Seizure Disorder

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Definition

A seizure is a sudden disruption of the brain's normal electrical activity accompanied by altered consciousness and/or other neurological and behavioral manifestations. Epilepsy is a condition characterized by recurrent seizures that may include repetitive muscle jerking called convulsions.

Description

There are more than 20 different seizure disorders. One in ten Americans will have a seizure at some time, and at least 200,000 have at least one seizure a month.

Epilepsy affects 1–2% of the population of the United States. Although epilepsy is as common in adults over 60 as in children under 10, 25% of all cases develop before the age of five. One in every two cases develops before the age of 25. About 125,000 new cases of epilepsy are diagnosed each year, and a significant number of children and adults that have not been diagnosed or treated have epilepsy.

Most seizures are benign, but a seizure that lasts a long time can lead to status epilepticus, a life-threatening condition characterized by continuous seizures, sustained loss of consciousness, and respiratory distress. Non-convulsive epilepsy can impair physical coordination, vision, and other senses. Undiagnosed seizures can lead to conditions that are more serious and more difficult to manage.

Generalized epileptic seizures occur when electrical abnormalities exist throughout the brain. A partial seizure does not involve the entire brain. A partial seizure begins in an area called an epileptic focus, but may spread to other parts of the brain and cause a generalized seizure. Some people who have epilepsy have more than one type of seizure.

Motor attacks cause parts of the body to jerk repeatedly. A motor attack usually lasts less than an hour and may last only a few minutes. Sensory seizures begin with numbness or tingling in one area. The sensation may move along one side of the body or the back before subsiding.

Visual seizures, which affect the area of the brain that controls sight, cause people to see things that are not there. Auditory seizures affect the part of the brain that controls hearing and cause the patient to imagine voices, music, and other sounds. Other types of seizures can cause confusion, upset stomach, or emotional distress.

GENERALIZED SEIZURES. A generalized tonic-clonic (grand-mal) seizure begins with a loud cry before the person having the seizure loses consciousness and falls to the ground. The muscles become rigid for about 30 seconds during the tonic phase of the seizure and alternately contract and relax during the clonic phase, which lasts 30–60 seconds. The skin sometimes acquires a bluish tint and the person may bite his tongue, lose bowel or bladder control, or have trouble breathing.

A grand mal seizure lasts between two and five minutes, and the person may be confused or have trouble talking when he regains consciousness (post-ictal state). He may complain of head or muscle aches, or weakness in his arms or legs before falling into a deep sleep.

PRIMARY GENERALIZED SEIZURES. A primary generalized seizure occurs when electrical discharges begin in both halves (hemispheres) of the brain at the same time. Primary generalized seizures are more likely to be major motor attacks than to be absence seizures.

ABSENCE SEIZURES. Absence (petit mal) seizures generally begin at about the age of four and stop by the time the child becomes an adolescent.

Absence seizures usually begin with a brief loss of consciousness and last between one and 10 seconds. A person having a petit mal seizure becomes very quiet and

may blink, stare blankly, roll his eyes, or move his lips. A petit mal seizure lasts 15-20 seconds. When it ends, the person who had the seizure resumes whatever he was doing before the seizure began. He will not remember the seizure and may not realize that anything unusual has happened. Untreated, petit mal seizures can recur as many as 100 times a day and may progress to grand mal seizures.

MYOCLONIC SEIZURES. Myoclonic seizures are characterized by brief, involuntary spasms of the tongue or muscles of the face, arms, or legs. Myoclonic seizures are most apt to occur when waking after a night's sleep.

A jacksonian seizure is a partial seizure characterized by tingling, stiffening, or jerking of an arm or leg. Loss of consciousness is rare. The seizure may progress in characteristic fashion along the limb.

Limp posture and a brief period of unconsciousness are features of akinetic seizures, which occur in young children. Akinetic seizures, which cause the child to fall, are also called drop attacks.

PARTIAL SEIZURES. Simple partial seizures do not spread from the focal area where they arise. Symptoms are determined by what part of the brain is affected. The patient usually remains conscious during the seizure and can later describe it in detail.

COMPLEX PARTIAL SEIZURES. A distinctive smell, taste, or other unusual sensation (aura) may signal the start of a complex partial seizure.

Complex partial seizures start as simple partial seizures, but move beyond the focal area and cause loss of consciousness. Complex partial seizures can become major motor seizures. Although a person having a complex partial seizure may not seem to be unconscious, he does not know what is happening and may behave inappropriately. He will not remember the seizure, but may seem confused or intoxicated for a few minutes after it ends.

