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Epilepsy is a disorder in which nerve cells of the brain from time to time release abnormal electrical impulses. These cause a temporary malfunction of the other nerve cells of the brain, resulting in alteration of, or complete loss of consciousness. If you are unable to find the information you are searching for, please feel free to contact our staff and we will do what we can to find the answer to any questions you are searching for.

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TABLE OF CONTENTS

What is epilepsy?
A Common Disorder
The most carefully collected data from international surveys indicate that about 1 adult in 200 suffers from recurrent epilepsy. If we include infants who have suffered seizures caused by fever (usually a temporary problem) and adults who have only ever had one seizure, the figure rises to about 1 person in 80. Epilepsy is hardly rare, but despite this, it is not well understood.

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What Causes Epilepsy?
To understand how epilepsy arises, we must briefly outline how the brain functions normally. The brain consists of millions of nerve cells, or neurons, and their supporting structure. Each neuron maintains itself in an electrically charged state. It receives electrical signals from other neurons, and passes them on to others. What actually happens is that a tiny quantity of a special neurotransmitter substance is released from the terminals of one neuron. This chemical excites an electrical response in the neuron next in the chain, and so the signal moves onward.

All the functions of the brain, including feeling, seeing, thinking and moving muscles depend on electrical signals being passed from one neuron to the next, the message being modified as required. The normal brain is constantly generating electrical rhythms in an orderly way.

In epilepsy this order is disrupted by some neuron discharging signals inappropriately. There may be a kind of brief electrical "storm" arising from neurons that are inherently unstable because of a genetic defect (as in the various types of inherited epilepsy), or from neurons made unstable by metabolic abnormalities such as low blood glucose, or alcohol. Alternatively, the abnormal discharge may come from a localized area of the brain (this is the situation in patients with epilepsy caused by head injury, or brain tumor).

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Can anyone have Epilepsy?
Virtually everyone can have a seizure under the right circumstances. Each of us has a brain seizure threshold which makes us more or less resistant to seizures. Seizures can have many causes, including brain injury, poisoning, head trauma, or stroke; and these factors are not restricted to any age group, sex, or race and neither is Epilepsy.

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Does Epilepsy strike at any particular age?

Epilepsy can strike anyone at any age. But, as the table below (adapted from an EFA publication) shows, some age groups are more susceptible than others.

Age groups First seizures occurring - %
Age Group Percentage
0-9 47
10-19 30
20-29 13
30-39 6
40+ 4

Age group by % all first seizures occurring in each age group

Most people who develop seizures during their earlier years tend to experience a reduction in the intensity and frequency of their seizures as they grow older. In many cases the Epilepsy will disappear completely.

50% of all cases develop before 10 years of age.

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Varieties of Epilepsy
There are several forms of epilepsy. Most people will have seen someone suffer a major epileptic seizure, suddenly losing consciousness, jerking the arms and legs, etc. But there are other types of epilepsy - for example, one common form of epilepsy in children merely consists of staring blankly and losing contact with the surroundings for a few seconds.

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What is a seizure?
The best available classification of seizures is that proposed by the International League Against Epilepsy ("seizure" is an alternative term for "epileptic attack").

It starts by dividing seizures into partial seizures, where the abnormal electrical discharge originates from one specific area of the brain, and generalized seizures, where the whole brain is involved. What makes it a little confusing is that a partial seizure may occasionally go on to become generalized, if the epileptic discharge originating in one area of the brain is strong enough to then spread to the whole brain. However, even if the situation of a partial seizure progressing to become generalized, with complete loss of consciousness, convulsions, etc., the initial symptoms will be prominent, and will distinguish it from other forms of generalized epilepsy, where the whole brain is involved from the outset.

