders other than the seizures.
Other types of epilepsy may be induced through occupational damage, due to repeated exposure to acoustic or visual stimuli, or as a result of an isolated high-intensity auditory or visual stimulus. Whatever the case, the sensory stimulation induces chemical changes in the related brain areas, causing a kind of electrical short-circuit, with a group of neurons briefly firing in a synchronous rhythm. These stimuli-induced forms of seizures are known as acquired epilepsy. A dramatic example of seizures induced by repeated sensory stimuli happened in Japan on December 17, 1997, when hundreds of children suffered simultaneous epileptic seizures induced by the flashing red eyes of a Pokemon cartoon character. Epilepsies induced by sensory stimuli are also known as reflex epilepsies.
Absence epilepsy (e.g., non-convulsive epilepsy) occurs mostly in children between three and eight years of age, usually disappearing in adolescence. Non-convulsive epileptic episodes may happen one or more times a day, being characterized by a brief impairment of consciousness, absence of response to external stimuli, "stargazed" expression, and spatial disorientation. However, in contrast to reflex epilepsies, it cannot be induced by sensory stimulation. Convulsive forms of epilepsy are generally preceded by a brief state of dizziness, or external sensory shutdown, followed by convulsion. After convulsion, the person also experiences confusion, poor body equilibrium, and a few minutes of spatial disorientation.
Ignorance and prejudice in the past led to the popular and institutional belief that epilepsy was a kind of mental illness or disability that required institutionalization in psychiatric hospitals. It was also believed that some epileptic individuals entered in a state of somnambulism (unawareness) during the seizures and could commit crimes, which they could not recollect later. Thanks to the advances in neurosciences in the last fifty years, such assumptions have been disproved. However, popular prejudice and legal confusion still persist as to the degree of legal responsibility of epileptic offenders, both from the prosecution and the defense point of view. Expert witnesses in neurology and psychiatry are often requested to evaluate epileptic defendants and to inform the court about the nature of the disorder and the characteristics of seizures. In most developed countries, epileptic seizures are not considered a legal impediment for the full fruition of individual civil rights and liberties.
Epilepsy treatment usually requires the regular intake of controlled anti-convulsive medications. Law enforcement personnel are educated about the different intensities and types of epileptic seizures in order to prevent misinterpreting behavior, such as the appearance of intoxication, exhibited by persons experiencing a seizure or in the immediate recovery period.
see also Brain wave scanners; Expert witnesses; Nervous system overview; Neurotransmitters.
"Epilepsy." World of Forensic Science. 2005. Encyclopedia.com. (May 27, 2016). http://www.encyclopedia.com/doc/1G2-3448300214.html
"Epilepsy." World of Forensic Science. 2005. Retrieved May 27, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3448300214.html
epilepsy, a chronic disorder of cerebral function characterized by periodic convulsive seizures. There are many conditions that have epileptic seizures. Sudden discharge of excess electrical activity, which can be either generalized (involving many areas of cells in the brain) or focal, also known as partial (involving one area of cells in the brain), initiates the epileptic seizure. Generalized seizures are classified as tonic-clonic (grand mal), in which there is loss of consciousness and involuntary contraction of all the muscles of the body, lasting a few minutes; or absence (petit mal), in which there is clouding of the consciousness for about 1 to 30 sec and no falling, with as many as 100 attacks occurring daily. Partial seizures include Jacksonian epilepsy, characterized by jerking in the hand and face on the side opposite the brain activity; and psychomotor seizures, in which there may be localized convulsion with no loss of consciousness, as well as incoherent speech and various involuntary movements of the body. Often these are accompanied by a warning cluster of signs and symptoms called an aura. First aid, such as cushioning the head, is used to prevent the person from self-inflicted injuries during seizures.
The cause is unknown in over half the cases of epilepsy, especially in those with onset under age 20. Predisposing factors in other cases include familial history, head injury, alcohol withdrawal, infections (such as meningitis or by pork tapeworm larvae), and abnormalities (such as tumors) of the brain.