— Maureen Haggerty

Definition

The words "epilepsy" and "epileptic" are of Greek origin and have the same root as the verb "epilambanein," which means "to seize" or "to attack." Therefore, epilepsy means seizure, while epileptic means seized. In the modern understanding of epilepsy, it should not be considered a disease. Rather, it is a symptom indicating a medical condition in the brain that causes a potential for recurrent seizures. The condition of epilepsy has many causes and the kinds of seizures that occur can vary widely.

Description

The word epilepsy is actually a descriptive term. It takes into account an individual's risk of recurrent seizures. However, when people are suffering from meningitis and have a seizure, they would not be considered to have epilepsy unless they had a seizure after the meningitis resolved. In this case, these individuals have a risk for recurrent seizures and, hence, epilepsy. If an individual over time does not have any seizures off medications, then it could be said that epilepsy has resolved or gone into remission.

For thousands of years, epilepsy was looked upon differently than most other medical problems. Because of this, epilepsy has been fraught with social stigmas, even up to today. The ancient Greeks knew about the condition that led to a sudden attack upon the unfortunate. Although Hippocrates, in roughly 400 B.C., referred to epilepsy as the sacred disease, he did so to emphasize the general public's superstitious view of the condition. Of course, it certainly was not an affliction sent from a deity, nor was it even a demon. Nevertheless, seizures, which manifest in unusual behaviors, mystified observers who considered this illness, from all others, as coming from another world.

The current understanding of epilepsy is a recent development. Previously, it was not even believed that the brain had electrical properties. It was not until the last few centuries that the brain was considered the seat of the mind; it was the heart or the lungs that were commonly regarded as the organ of thought. Physicians struggled with what to even call a seizure. In general, any behavior that resulted in a loss of consciousness or convulsions was labeled a seizure. It is likely that episodes of fainting were erroneously called seizures.

Finally, in 1873, an adequate definition for the term seizure finally came into existence. The famous English neurologist John Hughlings Jackson explained epilepsy as "a sudden, excessive, and rapid discharge of gray matter of some part of the brain" that would correspond to the patient's experience.

Demographics

More than 2.5 million Americans suffer from epilepsy, and more than another 50 million worldwide. Epilepsy is more common than Parkinson's disease, multiple sclerosis, cerebral palsy, and muscular dystrophy all combined. The risk of experiencing one seizure in the course of a lifetime, from any cause, is close to 10%. However, there is an approximately 1% chance of developing epilepsy in the general population before the age of 20. The risk increases to 3% by age 75. Of course, depending on the age group being studied, the cause of epilepsy will vary. The incidence of epilepsy is relatively constant among different ethnic groups and similar between genders. However, there may be variation in incidence in underdeveloped countries due to access to care and endemic illness that can cause seizures, such as neurocystercercosis in Latin American countries.

Causes and symptoms

Epilepsy has many causes that, in part, have an affect on the clinical presentation of symptoms. In order for epilepsy to occur, there must be an underlying physical problem in the brain. The problem can be so mild that an individual is perfectly normal other than seizures. The brain has roughly 50–100 billion neurons. Each neuron can have up to 10,000 contacts with neighboring neurons. Hence, trillions of connections exist. However, only a very small area of dysfunctional brain tissue is necessary to create a persistent generator of seizures and, hence, epilepsy. The following are potential causes of epilepsy:

• genetic and/or hereditary
• perinatal neurological insults
• trauma with brain injury
• stroke
• brain tumors
• infections such as meningitis and encephalitis
• multiple sclerosis
• ideopathic (unknown or genetic)

Any of the above conditions have the potential for causing the brain or a portion of it to be dysfunctional and produce recurrent seizures. Regardless of the exact cause, epilepsy is a paroxysmal (sudden) condition. It involves the synchronous discharging of a population of neurons. This is an abnormal event that, depending on the location in the brain, will correspond to the particular symptoms of a seizure. The International League Against Epilepsy (ILAE) issued a classification of types of seizures. The list gives the kind of seizures that can occur. Individual seizure types are based on the clinical behavior (semiology) and electrophysiological characteristics as seen on an electroencephalogram (EEG). Generalized seizures included in the list are:

• tonic-clonic seizures (includes variations beginning with a clonic or myoclonic phase)
• clonic seizures, including without tonic features and with tonic features
• typical absence seizures
• atypical absence seizures
• myoclonic absence seizures
• tonic seizures
• spasms
• myoclonic seizures
• eyelid myoclonia, including without absences and with absences
• myoclonic atonic seizures
• negative myoclonus atonic seizures
• reflex seizures in generalized epilepsy syndromes

Focal seizures included in the ILAE list are:

