Epilepsy

Epilepsy is a common neurological disorder that currently affects around 50 million of the population worldwide. More than 80% of the people affected with epilepsy reside in middle to low-income countries. It is characterised by seizures, which are uncontrolled jerky movements of a part or whole body, and is sometimes associated with loss of consciousness and loss of control of bladder and bowel movements. Seizures are caused due to an excessive release of electrical impulses in the brain cells. The frequency of episodes can vary from one to two in a year to many times in a day. 

Seizures are categorised into two types: 

Focal seizures
When the seizures arise from one part of the brain, they are termed as focal or partial seizures. Focal seizures can be of two types:

• Focal seizures without loss of consciousness
  During this type of seizures, the person is awake during the episode. They may experience altered smell, taste or emotions. Some people may experience involuntary movements of the arms and legs, tingling and dizziness. These are also known as partial or simple seizures.
• Focal seizures with altered awareness 
  In this type of seizures, the person may be unconscious or may experience altered awareness. They may stare into space without responding when spoken to or even perform repetitive movements like swallowing or chewing. These are also called complex seizures.

Generalised seizures
These type of seizures affect both halves of the brain. They are of two types:

• Absence seizures
  There is rapid eye blinking or moments where the person is staring into space and appears to be disconnected from the surroundings, and may not hear if you call out their name.
• Tonic-clonic seizures
  The person may lose consciousness, cry, fall to the ground, have jerky movements and may feel tired after the episode.

Symptoms depend on the location of the involved area in the brain from which the seizures originate. Symptoms include: 

• Loss of consciousness.
• Confusion.
• Staring at a point.
• Jerking movements of the arms and legs.
• Disturbances in senses like vision, hearing and taste.
• Mood changes, such as fear and anxiety.

Causes

It is seen that in almost half the cases, the cause of epilepsy is unknown. There are many types of epilepsies, and the underlying causes may vary. In many cases, there may be more than one causative factor, making it difficult for doctors to identify and treat the condition. The causes of epilepsy are:

• Genetic
  Epilepsy can be inherited from either or both the parents. In some cases where epilepsy is not inherited from either parent, certain genes, which are linked with specific types of epilepsy may suddenly become activated due to changes in the environment and may trigger seizure attacks. Certain developmental disorders, such as autism and cerebral palsy are also linked with epilepsy. Genetic conditions that may cause brain malformations leading to epilepsy, include:
  • Tuberous sclerosis
    This is a genetic condition in which there are tissue overgrowths seen in various organs of the body including the brain.
  • Neurofibromatosis
    In this genetic condition, benign tumours form on the layers that cover the nerves.
• Head injury/trauma
  Head injuries sustained as a result of road traffic accidents, accidents at home such as a fall, slip or trip from the stairs, sports injuries, being hit on the head, assault or any other type of traumatic injury can lead to epilepsy. 
• Injuries before/at the time of birth
  During pregnancy, any infection in the mother can result in nutritional deficiency and a low birth weight baby. During the time of delivery, any injury to the brain, like a forceps delivery or improper handling of the baby’s head, or umbilical cord entangled around the neck can compromise the oxygen reaching the brain and can result in epilepsy. 
• Diseases of the brain
  Conditions of the brain that can cause a decreased oxygen supply can result in epilepsy. Stroke, brain tumours, Alzheimer’s disease, meningitis, HIV, encephalitis and brain abscess are some of the conditions that can lead to epilepsy. In neurocysticercosis, a disease that is caused by worms seen mainly in tropical areas, seizures can occur if the worms enter the brain, and is a major cause for seizures in people living in that region. Studies have shown that stroke is the most common cause of epilepsy after the age of 35 years. 

Risk Factors

There are certain risk factors that may increase the risk of epilepsy.

• Age
  Although epilepsy can occur at any age, it is very common in young children and adults. 
• Family history
  If there is a family history of epilepsy, then the person is at a higher risk of developing the disorder too.
• Head trauma
  People with a history of head injury, especially those that happen because of adventure sports like motorcycle racing or skiing are at a high risk of epilepsy. 
• Dementia
  A history of dementia, Alzheimer’s and other such diseases are associated with a higher risk of developing epilepsy at some point. It has been seen that between 10% and 22% of such individuals show symptoms of epilepsy. 
• Childhood seizures
  Children who have prolonged seizures along with fever or other brain-related disorder are at a higher risk of developing epilepsy in adult life. 

If the cause of epilepsy is unknown, it can be difficult to prevent seizures. Measures to prevent seizures in persons with an identifiable cause include: 

• Take preventive measures to avoid head injuries.
• Proper care and handling at the time of delivery to prevent injuries, and providing adequate oxygen to the newborn can prevent the development of epilepsy later in life. Proper treatment given to the mother during pregnancy can help in preventing nutritional deficiency and reducing the incidence of low birth weight babies.
• Treatment of brain and nervous system infections well in time. These diseases that are common in tropical areas or where several low-income, middle-income and developing countries.
• Use of medications to decrease body temperature, which can reduce the chances of developing seizures in children with fever.
• Killing specific parasites that cause infections, such as neurocysticercosis with the help of government-approved health programmes to prevent epilepsy in specific and high-risk areas.