The recording of brain waves by electroencephalography is an important diagnostic test for epilepsy. Other diagnostic technologies include CAT scan and magnetic resonance imaging (MRI). Standard treatment of epilepsy is with antiseizure drugs (also known as anti-epileptic and anticonvulsive drugs), including carbamazepine, phenytoin, valproic acid, and others; proper treatment requires a careful analysis of seizure motor activity, anatomical cause, precipitating factors, age of onset of the disorder, severity, daily rhythms, and prognosis. Roughly 70% of persons with epilepsy are successfully treated with drugs, and many people with the disease lead normal lives. Repeated seizures that lead to unconsciousness, however, appear to be associated with damage to the hippocampus in the brain and sudden unexpected death.
Some cases of childhood epilepsy (which is often eventually outgrown) have been successfully treated with surgery or a very high-fat "ketogenic" diet. The diet results in a natural buildup of ketones in the body, which appear to inhibit the seizures. A number of different surgical procedures may be used if medication does not control the seizures; the procedures vary according to the focus of the seizure in the brain, and surgery is not always appropriate. If a patient with uncontrolled seizures is not a good surgical candidate, a vagus nerve stimulator or a responsive neurostimulator may be implanted in some cases. The former is implanted in the chest and connected by a wire to the vagus nerve (a cranial nerve) in the neck; like a pacemaker, the device regularly stimulates the nerve to counteract seizures. It also may be activated by the patient in response to a seizure. The responsive neurostimulator is implanted in the skull, and wires connect it to brain regions that are the focus of seizures. In reaction to developing seizure, it electrically stimulates those regions in an effort to stop the seizure. Patients with such devices take antiseizure medications as well, and these devices typically reduce but do not eliminate seizures.
See H. Reisner, ed. Children with Epilepsy (1988); R. J. Gunnit, Living Well with Epilepsy (1990); O. Devinsky, A Guide to Understanding and Living with Epilepsy (1994); publications of the Epilepsy Foundation of America.
"epilepsy." The Columbia Encyclopedia, 6th ed.. 2016. Encyclopedia.com. (May 27, 2016). http://www.encyclopedia.com/doc/1E1-epilepsy.html
"epilepsy." The Columbia Encyclopedia, 6th ed.. 2016. Retrieved May 27, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1E1-epilepsy.html
—epileptic (epi-lep-tik) adj., n.www.epilepsy.org.uk Website of Epilepsy Action
"epilepsy." A Dictionary of Nursing. 2008. Encyclopedia.com. (May 27, 2016). http://www.encyclopedia.com/doc/1O62-epilepsy.html
"epilepsy." A Dictionary of Nursing. 2008. Retrieved May 27, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O62-epilepsy.html
Epilepsy is a seizure disorder. A seizure is an event that involves loss of consciousness and motor (muscular) control. A person with a seizure disorder often experiences repetitive muscle jerking called convulsions. The condition is caused by a sudden change in electrical activity in the brain.
The medical profession now recognizes about twenty different kinds of epilepsy. These forms of the disorder vary on the basis of severity and the parts of the body affected by the seizure. Most patients have only one form of epilepsy. About 30 percent have two or more forms of the disorder.
Experts estimate that about 2 percent of the general population has some form of epilepsy. One in ten Americans experience at least one epileptic seizure at some time in their lives. At least 200,000 Americans have at least one seizure a month.
About 125,000 new cases of epilepsy are diagnosed in the United States each year. About a quarter of those cases are diagnosed in children younger than five years old.
The two most common types of epilepsy are called tonic-clonic seizures and absence seizures. At one time, these forms of the disorder were better known as grand mal ("great illness") and petit mal ("small illness"). About 90 percent of people with epilepsy experience tonic-clonic seizures, and 25 percent experience absence seizures. Less than 20 percent of patients experience other forms of epilepsy alone or in various combinations.
The brain contains a mass of neurons (nerve cells) that constantly communicate with each other. They communicate in two ways: by sending certain chemicals back and forth, and by the passage of electric currents among them. Under certain conditions, those electric currents can be disrupted. Instead of traveling smoothly between neurons, they go out of control.
When this happens, messages traveling through the brain are wildly disrupted. The brain begins to send out irregular and unpredictable messages to the rest of the body. Muscles throughout the body begin to contract and relax in random patterns. These changes bring about the symptoms of epilepsy.