• focal sensory seizures with elementary sensory symptoms (e.g., occipital and parietal lobe seizures) and experiential sensory symptoms (e.g., temporo-parieto-occipital junction seizures)
• focal motor seizures with elementary clonic motor signs, asymmetrical tonic motor seizures (e.g., supplementary motor seizures), typical (temporal lobe) automatisms (e.g., mesial temporal lobe seizures), hyperkinetic automatisms, focal negative myoclonus, and inhibitory motor seizures
• gelastic seizures
• hemiclonic seizures
• secondarily generalized seizures
• reflex seizures in focal epilepsy syndromes

In 1989, the International League Against Epilepsy also issued the following classification of epilepsies and epileptic syndromes:

• benign familial neonatal seizures
• early myoclonic encephalopathy
• Ohtahara syndrome
• migrating partial seizures of infancy (syndrome in development)
• West syndrome
• benign myoclonic epilepsy in infancy
• benign familial and non-familial infantile seizures
• Dravet's syndrome
• HH syndrome
• myoclonic status in nonprogressive encephalopathies (syndrome in development)
• benign childhood epilepsy with centrotemporal spikes
• early onset benign childhood occipital epilepsy (Panayiotopoulos type)
• late-onset childhood occipital epilepsy (Gastaut type)
• epilepsy with myoclonic absences
• epilepsy with myoclonic-astatic seizures
• Lennox-Gastaut syndrome
• Landau-Kleffner syndrome (LKS)
• epilepsy with continuous spike-and-waves during slow-wave sleep (other than LKS)
• childhood absence epilepsy
• progressive myoclonus epilepsies
• idiopathic generalized epilepsies with variable phenotypes include juvenile absence epilepsy, juvenile myoclonic epilepsy, and epilepsy with generalized tonic-clonic seizures only
• reflex epilepsies
• idiopathic photosensitive occipital lobe epilepsy
• other visual sensitive epilepsies
• primary reading epilepsy
• startle epilepsy
• autosomal dominant nocturnal frontal lobe epilepsy
• familial temporal lobe epilepsies
• generalized epilepsies with febrile seizures plus (syndrome in development)
• familial focal epilepsy with variable foci (syndrome in development)
• symptomatic focal epilepsies
• limbic epilepsies
• mesial temporal lobe epilepsy with hippocampal sclerosis
• mesial temporal lobe epilepsy defined by specific etiologies
• neocortical epilepsies
• Rasmussen syndrome

Classifying epilepsy can help in the evaluation and management of patients with seizure disorders. The combination of seizure type(s), etiology (cause), age of onset, family history, and other medical or neurological conditions can be used to identify an epilepsy syndrome. Classification helps clinicians and researchers understand the broader picture of seizure disorders. On a practical level, syndrome identification can help in planning the management of patients. Syndrome classification schemes are revised periodically as individual components of particular categories are better understood.

The term idiopathic refers to a cause that is suspected to be, if not genetic, then unknown. Cryptogenic is a term that suggests that an underlying cause is suspected, but not yet fully understood. Symptomatic is a term that is applied to epilepsies that are a result of understood underlying pathologies.

The management and prognosis vary considerably among these differing syndromes. Epilepsies that have a genetic basis can be inherited or occur spontaneously. A detailed family history can often identify other family members who have had seizures. However, because seizures are common, it is possible to have more than one family member with epilepsy, though the etiologies may not be related. To say that a particular type of epilepsy is genetic does not mean that it is necessarily transmitted by heredity. Often, disorders can have a genetic cause, but be spontaneously occurring in only one member of a family. In this case, there may simply be a random mutation in that particular person's genes.

There are several mechanisms in which epilepsies can be inherited. So-called simple Mendelian inheritance occurs with benign familial neonatal convulsions and autosomal dominant nocturnal frontal lobe epilepsy. On the other hand, complex inheritance mechanisms can involve more than one gene, or a gene mutation in combination with environmental or acquired factors such as juvenile myoclonic epilepsy. As the genetics of the epilepsies become better understood, the classification scheme will evolve.

With epilepsy, symptoms vary considerably depending on the type. The common link among the epilepsies is, of course, seizures. The different epilepsies can sometimes be associated with more than one seizure type. This is the case with Lennox-Gastaut syndrome.

