Epilepsy
Epilepsy is a physical condition which comprises sudden depolarization of groups of cerebral neurons which may remain localized (focal) or which may spread to cause generalized seizures
OR Abnormal, spontaneous, recurrent abnormal activity in the central nervous system which may clinically manifest as motor, sensory or psychomotor experiences.
Seizure is defined as when there is a non-recurrent abnormal electric activity in the brain or central nervous system resulting in abnormal motor, sensory or psychomotor experiences.
Therefore when a person has recurrent, intermittent tendency to develop a seizure, we say he is having epilepsy.
EPILEPSY
Epilepsy is a neurological disorder in which the brain activity becomes abnormal, causing seizures or periods of unusual behaviour, sensations, and sometimes loss of awareness.
Epilepsy is the commonest neurological disorder in Uganda. it presents in different ways and this complicates the attempts of its diagnosis. However, its very important to make its clear diagnosis early to prevent neurological complications, promote good control and improve welfare and quality of life of the affected.
Anyone can develop epilepsy at any age irrespective of sex or race. It presents a significant burden of disease and remains largely untreated especially in developing countries.
Causes
Epilepsy has no identifiable cause in about half of the people with the condition.
- Genetic influence especially primary epilepsy; condition runs in families
- Head trauma from accidents, domestic violence etc.
- brain tumors
- Brain conditions such strokes or any condition that damages the brain
- uncontrolled convulsions in fever during the first four years of life (febrile convulsions)
- Infectious diseases such as AIDS, meningitis, encephalitis etc.
- birth trauma to an infant
- Prenatal injury such as infections to the mother, poor nutrition or oxygen deficiency.
- Prematurity
- Malnutrition
- Post maturity
- alcohol and drug abuse
Types of epilepsy
- Grand mal epilepsy (major), (generalised tonic-clonic epilepsy)
- Petit mal epilepsy (minor), (absences)
- Temporal lobe epilepsy psychomotor
- Jacksonian epilepsy (focal)
Grand mal epilepsy
Is a major form of epilepsy characterized by total loss of consciousness and occurrence of a fit lasting 3-5 minutes. the patient regains consciousness spontaneously and may sustain injuries during the episode.
It is characterised by a grand mal seizure which occurs in four phases
- Aura phase
- Tonic phase
- Clonic phase
- Deep sleep or post convulsive phase
Aura phase
Is a brief warning sensation which can be a sound, a flash of light, a peculiar taste in the mouth , feeling of weakness, dizziness, arm or leg numbness or a brief pain in the stomach at the onset of some seizures. It occurs in 50% of patients and it takes less than 10 seconds.
Tonic phase
It follows aura phase for those who have. There is total loss of consciousness and falling down with contraction of all muscles such that the whole body is hyperextended. There is often a cry as air is being forced through a tight and narrowed vocal cord. It lasts for about 20seconds.
Clonic phase
This is characterised by repeated contractions and relaxation of all muscles of the body. There is gross motor activity resulting into jerking of the limbs. It is at this stage that the bladder is emptied and rarely stool is released through the sphincters of the rectum.
A lot of frothy saliva comes from the mouth, sometimes its blood stained if the tongue and lips are beaten.
This lasts between 30 and 90 seconds.
Deep sleep
The patient goes into deep sleep for about two hours, upon waking up, the patient is confused for a few minutes, complains of headache as has amnesia for the entire attack.
Note; Pre ictal stage is a stage that occurs in hours, days or weeks before an episode of epilepsy. It is characterise by
- Talkativeness
- Violence
- Irritability
- Restlessness
- Depression
Post ictal stage is a stage that occurs after an episode of a disease i.e
- Calmness
- Quietness
- Isolation
- Retarded mobility
- Depression
Different Types of Generalized Seizures
Absence Seizures
Once known as “petit mal” seizures, these are staring spells that start suddenly and may be mistaken for simple daydreaming. The person having an absence seizure will typically stop moving and stare in one direction for 15 seconds or less.
