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The term epilepsy implies that there has been more than one epileptic fit. Many people can have a single seizure and have no other problem in their life. There are however 385,000 or so people with epilepsy in the United Kingdom and this diagnosis does have a major impact on people's lives. Unfortunately the general public have a great deal of suspicion and poor understanding about people who have epilepsy. This unfortunately leads to a great deal of prejudice in society as a whole and little has been done outside of the support groups to change this approach.
An epileptic fit or seizure occurs when there is an abnormal electrical discharge from brain cells. An epileptic fit can occur in many different ways. Not all seizures involve jerking movements. An individual may suffer from different types of epileptic attacks. Usually however the type of attack is similar in the same person.
In a generalised epileptic fit, there is loss of consciousness. An abnormal electrical discharge involves the whole brain. Usually there is very little warning and there will be a tendency to fall if standing. In the so-called tonic clonic epileptic fit, there will be a rigidity. This will be followed by a jerking movement. The tongue may be bitten, urine may be passed and the breathing may change or even stop temporarily. This can be seriously frightening to anybody who witnesses an attack for the first time.
It is possible in a generalised epileptic fit for the tone in the body to be increased without the jerking. An individual tends to fall like a tree trunk. There can be complete loss of muscle tone which makes the individual fall to the ground like a sack of potatoes.
There are other types of generalised seizure where there is a sudden jerk of the limbs and this is called myoclonic epilepsy. There are also attacks where an individual can just be absent (absence seizures). Children commonly with their epilepsy get this type of attack where there may just be a fluttering of the eyelids or a smacking of the lips with a lack of awareness of what is taking place.
If a local area of the brain is affected, then a partial seizure may take place. When epileptic attacks are partial, then they can be simple partial, complex partial or they may within that framework become secondarily generalised. Depending on the part of the brain that gives out an electrical discharge will determine the type of simple partial seizure. The complex partial seizure merely means that rather more areas of the brain are involved. Complex partial seizures can be particularly worrying as there may be some degree of movement almost as if an individual knows what they are doing except that is clearly not the case.
If the partial seizure goes on to involve loss of consciousness, then this is called a secondary generalised epileptic fit.
Because the presentation of epilepsy can be so varied, it is difficult to give a very full account of every type of attack.
The diagnosis of epilepsy requires a clear account of the nature of the attack. As the individuals themselves may not know anything about it, it is absolutely fundamental for a witnessed account to be obtained. There are many people who have a diagnosis of epilepsy when this is not correct. Likewise people may have epileptic seizures and not be diagnosed because of the inability to go and see a neurologist. The diagnosis is usually made on that history alone. Certain questions are very helpful to a witness. These would be as follows.
1. What happened before, during and after the attack and how long did the episode last?
2. Did the individual have any warning that the episode was going to occur?
3. Were there any other factors or circumstances that preceded the episode?
4. Did they bite their tongue or become incontinent?
5. Was the loss of consciousness prolonged?
6. Did they change colour during the episode?
7. How quickly did the individual come round and were they confused?
Questions about a high fever for instance in a child may help with the diagnosis of a febrile convulsion. Likewise knowing if there had been any birth injuries or head injuries may assist although will not make the diagnosis for certain.
Usually the diagnosis is made by the history and not by investigation. There are a number of tests however and these include the following.
A number of blood tests ought to be carried out to exclude a metabolic cause. It is necessary to know the sodium and potassium levels. A calcium, glucose and liver function tests are normally performed. A full blood picture is usefully carried out on everybody with any kind of blackout. Anaemia for instance makes many conditions more likely to happen and in particular a faint.
Many people believe that an EEG is needed for the diagnosis of epilepsy. This is
not correct. The only way that the EEG confirms the diagnosis is if an attack occurs
during the recording and the EEG changes in a typical way. It can be said however
that if an EEG is very abnormal with epileptic discharges and the attacks sound like
epilepsy, then there is a great likelihood that this is the diagnosis.
The test involves putting electrodes on the scalp. A specialist trained technician does the test. They are not medically qualified but they can do the technical recording and reporting. The test is quite painless lasting up to thirty minutes or more. The patient will be asked to breathe deeply, open and close their eyes and they may well be asked to look at a flashing light to see if the brain wave responses change to this stimulus. Out of interest, in the condition called photosensitive epilepsy, photic stimulation as it is called may well generate epileptic discharges.
More sophisticated recordings such as sleep deprived/sleep induced EEG recordings can be carried out. For this test, the individual would be asked to stay awake all night and then of course they usually fall asleep when they come into the laboratory to have the test done. Occasionally it is necessary to use a mild sedative particularly in children to make sure that they do go off to sleep in the excitement of having the test done.