Diagnosis

Arriving at a diagnosis of epilepsy is relatively straightforward: when people suffer two or more seizures, they would be considered to have epilepsy. However, diagnosing the specific epilepsy syndrome is much more complex. The first step in the evaluation process is to obtain a very detailed history of the illness, not only from the patient but from the family as well. Since seizures can impair consciousness, the patient may not be able to recall the specifics of the attacks. In these cases, family or friends that have witnessed the episodes can fill in the gaps about the particulars of the seizure. The description of the behaviors during a seizure can go a long way to categorizing the type of seizure and help with the overall diagnosis. Moreover, in the initial visit with the physician, the entire history of the patient is obtained. In a child, this would include birth history, complications, if any, maternal history, and developmental milestones. At any age, socalled co-morbidities (other medical problems) are considered. Medications that have been taken or currently being prescribed are documented.

A complete physical examination is performed, especially a neurological exam. Because seizures are an episodic disorder, abnormal neurological findings may not be present. Frequently, people with epilepsy have a normal exam. However, in some, there can be abnormal findings that can provide clues to the underlying cause of epilepsy. For example, if someone has had a stroke that subsequently caused seizures, then the neurological exam can be expected to reveal a focal neurological deficit such as weakness or language difficulties. In some children with seizures, there can be a variety of associated neurologic abnormalities such as mental retardation and cerebral palsy that are themselves non-specific but indicate that the brain has suffered, at some point in development, an injury or malformation. Also, subtle findings on examination can lead to a diagnosis such as in tuberous sclerosis. This is an autosomal dominantly inherited disorder associated with infantile spasms in 25% of cases. On examination, patients have so-called ash-leaf spots and adenoma sebaceum on the skin. There can also be a variety of systemic abnormalities that involve the kidneys, retina, heart, and gums, depending on severity.

In the course of evaluating epilepsy, a number of tests are typically ordered. Usually, magnetic resonance image (MRI) of the brain is obtained. This is a scan that can help in finding many known causes of epilepsy such as tumors, strokes, trauma, and congenital malformations. However, while MRI can reveal incredible details of the brain, it cannot visualize the presence of abnormalities in the microscopic neuronal environment. Another test that is routinely ordered is an electroencephalogram (EEG). Unlike the MRI scan, this can be considered a functional test of the brain. The EEG measures the electrical activity of the brain. Some seizure disorders or epilepsies have a characteristic EEG with particular abnormalities that can help in diagnosis. Other tests that are frequently ordered are various blood tests that are also ordered in many medical conditions. These blood tests help to screen for abnormalities that can be a factor in the cause of seizures. Occasionally, genetic testing is performed in those instances where a known genetic cause is suspected and can be tested. A major concern in the course of an evaluation of epilepsy is to identify the presence of life-threatening causes such as brain tumors, infections, and cerebrovascular disease. Also, an accurate diagnosis can expedite the most effective treatment plan.

The symptoms of epilepsy are dependent in part on the particular seizures that occur and other medical problems that may be associated. Seizures, themselves, can take on a variety of features. A simple sustained twitching of an extremity could be a focal seizure. If a seizure arises in the occipital lobes of the brains, then a visual experience can occur. Aura is a term often used to describe symptoms that a person may feel prior to the loss of consciousness of a seizure. However, auras are, themselves, small focal seizures that have not spread in the brain to involve consciousness. Smells, well-formed hallucinations, tingling sensations, or nausea have each occurred in auras. The particular sensation can be a clue as to the location in the brain where a seizure starts. Focal seizures can then spread to involve other areas of the brain and lead to an alteration of consciousness, and possibly convulsions. In certain epilepsy syndromes such as Lennox-Gastaut, there can be more than one type of seizure experienced, such as atonic, atypical absence, and tonic-axial seizures.

Treatment

One challenge in predicting the course of epilepsy is that for any type, there can be a variable response to treatment. Sometimes, seizures may play a rather small role in the manifestation of a medical condition. For example, a severe head injury could result in seizures that readily respond to medication, but severe neurological impairments and disabilities may still be present. On the other hand, a different head injury may result in relatively mild neurological problems, but there may be seizures that are severe and be resistant to medications.

Whatever the case, the ultimate goals when treating epilepsy are to:

• strive for complete freedom from seizures
• have little to no side effects from medications
• be able to follow an easy regimen so that compliance with treatment can be maintained

Up to 60% of patients with epilepsy can be expected to achieve control of seizures with medication(s). However, in the remaining 40%, epilepsy appears to be resistant, to varying degrees, to medications. In these cases, the epilepsy is termed medically intractable.

Generally, the choice of medication is somewhat trial and error. There are, however, a number of considerations that guide the choice of treatment. Each medication has a particular side effect profile and mechanism of action. Some medications seem to be particularly effective for certain epilepsy syndromes. For example, juvenile myoclonic epilepsy responds well to valproic acid. On the other hand, ethosuxamide is primarily used for absence seizures.

