Epilepsy Health Corner

Epilepsy and Seizures

Prevalence, Causes, Classification and Types.

Epilepsy Diagnosis & Treatment

Management, Treatment Options and Care.

First Aid.

for Seizure and Epilepsy

Living and Managing with Epilepsy.

Driving, Workplace and Pregnancy.

EPILEPSY AND SEIZURES  

So, what is epilepsy?

What is seizure?

Will I have seizures forever?

You may have a lot of questions about epilepsy. In Biomedresearches - Epilepsy Awareness Campaign, we will help you to understand the basics, answer the most common questions, and empower you with the information you need to find a place for epilepsy in your life without turning it chaotic.

As per ILAE epilepsydiagnosis.org, Epilepsy is a disease of the brain defined by any of the following conditions:

  • At least two unprovoked (or reflex) seizures occurring more than 24 hours apart.
  • One unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years.
  • Diagnosis of an epilepsy syndrome.

Epilepsy cannot be cured, but it may be controlled through medication or surgery. There's no cure for epilepsy, but early treatment can make a big difference. Epilepsy is a medical condition that produces seizures affecting a variety of mental and physical functions. In another words, Epilepsy is the continuing tendency of a person to have seizures. In epilepsy, the brain cells fire abnormal electrical signals that physically manifests as “seizure”. An epileptic seizure is caused by an abnormal electrical discharge from a group of nerve cells (neurons) in the brain. There are various types of epilepsy and seizures with many different causes of epilepsy, but the common for all of them involves abnormal electrical activity in the brain that causes an involuntary change in body movement or function, sensation, awareness, or behavior. When a person has two or more unprovoked seizures, they are considered to have epilepsy, which is usually controlled, but cannot be cured with medication, although surgery and other methods may be considered in difficult cases or the one’s not responding to medication. Statistically, about one-third of people with epilepsy do not have seizure control with medications. Not all epilepsy syndromes are lifelong – some forms are confined to particular stages of childhood.

Seizure is the condition in which epilepsy appears. It happens when a brief, strong surge of electrical activity affects part or all of the brain. One in 10 adults will have a seizure sometime during their life. Seizures can last from a few seconds to a few minutes. They can have many symptoms, from convulsions and loss of consciousness to some that are not always recognized as seizures by the person experiencing them or by health care professionals like: blank staring, lip smacking, or jerking movements of arms and legs. The seizures in epilepsy may be related to a brain injury or a family tendency, but most of the time the cause is unknown. Epileptic seizures can be classified as focal or generalized, aware or impaired awareness. In focal epileptic seizures, the activity is restricted to a local area in the brain, whereas in generalized seizures a larger area and both sides of the brain are affected, such that the fitting normally associated with epileptic seizures can occur. An aware epileptic seizure is the one where there is no loss of consciousness. In an impaired awareness epileptic seizure, there may be loss of awareness.

As per WHO, Epilepsy accounts for a significant proportion of the world’s disease burden, affecting around 50 million people worldwide. The estimated proportion of the general population with active epilepsy (i.e. continuing seizures or with the need for treatment) at a given time is between 4 and 10 per 1000 people.
Globally, an estimated five million people are diagnosed with epilepsy each year. In high-income countries, there are estimated to be 49 per 100 000 people diagnosed with epilepsy each year. In low- and middle-income countries, this figure can be as high as 139 per 100 000. This is likely due to the increased risk of endemic conditions such as malaria or neurocysticercosis; the higher incidence of road traffic injuries; birth-related injuries; and variations in medical infrastructure, the availability of preventive health programs and accessible care. Close to 80% of people with epilepsy live in low- and middle-income countries.

Epilepsy is a disorder with many possible causes. Anything that disturbs the normal pattern of neuron activity, from illness to brain damage to abnormal brain development can lead to seizures. Causes of epilepsy usually involve some form of injury to the brain or any condition that affects brain function. For most people, though, epilepsy causes aren't known, On the other hand, acute neurologic conditions such as stroke or trauma may produce structural damage to the brain. Even, functionally minor damage can permanently alter neuronal excitability and synchronization, resulting in a tendency toward recurrent unprovoked seizures. There is a clear cause for epilepsy in only a minority of the cases. Because epilepsy has so many causes and can be linked to a number of other conditions, it is sometimes very difficult to determine the cause of a particular case.
Some of the main causes of epilepsy include (click through):

Brain chemistry:

Epilepsy may develop because of an abnormality in brain wiring, an imbalance of nerve signaling chemicals called neurotransmitters, or some combination of these factors. Researchers think that some people who have epilepsy have too much of a neurotransmitter that increases impulse transmission and others have too little of neurotransmitters that reduce transmission. Either situation can result in too much neuronal activity and cause epilepsy. It may also be caused by changes in brain cells called glia, which regulates concentrations of chemicals in the brain that can change the way neurons signal. In some cases, the brain's attempts to repair itself after a head injury, stroke, or other problem may inadvertently generate abnormal nerve connections that lead to epilepsy. Abnormalities in brain wiring that occur during brain development also may disturb neuronal activity and lead to epilepsy. The tendency to abnormal brain chemistry can sometimes be inherited and can sometimes be caused by an injury or a disease.