Epilepsy: Words to Know
- A set of warning signals that an epileptic attack is about to begin.
- Clonic phase:
- The stage of a grand mal attack in which muscles alternately contract and relax.
- Electroencephalogram (EEG):
- A test used to measure electrical activity of the brain to see if the brain is functioning normally.
- Grand mal:
- An alternative term used for tonic-clonic epilepsy.
- Idiopathic epilepsy:
- A form of epilepsy for which no cause is known.
- A nerve cell.
- Petit mal:
- An alternative term used for absence epilepsy.
- A convulsion; a series of involuntary muscular movements that alternate between contractions and relaxations.
- Symptomatic epilepsy:
- A form of epilepsy for which some specific cause is known.
- Tonic phase:
- The stage of a grand mal attack in which muscles become rigid and fixed.
Epilepsy is usually classified as symptomatic or idiopathic (pronounced ih-dee-uh-PA-thik). Symptomatic epilepsy is a form of the condition for which a cause is known. For example, a person may receive a blow to the head. The injury may cause damage that leads to the development of epilepsy. Some conditions that can cause symptomatic epilepsy include:
- Serious infections of the central nervous system
- Heat stroke (see heat disorders entry)
- An abscess (open sore) in the brain
- Rabies, tetanus, and malaria (see entries)
- Toxic (poisonous) materials, such as lead or alcohol
- Damage to the brain or skull (see head injury entry)
- Drug allergy
- Stroke (see stroke entry)
Idiopathic epilepsy is epilepsy for which no specific cause has been identified. Some authorities believe that idiopathic epilepsy is caused by damage to a newborn baby's brain during delivery.
About 75 percent of all cases of epilepsy are idiopathic. Individuals with this condition usually experience their first seizure between the ages of two and fourteen. Symptomatic epilepsy usually does not appear until later in life, after the age of twenty-five.
Symptoms vary depending on the type of seizure.
A person who is about to have a tonic-clonic seizure often has a warning. That warning is called an aura. During the aura, the patient may emit a loud cry. The attack actually begins when the person loses consciousness and falls to the ground. His or her muscles become rigid for about thirty seconds. This period is known as the tonic phase of the disorder. The muscles then alternately contract and relax, causing the patient to thrash about. This phase of the attack is known as the clonic stage. The patient may also lose control of his or her bladder or bowels, or have trouble breathing.
A tonic-clonic attack usually lasts between two and five minutes. After the attack, the patient may be confused or have trouble talking. He or she may complain of headache or muscle soreness or weakness in the arms or legs. In some cases, the patient may fall into a deep sleep.
An absence seizure is a milder form of a tonic-clonic seizure. An absence seizure usually begins with a brief loss of consciousness. This phase of the attack lasts between one and ten seconds. Patients may become very quiet. They may stare blankly, roll their eyes, or move their lips. The whole attack is usually over in fewer than twenty seconds.
After an absence seizure, patients generally do not remember anything about the event. They just continue with whatever they were doing before the attack began. They may not realize that anything unusual has taken place. In cases of absence seizures that are not treated, a patient may experience as many as one hundred attacks a day. Eventually, the condition may progress to the tonic-clonic form of epilepsy.
The first goal of diagnosis is to eliminate other possible causes of the patient's symptoms. Other disorders of the brain, such as small strokes, fainting, and sleep disorders (see sleep disorders entry), can be confused with seizure disorders. A doctor needs to eliminate these possibilities before deciding how to treat the patient.
One goal of diagnosis is to distinguish between symptomatic and idiopathic epilepsy. In symptomatic epilepsy, it may be possible to provide treatment to cure the disorder. For example, a person may have had a severe allergic reaction to a food or drug. The allergic reaction may be responsible for the epileptic attack. This type of case can be treated by avoiding whatever
caused the attack in the first place. In cases of idiopathic epilepsy, where a cause is not found, other types of treatment are necessary.