The episode resolves on its own, and though the person may not remember what happened during the seizure, their normal state of alertness returns immediately afterward.
Atonic Seizures (Drop Attacks)
A seizure of this type involves a sudden decrease in muscle tone, causing a person’s body to go limp, slump or collapse, possibly causing injury. Atonic seizures characterize certain epilepsy syndromes such as Lennox-Gastaut syndrome.
Myoclonic Seizures
Myoclonic seizures are characterized by a sudden body “jolts” or increases in muscle tone as if the person had been jolted with electricity. A myoclonic seizure is similar to the single or multiple sudden jerks people sometimes experience as they are falling asleep. “Sleep myoclonic” jerks are benign whereas myoclonic seizures can be harmful, since the “jolts” occur in bouts.
Infantile spasms is a subtype type of myoclonic epilepsy that typically begins between the ages of 3 and 12 months of age and may persist for several years. Infantile spasms typically consist of a sudden jerk followed by stiffening. Often the child’s arms fling outward as the knees pull up and the body bends forward. Each spasm lasts only a second or two but they usually occur close together in a series. Sometimes the spasms are mistaken for colic, but the cramps of colic do not typically occur in a series. Infantile spasms are most common just after waking up or falling asleep. This particularly severe form of epilepsy can have lasting effects on a child and should be evaluated and treated promptly.
Tonic and Clonic Seizures
In a tonic seizure, the person’s muscles stiffen, and they lose consciousness. The eyes roll back in their head, and muscles of the chest, arms and legs stiffen, causing the back to arch. The contracting muscles in the chest make it hard to breathe, and the person’s lips and face may turn gray or blue. The person may make gurgling sounds while struggling to breathe.
Clonic seizures cause a person’s muscles to spasm and jerk. Muscles in the elbows, legs and neck flex and then relax in rapid succession. The jerking motion slows down as the seizure subsides, and finally stops altogether. As the jerking stops, it is common for the person to let out a deep sigh before resuming normal breathing. Tonic-clonic seizures , once known as “grand mal” or “convulsive” seizures, occur when tonic and clonic movements happen at the same time. Though witnessing a seizure can be frightening, it is a myth that a person having a seizure is in danger of swallowing their tongue, which is not anatomically possible. NEVER put anything in the mouth or forcefully open a tightly clenched jaw while the seizure is happening as this could harm the person.
A seizure typically lasts a few minutes or less, after which the person is likely to remain unconscious for a few minutes more, depending on the intensity of the seizure. This is the post-seizure or post-ictal period, and during this phase the person’s brain is extremely active as it tries to contain the abnormal electrical impulses and bring the seizure under control. People regaining consciousness after a seizure are likely to be sore, confused or frightened and very tired. Providing assurance and support is the best help an observer can offer.
Tonic for stiffness, Clonic for Jerking, Tonic-clonic, for stiffening then jerking, Atonic for loosing tone and body becomes like a lump and myoclonic for recurrent tendency for a part of the body to jerk.
PETIT MAL EPILEPSY
Is a minor form of epilepsy in which there is absence of a fit or a fall. It commonly occurs in children. There is a brief loss of awareness which lasts for about 15seconds.
The patient usually does not fall down and does not know that something unusual has happened to him or her. Slight muscle contractions may occur; bladder control is hardly lost.
It starts at childhood and disappears at adolescence or can be complicated into grand mal epilepsy.
The first indication of petit mal epilepsy is when a developing child gets short disruption in motor activity and if writing, he stops and the pen drops down or when a child drops cups, plates unknowingly. This attack may occur several times in a day and may present with poor academic performance in school
JACKSONIAN EPILEPSY
This type of epilepsy has got its point of focus in the motor sensory area in the cerebral cortex.
It disrupts the function of a particular part of the body resulting from excessive electrical discharges from a focal point in the brain that controls that part for example if the focus of epilepsy is the part of the brain that supplies the left hand, there will be twitching or tremors that can start from the thumb, fingers or the whole hand. The seizure may insidiously or gradually spread to involve the whole body as a grand mal seizure.