History and examination

For diagnosing a person with epilepsy, the doctor will carefully note down the symptoms and a complete medical history. A thorough neurological examination will be performed, which includes evaluation of behaviour, motor responses, mental abilities and functions of other parts of the brain to diagnose the type of epilepsy.

Electroencephalogram (EEG)

This is the most commonly employed procedure to diagnose epilepsy. During an EEG, the doctor makes use of special electrodes that are attached to the scalp. These electrodes help in recording the electrical activity in the brain. The doctor may record an EEG while the patient is awake or during sleep to record any unusual activity. For some people, a high-density EEG may be advised, in which the electrodes are attached more closely to each other. This type of EEG can determine the specific area of the brain that is causing epilepsy.

Computed tomography (CT) scan

A CT scan may be helpful in diagnosing cysts, tumours or any bleeding in the brain, which could give rise to seizures.

Magnetic resonance imaging (MRI)

An MRI helps to detect any abnormalities, such as lesions or tumours in the brain that could be a cause of epilepsy. In some people, a functional MRI may be advised before surgery, so that doctors can avoid areas associated with important body functions like speech, gait, among others.

Single-photon emission computed tomography (SPECT)

This procedure is generally advised when MRI and EEG are unable to locate the area of the brain causing epilepsy. In this procedure, a small dose of radioactive material is injected which produces a 3D image of the flow of blood in various parts of the brain.

Neuropsychological tests

Neuropsychological tests assess a person’s memory, thought process, speech and motor skills. This helps to identify the affected or involved areas in the brain.

Other investigations

Along with the above tests, specific blood tests to rule out infections, genetic diseases and any other diseases may be performed as per the doctor’s orders.

Treatment of epilepsy mainly consists of:

Anti-epileptic drugs 

Anti-epileptic drugs are the commonly employed treatment of choice. It has been reported that these medications have helped in controlling or relieving the symptoms or seizures in more than 70% of cases. These medications help to decrease the intensity and the frequency of seizures by altering the amount of chemicals released by the brain. Although these medications do not help to cure epilepsy, they can reduce the number of episodes with regular treatment. These medicines are available in multiple forms. A low dose is often given at the beginning of the treatment and the dosage is slowly increased until the episodes stop. The doctor may change the medicine if there is no significant response or improvement. The type of medication depends on the type of epilepsy, and these medications are to be prescribed only by a physician. If the person is taking any other medications, the physician should be notified.

Side effects of these medications include:

• Headaches.
• Lack of energy.
• Hair fall or excessive hair growth.
• A swelling in gums.
• Skin rashes.
• Tremors.

If there are any such side effects, they should be brought to the notice of the physician immediately. Hence, it is best to take the medications exactly as they are prescribed. Speak with the doctor regarding any change in dosage or even the generic version of the medicine. Do not stop the medication without the permission of the physician. If there are any changes in behaviour or mood, they should be notified. With time, most anti-epileptic medications are discontinued and the person can live without any symptoms.

Surgery

If the medications do not provide adequate relief or produce several side effects, surgery may be advised. During the operation, the affected area of the brain is removed. Surgery is performed only when a small area of the brain is affected and the area does not affect critical bodily functions, such as speech, hearing, gait, motor activity among others.

Lifestyle management

It is important to control seizures, as they may be dangerous and produce complications. 

• Take medications regularly. Do not skip or stop any dose without the doctor’s permission
• Identify triggers that may cause seizures or epilepsy. The most common triggers include alcohol, lack of sleep, stress, bright light, loud sounds and more.
• Maintain a diary of the seizure episodes, its intensity and duration along with the details of the activities you were doing before the episode took place.
• Try to deal with trigger factors by:
  • Trying to sleep early.
  • Performing light breathing exercises. 
  • Reducing alcohol intake.
• If your seizures are frequent, avoid activities such as driving, swimming and cooking, as these may harm if seizures precipitate during these activities.
• Install smoke detectors in the house.
• Use furniture with smooth edges.
• Do not lock the door while bathing.
• Take showers instead of baths to prevent drowning if a seizure precipitates.
• Go swimming with a partner who is able to rescue in cases of a seizure attack.
• Use a helmet while engaging in outdoor sports.

Prognosis

There is no cure for epilepsy. However, the seizures can be controlled almost entirely with the help of medications. The outcome depends on the type of seizure and its intensity and duration. Some individuals may be able to discontinue medications earlier, whereas others may need medications for longer periods. Studies have shown that people who have had longer epilepsy episodes from a very young age have a poor prognosis. Uncontrolled seizures may cause brain damage along with behavioural and emotional problems. 

Complications

Complications of epilepsy may include:

• Repeated injuries, self-biting and falls during driving or performing tasks.
• Brain damage resulting in a stroke.
• Food going into the lungs during an attack, which can lead to a condition called aspiration pneumonia.
• Difficulty in speech and learning.