The primary means of diagnosing epilepsy is the electroencephalogram (EEG, pronounced ih-LEK-tro-in-SEH-fuh-lo-gram). The EEG is a device that measures electrical activity in the brain. The results obtained from an EEG test are recorded on graph paper as a pattern of wavy lines. A doctor is able to read the lines on the paper and determine whether or not the brain is functioning normally. Seizure disorders produce characteristic patterns in an EEG test.
Doctors may try to schedule an EEG test during a seizure. They know that flashing lights (like strobe lights) or forcing the patient to breathe very deeply can trigger a seizure in patients with epilepsy. Or the patient may simply be kept in the hospital until an attack occurs. In such cases, the electrical activity of the brain during an attack can be observed and recorded.
Cases of symptomatic epilepsy are treated by treating the basic cause that brought on the seizure disorder. Treatment of idiopathic epilepsy involves two steps. The first step involves protecting the patient during an attack. The second step involves the use of medications to reduce the frequency and severity of symptoms.
Patients with absence epilepsy usually require little protection. They may need help in case they lose consciousness for long enough to lose their balance and fall. Attacks of tonic-clonic epilepsy require somewhat more attention. The patient should be made comfortable during an attack by loosening clothing around the neck and providing a pillow under the head. A soft object, such as a folded handkerchief, should be placed between the teeth. The object prevents the patient from biting his or her tongue. No effort should be made to hold the tongue, however.
Several medications are now available for the treatment of epilepsy. Most of these drugs fall into the category of anticonvulsants. That is, they tend to prevent or minimize the shaking and thrashing that accompanies a seizure. Some examples of these drugs are phenobarbital (pronounced FEE-no-bar-bih-tall), primi-done (pronounced PRIM-ih-doan), trimethadione
(pronounced TRI-meth-uh-DIE-own), and valproate (pronounced val-PRO-ate).
No one drug is effective for all patients or for any one form of epilepsy. In fact, effective treatment of epilepsy requires finding exactly the right dose of exactly the right drug (or combination of drugs) for each individual patient. Most patients go through a period of testing in which various drugs in various combinations are tried. Eventually, the most suitable dose and combination are determined.
Medications have made it possible for most patients with epilepsy to lead relatively normal lives. However, there is one problem with drug therapy. Many drugs have side effects that can range from mild to severe for any one patient. The most common side effects are drowsiness, nausea, lethargy, and skin rash.
An important aspect of treating epilepsy is teaching the patient and his or her family how to live with the disorder. Patients are encouraged to pursue a normal life with moderate exercise and regular social activities. Families are encouraged not to become overprotective and, insofar as possible, to treat the patient as if he or she had no disorder.
Intractable seizures are seizures that cannot be controlled without medication or without sedation or other unacceptable side effects. Surgery may be used to eliminate or control intractable seizures. This treatment is not very common as only seizures meeting very specific criteria can be controlled this way.
Relaxation techniques can help people with epilepsy avoid some of the pressures that may bring on an attack. Yoga, meditation, hydrotherapy, aromatherapy, and acupressure may be helpful in this regard. These approaches, however, should never be substituted for the patient's regular program of medication.
For people with symptomatic epilepsy, dietary changes may be essential. Patients may need to identify the foods to which they are allergic and then eliminate those foods from their diets.
The prognosis for most patients with epilepsy today is good. The most severe symptoms of the disorder can usually be controlled by the proper program of medications. Educating the patient about his or her condition can increase the chance that attacks will be handled properly and will not produce unnecessary emotional upsets for the patient.
In most cases, however, epilepsy is a lifelong condition. A patient has to learn to live with its symptoms while trying to lead as normal a life as possible. One important step the patient can take is to wear a medical bracelet indicating that he or she is epileptic. The bracelet should also list any medications the patient is taking.
One serious complication of tonic-clonic epilepsy is called status epilepticus (pronounced STA-tuss EP-ih-LEP-tih-kuss). Status epilepticus is a condition in which attacks of tonic-clonic seizures follow each other closely. There is no recovery period between attacks when the patient returns to consciousness and normality. The patient may have trouble breathing and his or her blood pressure may rise to dangerous levels. The condition can cause death if not treated immediately. Fortunately, status epilepticus is a rare condition.
Symptomatic epilepsy can be prevented if the cause of the disorder can be identified and eliminated. There is no way to prevent idiopathic epilepsy.