Genetic Factors:

Dozens of genetic syndromes representing a variety of seizure patterns may account for the different forms epilepsy. There is strong evidence that genetics may cause or contribute to many types of epilepsy. A hereditary component in the susceptibility to epilepsy has been suspected for many years, but only in the last few decades has progress been made in identification of specific genetic influences on epilepsy. Genetic abnormalities may be some of the most important factors contributing to epilepsy. Some types of epilepsy have been traced to an abnormality in a specific gene. Many other types of epilepsy tend to run in families, which suggests that genes influence epilepsy. Some researchers estimate that more than 500 genes could play a role in this disorder. However, it is increasingly clear that, for many forms of epilepsy, genetic abnormalities play only a partial role, perhaps by increasing a person's susceptibility to seizures that are triggered by an environmental factor.
Hereditary factors are not always a direct cause of epilepsy but may influence the disease indirectly. Genes can affect the way people process drugs or can cause areas of malformed neurons in the brain.

levels during birth:

low oxygen during birth and Low blood sugar or sodium levels in the blood.

Head Injuries:

Head injuries that occur during birth and labor or from accidents during youth or adulthood can in some cases cause epilepsy. If the head injury is severe, the seizures may not begin until years later. If the injury is mild, the risk is slight.

Prenatal Injury and Developmental Problems:

In a fetus, the developing brain is susceptible to prenatal injuries that may occur if the pregnant mother has an infection, doesn't eat properly, smokes or abuses drugs or alcohol. These conditions may cause cerebral palsy. About 20 percent of seizures in children are due to cerebral palsy or other neurological abnormalities.

Tumors:

Tumors (such as brain tumors) or other structural brain lesions (such as bleeding in the brain).

Brain Injury:

Traumatic brain injury, Illnesses that cause the brain to deteriorate, stroke, heart attacks and other conditions that affect the blood supply to the brain.

Poisoning:

Seizures can result from exposure to lead, carbon monoxide, and many other poisons. They also can result from exposure to street drugs and from overdoses of antidepressants and other medications.

Other Factors:

  • Alcoholism and stopping alcohol after drinking heavily on most days.
  • Dementia such as Alzheimer's disease.
  • Kidney or liver failure.
  • Use of cocaine, amphetamines, or certain other recreational drugs.
  • Stopping certain drugs, such as barbiturates, painkillers (morphine, gabapentin) and sleeping pills, after taking them for a period of time.
  • Infections and infectious diseases such as brain abscess, AIDS, meningitis, encephalitis, neurosyphilis.
  • Phenylketonuria (PKU), which can cause seizures in infants.
  • Metabolic and developmental disorders including cerebral palsy, neurofibromatosis, pyruvate dependency, tuberous sclerosis, Landau-Kleffner syndrome, and autism.
  • Lack of sleep, stress, or hormonal changes.
  • Withdrawal from certain antidepressant and anti-anxiety drugs.

Epilepsy:

Epilepsy is classified according to:

  • First cause (or etiology).
  • Semiology or the observable manifestations of the seizures.
  • The location in the brain where the seizures originate.
  • Identifiable medical syndromes.
  • The event that triggers the seizures.

Symptoms of Epilepsy:

All types of epilepsy have seizures as a symptom.
People usually think that epilepsy manifests only through motor (muscle) symptoms such as jerks. In fact, epilepsy has a wide range of symptoms, which can be broadly grouped into three types:

  • Motor symptoms, such as limb shaking or weakness.
  • Sensory symptoms, such as numbness, electrical shocklike sensation over a specific area.
  • Mental symptoms, such as fear, confusion, visual and auditory hallucinations.

Epilepsy Syndromes:

There are many different types of epilepsy Syndromes. Each epilepsy syndrome has a specific set of symptoms.

Syndromes:

An epilepsy syndrome is defined by a number of features put together. It is important to consider the age at which a seizure begins, and the symptoms that appear during a seizure, if there are people in the family who get similar seizures, the time of getting seizures, if it follows a particular pattern, the prospects of recovery and other health disorders if any. There are hundreds of epilepsy syndromes, many of them very rare. These syndromes are often named for their symptoms or for the part of the brain where they originate.

Epilepsy isn't one disease or condition. There are many kinds of epilepsy with different symptoms and patterns, The area of the brain from where the seizure starts and its ability to spread to other parts can further define the type of epilepsy.

Epilepsy syndromes are categorized as:

  • Self-limited neonatal seizures and self-limited familial neonatal epilepsy.
  • Self-limited familial and non-familial infantile epilepsy.
  • Early myoclonic encephalopathy.
  • Ohtahara syndrome.
  • West syndrome.
  • Dravet syndrome.
  • Myoclonic epilepsy in infancy.
  • Epilepsy of infancy with migrating focal seizures.
  • Myoclonic encephalopathy in non-progressive disorders.
  • Febrile seizures plus, genetic epilepsy with febrile seizures plus.
  • Epilepsy with myoclonic-atonic seizures.
  • Epilepsy with eyelid myoclonias.
  • Lennox gastaut syndrome.
  • Childhood absence epilepsy.
  • Epilepsy with myoclonic absences.
  • Panayiotopoulos syndrome.
  • Childhood occipital epilepsy (Gastaut type).
  • Photosensitive occipital lobe epilepsy.
  • Childhood epilepsy with centrotemporal spikes.
  • Atypical childhood epilepsy with centrotemporal spikes.
  • Epileptic encephalopathy with continuous spike-and-wave during sleep.
  • Landau kleffner syndrome.
  • Autosomal dominant nocturnal frontal lobe epilepsy.
  • Juvenile absence epilepsy.
  • Juvenile myoclonic epilepsy.
  • Epilepsy with generalized tonic-clonic seizures alone.
  • Autosomal dominant epilepsy with auditory features.
  • Other familial temporal lobe epilepsies.
  • Familial focal epilepsy with variable foci.
  • Reflex epilepsies.
  • Progressive myoclonus epilepsies.