TEMPORAL LOBE EPILEPSY
Temporal lobe seizures begin in the temporal lobes of the brain, which process emotions and are important for short-term memory. This may occur following anoxia at birth, anatomical defect or a scar in a temporal lobe. And because of that, the temporal lobes are seen to be vulnerable to low oxygen levels.
During a temporal lobe seizure, a patient may remain aware of what is happening, but in more intense seizure, the patient might look awake but be unresponsive, lips and hands may make purposeless repetitive movements like chewing, swallowing or smacking of lips
Some symptoms of a temporal lobe seizure may be related to these functions, including having odd feelings — such as euphoria, deja vu or fear.
Temporal lobe seizures are sometimes called focal seizures with impaired awareness. Temporal lobe seizures may stem from an anatomical defect or scar in your temporal lobe, but the cause is often unknown. Temporal lobe seizures are treated with medication. For some people who don’t respond to medication, surgery may be an option.
Symptoms
An unusual sensation (aura) may precede a temporal lobe seizure, acting as a warning. Not everyone who has temporal lobe seizures has auras, and not everyone who has auras remembers them.
The aura is actually the first part of a focal seizure before consciousness is impaired. Examples of auras include:
- A sudden sense of unprovoked fear or joy
- A deja vu experience — a feeling that what’s happening has happened before
- A sudden or strange odor or taste
- A rising sensation in the abdomen
Sometimes temporal lobe seizures impair ones ability to respond to others. This type of temporal lobe seizure usually lasts 30 seconds to two minutes. Characteristic signs and symptoms include:
- Loss of awareness of surroundings
- Staring
- Lip smacking
- Repeated swallowing or chewing
- Unusual finger movements, such as picking motions
After a temporal lobe seizure, patient may have:
- A period of confusion and difficulty speaking
- Inability to recall what occurred during the seizure
- Unawareness of having had a seizure
- Extreme sleepiness
In extreme cases, what starts as a temporal lobe seizure evolves into a generalized tonic-clonic (grand mal) seizure — featuring convulsions and loss of consciousness
COMPLICATIONS OF EPILEPSY
This is considered as a complication of grand mal epilepsy rather than a certain type of epilepsy.
It is both a medical and psychiatric emergency.
Status epilepticus is a single epileptic seizure lasting more than five minutes or two or more seizures within a five minute period without a person returning to normal between them. It is common in young children and the elderly.
Note, most seizures last for not more than 2 minutes. This condition is life threatening and getting treatment started fast is vital.
Management
This condition requires urgent medical treatment to lessen the chances of serious complications and death.
- oxygen is administered to the patient with other support breathing
- intravenous line is connected for intravenous fluids and emergency drugs
- anaesthetics are used in hospitals to put a person into comma to stop the seizures.
- Continuous EEG monitoring may be needed to monitor the seizures and how a person responds to treatment.
- Various tests are done to find out the cause so as to give appropriate treatment.
- Mental deterioration
This is another complication of epilepsy which occurs after years of uncontrolled seizures. It is a form of chronic brain syndrome in which brain damage results from repeated seizures. This is why it’s important to diagnose and treat epilepsy early enough there by keeping a number of convulsions minimum or if possible eradicate them totally.
Diagnosis
- Observation of a fit
- History of a fit
- Neurological examination to check he reflexes
- Electro encephalogram ma reveal epileptiform activity
- CT scan to reveal brain function
- skull X ray may indicate evidence of lessions
Triggers of an epileptic fit
- fevers in childhood
- sleep; convulsions during sleep may occur soon after the child wakes up from bed
- daylong or overnight fast
- emotional arousal e.g fear, anger, excitement etc
- flickering lights
- intoxication with alcohol
- alcohol withdrawal
- fatigue and boredom
- high altitude
Treatment and management of a grand mal seizure
Management of grandma fit is divided into two parts;
- Emergency management
- General management
An epileptic seizure is usually sudden and time to prepare for it is not there. It can occur at any time in any place.