As with any medication, individuals can have very different experiences with same drug. Consequently, it is difficult to predict the efficacy of treatment in the beginning. A key concept of treatment is to first strive for monotherapy (or single drug therapy). This simplifies treatment and minimizes the chance of side effects. Sometimes, however, two or more drugs may be necessary to achieve satisfactory control of seizures. As with any treatment, potential side effects can be worse than the disease itself. Moreover, there is little point in controlling seizures if severe side effects limit quality of life. If a seizure disorder is characterized by mild, focal, or brief symptoms that do not interfere with day-to-day life, then aggressive treatments may not be justified. Epilepsy medications do not cure epilepsy; the medications can only control the frequency and severity of seizures. A list of the most commonly used medications in the management of epilepsy includes:

• phenobarbital
• phenytoin (Dilantin, Phenytek)
• clonazepam (Klonipin)
• ethosuxamide (Zarontin)
• carbamazepine (Tegretol, Carbatrol)
• divalproex sodium (Depakote, Depakene)
• felbamate (Felbatol)
• gabapentin (Neurontin)
• lamotrigine (Lamictal)
• topiramate (Topamax)
• tiagabine (Gabatril)
• zonisamide (Zonegran)
• oxcarbazepine (Trileptal)
• leviteracetam (Keppra)

It has been found that the initial, thoughtfully chosen medication can be expected to make almost 50% of patients seizure free for extended periods of time. If the initial drug fails, another well-chosen drug may make an additional 14% of people seizure free. If that drug fails, then the likelihood of rendering someone with epilepsy seizure free is poor. This does not mean that trying more medications or combinations of them may not be successful, but rather, these statistics give the neurologist and the patient an understanding of the realities of epilepsy treatment. In cases where medications do not fully control epilepsy, it is recommended that a more extensive evaluation at a comprehensive epilepsy center be conducted where an epileptologist (a specialist in epilepsy) will more thoroughly assess the particular aspects of the seizures. When medications are clearly ineffective, the other types of therapy that can be considered are the ketogenic diet, brain surgery, and vagal nerve stimulation.

Ketogenic diet

The ketogenic diet is based on high-fat, low-carbo-hydrate, and low-protein meals. The ketogenic diet is named because of the production of ketones by the breakdown of fatty acids. The most common version of the diet involves long-chain triglycerides. These are present in whole cream, butter, and fatty meats.

The ketogenic diet is administered with the support of a nutritionist with experience in this treatment modality. It is mostly used in children with medically intractable epilepsy and whose diet can be controlled. The ketogenic diet can be considered a pharmacologic treatment. As such, there are potential side effects that limit its tolerance. This includes hair thinning, lethargy, weight loss, kidney stones, and possibly cardiac problems. Sugar-free vitamin and mineral supplementation is necessary. The diet may not be appropriate for certain individuals, particularly in children, who may have certain metabolic diseases.

Overall, the diet has been very helpful in the control of seizures in many patients. Roughly 50% of patients can hope to achieve complete control of seizures, 25% of the patients see improvements, and another 25% are non-responders. There are some patients who have an improvement in behavior. If the diet is well tolerated with good results, then it can be maintained for up to two years, followed by a careful gradual transition to regular meals.

Epilepsy surgery

Epilepsy surgery is an option in the attempt to either cure or significantly reduce the severity of medically resistant cases. It is thought that up to 100,000 patients in the United States could be potential candidates for a surgical treatment. However, only about 5,000 cases are performed throughout the United States annually. This is likely due to several factors, including the belief that any brain surgery is a last resort, the lack of awareness or understanding of the benefits of surgery, and the false hope that some medication will come along that will be effective.

There are several kinds of surgery that are available depending on the nature of the seizure disorder. A list of operations that are utilized regularly for epilepsy include:

• lobectomy
• lesionectomy
• corpus collosotomy
• multiple subpial transection
• hemispherectomy

The type of surgery that is performed depends on the nature of the individual seizure disorder. If a seizure can be localized to a particular area in the brain, then this abnormal region can potentially be surgically removed. Epileptic brain tissue is abnormal and its removal can provide a chance of a cure. Generally, surgery should be a consideration when the risk and benefits of it outweigh the long-term risks of uncontrolled epilepsy.

The approach taken in any brain surgery for epilepsy is highly individualized and great care is taken to avoid injury to essential brain tissue. The most common epilepsy surgery performed is the temporal lobectomy. Brain tumors are frequently associated with seizures. In many cases, surgery to remove the tumor is planned so that regions that may be causing seizures are removed as well. However, in many cases, epilepsy surgery cannot be done.