Epilepsy Etiology

The advancement in modern neuroimaging and genetic testing have led to a better understanding of etiologies of the epilepsies, which in turn resulted in a precise description of epilepsies by their specific underlying etiologies.

Epilepsy Etiologies are categorized as:

  • Chromosomal abnormalities.
  • Gene abnormalities.
  • Malformations of cortical development.
  • Vascular malformations.
  • Hippocampal sclerosis.
  • Hypoxic-ischemic structural abnormalities.
  • Traumatic brain injury.
  • Tumors.
  • Porencephalic cyst.
  • Biotinidase and holocarboxylase synthase deficiency.
  • Cerebral folate deficiency.
  • Creatine disorders.
  • Folinic acid responsive seizures.
  • Glucose transporter 1 (GLUT1) deficiency.
  • Mitochondrial disorders.
  • Peroxisomal Disorders.
  • Pyridoxine dependent epilepsy/PNPO deficiency.
  • Rasmussen syndrome.
  • Antibody mediated etiologies.
  • Bacterial meningitis or meningoencephalitis.
  • Cerebral malaria.
  • Cerebral toxoplasmosis.
  • CMV: CMV is the commonest fetal viral infection.
  • HIV.
  • Neurocysticercosis.
  • Tuberculosis.
  • Viral encephalitis.
  • Other infections: toxocariasis, schistosomiasis and Lyme disease (neuroborreliosis).

'Unknown' is meant to be viewed neutrally and to designate that the nature of the underlying cause of the epilepsy is as yet unknown; it may have a fundamental genetic defect at its core or there may be a separate as yet unrecognized disorder.

Epilepsy Types and New Terms (ILAE 2017 Guidelines)

Epilepsy and seizure guidelines and other related instructions and standards were according to 1981 guidelines issued by International League Against Epilepsy (ILAE is the main organization that studies the condition, came up with a new way to organize and describe seizures and epilepsy types). These guidelines have been replaced by 2017 one, which made things more easier, simpler and comprehensive by introducing new terms that substituted some older ones.
Epilepsy is now classified into four basic types based on the seizures you're having (unlike 1981 classification), which are:

Type Description
Generalized Epilepsy Patients with generalized epilepsy have generalized seizure types, and may have typical interictal and/or ictal EEG findings that accompany generalized seizure types (for example generalized spike and wave). A family history of generalized seizure types or generalized epilepsy is supportive. This type of epilepsy has two basic kinds of seizures, which are either Generalized motor seizures OR Generalized non-motor (or absence) seizures.
Focal Epilepsy Patients with focal epilepsy have focal seizure types, and may have typical interictal and/or ictal EEG findings that accompany focal seizure types (such as focal sharp waves or focal interictal slowing). Imaging showing a focal structural brain abnormality may be supportive, although patients with genetic etiologies and normal imaging can also have focal epilepsy. Focal epilepsies may be unifocal, multifocal or hemispheric.
Focal epilepsy seizures come in four categories as: Focal aware seizures; Focal impaired awareness seizures; Focal motor seizures; Focal non-motor seizures.
Combined Generalized and Focal Epilepsy Patients may have both generalized and focal seizure types, with interictal and/or ictal EEG findings that accompany both seizure types. Patients with Dravet syndrome and Lennox Gastaut syndrome may have generalized and focal epilepsy.
Unknown Epilepsy The term 'unknown' is used to denote where it is understood that the patient has epilepsy, but it is not possible to denote whether it is focal, generalized, or combined focal and generalized. This may occur due to insufficient information to classify the epilepsy, for example if the EEG is normal/uninformative.

Source: International League Against Epilepsy "ILAE" epilepsydiagnosis.org Project, Via a Creative Commons Attribution-ShareAlike 4.0 International License.

Seizure:

There are different types of seizures, which fall into two major categories: Focal Seizure which takes place in one particular part of the brain (local or partial seizure), and Generalized seizure which affects the whole brain (both hemispheres).
The term "Focal to bilateral tonic-clonic" may be used to describe a Focal seizure that later spreads to the whole of the cortex and becomes generalized. Note that, People may experience just one type or more than one. The kind of seizure a person has depends on which part, and how the brain is affected by the electrical disturbance that produces the seizure.

Seizure Classification:

International League Against Epilepsy (ILAE) issued the “2017 latest classification” of seizure and epilepsy, which has replaced the 1981 classification. The model change meant to simplify terminologies in order to make it easily understood by patients and their caregivers.