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How long does a seizures last?
Depending on the type of seizure, they can last anywhere from a few seconds to several minutes. In rare cases, seizures can last many hours. For example, a tonic-colonic seizure typically lasts 1-7 minutes. Absence seizures may only last a few seconds, while complex partial seizures range from 30 seconds to 2-3 minutes. "Status Epilepticus" refers to prolonged seizures that can last for many hours, and this can be a serious medical condition. In most cases, however, seizures are fairly short and little first aid is required.

Partial Seizures
Simple partial seizures are those in which the epileptic activity in one area of the brain does not interfere with consciousness. Thus, a person whose epilepsy has been caused by injury to the area of the brain which controls movements of one leg may experience a series of involuntary jerking movements of that leg as the only symptom.

Complex partial seizures do involve some alteration of awareness. The commonest example is where the discharge originates from one of the temporal lobes of the brain. Here the attack may consist of a feeling of intense familiarity with the surroundings ("deja vu") but being unable to respond. Automatic chomping movements of the jaw may occur.

As mentioned, it is possible that each form of partial seizure may, if the epileptic disturbance is strong enough, occasionally lead to a generalized tonic-clonic seizure.

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Generalized Seizures
Absence seizures are not dramatic - in fact, they may not even be noticed at first. This form of epilepsy was previously known as "petit mal", (from French, meaning "little sickness"), and begins in childhood, between the ages of 5 and 10. It may cease at puberty, or continue throughout adult life. Typically, the child may be seen to stare vacantly for a few seconds, often fluttering the eyelids briefly, and seeming to be out of contact with surroundings. The child does not fall to the ground, and recovery is prompt, although the attacks may recur repeatedly, up to many times in the same day. The school work then suffers, and the child may be accused wrongly of "daydreaming".

Tonic-clonic seizures were previously called "grand mal" attacks (from French, meaning "big sickness"). The episodes are dramatic. There may be a brief warning consisting of a feeling of sinking or rising in the pit of the stomach, or the person may cry out or groan before losing consciousness completely. The limbs become stiff and rigid, and breathing stops, causing the lips to go blue. The eyes are rolled upward, and the jaws are clenched - if the tongue or lips are in the way, they will be bitten. This "tonic phase" is followed, within 30 to 60 seconds by the "clonic phase", in which the body is a shaken by a series of violent, rhythmic jerkings of the limbs. These usually cease after a couple of minutes. The person then recovers consciousness, but may be confused for several minutes, and wishes to sleep for an hour or two afterward. Headache and soreness of the muscles which have contracted so violently are commonly experienced for a day or more after the attack.

Other varieties of generalized epilepsy are uncommon. They include:

Myoclonic seizures where there may be sudden, symmetrical, shock-like contractions of the limbs, which may or may not be followed by loss of consciousness.

Atonic seizures, in which there is momentary loss of tone in the muscles of the limbs, leading to sudden falling to the ground or dropping of the head. The pattern is most often seen in children who have suffered injury to the brain, through lack of oxygen at birth, meningitis in infancy, etc.

Tonic seizures, where stiffening of the body (arching the back) is the predominant feature. This type of attack may or may not be followed by loss of consciousness. It too is most commonly seen in children who have suffered some form of major insult to the brain.

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The Causes of Epilepsy
What is it that makes neurons of the brain discharge abnormally?

An inherited instability in the functioning of neurons seems to be responsible for the common forms of generalized epilepsy, especially absence attacks, and tonic-clonic seizures where there is a family history of similar disorder. How this genetic defect operates has yet to be established - perhaps the abnormality lies in the structure of the neuron's outer membrane, leading to electrical instability.

Injury to the brain may certainly cause epilepsy. This includes deprivation of oxygen at birth, trauma to the head at any time of life, and stroke (injury to part of the brain caused by blockage or hemorrhage of one of its blood vessels).

Metabolic disturbance can produce generalized seizures through disturbing the normal functioning of neurons. This may occur when there is severe lowering of blood glucose levels, and when there is severe malfunctioning of the liver or kidneys.

Alcohol and drug abuse may cause seizures during intoxication, or when the offending substance is being withdrawn. Withdrawal of certain medications, such as barbiturates and other sedatives, can cause epileptic seizures in those who have taken them for long periods.