Vagus nerve stimulation

Another non-medicinal approach to treating epilepsy is a novel method that became available in July 1997. The Food and Drug Administration (FDA) approved the use of the vagal nerve stimulator (VNS) as add-on therapy in patients who experience seizures of partial onset. The VNS is designed to intermittently deliver small electrical stimulations to a nerve in the neck called the vagus nerve. There are two vagal nerves, one on each side of the neck near the carotid arteries, making a pair of cranial nerves (there are 12 different paired cranial nerves). The vagus nerve carries information from the brain to many parts of the thoracic and abdominal organs. The nerve also carries information from these same organs back to the brain. VNS takes advantage of this fact and, by intermittent stimulation, there is an effect on many brain areas that can be involved in seizures.

About 50% of patients experience at least 50% reduction in the frequency of their seizures. The responses to VNS range from complete control of seizures (less than 10% of patients) to no noticeable improvement. The device is not a substitute for epilepsy surgery and should be considered only after there is an evaluation for epilepsy surgery. The implantation of the device requires relatively minor surgery with two incisions, one in the neck and the other in the left upper chest area.

The battery in the device lasts up to eight to ten years, after which the device can be replaced. Side effects of VNS therapy include voice hoarseness that typically does not impair communication. Like any surgery, there is an initial risk of infection, bleeding, and pain. Recovery takes a few weeks. Individuals can return to their usual activities once the incisions have healed.

Clinical trials

The National Institute of Neurological Disorders and Stroke list a number of clinical trials. There are also a number of studies being conducted at a more basic science stage evaluating the role of the following in seizures and epilepsy: neurotransmitters, non-neuronal cells, and genetic factors. Treatment strategies including deep brain stimulation and intracranial early seizure detection devices are being studied at different stages.

Prognosis

The prognosis of epilepsy varies widely depending on the cause, severity, and patient's age. Even individuals with a similar diagnosis may have different experiences with treatment. For example, in benign epilepsy of childhood with centrotemporal spikes (also called benign rolandic epilepsy), the prognosis is excellent with nearly all children experiencing remission by their teens. With childhood absence epilepsy, the prognosis is variable. In this case, the absence seizures become less frequent with time, but almost half of patients may eventually develop generalized tonic-clonic seizures. Overall, the seizures are responsive to an appropriate anticonvulsant. On the other hand, the seizures in Lennox-Gastaut syndrome are very difficult to control. In this case, however, the ketogenic diet can help. In seizures that begin in adulthood, one can expect that medications will control seizures in up to 60–70% of cases. However, in some of the more than 30% of medically intractable cases, epilepsy surgery can improve or even cure the problem.

Overall, most patients have a good chance of controlling seizures with the available options of treatment. The goal of treatment is complete cessation of seizures since a mere reduction in seizure frequency and/or severity may continue to limit patients'quality of life: they may not be able to drive, sustain employment, or be productive in school.

Resources

BOOKS

Browne, T. R., and G. L. Holmes. Handbook of Epilepsy, 2nd edition. Philadelphia: Lippincott Williams & Wilkins. 2000.

Devinski, O. A Guide to Understanding and Living with Epilepsy. Philadelphia: F.A. Davis Company. 1994.

Engel, J., Jr., and T. A. Pedley. Epilepsy: A Comprehensive Textbook. Philadelphia: Lippincott-Raven. 1998.

Freeman, M. J., et al. The Ketogenic Diet: A Treatment for Epilepsy, 3rd Edition. New York: Demos Medical Publishing, 2000.

Hauser, W. A., and D. Hesdorffer. Epilepsy: Frequency, Causes, and Consequences. New York: Demos Medical Publishing, 1990.

Pellock, J. M., W. E. Dodson, and B. F. D. Bourgeois. Pediatric Epilepsy Diagnosis and Therapy, 2nd Edition. New York: Demos Medical Publishing, 2001.

Santilli, N. Managing Seizure Disorders: A Handbook for Health Care Professionals. Philadelphia: Lippincott-Raven. 1996.

Schachter, S. C., and D. Schmidt. Vagus Nerve Stimulation, 2nd Edition. Oxford, England: Martin Dunitz, 2003.

Wyllie, E. The Treatment of Epilepsy: Principles and Practice, 3rd Edition. Philadelphia: Lippincott Williams & Wilkins, 2001.

PERIODICALS

Kwan, P., and M. J. Brodie. "Early Identification of Refractory Epilepsy." New England Journal of Medicine no. 342 (2000): 314–319.

ORGANIZATIONS

American Epilepsy Society. 342 North Main Street, West Hartford, CT 06117-2507. 860.586.7505. www.aesnet.org.