Basically, seizures are now classified as:

  • Generalized Seizures. Start on both sides of the brain hemispheres. They are as:
    • Generalized motor seizure: Previously it was called "grand mal" seizure. It causes the body to shake, muscles to stiffen and jerk in an uncontroled way with lost of consciousness. It may also include clonic, tonic, and myoclonic.
    • Generalized non-motor (or absence) seizure: Previously it was called “petit mal”. Some specific types are typical, atypical, and myoclonic. The reason it is also called absence seizure because a person having it may look like detached from reality and stare, with a possibility of doing same movements over and over, like smacking the lips.
  • Focal Seizures. Start in a particular area and one side of the brain. They are as:
    • Focal aware seizure: Previously it was called "simple partial seizures". In this type, the person does not lose consciousness and remains aware of what’s happening during the seizure.
    • Focal impaired awareness seizure: Previously it was called "complex partial seizures". In this type, the person is confused and do not know or remember what happened during the seizure.
    • Focal motor seizure: In this type, the movement is not severe, but rather to some extent like twitching, spasms, rubbing hands, walking around, etc. it is also may characterized as of spasms, myoclonic, epileptic, atonic, clonic, and tonic.
    • Focal non-motor seizure: Contrary to focal motor, this type of seizure does not cause movements. It is seen with sensory and perceptual changes like how you feel or think. You might feel cold or hot; having intense emotions, strange feelings, or symptoms like a racing heart, goose bumps, etc.
  • Unknown Onset:
    • A seizure may be unclassified due to inadequate information to allow it to be placed in the focal, generalized or unknown onset categories. This may occur if it was not witnessed at onset, and if results of investigations (such as EEG and imaging) are not yet available. Seizures with unknown onset can be further classified as motor (for example epileptic spasm, tonic-clonic), or non-motor (for example, behavior arrest) in type.

Summary of 2017 ILAE Seizure Classification:

Source Of the slides and Attribution: These slides have been extracted from PowerPoint presentation illustrating the 2017 Classification of Seizure Types on ILAE website, and it is attributed to Fisher et al. Instruction manual for the ILAE 2017 operational classification of seizure types. Epilepsia doi: 10.1111/epi.13671.

Seizure Warning Signs:

Some people with epilepsy can detect when a seizure is approaching. This sensation has been called an “aura,” and can be for example as: feeling of pins and needles or a strange taste or smell.

Factors which might trigger a seizure (including and not limited to):

  • Missing a dose of medication.
  • Tiredness.
  • Missing meals.
  • Taking illicit drugs.
  • Increased stress level.
  • Flashing lights.
  • Drinking alcohol.
  • Overheating or overexertion (hyperthermia).

Epilepsy Treatment and Care  

Diagnosis

First of all, when you visit the doctor after you had a seizure, he/she will review your symptoms and medical history, and will pay attention to the smallest details of you or anyone else who was present during the seizure. This is known as “history”, and its importance lies in the fact that the symptoms you experience during the seizure may give the doctor an idea of the type, which contributes after doing the necessary lab and diagnostic tests to determine your treatment.

During the visit, you will be asked questions such as: When did the seizure occur? how long it lasted; were you fully conscious during it; did you remember what happened; were you exposed to external stimuli such as intermittent lights or loud sounds; did you sleep enough the night before; did you make a lot of effort before it; were you subject to psychological effects; do you have epilepsy family history; have you had any accidents recently or neurological diseases, etc...

Evaluation Tests

Your doctor may ask for any of the following tests to evaluate your condition:

While you are in the doctor's office, neurological exams might be performed to assist the determination of your epilepsy type. This includes behavioral testing, motor abilities, mental function (thinking, memory and speech skills). These can help doctors determine which area of the brain is affected). Further, a cell blood test “CBC” and other blood tests may be ordered to check for signs of infections, genetic conditions or other conditions that may be associated with seizures.

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Electroencephalogram "EEG" is a noninvasive test for measuring the electrical activity (patterns) of the brain, through measuring potential difference of placed electrodes (active and reference) on the scalp, to detect abnormalities. EEG is one of the main diagnostic tests for epilepsy. During the procedure, electrodes are placed onto your scalp using a sticky substance. These electrodes pick up the electrical signals from your brain and send them to an EEG machine, which will record the signals and displays them as wavy lines on a computer screen. The EEG machine records your brain's electrical activity as a series of traces, each trace corresponds to a different region of the brain. EEG is a painless procedure that takes 30 to 45 minutes with rarely causes of any side effects. If you have epilepsy, it's common to have changes in your normal pattern of brain waves, even when you're not having a seizure. The result of your test will be either normal or abnormal, showing healthy normal brainwave patterns or abnormalities, but might not be exclusive, as there are occasions where the person has seizure or epilepsy but his/her EEG shows normal patterns. In this case, your doctor might ask for further investigative tests like HD-EEG or anatomical imaging (MRI, fMRI, PET, etc).

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High density EEG (HD-EEG) is a promising tool to achieve new insights not only regarding epilepsy diagnosis but even in sleep physiology and related disorders. In a variation of a conventional EEG and compared to it, HD-EEG combines both very good spatial resolution obtained from neuroimaging, and optimal temporal resolution obtained from conventional EEG. HD-EEG uses 256-channels with spaces between them half a centimeter apart, contrary to conventional EEG which uses 10-20 electrode placement system, where the electrodes are as far as 7 centimeters apart. High-density EEG may help your doctor more precisely determine which areas of your brain are affected by seizures.
Despite the studies and publications that show the great value of HD-EEG, still it is not widely used in the clinical context, but rather in the research, and few products have approval from regulatory authorities to be used in the clinical practice.