The occurrence of a fit with or without warning, the following should be done to
- Avoid injury to the patient
- To prevent complications
Emergency Management
- Stay calm and speak calmly if you are to give instructions or when reassuring bystanders
- Remove the person from danger or vice versa if the patient is safe, don’t move them.
- Note the time the seizure starts and continue checking if it does not stop in 5 minutes, call for an ambulance.
- Loosen ties, necklaces or any cloth around the neck that may make it hard to breathe
- Support the head with a soft flat material under like a folded jacket so as to protect it from injury during jerking
- Clear space and minimize any form of crowdness such that the patient receives fresh air.
- As soon as the fit stops, Make the patient lie down in a lateral position so as to ensure he does not chock with his own saliva
- Check that breathing is returning to normal if their breathing sounds difficult after the seizure has stopped call for an ambulance.
- Check gently to see that nothing is blocking their airway such as false teeth.
- Stay with the patient until when the patient is fully awake
- After recovery, reorient the patient and reassure incase he is embarrassed.
The following should not be done;
- Don’t put any hard object like spoon in the mouth this can injure teeth or jaw.
- Don’t hold his limbs tightly because that prevents contraction and relaxation of muscles
- Don’t give anything to eat or drink until he is fully alert
- Do not try to give mouth to mouth breaths, people usually start to breath again on their own after a seizure
Drug management
- Drugs do not cure epilepsy but they are intended to reduce the frequency of seizures or to eradicate them altogether.
The commonly available used drugs include
- Phenobarbitone 30 to 90 mg tds daily in divided doses
- Phenytoin sodium 100-300mg DDD
- Sodium valproate 200-1200mg tds in divided doses
- Carbamazepine 100-1200mg in 3 divided doses
Encourage the patient to review clinical progress after every 2-4 weeks till control is achieved. The maximum dose for each patient depends on control of the fit and tolerance of side effects.
GENERAL PRINCIPLES OF THE TREATMENT OF EPILEPSY
- Treat the causative factors if you can identify them e.g. febrile illness like malaria, infections like meningitis, and cerebral growths such as neoplasm.
- Avoidance of precipitating factors e.g. alcohol, stress, exposure to chemicals and gases especially poisonous ones.
- Anticipation of natural variation of a seizure e.g. period when the seizure occurs helps in planning patient’s managements.
- Appropriate and regular administration of antiepileptic drugs.
Education of caretakers and persons with epilepsy
The following should be taught to the patient and the community at large
- Epilepsy is an illness just like any other illness and on treatment a person gets better
- People with epilepsy should be encouraged to enjoy as much as possible
- Isolating, stigmatizing and labelling an epileptic patient is very traumatizing to the patient, family and clan members so they should be avoided
- Children with epilepsy are encouraged to attend school
- Teachers, school children and other school personnel should be educated about the illness so that they are enlightened
- Adults with epilepsy can marry and should be encouraged to do so
- Persons with epilepsy should avoid dangerous activities such as driving, climbing height, operating heavy machines, swimming
- People have to be taught that epilepsy is not contagious so patients should be treated fairly like other people
- Epileptic seizures can effectively be controlled if drugs are taken as prescribed.
An epileptic seizure becomes an emergency only when;
- The person has never had a seizure before
- The person has difficulty breathing or walking after the seizure
- The seizure lasts longer than 5 minutes
- The person has another seizure soon after the first one
- The person is hurt during the seizure
- The seizure happens in water
- The person has a health condition like diabetes, heart disease or is pregnant
Prevention of epilepsy
- Prevent head injury by wearing seat belts and bicycle helmets.
- Seek medical help Immediately after suffering a first seizure.
- Mothers should be encouraged to get good prenatal care to prevent brain damage to a developing fetus
- Treatment of hypertension
- Avoid excess alcohol abuse and alcohol intake
- Treating high fevers in children
- Treatment of any infections and proper nutrition including adequate vitamin intake.
ANTICONVULSANTS
Well organized notes
Harder brother