Epilepsy Foundation of America. 4351 Garden City Drive, Landover, MD 20785-7223. (800) 332-1000. www.epilepsyfoundation.org.

International League Against Epilepsy. Avenue Marcel Thiry 204, B-1200, Brussels, Belgium. + 32 (0) 2 774 9547; Fax: + 32 (0) 2 774 9690. www.epilepsy.org.

Roy Sucholeiki, MD

Conditions in which there are recurrent seizures. Such conditions are also known as epilepsy; the isolated occurrence of a seizure, however, is not designated as epilepsy. A seizure (ictus) is an event in which there is a sudden alteration in function of nerve cells, most commonly involving excessive electrical activity of the cells. This sudden change in nerve cell function is usually relatively brief, lasting seconds to minutes. Soon after a seizure, the brain may function quite normally. The manifestation of a seizure varies depending on which area of the brain is involved. Focal motor epilepsy, temporal lobe seizures, grand mal, and generalized nonconvulsive seizures are the four common seizure types. See also Brain; Nervous system (vertebrate).

Focal motor epilepsy, also known as a simple partial seizure with motor symptoms, is manifested by uncontrolled rhythmic jerking of the face, arm, or leg, caused by excessive abnormal discharges of nerve cells within the area of the brain, which under usual circumstances controls movement in that part of the body.

Temporal lobe seizures are known as simple partial seizures and may be manifested by a myriad of symptoms depending upon which part of the lobe is involved. Psychomotor, or complex partial, seizures are the most common type. Clinically, they are characterized by an alteration in the state of consciousness and performance of repetitive, patterned, non-goal-directed activity. These types of seizures are characterized electrically by abnormal discharges occurring within the temporal lobe for the duration of the seizure.

Grand mal seizures, also referred to as generalized tonic-clonic convulsive seizures, major motor seizures, or convulsions, occur if the abnormal discharges involve the entire brain all at once. In this condition there are forceful, generalized, symmetrical musculature contractions accompanied by loss of consciousness, and, at times, by urinary incontinence and tongue biting.

Generalized nonconvulsive seizures may be atonic seizures, which are characterized by a sudden loss of muscle tone, or they may be absences (petit mal), which consist of brief periods of loss of consciousness and immediate recovery. This type of seizure is more frequently seen in children than in adults.

Epilepsy is not a disease in itself. It is a symptom of an underlying disease process. That disease process may be metabolic, such as uremia, decreased brain oxygen, or low calcium levels; or structural brain damage, such as from head trauma at birth, brain injuries, brain tumors, strokes, or congenital malformations, or previous encephalitis or meningitis. In many instances, however, a cause is not found. The disorder is then referred to as idiopathic or primary epilepsy.

Seizures should be distinguished from other conditions which have some clinical similarities. These include fainting from hypoglycemia, cardiovascular disorders, or hysteria. The tools necessary to make this differential diagnosis are the history of the illness, the general physical exam, and a neurologic exam, all of which may be entirely normal or which may demonstrate signs of underlying disease processes. An electroencephalogram may demonstrate abnormal electrical discharges during a time the patient is seizure-free. These discharges may indicate that portion of the brain from which the seizures arise. Computerized tomography scans or magnetic resonance imaging may show any gross structural abnormality. Examination of the blood may demonstrate abnormal circulating chemicals. See also Computerized tomography; Electroencephalography; Medical imaging.

The ideal treatment of epilepsy is removal of the cause. In many instances, however, the cause cannot be established or may not be amenable to direct treatment. When the cause cannot be removed, the symptoms (seizures) are treated. The initial method of obtaining seizure control is antiepileptic drugs. About 80% of the people with epilepsy obtain good control or elimination of seizures with medication. These medications are chemicals of varying structures and may be effective by a number of different brain mechanisms. Brain surgery is a therapeutic potential for some of the 20% of the people with epilepsy who do not achieve control on medication. Surgery may be considered if the abnormally discharging nerve cells which cause the epilepsy are in a dispensable area of brain, that is, one of the frontal or temporal lobes.

Epilepsy may well be one of mankind's oldest diseases. Hippocrates (c.450-377 bce) wrote On the sacred disease, which is usually interpreted as being epilepsy, arguing that it could be treated by regular attention to a healthy way of life, especially by the proper and moderate use of food and drink, which would correct the causative physiological blockages. That is, the Hippocratic tradition regarded epilepsy as a disease as natural as any other, and not due to supernatural influences, whilst prior to the Hippocratic corpus a range of disturbed gods had been invoked to account for epilepsy's signs and symptoms.