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A computerized tomography scan (CT or CAT scan) helps to see inside the human body. It uses computers and rotating X-ray machines to create cross-sectional images of the body (organs, bones, soft tissues, blood vessels). These images provide more detailed information than normal X-ray images. CT scan can be done for any part of the body (images may be combined to produce a 3-D image of a particular area of the body). CT can accurately detect hemorrhage, infarcts, gross malformations, lesions with underlying calcification, and large tumors. CT scans can identify any brain abnormalities that might be causing seizures, such as tumors, bleeding cysts, scar tissue, or malformed blood vessels. They can also identify any spinal fluid circulation problems. Advantages of CT scan and modern one’s are lower cost, ready accessibility, scan speed (new generation CT scanners can generate an image of the brain in seconds.), etc.
Availability of MRI has reduced the use of CT scan for the diagnosis of epilepsy (still it can be the proper choice for certain patient conditions such as in acute situations like head injury, intracranial hemorrhage, or infarcts), but in other types of epilepsy, CT Scan was found not useful or inconclusive to detect abnormalities, noting that CT has poor resolution of the temporal fossa.

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Magnetic resonance imaging (MRI): It is an imaging technique that uses strong magnetic fields, magnetic field gradients, and radio waves to create a detailed view of brain. It is helpful to detect lesions or abnormalities in the brain that could be causing seizures. MRI is the preferred imaging procedure for screening patients with epilepsy. The disadvantages of an MRI scan are its lack of availability for more patients, its higher cost, and the need for longer scan times. The main role of MRI is to identify structural abnormalities that underlie seizure disorders such as identifying mesial temporal sclerosis and malformation of cortical development. MRI is accurate in understanding the root cause of and diagnosing certain types of epilepsy. Scan results are quite adept at pin-pointing potential physical causes for symptoms, such as scarring on the brain or tumors. However, not all epilepsy has a physical cause that shows up on scans. In some cases, providers may use the scans to view brain activity instead, looking for trends that might explain seizures. MRI is so accurate in these endeavors that the UK National Institutes of Health (NIH) has previously suggested that it could be used in a program not just to identify existing epilepsy but to identify the potential of epilepsy in the future.

Functional neuroimaging has been used for localizing cerebral dysfunction, predominantly through disturbances in an individual's metabolism or blood flow. The techniques available include SPECT, PET, functional MRI, and magnet resonance spectroscopy (MRS).

SPECT: Single photon emission computerized tomography is a nuclear medicine imaging method that allows for the quantitative and qualitative evaluation of regional cerebral perfusion. It is not indicated in most of the patients with epilepsy but has an important role in presurgical evaluation of refractory epilepsy patients. The use of SPECT in epilepsy stems from the known association of seizures with increased ictal regional cerebral perfusion or interictal decrease in perfusion.

PET: Positron emission tomography uses a small amount of low-dose radioactive material known as a tracer that is injected into a vein to help visualize active areas of the brain and detect abnormalities. The tracer sends out small, positively charged particles (positrons) that interact with negatively charged particles (electrons) in your body. The PET scanner is able to detect the product of this interaction and uses it to make an image. The PET scan shows the brain's use of oxygen or sugar (glucose). PET scans can help identifying the area of the brain where focal seizures start. It may be done in the period between seizures (the interictal period). PET is an expensive test and is not the first choice of tests for patients with epilepsy.

MRS: Magnetic resonance spectroscopy is a noninvasive diagnostic test for measuring biochemical changes in the brain (brain metabolites), especially the presence of tumors. It compares the chemical composition of normal brain tissue with abnormal tumor tissue. This test can also be used to detect tissue changes in stroke and epilepsy. It is extremely sensitive in detecting metabolic changes in dysfunctioning epileptic zone, it can even detect metabolic changes when structural imaging yields normal results. MRS also has been used to measure lactate levels postictally.

Functional MRI (fMRI). Is a new MRI technique that studies brain functions. It measures the changes in blood flow that occur when specific parts of brain are working (changes in blood oxygenation). It is used for seizure localization and has successfully been used to map focal aware seizures. It is also used in the presurgical evaluation of epileptic patients to map functional areas such as language, motor function, and visual cortices with high accuracy, which is essential before epilepsy surgery, and to map as well the interictal spikes. However, capturing seizures with fMRI is difficult, because seizures are unpredictable and focal impaired awareness seizures are usually associated with movement that obscures the fMRI image. It is also used to predict deficit after temporal lobe resection. Using fMRI technology, doctors can determine which part of the central nervous system (CNS: brain and spinal cord) is active during a given task by tracking blood oxygen levels in the brain. fMRI evaluates cerebral blood flow by looking at the difference between venous oxyhemoglobin and deoxyhemoglobin; this is called the blood oxygen level-dependent (BOLD) contrast technique.

Magnetoencephalography (MEG). A revolutionary non-invasive medical imaging technology that provides unprecedented insight into the workings of the human brain through the measurement of electromagnetic activity. It is used for mapping brain activity by recording magnetic signals produced by electrical currents in the brain (measuring the magnetic fields created by the electric current flowing within the neurons). MEG is particularly effective in pre-surgical localization among epilepsy patients, as well as in the functional mapping of eloquent brain functions.

For the best diagnosis and treatment of epilepsy and depending on the case, doctors may use a combination of analysis techniques to help determine where in the brain seizures start. These techniques may include:

Statistical parametric mapping (SPM): A helpful voxel-based analysis technique used in epilepsy patients that compares areas of the brain which have increased metabolism during seizures to normal brains. This can give doctors an idea of where seizures begin. It assesses the differences in the brain activity recorded during functional neuroimaging experiments using PET or fMRI.