The risks posed by epileptic attacks, however, can be reduced. For example, people with the condition should try to get enough sleep and exercise, and eat properly. They should avoid hyperventilating (breathing rapidly and deeply), which can bring on an attack. Individuals should make sure that they take their medications regularly, according to the prescribed pattern. If they experience an aura, they should find a safe place to lie down until the attack passes.
FOR MORE INFORMATION
Carson, Mary Kay. Epilepsy. Hillside, NJ: Enslow Publishers, Inc., 1998.
Landau, Elaine. Epilepsy. New York: Twenty First Century Books, 1995.
Lechtenbert, Richard. Epilepsy and the Family: A New Guide, 2nd edition. Cambridge, MA: Harvard University Press, 1999.
Sander, J., and Y. Hart. Epilepsy: Questions and Answers. Chicago: Merit Publishing International, 1997.
Shaw, Michael, ed. Everything You Need to Know about Diseases. Springhouse, PA: Springhouse Corporation, 1996.
Wilner, Andrew N. Epilepsy: 199 Answers: A Doctor Responds to His Patients' Questions. New York: Demos Vermande, 1996.
American Epilepsy Society. 638 Prospect Ave., Hartford, CT 06105–4298. (205) 232–4825.
Epilepsy Concern International Service Group. 1282 Wynnewood Dr., West Palm Beach, FL 33417. (407) 683–0044.
Epilepsy Foundation of America. 4251 Garden City Dr., Landover, MD 20875–2267. (800) 532–1000.
Epilepsy Information Service. (800) 642–0500.
"Ask NOAH About: Epilepsy." NOAH: New York Online Access to Health. [Online] http://www.noah.cuny.edu/neuro/epilepsy.html (accessed on October 25, 1999).
Epilepsy. [Online] http://www.ninds.nih.gov/healinfo/disorder/epilepsy/epilepfs.htm (accessed February 28, 1998).
Epilepsy Facts and Figures. [Online] http://www.efa.org/what/education/FACTS.html (accessed on February 28, 1998).
"Epilepsy." UXL Complete Health Resource. 2001. Encyclopedia.com. (May 27, 2016). http://www.encyclopedia.com/doc/1G2-3437000143.html
"Epilepsy." UXL Complete Health Resource. 2001. Retrieved May 27, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3437000143.html
"epilepsy." World Encyclopedia. 2005. Encyclopedia.com. (May 27, 2016). http://www.encyclopedia.com/doc/1O142-epilepsy.html
"epilepsy." World Encyclopedia. 2005. Retrieved May 27, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O142-epilepsy.html
Epilepsy (EP-i-lep-see) is a condition of the nervous system characterized by recurrent seizures that temporarily affect a persons awareness, movements, or sensations. Epileptic seizures occur when powerful, rapid bursts of electrical energy interrupt the normal electrical patterns of the brain. The cause of epilepsy is unknown in most cases, but it is known that some cases are hereditary, or run in families. Epilepsy is not contagious.
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It happened at her birthday party. Eleven-year-old Erin was ready to blow out the candles on her cake when she suddenly released a loud cry and dropped to the carpet. Her arms and legs thrashed and twitched. When her friends called to her she did not respond. Her mother knelt beside her, turned Erin gently onto her side, and loosened the top button on her shirt. In a few moments, Erin regained consciousness, exhausted and more than a little embarrassed that her friends had seen what had happened. She was not scared because it had occurred before. Her mother explained to her friends that Erin had had an epileptic seizure, and that as soon as she had time to rest, she would be fine.
In a normal brain, millions of tiny electrical charges pass between nerve cells and to all parts of the body. Those cells “fire” in an orderly and controlled manner. In the brain of a person with epilepsy, overactive nerve cells send out powerful, rapid electrical charges that disrupt the brain’s normal function. During a seizure such as the one experienced by Erin, brain cells can fire at up to four times their normal rate, temporarily affecting how a person behaves, moves, thinks, or feels.
Some people with epilepsy know what will trigger a seizure, but others do not. Many people with epilepsy can sense that they are about to have a seizure. The attack may be preceded by a feeling of unease, anxiety, or discomfort. They may sense or see flickering lights. Despite these warning signals, people with epilepsy still cannot stop the oncoming seizure.