Brain tumor is, fortunately, a relatively uncommon cause of epilepsy, but it must be excluded in all patients who develop epilepsy for the first time during adult life. Tumor should also be excluded in children and adolescents in whom the appearances of the EEG test (see below) are not typical of genetic epilepsy, or where these does not seem to be an adequate alternative explanation (such as birth injury).

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INVESTIGATION OF EPILEPSY


All patients who are suspected of having suffered an epileptic seizure should have an EEG (electroencephalogram), in which the brain's electrical rhythms are monitored by electrodes placed on the scalp, and recorded on videotape or on a paper chart.

The EEG is described in more detail below. Occasionally, the EEG will be the only investigation that is required for example, when abnormal runs of 3 cycle per second spike and wave activity appear in the EEG of a child with a history of absences. However, there may be other situations in which extensive investigations will be needed, say when the EEG is normal (a proportion of patients will have no abnormality in their EEG patterns between attacks) or when the EEG pattern or the patients symptoms indicate a localized origin.

Epilepsy appearing for the first time in adult life is another situation requiring extensive investigation, to exclude metabolic causes, tumor of the brain, etc.

Additional investigations may include blood tests (especially checking the level of glucose after an overnight fast, and levels of calcium, magnesium and tests of liver and kidney function), and special tests in which the brain itself is subjected to diagnostic imaging by CT scanning (also known as CAT scanning) or MRI (magnetic resonance imaging). In selected cases, radioisotope scanning by SPECT (single photon emission tomography) or PET positron emission tomography) may be used to determine whether there is a single epileptic focus which could be removed surgically, or whether there are in fact multiple epileptic foci which would render surgery invalid.

The selection of which tests other than the EEG are required will of course be based on availability of facilities as well as the commonsense of doctor on command.

At this stage, description of the diagnostic tests mentioned would be in order.

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The Electroencephalogram (EEG)
The EEG is central to the diagnosis of epilepsy. To record the brain's electrical rhythms, a number of electrodes (usually 22) are placed against the scalp, arranged in a fixed pattern. They may be held in place by a rubber cap device, or, if longer recordings are required, they can be secured by an adhesive chemical (collodion) The modern EEG machine now allows the recording of information from all leads simultaneously. The brain's rhythms can be traced out on folding chart paper, or recorded on videotape. Routinely, brain rhythms are recorded for about 30 minutes.

There are special cases where it is desirable to continue the recording for hours or even days, (for example when there is doubt whether a patient's "turns" are really epileptic). Here, special equipment is required for EEG monitoring, the technique being known as EEG telemetry. One method is to record the EEG by portable equipment which the patient "wears" for up to a few days ("ambulatory EEG"). The most outstanding example of EEG telemetry was that used in the Apollo astronauts' excursions to the moon - each astronaut's EEG was recorded from electrodes inside the space helmet and appeared on the controllers' screens in Houston.

The electrical potentials of the EEG are minute (microvolts) and they require special filtration and amplification. Movements such as coughing and tensing of the scalp muscles adversely affects the quality of the recording, so during a standard EEG, the patient should relax as fully as possible.

Opening and closing the eyes have an important effect on brain rhythms, and during the normal EEG, the patient is asked to open and close the eyes at frequent intervals. Toward the end of the recording, the effect on brain rhythms of deep, slow breathing for 3 minutes is checked. This has the effect of reducing the flow of blood to the brain as the carbon dioxide content of the blood is lowered, and abnormalities may be more easily shown.

The effect of exposing the patient to light flashes of varying frequencies is also routinely checked, since some forms of epilepsy are triggered by flashing light.

Patients can assist in preparing for the EEG by observing these points.

The hair should be freshly washed and soft
Women should avoid hair spray and elaborate hair styles
Men should avoid hair oil or cream
Patients should try to relax. The procedure is not unpleasant, and muscle tension makes interpretation of the results difficult.
Small children may require sedation, since restlessness makes it impossible to record an EEG accurately.