Curry analysis: Curry analysis is a technique that takes EEG data and projects it onto an MRI of the brain to show doctors where seizures are occurring.

EEG Electrical Source Imaging (ESI): is a neuroimaging technique that uses a patient’s EEG data co-registered with their MRI to localize the source of the scalp EEG signals within the patient’s brain.

Electromagnetic Source Imaging (EMSI) is a functional imaging technique, which uses EEG and/or MEG measurements to map functional areas of the Cerebral cortex.

Summary

Correct diagnosis of epilepsy, knowing the seizure type and where it begins facilitate the best effective treatment, which is now more possible than decades ago due to the revolutionized developments in neuroimaging, that led to a more accurate diagnosis of the pathologic substrate of epilepsy, which is essential for accurate classification, determination of prognosis, and surgical candidacy. However, this does not deny that EEG remains the first and most widely used and accepted choice by doctors, noting that, in turn, it began to witness great technical and scientific developments which as several studies indicating it to be conclusive than neuro imaging itself in certain areas like HD-EEG. The only issue is many of these methods and tools are not yet approved for the clinical use and they are more in the research side.

Treatment

Treatment may include medication, lifestyle changes, surgery, etc.

Surgical procedures are another dimension in treatment, and can be an option if medication fails to control seizures. Medication can successfully control seizures in many people. Avoiding known triggers and paying attention to lifestyle issues, such as getting adequate sleep, can also help. The majority of epileptic seizures are controlled through drug therapy, particularly anticonvulsant drugs. The type of treatment prescribed will depend on several factors including the frequency and severity of the seizures as well as the person's age, overall health, and medical history. An accurate diagnosis of the type of epilepsy is also critical to choosing the best treatment. Treatment aims to prevent seizures, which usually leads to improved quality of life. When the doctor has made a diagnosis of seizures or epilepsy, the next step is to select the best form of treatment. The doctor will usually prescribe regular use of seizure-preventing drugs. If drugs are not successful, other methods may be tried, including surgery, a special diet, deep brain stimulation (DBS) or vagus nerve stimulation (VNS). The goal of all epilepsy treatment is to prevent further seizures, avoid side effects, and make it possible for people to lead active lives. Note that, The same treatment does not work for every patient because the type and severity of epilepsy varies.

Treatment Options:

  • Medication: For many patients, medication taken regularly and as prescribed will prevent seizures. When medications fail to control or substantially reduce the frequency of seizures, brain surgery may be recommended.
  • Surgical treatment: Most patients with epilepsy do not require surgery. However, Epilepsy surgery is an option for patients whose seizures remain resistant to treatment with anticonvulsant medications. The goal is to control epileptic seizures, although anticonvulsant medications may still be required. The success of surgery and the risks of complications differ for each person. Surgery is not intended to be a substitute for medication. Noting that, the doctor always weighs the expected benefits from the surgery with the side effects or complications, to decide what is best for the patient. Brain surgery possible risks may be such as: infection, stroke, paralysis, speech problems, loss of vision, loss of motor skills, more seizures, etc.
    • Usual types of surgery are:
      • 1. Resective Surgery: It is the most commonly used, and by means of which the part of the brain that causes the seizures is removed, such as temporal lobectomy and other procedures.
      • 2. Hemispherectomy: Is a rare radical procedure which is typically done in children (also occasionally in adults) when medication fails to stop or control severe and intractable seizure disorders, and often have severe damage to only one side of the brain (although not always), and may already have paralysis on one side of the body (hemiparesis). In this type of surgery as the name indicates, half of the brain known as hemisphere is removed.
      • 3. Multiple subpial transection (MST): A new and rare procedure that is done in case of no response to medication and also when an area of the brain is not resectable (able to be removed) due to the location of the lesion (like in a vital area of the brain as areas that control movement, feeling, language, or memory). It uses the technique of disconnecting areas of the brain where seizure activity occurs (destroy fibers in the gray matter that transfer the epileptic electrical activity while protecting other fibers in the white matter that provide critical function such as language and motor skills).
      • 4. Corpus callosum: Is a band of nerve fibers located deep in the brain that connects the two halves (hemispheres) of the brain. The procedure is a palliative surgical most often used in children, and meant to decrease the severity of seizures and not to stop them by cutting the nerve fibers between the two halves (hemispheres) of the brain, to help stop seizures from spreading from one hemisphere to the other, which can make seizures less severe as they cant spread from one side of the brain to the other once disconnected. Therefore, seizures remain only on the side where it originates only.
  • The ketogenic diet: Is one of the oldest treatments for epilepsy. It was developed in the 1920s. It works on the principle of a strict diet that's high in fats and low in carbohydrates, so that the body breaks down fats instead of carbohydrates for energy. The high fat, low carbohydrate and protein diet creates ketones when the body burns fat for a source of energy. This state is known as ketosis and causes changes in body chemistry that may help to control seizures. ketogenic diet is helpful to reduce seizures frequency for some children when medications don’t, and even can result after few years for some children to be seizure-free with a direct and close medical supervision of your doctor and health specialists, who in turn can help the diet to be properly followed resulting in a fewer side effects like dehydration, constipation, slowed growth because of nutritional deficiencies and a buildup of uric acid in the blood.
  • Modified Atkins Diet: Originally, the Atkins Diet was developed in the 1960s by cardiologist Robert C. Atkins. It is a popular low-carbohydrate eating plan which restricts carbohydrates while emphasizing protein and fats. The Modified Atkins Diet (MAD) is more palatable and less restrictive variation of the classical ketogenic diet. This diet is started on an outpatient basis without a fast, allows unlimited protein and fat, and does not restrict calories or fluids. Some studies have shown good efficacy and tolerability of this diet in refractory epilepsy. It is a prudent therapeutic option especially for older children and adolescents as it is a more “liberalized” diet as compared to classical ketogenic diet.
  • Vagus nerve stimulation (VNS): It is an extracranial neurostimulators technique that uses computerized electrical device (a pacemaker-like device) implanted underneath the skin of the upper chest below the collar bone with a built-in battery, and electrode wrapped around the vagus nerve on the left side of the neck, the leads send regular, mild pulses of electrical energy to the brain via the vagus nerve. By stimulating the vagus nerve, the brain’s potential to generate or spread abnormal seizure activity can be reduced. The stimulator is set to deliver a 30-second electrical impulse every five minutes. Each patient has a magnet that activates the device immediately and at a higher intensity if a seizure occurs. VNS is not a cure, and the total elimination of seizures is rare. However, some people who undergo VNS experience a significant reduction in the frequency of seizures, as well as a decrease in seizure severity. VNS can usually reduce seizures by 20 to 40 percent.
  • Deep brain stimulation (DBS): In DBS, an electrical device implanted under the skin in the upper chest in a manner similar to the VNS, but with different electrical stimulation area, specifically directly delivered to the deep brain structures (anterior nucleus of the thalamus) through depth electrodes implanted through the skull. The device (generator) through electrodes sends electrical pulses to control abnormal brain activity and reduce seizures. The electrical impulses can also adjust for the chemical imbalances within the brain that cause various conditions.
  • RNS (Responsive Neural Stimulation): RNS is a closed-loop matchbook-size device surgically implanted and attached to the surface of the brain. It is designed to interrupt and prevent seizure activity, through continuously monitoring brain activity patterns, to sense the onset of a seizure within a neural network, and then to deliver seizure-stopping electrical stimulation once seizure activity is detected.
  • Investigational and potential future treatments: Treatments being tested in clinical trials to determine their effectiveness. They may be an option for eligible patients.
  • Potential interplay among hormones, seizures and medications may create additional treatment considerations for women.
  • Immunotherapy If the epilepsy is autoimmune, then AEDs may not be able alone to control seizures, and a combination of treatments might be required to suppress the overly active immune system like giving the patient high- dose steroids; or a collection of human antibodies through the veins; or plasma exchange to filter the blood of disease-causing antibodies. In this relatively new epilepsy type, the immune system itself of the patient having epilepsy is the one who is attacking his own brain through antibodies.
  • Cannabidiol or CBD oil (medical marijuana), Marijuana as a cannabis plant has more than 80 chemical compounds. One of these compounds is called cannabidiol oil or CBD oil. This oil was found in few studies helpful to deal with certain types of epilepsy and control them when medication fails to do so. Presently, there is increasing interest in the potential utility of cannabis for a variety of medical conditions, as well as research on the potential adverse health effects from use of cannabis. U.S. FDA has approved only one cannabis-derived drug product: Epidiolex (cannabidiol), which contains a purified form of the drug substance cannabidiol (CBD) for the treatment of seizures associated with Lennox-Gastaut syndrome or Dravet syndrome in patients 2 years of age and older.
  • Natural treatments and alternative therapies: Such as procedures like biofeedback (training to voluntarily control seizures), chiropractic care, aerobic exercise, meditation, yoga and acupuncture or using vitamins (E, B-6, Magnesium, etc.) and herbs (such as: Skullcap, Tree of heaven, Mistletoe, Lily of the valley, Hydrocotyle “Water pennywort”, Valerian, Peony, burning bush, Mugwort “Artemisia vulgaris L.”, Groundsel, etc.).
    These have not mostly been approved for the treatment of epilepsy as there are no enough studies that support them, nor reliable researches to back their safety and efficiency. Although, some of what is said about them have been reported as they can be used in the treatment of epilepsy or controlling it, but this remains anecdotal with no scientific base, noting that, the use of some herbs and vitamins can be risky if it is without the consultation and approval of your doctor, as they might interact badly with your medications.

Avoiding triggers:

Certain conditions and activities can trigger seizures, so it may be helpful to avoid excessive alcohol consumption and nicotine usage; get enough sleep and manage to have reduced stress. In some cases, a very specific trigger such as reading can provoke seizures. In these rare cases, avoiding the trigger may prevent seizures. There are a number of other factors that may provoke seizures in some people. These can vary from person to person. Avoiding or reducing triggers may help to reduce seizures in some people, but not all triggers can be avoided and seizures can still occur without any obvious triggers.