The U.S. and the World
- Epilepsy is a common neurologic disease in the United States, affecting more than 6 out of every 1,000 people.
- Epilepsy most frequently begins in early childhood, during adolescence, or after age 65.
- Among people with epilepsy, 20 percent develop the disorder before age 5, and 50 percent develop it before age 25.
- Worldwide, some form of epilepsy affects about 40 million people. About 32 million of those people have inadequate access to medical treatment.
Because epilepsy is not contagious, one person cannot catch epilepsy from another. In about 7 out of 10 cases, doctors describe the disease as idiopathic (id-ee-o-PATH-ik), which means the cause is unknown. Most people with idiopathic seizures are between ages 5 and 20 and have no brain injuries or abnormalities. Many do, however, have a family history of epilepsy or seizure disorders.
In other cases, the following have been identified as causes of epilepsy:
- Maternal injury, infection, or illness that affects a developing fetus during pregnancy.
- Brain injuries. Although brain injuries can occur at any age, the highest incidence is among young adults. These injuries often result from car collisions, sports accidents, and falls. Blows to the head and gunshot wounds, particularly those that injure brain membranes and tissues, can lead to epilepsy. In general, the more severe the injury, the greater the chance of developing the disease.
- Brain tumor or stroke. Either can lead to injury or irritation of brain tissue.
- Metabolic abnormalities. Complications from diabetes, kidney failure, lead poisoning, use of alcohol or drugs, or withdrawal from alcohol or drugs can cause seizures.
The Road to Understanding
Ancient Greeks believed epileptic seizures were blessed visitations from the gods. During the Renaissance, a seizure was seen as a sign that a person was possessed by the devil.
In the early 1800s, epilepsy was still misunderstood. It was believed to be contagious, and people with the disease were often locked away in hospitals or “epileptics only” sanitariums.
By the mid-1800s, neurologists (doctors who treat disorders and diseases of the brain and spinal cord) began to investigate epilepsy and to make progress toward a better understanding of the disorder.
Fyodor Dostoyevsky (1821-1881) was a Russian writer who is considered one of the world’s great novelists. With brilliant psychological and philosophical insight, Dostoyevsky examined the human soul in Notes from the Underground, Crime and Punishment, and his masterpiece in 1880, The Brothers Karamazov. Dostoyevsky had epilepsy, and his fiction includes characters with epilepsy.
- Degenerative disorders. Stroke, cardiovascular disease, and Alzheimer’s disease are causes of epilepsy, particularly in people over 65.
- Infections. Epilepsy may develop after a major brain illness such as meningitis, encephalitis, brain abscess, or severe infections of any part of the body. Less frequently, mumps, measles, and diphtheria can lead to the disease.
- Complications of AIDS or other immune disorders, including systemic lupus erythematosus, also can cause epilepsy.
Anyone can have a seizure, but a person with epilepsy has many more seizures and experiences them over a longer period of time. For a person with epilepsy, many conditions that affect the brain can trigger a seizure. These triggers include: hormonal changes, such as those that occur during the menstrual cycle or pregnancy; hunger; exhaustion or sleep deprivation; rhythmic patterns of sound, touch, or light (particularly strobe lights). An epileptic seizure is not a medical emergency. However, if a person goes into status epilepticus (where a seizure lasts longer than 30 minutes or two seizures rapidly follow one another), the condition could be life threatening. Medical assistance should be summoned at once.
Because of the way they appear during or after an attack, people experiencing an epileptic seizure are sometimes mistakenly believed to be drunk, drugged, or mentally ill. Epileptic seizures have different symptoms or characteristics depending on where the seizure begins in the brain and how the electrical discharge spreads across the brain. Epileptic seizures can be divided into two categories: generalized seizures and partial seizures.