More sophisticated testing can be done by allowing the EEG to be worn for as long as seventy-two hours. This test is particularly helpful when there is doubt about the diagnosis and the attacks are occurring often albeit transiently on a regular basis. If an attack occurs an the individual can identify it as such, then they can press a button on the machine and keep a diary. The reporting neurologist or neurophysiologist together with a technician can then confidently compare the recording with the diary.
Even better is the use of video telemetry when an individual is monitored throughout recording by video control.
Only in the United Kingdom is CT scanning considered a useful test in the diagnosis
of epilepsy. It is my personal view that CT brain scanning, which is an x-ray test,
should not be carried out in epilepsy for any reason. The only test that should be done
with a potential diagnosis of epilepsy is MRI or magnetic resonance imaging. The only
exceptions to this rule would be if there was an absolute contra-indication to having an
MRI scan carried out such as individual who has a pacemaker or for instance a
metal splinter in their eye. It is remarkable that the National Society for Epilepsy still says
in its information sheets that CT scanning is a test that may be done. This only happens in Britain because of the pathetic number of MR scanners in the country.
Neurology doctors tell people significant diagnoses every day of their life. Unfortunately we see so many people with epilepsy being diagnosed for the first time that I fear we become hardened for the significance of this diagnosis to the individual. For young people, this will be without question the most important piece of information they have every received. It will have a profound effect on life whatever else is said or sympathy given. The telling of the diagnosis is a time for both skilled sympathy and objectivity. Sympathy is actually useless. What is needed is clear concise facts and guidance for the future. Without question, the biggest problem in adults over the age of seventeen is the driving regulations. In the UK, it is necessary to go one year fit free before driving can be resumed. It is necessary to inform DVLA and your insurance company. To continue driving would be illegal and doing so would be whilst uninsured with all the terrible consequences that this could generate. In my experience, it is this facet of information that almost overwhelms everything else. I can tell somebody that they do not have a brain tumour as a consequence of the MRI scan. Instead of being delighted with this wonderful news, all focus attaches to the driving regulations. In the areas where I work, the public transport system is abysmal and hence I do have enormous sympathy and understanding but the law is the law and it is imperative that the right information is given.
Following the diagnosis, it is necessary to give a full discussion as to the implications of suffering with epilepsy. This needs to include many aspects of life including commonsense measures such as care with taking a bath by oneself in a locked bathroom or swimming when there is no other adult who knows that there has been a blackout. The mainstay of treatment is drug therapy. There is almost no other treatment that makes the slightest difference to the frequency of epileptic seizures.
Alternative therapies may help reduce the frequency of attacks by various relaxation techniques but the predominant management involves the taking of tablets or syrup on a regular basis to block the attacks from happening. There are a series of first line and second line drugs. Information sheets from the National Society for Epilepsy are particularly helpful as they list all of the first line and second line drugs that are presently available. I would however take issue with their view that phenytoin is only a second line drug. There is no doubt in my mind that for individuals who are over the age of fifty because it is a once daily dosage and it can be given at the right dosage very readily, then it remains a first line drug of choice for this particular age group. It is not indicated for young people because of the long term potential side-effects.
Because epilepsy is so common, the drugs have been used in large numbers of patients and hence the side-effects of all these drugs are well known. The list of side-effects is actually overwhelming when you first see it. It needs to be remembered that these medications have been used in literally millions of people and hence the side-effects are likely to be slight. With most people, there are no significant side-effects. Although there is a worry about the same when drug treatment is started, usually at three years the main worry is the thought of having a breakthrough attack.
The prognosis of epilepsy depends on the cause. If there is a structural lesion, then the prognosis will depend on the nature of the condition that is underlying the cause of the epilepsy. If there is no clear structural lesion, then the prognosis will depend on whether or not drug treatment is effective. For 80%-90% of patients, a single drug in the correct dose will get control of the seizures. There are however between 10% and 20% of patients in whom control is very difficult. It is this group that often find themselves needing regular contact with a consultant neurologist and the use of the various second line drug regimes which may involve the taking of more than one tablet. It is essential to get people on to a drug regime that involves taking tablets no more than twice each day. If you are suffering with epilepsy and you are still taking pills three times daily, then you need to ask your neurologist or doctor whether this is really necessary. From my own perspective, if I ever have to take even a course of antibiotics three times a day for more than five days, I miss out on the middle day dose. Quite simply, it is a failure to comply with treatment that is the commonest cause of having a breakthrough attack. The other reasons why breakthrough attacks occur are because of having a fever or some kind of tummy upset that causes diarrhoea or vomiting, drinking too much alcohol, getting excessively tired or missing meals such that there is relative drop in blood sugar levels.