Epilepsy

What is it?
Epilepsy is a condition characterised by sudden disturbances in the
electrical impulses of the brain, causing the individual to have a seizure.
There are many different causes of seizures so diagnoses of epilepsy,
and the type of epilepsy, is based on the type of seizure the patient has.
Epilepsy can develop at any time of life. In the UK there are about
420,000 people with epilepsy, about 1 in every 130, of which
approximately 43,500 are children.
What causes it?
The causes of epilepsy are still unknown in the majority of cases. In those
cases where cause is identified epilepsy can be due to a number of
reasons including:
• injury to the brain caused by lack of oxygen at birth;
• trauma to the head;
• stroke;
• infections like meningitis or encephalitis;
• metabolic disturbance caused by severe lowering of blood glucose levels, or
severe malfunctioning of the liver and kidneys;
• genetic inheritance;
• brain tumour;
• alcohol and drug abuse. Seizures can occur either during intoxication or when
withdrawing from the substance. Sometimes withdrawal from
medications like barbiturates and other sedatives can provoke a seizure
if the medication has been taken over long periods.
Types of epilepsy
There are many different types of epilepsy but it is usually divided into the
following three groups: symptomatic, idiopathic and cryptogenic
epilepsy.
• Idiopathic epilepsy starts in childhood or adolescence and is intrinsic to the
individual. It is not due to structural change or lesions in the brain and the
cause is not known.
• Symptomatic epilepsy is thought to be caused by an underlying structural
abnormality of the brain.
• Cryptogenic epilepsy is a term employed where the cause is suspected but
can't be proved.
Types of seizures
Doctors generally use variations of the International Classification of
Epileptic Seizures as defined by the International League Against
Epilepsy to help them to define the type of epilepsy they are dealing with.
Seizures are divided into three categories: generalised seizures, partial
(focal) seizures, and epilepsy syndromes.
• Generalised seizures: this is when both sides of the brain are involved in the
seizure and the individual looses consciousness. There are six main
types of generalised seizures.
◦ Tonic-clonic seizures (grand mal): these last from 3 to 4 minutes
and describe the action of the seizure. Tonic means contracting
and the muscles of the individual contract and become so rigid
 they fall to the ground. Muscles around the lungs also contract
causing the recognisable involuntary 'epileptic cry'. Clonic means
convulsive and this is what happens after the contraction of the
muscles, a rhythmic convulsion.
◦ Tonic seizures: this type of attack only has the rigid phase.
◦ Clonic seizures: this type of attack only has the convulsive phase.
◦ Atonic seizures (or drop attacks) - this is where loss of muscle tone
occurs and the individual may fall to the ground.
◦ Myoclonic seizures: sudden muscle jerks.
◦ Absence seizures (petit mal) consciousness is absent due to an
interruption of brain activity. They sometimes last only a few
seconds and so can be missed and are more prevalent in girls
than boys.
• Partial (focal) seizures: these begin at a particular point in the brain but may
also spread to the whole brain and become what is known as a
secondarily generalised seizure. Consciousness may be lost depending
on whether the seizure is simple or complex. There are two types of
partial (focal) seizures.
◦ Simple partial seizures (also known as Jacksonian seizures).
Consciousness will be unaffected as long as the seizure activity
remains within a small area. If however, activity spreads over both
hemispheres of the brain, the seizure becomes a secondarily
generalised seizure and the individual will lose consciousness. In
these cases the simple seizure is a warning of the bigger attack
and is known as an aura. There are many different auras or
warnings of attacks; the most common are a feeling of nausea
and a feeling of fear.
◦ Complex partial seizure these occur when seizure activity spreads to
a larger area of the brain so affecting the individual's
consciousness
◦ more.
• Epilepsy syndromes: this term is employed when seizures seem to follow
recognisable patterns or typical courses, however a clear diagnosis is not
always possible but is useful for both prescribing treatment and for
predicting the likely outcome or prognosis. The following is a list of
syndromes that occur in childhood. For more information on specific
syndromes contact the epilepsy organisations listed at the end of the fact
sheet.
◦ Benign rolandic epilepsy of childhood (BREC) also known as
benign
◦ partial epilepsy with centro-temporal or rolandic spikes.
◦ Juvenile myoclonic epilepsy (JME) also known as Janz Syndrome
◦ West syndrome, also known as infantile spasms or salaam spasms
◦ Lennox-Gastaut syndrome
◦ Landau-Kleffner syndrome (LKS)
◦ Sturge-Weber syndrome (SWS)
◦ Rasmussen's syndrome
• Some conditions that affect the brain, such as cerebral palsy, autism
and learning difficulties, can increase the likelihood of epilepsy, due
to the underlying brain damage that has caused both conditions.
 For those with the two conditions combined, the epilepsy is likely to
be of a more severe form, sometimes called 'epilepsy plus'. Some
30%-40% of children who develop epilepsy below the age of 16 will
outgrow it before adulthood. Unfortunately though, it is impossible
to predict an individual's prognosis.
• Status epilepticus. This is an extremely dangerous occurrence and is
the term for seizures that last for at least 30 minutes, or for seizures
that occur one after another for a period of 30 minutes with no
return to consciousness in between. The dangers of status
epilepticus are brain damage, and sometimes death, caused by
lack of oxygen to the brain. To counter status epilepticus anti-
epileptic drugs need to be injected into the muscles or the veins.
Women and Epilepsy
Women who have epilepsy often report that their seizures bear some
relation to their menstrual cycle. Many women find they have more
seizures around ovulation or around menstruation (catamenial epilepsy).
It is thought that they may be caused by changes in levels of the
hormones oestrogen and progesterone, or to alterations in body fluids
which affects the efficacy of anti-epileptic medication.
Epilepsy and pregnancy