Sleep EEG's may be required where epilepsy is strongly suspected, yet the normal routine alert EEG is negative. Abnormal rhythms may appear as the patient is falling asleep, or when fully asleep. It is best if sleep is "natural" rather than drug-induced, so the patient is instructed to stay up the night before, and to come in a very tired state. There are special EEG techniques (e.g. sphenoidal lead recordings; recording from pharyngeal electrodes) which are used in certain circumstances.

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CT Scanning
Computerized Tomography (CT) is a procedure which allows the radiologist to study images of the brain, as if the brain could be "sliced". In this way, the brain can be examined to exclude tumors, strokes, and other localized abnormalities which may have given rise to seizures.

CT scanning (previously known as CAT scanning) is widely used, and is a quick, non invasive procedure. The patient lies on a table with the head (but not the face) partly within the machine. The X-ray tube turns many times in an arc about the head as each brain "slice" is imaged.

The risk of CT scanning lies in using dye to improve the quality of the images. This dye is injected into a vein of the forearm or hand. It is usual to experience flushing of the face, and occasionally, nausea during the injection. Symptoms of mild allergy to the dye are common. Sometimes a severe allergic reaction can occur, and rarely, this can be fatal (available data suggest that the risk of a fatal reaction is about 1 in 100,000). The risk of a serious reaction to the dye is highest in patients with a history of asthma and allergy in general. It can probably be reduced by using the newer (more expensive) non-ionic contrast media (dyes).

In practice, provided the radiologist carefully questions the patient concerning a history of allergy or asthma and exercises caution in selection and injection of dye, the risk of a serious adverse reaction is ver6y small, and the diagnostic information gained is so valuable that CT scanning has proved to be of enormous benefit in investigating certain epileptic patients.

Some soreness and reddening of the forearm veins extending upward from where the dye was injected (if one of the veins of the hand were used) is not uncommon, and may last for a few days. The arm should be kept elevated, especially during sleep, and if the problem persists, the radiologist who performed the test, or the family doctor should be consulted.

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MRI Scanning
Magnetic Resonance Imaging (MRI) was introduced in the 1980's, and is extremely valuable in providing images of the brain that are far superior to those obtained by CT scanning. MRI does not routinely require the injection of dye, though contrast media are available for special applications. The technology utilizes the principle of magnetic resonance.

Put simply, MRI depends on the fact that electrically charged spinning bodies generate magnetism. Brain tissue, in common with other tissues, contains water in which are found some free atoms of hydrogen. The hydrogen atom consists of one single positively charged proton forming the nucleus, and a single negatively charged orbiting electron. The natural spinning of the hydrogen nucleus converts it into a tiny natural magnet. Now if the patient's head is exposed to a strong external magnetic field, some of these natural "magnets" (i.e., hydrogen nuclei or protons) will become aligned under its influence. It is then possible to impart energy to these protons by providing a brief radio frequency pulse. When the pulse ends, the protons will give off energy in resuming their previous orientation. This energy is measured by special detectors, and used by computers to build up detailed images of the brain.

MRI is allowing us to "see" abnormalities of the brain in a far higher proportion of patients with certain types of seizures, such as complex partial seizures arising from the temporal lobe or elsewhere, than was the case with CT. In fact, MRI scanning is superior to CT scanning in every respect other than cost. The minimum cost of an MRI scanner is around $2 million, which is about four times the cost of a CT installation.

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Scanning with Radioisotopes
Almost 30 years ago, before CT scanning was invented, the first images of the brain were obtained by injecting a radioactive chemical into the blood, and recording radioactively from Geiger counters placed next to the head. Though CT and MRI scanning have made radioactive imaging obsolete for routine investigation, it has retained its value in the selection of patients for surgery.