Epilepsy Medication:

Treatment of seizures firstly can be by prescribing one medication or a combination of drugs depending on your case. Concerning medication, there are two classes of them as narrow-spectrum AEDs or broad-spectrum AEDs. ( Click to Browse)

Narrow-spectrum AEDs Are generally prescribed for specific types of seizures, and often used to treat or prevent seizures that occur in a specific part of the brain on a regular basis (focal seizures “previously called partial seizures”).
Narrow-spectrum AEDs brands for the treatment of seizures or epilepsy can be as (and not limited to them):
Carbamazepine (Carbatrol, Tegretol, Epitol, Equetro); Eslicarbazepine (Aptiom); Ethosuximide (Zarontin); Everolimus (Afinitor, Afinitor Disperz); Gabapentin (Neurontin); Lacosamide (Vimpat); Oxcarbazepine (Trileptal, Oxtellar XR); Phenobarbital; Phenytoin (Dilantin, Phenytek); Pregabalin (Lyrica); Tiagabine (Gabitril); Vigabatrin (Sabril).
Broad-spectrum AEDs Are used if you have more than one type of seizure, especially if seizures occur in both brain hemispheres.
Broad-spectrum AEDs brands for the treatment of seizures or epilepsy can be as (and not limited to them):
Acetazolamide; Brivaracetam (Briviact); Cannabidiol (Epidiolex); Cenobamate (Xcopri); Clobazam (Onfi, Sympazan); Clonazepam (Klonopin); Clorazepate (Gen-Xene, Tranxene-T); Diazepam (Valium, Valtoco, Diastat); Divalproex (Depakote, Depakote ER); Felbamate (Felbatol); Fenfluramine (Fintepla); Lamotrigine (Lamictal, Lamictal CD, Lamictal ODT, Lamictal XR); Levetiracetam (Elepsia XR, Keppra, Keppra XR, Spritam); Lorazepam (Ativan); Methsuximide (Celontin); Perampanel (Fycompa); Primidone (Mysoline); Rufinamide (Banzel); Stiripentol (Diacomit); Topiramate (Topamax, Qudexy XR, Trokendi XR); Valproic acid; Zonisamide (Zonegran).

American Academy of Neurology (AAN) AEDs use guidelines (Text extracted and cited from Healthline).

In 2018, the American Academy of Neurology (AAN) published updated guidelines on the use of newer AEDs as the following: Part One Focuses on the treatment of new onset epilepsy, and part two focuses on treatment-resistant epilepsy.

  Ⅰ. According to the guidelines, there’s strong evidence (Level A) to support the following recommendations:

  • perampanel and immediate-release pregabalin for use in treatment-resistant adult focal epilepsy (TRAFE).
  • rufinamide and vigabatrin for use in TRAFE, but not as first-line treatments.
  • rufinamide as an add-on treatment for people with Lennox-Gastaut syndrome.

  Ⅱ. There’s moderate evidence (Level B) to recommend:

  • clobazam as an add-on treatment for people with Lennox-Gastaut syndrome.
  • eslicarbazepine for the treatment of TRAFE.
  • ethosuximide instead of lamotrigine for absence seizures in children, unless there are concerns about negative events.
  • lacosamide for the treatment of TRAFE.
  • lamotrigine.
    • For new-onset focal epilepsy in adults
    • For unclassified generalized tonic-clonic seizures in adults
    • As an add-on treatment for adults with treatment-resistant generalized tonic-clonic seizures.
  • levetiracetam, as add-on treatments for:
    • Treatment-resistant generalized tonic-clonic seizures
    • Treatment-resistant juvenile myoclonic epilepsy
    • Treatment-resistant focal epilepsy in people 1 month to 16 years old
  • oxcarbazepine as an add-on treatment for treatment-resistant focal epilepsy in people 1 month to 4 years old.
  • Extended-release topiramate for the treatment of TRAFE.
  • valproic acid instead of lamotrigine for absence seizures in children, unless there are concerns about negative events
  • zonisamide as an add-on treatment for treatment-resistant focal epilepsy in people 6 to 17 years old.
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Epilepsy Drugs Side Effects

The occurrence of side effects depends on the dose, type of medication, and length of treatment. The side effects are usually more common with higher doses but tend to be less severe with time as the body adjusts to the medication. Anti-epileptic drugs are usually started at lower doses and increased gradually to make this adjustment easier. anticonvulsant medications have unique side effects. These are those that are not shared by other drugs in the same class.

Anticonvulsant medications have unique side effects, and it may include some of the following:

  • Double Vision
  • Fatigue
  • Sleepiness
  • Dizziness
  • Loss of bone density
  • Loss of coordination
  • Memory and thinking problems
  • Stomach Upset
  • Mood Changes
  • Unsteadiness
  • Weight gain
  • Skin rashes
  • Speech problems

Rare side effects include:

  • Depression
  • Suicidal thoughts and behaviors
  • Severe rash
  • Inflammation of certain organs, such as your liver

Seizure medication works best if you adhere by the following:

  • Follow your doctor’s prescription exactly. Noting that, at least half the people newly diagnosed with epilepsy will become seizure-free with their first medication.
  • Confirm from your doctor for any changes you make to the medication such as taking a generic one instead of what your doctor has prescribed to you. This applies also to if you are taking other prescription medications from any category for any of your health conditions.
  • Do not act from your own and stop the medication. This is your doctor’s decision in regard to your condition.
  • If specific side effects increased or affecting your life, then you have to notify your doctor.
  • For some health conditions like migraine, make sure to inform your doctor about it prior, so to prescribe you an AED medication that can treat both epilepsy and migraine.

Continue reading the Epilepsy Health Corner by browsing the next page

Epilepsy and Seizure First Aid.

Guidelines for Seizure and Epilepsy

Living and Managing with Epilepsy.

Driving, Workplace and Pregnancy.

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