Generalized seizures affect nerve cells throughout the cerebral cortex (the cauliflower-like outer portion of the brain), or all of the brain. The most common generalized seizures are:
- Generalized tonic-clonic seizure (formerly called grand mal). In the tonic phase of this seizure, people often lose consciousness, drop to the ground, and emit a loud cry as air is forced through their vocal cords. In the clonic phase, body muscles can contract at once or in a series of shorter rhythmic contractions, causing the thrashing motions experienced by Erin. Usually, this kind of seizure lasts for about one or two minutes, and is followed by a period of relaxation, sleepiness, and possibly a headache. Incontinence* often occurs during this type of seizure.
- Absence seizure (formerly called petit mal). Loss of consciousness in this seizure is often so brief that a person does not even change positions. The person may display a blank stare, rapid blinking, or chewing movements. Facial or eyelid muscles may jerk rhythmically. Absence seizures often are genetic and occur mostly in children.
- * incontinence
- (in-KON-ti-nens) is loss of control of urination or bowel movement.
Partial seizures are contained within one region of the cerebral cortex. Types of partial seizures include:
- Simple partial. In this type of seizure, the seizure-related brain messages remain very localized, and the patient is awake and alert. Symptoms vary depending on what area of the brain is involved. They may include jerking movements in one part of the body, emotional symptoms such as unexplained fear, or an experience of abnormal smells or nausea.
- Complex partial. In this type of seizure, a person loses awareness of surroundings and is unresponsive or only partially responsive. There may be a blank stare, chewing movements, repeated swallowing, or other random activity. After the seizure, the patient has no memory of the experience. In some cases, the person who has had the seizure may suddenly become confused, begin to fumble, to wander, or to repeat inappropriate words or phrases.
Because not every person who has a seizure necessarily has epilepsy, the doctor must determine the seizure’s cause by a physical exam and medical history, including the seizures that have already occurred. Risk factors such as sleep deprivation and alcohol use need to be assessed, as well as any head injuries, childhood seizures, or family history of seizures.
Physicians also will be interested to know if the patient has experienced an aura* because that can help confirm that the seizure is a brain disorder and help establish its location. The doctor also will ask about the nature of the movements the person made during a seizure.
- * aura
- is a warning sensation that precedes a seizure or other neurological event.
If it is established that the patient has experienced an epileptic seizure, the next step is to identify the type of seizure. The first tool doctors use is an electroencephalograph (e-lek-tro-en-SEF-a-lo-graf). Commonly known as an EEG, this machine records electric currents in the brain, and it can track abnormal electrical activity. If the EEG does
not show the seizure activity, or if there are certain other features in the patient’s physical exam or medical history, then doctors may try other types of scans, including CT (computerized tomography) or MRI (magnetic resonance imaging).
Treating epilepsy involves three goals: to eliminate seizures or at least reduce their frequency, to avoid side effects of long-term medical treatments, and to assist in maintaining or restoring normal activities of daily living.
Most cases of epilepsy can be fully or partially controlled with anticonvulsant medications, although some seizure disorders of infancy or early childhood may not respond well to medications. If a person is free of seizures for several years, doctors may reduce or even eliminate medication. In many cases, however, epilepsy remains a lifelong, chronic condition with no medical treatment guaranteeing remission* or a permanent cure.
- * remission
- is an easing of a disease or its symptoms for a prolonged period.
If drug therapy does not work, a surgical procedure can remove the damaged cells that cause partial seizures. To qualify, however, the tissue must be located in one small area of the brain and the surgeon must be able to remove this tissue without harming a person’s mental abilities or personality. Although adults have undergone the surgery successfully, the results are usually better when the surgery is performed on children and infants.
A ketogenic diet (a doctor-monitored, high-fat, high-calorie diet) that was discontinued as a therapy when medicines became available, is being revived as a treatment. Some people believe the diet can stop seizures by creating ketosis (ke-TO-sis), a condition in which the body burns fat for energy instead of glucose. The ketogenic diet may be recommended for children who do not respond to standard treatment.
Biofeedback has been beneficial to some patients, when combined with other therapies. Biofeedback uses electronic instruments to monitor a person’s brain waves, blood pressure, heart rate, and skin temperature. This information is then “fed back” to the patient, who has been taught techniques to alter these bodily functions to a lower, more relaxed level.
Epilepsy research is an active field. One promising technique now in development is called vagus nerve stimulation.