Removal of an epileptic focus is contemplated when all attempts at control with anti-epileptic medication have failed, and when the abnormality is situated in an area of the brain where surgery will not lead to permanent impairment. Moreover, it must be established that the epileptic focus is solitary. It is here that radioisotope scanning comes into its own.

For this purpose, two types of scanning may be used:

SPECT (Single Photon Emission Tomography)
PET (Positron Emission Tomography)
SPECT is available in a number of teaching hospitals, and is being made increasingly more competitive, in terms of cost-benefit and reliability, with PET, which in Australia is available only at Royal Price Alfred Hospital, Sydney, and at the Austin Hospital, Melbourne. PET has valuable research uses, but its enormous cost (the PET scanner and its associated cyclotron, needed to generate short-acting radioisotopes, recently installed at Royal Prince Alfred Hospital cost $23.5 million) means that it will never be widely available for the selection of epileptic patients for surgery. Instead, this role will probably be played with increased frequency by improved SPECT scanners.

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TREATMENT OF EPILEPSY

The conquest of epilepsy, which really began in the 1930's with the introduction of Dilantin (Warner-Lambert), has been a triumph of modern medicine. The development of newer medications, especially Tegretol (Ciba-Geigy) and Epilim (Reckitt & Colman) has meant that epilepsy can be suppressed in most patients without serious or annoying side effects.

This is not to say that every patient can be fully controlled, or that side effects do not occur. A continuing effort is being made by international pharmaceutical companies to find safer, more effective treatments for epilepsy. New drugs are not cascading onto the market however, for the high cost of research, development and marketing (About A$150 million for any new drug) is an important disincentive.

How do drugs prevent seizures? Strange to say, most of the drugs used in treating epilepsy today were discovered to have anti-epileptic properties by chance. We have used these drugs with great benefit for years without really knowing how they work. However, a more systematic search for new anti-epileptic drugs is now under way, based on research progress in understanding how neurons transmit impulses to each other, and our increasing knowledge of the structure and function of the membrane which surrounds each neuron.

The messages that one neuron sends to the next, meditated by releasing neurotransmitter chemicals, can either excite the neuron next in line, or can inhibit its electrical activity. The identification of gamma-amino butyric acid (GABA for short) as an important natural inhibitory neurotransmitter led to a search for drugs which might suppress epilepsy through enhancing the activity of GABA. The drug Vigabatrin is a product of this approach.

Conversely, if the activity of natural excitatory neurotransmitters could be reduced, the epileptic tendency too would be lessened. Another drug, Lamotrigine, owes its anti-epileptic properties to its ability to prevent the release of the excitatory neurotransmitter glutamine from nerve endings.

Epileptic attacks should be suppressed for several reasons. Apart from prevention of injury caused by falling, biting the tongue, etc. in major attacks, frequent seizures impair memory and academic performance. The unpredictable nature of the attacks may have serious repercussions on employment and family life. Moreover, driving is not permitted until it can be shown that a person's epilepsy is under satisfactory control (more of this later).

If there is some doubt about whether a "turn" was genuinely epileptic or not, or where there were special circumstances, and the EEG and other tests are found to be normal, the treating doctor might reasonably prefer to wait without giving medication, to see what happens; in this situation, commonsense in not driving for a period, and in avoiding risky situations must be exercised. However, a second seizure would strongly indicate the need to start medication without any further delay.

The only effective means of treating epilepsy currently available are medication and, in a small proportion of patients in whom medication is not effective, surgery on the brain. Treating epilepsy by "natural" means alone (e.g. with herbal remedies) is ineffective and may be dangerous.

What is a ketogenic diet?

A ketogenic diet is very rich in lipids (fats) and oils, but low in proteins and carbohydrates. This unusually high intake of lipids and oils creates a condition in the body know as "ketosis". The metabolic shift that is created increases the seizure threshold for some. This diet is also calorie and liquid restricted. The Ketogenic diet is mainly effective in children. It requires careful preparation and strict adherence. Although it takes a significant commitment to be successful, many children have greater seizure control with this diet than with conventional (drug) therapies. Some are able to reduce or eliminate anti-seizure medications. Careful medical supervision is essential when using this as a therapy.