Anti-epileptic drugs can lead to complications in pregnancy. There is a
definite risk of malformation of the foetus caused by drugs (see under
medication below for further information). Conversely, if the pregnant
woman experiences a tonic-clonic seizure this can lead to lack of oxygen
to the foetus with the risks that that presents. Miscarriage in early
pregnancy, premature labour in more advanced pregnancy, and injury are
additional risks of uncontrolled epilepsy. Anti-epileptic drugs deplete the
supply of folic acid, so women planning to conceive should take a higher
dose than that usually recommended. However this should be done with
your doctor's knowledge, as some research seems to show that this
makes the epilepsy worse.
Foldvary N. Treatment issues for women with epilepsy. Neurol Clin 2001
May;19(2):409-25 "Affected women are unaware of many of the unique
issues they face, including the relationship between antiepileptic drug
therapy and contraception, the risk of abnormal pregnancy outcomes, the
effect of hormones and aging on seizure control, and the increased
incidence of reproductive dysfunction. "
Sudden unexplained death in epilepsy
There are believed to be between 200 and 500 deaths due to epilepsy in
the UK alone, and the risk of a premature death in people with epilepsy is
about 2 to 4 times higher than the population in general. The highest risk
group is young men (between 20 and 30) with uncontrolled epilepsy and
who experience tonic-clonic seizures.
Treatment
There are a number of different ways of dealing with epilepsy including
surgery, anti-epileptic medication; alternative therapies, the ketogenic diet
and self-help.
1. SurgeryAll surgery for epilepsy is performed on the brain. The area of
the brain involved depends on the type of epilepsy. Surgery for epilepsy is
relatively safe with complications occurring only in 4% of operations (4).
There are five types of surgery: lobectomies; corpus callosotomies;
hemispherectomies; and multiple subpial transection.
1 LobectomiesThis is where an area of the brain (called a lobe) is removed
either partially or totally. This type of surgery is performed if the seizure
originates in the same area of the brain each time. It is only performed if
the area of the brain removed does not affect vital functions.
2 Corpus callostomies (split brain surgery)This surgery is performed on
those whose epilepsy does not originate in one area of the brain but both
sides at once. The corpus callosum is the name of the nerve fibres
connecting one side of the brain to the other and a corpus callostomy
cuts these nerve fibres with the aim of stopping the spread of the seizure.
Although this procedure does not entirely stop seizures it usually
significantly reduces the number of seizures and their effects are
generally less severe.
3 HemispherectomyThis is carried out when the epilepsy is caused by severe
brain disease on one side of the brain and so the complete hemisphere
is removed. In children the half that is left often takes over some of the
functions of the removed half, however there will be some noticeable
effects of weakness and loss of some movement on the opposite side of
the body to the hemisphere removed, and also a loss of peripheral (side)
vision.
4 Multiple subpial transection (MST)When seizures originate in the parts of
the brain that are responsible for vital function it is not possible to remove
them so a MST is performed. It involves making small incisions in the
brain, which interfere with the spread of seizure impulses.
Other surgical interventions:
• LesionectomySurgeons at the Mayo Clinic in Rochester, Minnesota have
pioneered a surgical technique that gives them access to the most
remote and sensitive areas of the brain. Using a computer, a surgeon
can view and vaporise the tiny tumours that cause some cases of
epilepsy. The procedure can be performed with minimal damage to the
healthy tissue in the brain.
• Vagus nerve stimulationThis involves surgery, but not brain surgery. Vagus
nerve stimulation consists of a small programmable pulse generator (a
type of battery that can last up to 12 years) that is implanted under the
skin of the left upper chest with electrodes running under the skin and
connected to the vagus nerve in the neck. The doctor programs the
device to deliver short bursts of electrical energy to the brain via the
vagus nerve. If necessary the patient or a companion can use a magnet
to stimulate the generator for an extra burst of electrical energy, if a
seizure seems imminent. The vagus nerve is used because it contains
few if any pain fibres, over 80% of the electrical signals applied to the
vagus nerve in the neck are sent upwards to the brain, and connecting
the device does not involve brain surgery. Side effects of vagus nerve
stimulation seen so far have been voice change, throat discomfort, a
feeling of shortness of breath and a cough.
•
• Vagus nerve stimulation does not cure epilepsy, but according to research
seems to substantially improve the overall quality of life of a third of
patients who use it, another third experience a good improvement in the
quality of life, while the remaining third experience little or no
improvement. As yet there is no way to determine how an individual will
respond to the therapy.
•
• Vagus nerve stimulation has been available in the UK for about 4 years now
and is performed at various hospitals around the country. A neurologist
usually recommends vagus nerve stimulation after they have decided
that
• phamacalogically and surgically they can go no further. Some health
authorities do not provide VNS on the national health. If this proves to be
the case there is a charity, set up to help individuals find funding so that
the procedure can be carried out.
Research:

- Patwardhan RV, Stong B, Bebin EM, Mathisen J, Grabb PA. Efficacy of

vagal nerve stimulation in children with medically refractory epilepsy.
Neurosurgery 2000 Dec;47(6):1353-7; discussion 1357-8
"VNS should be considered for children with medically refractory epilepsy
who have no surgically resectable focus."
For further information contact:
F.A.B.L.E (For A Better Life with Epilepsy)Ashgate House
9-13 Ashgate Road
Broomhill
Sheffield S10 3BZ
Tel: 0800 521629
Website: http://www.fable.org.uk
Fable help put people in touch with others in the same situation, and in
the future they aim to open respite care homes.