Medic Alert Tags
People with epilepsy often wear medical alert identification tags or bracelets that provide vital information for caregivers during seizures.
Some companies offer tags with identification numbers so that medical personnel anywhere can retrieve a patient’s medical history.
Because so many cases of epilepsy have no known cause, there are no prevention guidelines. However, anything that injures the brain can cause epilepsy. With that in mind, safety precautions and good health practices would include:
- In a car, always buckling seat belts and observing speed limits.
- Always wearing approved helmets and protective headgear while skating, bicycling, playing sports, or riding motorcycles.
- Using drugs only as prescribed.
- Immunizing children against infectious diseases.
Most people with epilepsy can lead normal and active lives, although they must follow a few safety restrictions. People with epilepsy must be free of seizures for a period of time specified by their home state before they are permitted to drive. People with uncontrolled seizures are prohibited from driving a car.
A person with a seizure disorder should avoid working in jobs that involve heights, dangerous machinery, or underwater environments. To avoid the risk of drowning during a seizure, showers are safer than baths, and swimming in a pool or lake with other people is safer than swimming alone.
People with epilepsy also are at risk for depression. In part, the depression may stem from loss of mobility, or from the effects of prejudice at school or at work on the part of those who fear or do not understand the condition. Parents may be overly protective of children with epilepsy, keeping them from normal childhood activities. It is common for depressed adolescents to refuse to comply with their medication schedules, running the risk of additional seizures. Alcohol also may increase the risk of seizures for some people, and mixing alcohol with anticonvulsant medications can be deadly.
Understanding the facts about epilepsy and providing a positive environment in which treatment becomes a part of everyday life can help people with epilepsy and their families.
Wilner, Andrew N. Epilepsy: 199 Answers. A Doctor Responds to His Patients’ Questions. New York: Demos Vermande, 1996.
The Epilepsy Foundation, 4351 Garden Drive, Landover, MD 20785. Formerly the Epilepsy Foundation of America, this national organization offers advocacy and resources. The website provides general information on diagnosis and treatment, plus web links and a chat room for teenagers. Telephone 800-332-1000 http://www.epa.org
"Epilepsy." Complete Human Diseases and Conditions. 2008. Encyclopedia.com. (May 27, 2016). http://www.encyclopedia.com/doc/1G2-3497700154.html
"Epilepsy." Complete Human Diseases and Conditions. 2008. Retrieved May 27, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3497700154.html
ep·i·lep·sy / ˈepəˌlepsē/ • n. a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain.
"epilepsy." The Oxford Pocket Dictionary of Current English. 2009. Encyclopedia.com. (May 27, 2016). http://www.encyclopedia.com/doc/1O999-epilepsy.html
"epilepsy." The Oxford Pocket Dictionary of Current English. 2009. Retrieved May 27, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O999-epilepsy.html
- Myshkin, Prince suffered fits from early youth, affecting his physical and mental health. [Russ. Lit.: Dostoevsky The Idiot ]
- Vitus, St. his chapel at Ulm famed for epileptic cures. [Christian Hagiog.: Brewster, 291]
"Epilepsy." Allusions--Cultural, Literary, Biblical, and Historical: A Thematic Dictionary. 1986. Encyclopedia.com. (May 27, 2016). http://www.encyclopedia.com/doc/1G2-2505500232.html
"Epilepsy." Allusions--Cultural, Literary, Biblical, and Historical: A Thematic Dictionary. 1986. Retrieved May 27, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-2505500232.html
T. F. HOAD. "epilepsy." The Concise Oxford Dictionary of English Etymology. 1996. Encyclopedia.com. (May 27, 2016). http://www.encyclopedia.com/doc/1O27-epilepsy.html
T. F. HOAD. "epilepsy." The Concise Oxford Dictionary of English Etymology. 1996. Retrieved May 27, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O27-epilepsy.html
"epilepsy." Oxford Dictionary of Rhymes. 2007. Encyclopedia.com. (May 27, 2016). http://www.encyclopedia.com/doc/1O233-epilepsy.html
"epilepsy." Oxford Dictionary of Rhymes. 2007. Retrieved May 27, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O233-epilepsy.html