For further information about the Ketogenic diet, see http://www-leland.stanford.edu/group/ketodiet/, a web site that has been created by the Pediatric Neurology Division at Stanford University School of Medicine to facilitate communication between health care providers who are using the ketogenic diet to treat epilepsy.

Once started on anti-epileptic medication, never stop it unless advised to do so by a doctor. Stopping medication on one's own is likely to produce a series of major seizures, a dangerous condition.

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WHAT MAY BRING ON A SEIZURE

Alcohol
Alcohol may induce a seizure when a person is heavily intoxicated, or the seizure may occur as alcohol levels fall, say in the morning after a night of heavy drinking.

It has to be said from the start: Alcohol and Epilepsy do not mix. This doesn't mean that alcohol is totally prohibited, but indulgence must be very limited.

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Lack of Sleep
Disturbing the sleep pattern favors seizures, especially sleeping in late to compensate for a very late night.

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Emotional Stress
A person with epilepsy may experience an increased frequency of seizures during periods of intense emotional stress.

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Menstruation
Hormonal changes have an important influence on epilepsy in many women.

In those forms of genetic epilepsy which begin in childhood, puberty usually has a major effect in modifying the frequency, and often the pattern of attacks. At this time, absence attacks may disappear, or be replaced by tonic-clonic seizures. Some women notice that their seizures are clearly synchronized with their menstrual cycle, with attacks clustered around the time of menstruation. An alteration in the frequency of attacks may occur in pregnancy.

The contraceptive pill, and hormone replacement therapy do not seem to have a consistent effect on epilepsy, and can be taken by most patients without any adverse consequence on seizure frequency. You should be aware however that some seizure medications can lead to failures of oral birth control pills and this should be discussed with your doctor.

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Exposure to Flickering Light
This is in fact an uncommon trigger for seizures, but exposure to certain frequencies of flickering light is known to cause attacks in some patients. Various situations in which this can occur include indulging in video games with a "wrap-around" arrangement, watching TV at a close distance, or being in a disco. Driving along a tree-lined road with the afternoon sun producing a flickering effect is another trap. Even watching the washing go around in a laundry has been known to bring on a seizure!

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Fever
In children under the age of 5 years, fever from any cause may sometimes initiate a generalized seizure, causing great alarm. These "febrile convulsions" are similar to tonic-clonic seizures, but are much briefer.

The tendency seems to run in families.

In infants and in small children under the age of 18 months, febrile seizures must be investigated especially with a view to excluding meningitis. In older children (up to the age of 5), seizures always linked to fever are unlikely to have a serious underlying cause unless abnormal physical signs are present.

A child who suffers from febrile convulsions generally does not have a strong risk of developing epilepsy in later life. Overall, the risk of developing epilepsy in a child who has no neurological abnormality other than febrile convulsions is not greater than 3%. Febrile seizures are confined to infancy and early childhood; epileptic attacks which occur in children over the age of 5 cannot be accepted as being febrile convulsions, even if they do occur in a setting of fever.

The risk of a young child suffering a further seizure during another feverish illness is about 30%. In most instances it is sufficient to lower the child's fever as soon as it appears by sponging the child with a lukewarm sponge, or actually bathing the child in lukewarm water and by giving paracetamol (such as "Panadol", Winthrop).

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Drug Withdrawal
When certain medications (especially anti-epileptic drugs) are stopped abruptly, seizures may result. Sometimes there is in fact a succession of generalized tonic-clonic convulsions in which one seizure leads to the next without any intervening recovery. This is a dangerous situation requiring urgent hospital treatment with intravenous drugs to break the cycle. The possibility of this condition of "status epilepticus" is the main reason why patients who have been put on anti-epileptic medication should never stop treatment except on medical advice.

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