Further, Hippocrates argued that the disease was inherited and was caused by a disturbance in the brain, and thus firmly fixed epilepsy as a natural disease, treatable by doctors and not by priests, an important development for both market and medical practices. This view was long held by learned doctors: the influential physician Alexander of Tralles (525-605), however, recommended treatments that included making the nail of a wrecked ship into a bracelet, which was to be decorated with ‘the bone of a stag's heart taken from its body whilst alive’, adding that this should be worn on the left arm, for ‘astonishing results’. Somewhat earlier, the Roman physician Pliny (c.23-79) had also reported that epileptic patients could be cured by drinking blood, especially of gladiators. Throughout the Middle Ages, the view that epilepsy was a medical problem continued to coexist with causative theories of demonic possession and spiritual imbalances. Treatments including Christian prayer (St Christopher was drafted in as a patron saint with special responsibility), pagan ritual, and humoral medicine all emerged. A prominent medieval surgeon, Guy de Chauliac (1298-1368), prescribed magic and prayer for epileptics — they were to write the names of the Three Wise Men in their own blood on parchment, and daily recite three Pater Nosters and Ave Marias for three months. It was at this time that mistletoe acquired a special association with epilepsy — mistletoe was hung around children's necks in Central Europe as a protective against seizures, and in Scandinavia knife handles were cut from oak mistletoe, for the same purpose. By the sixteenth century epileptics could be branded as witches, and little medical progress had been made. In the middle of the seventeenth century, Robert Boyle, a founder member of the Royal Society of London, was still advocating crushed mistletoe to be taken during the days of a full moon.

Gradually however, some effort was made to classify the different types of seizures, and by the beginning of the nineteenth century epileptics were often hospitalized. One advance occurred in 1838, when epileptic children in Paris were provided with education, rather than being completely hospitalized, although often epileptics were separated from the insane because of the growing belief that epilepsy was infectious. Thus epileptics were increasingly confined in separate wards, and soon in separate institutions.

By 1860 special hospitals for epileptics had been founded in Germany, France, and Britain. One of these was the Hospital for Epilepsy and Paralysis in Queen Square, London (later the National Hospital for Nervous Diseases). This meant that epileptics were increasingly seen and treated by physicians attached to such institutions, who became particularly experienced in the diagnosis and treatment of the disease. This led in particular to a more detailed differentiation and classification of epilepsy, including terms still in use today, such as grand mal, petit mal, absence seizures, and status epilepticus. By the latter part of the nineteenth century, the theories of the British neurologist, John Hughlings Jackson (1835-1911), and his French counterpart Jean Charcot (1825-93) began to define the neurological basis of the disease and its complex symptomatology. W. R. Gowers (1845-1915) authoritatively described the ‘aura’ that preceded a grand mal attack (although Hippocrates had not been ignorant of it).

In terms of treatment, bromides were the first successful medicine for epilepsy, from the 1850s onwards, abolishing attacks in some, and diminishing them in number or violence in most others; they started to be displaced only after the introduction of phenobarbital, first prescribed in 1912. Barbiturates continue to be one of the effective treatments, although further understanding of the underlying mechanisms have led to the development of alternative modern anticonvulsant drugs: those that potentiate or imitate the inhibitory neurotransmitter GABA, or stabilize the neuronal cell membrane, and thus prevent excessive firing.

It may seem obvious in the present day that the origin of the convulsions that characterize epilepsy lies in the brain — but this was not in fact established until the latter half of the nineteenth century. Indeed, there had been at that time a belief that they originated as abnormal reflexes from the spinal cord. This, together with the notion that there was not any localization of function in the cerebral cortex, was based on faulty interpretation of experimental studies. Broca initiated the concept of localization in the 1860s, with his description of the part of the left hemisphere responsible for speech function, followed by Hughlings Jackson's conclusion from his studies that convulsions on one side of the body are due to discharge from certain convolutions of the cortex on the opposite side of the brain. (Hippocrates had noted this association somewhat earlier in his writings on injuries to the head, but the knowledge had been submerged.) Studies on electrical stimulation of the brain of animals in the 1870s supported Hughling Jackson's suppositions. Anaesthesia and antisepsis followed by asepsis allowed the beginnings of modern brain surgery, and another historic event was in 1886, when Victor Horsley in London operated on the brain and cured a young man's fits by removing scarring resulting from a head injury in childhood.

The next landmark in the history of epilepsy was the electroencephalogram (EEG) — the first demonstration in the late 1920s that the electrical activity of the brain could be recorded through the intact skull, and that abnormal patterns appeared during an epileptic attack. In subsequent decades, electroencephalography advanced the diagnosis of epilepsy, and the localization of its site of origin in the brain. Meanwhile, exploration of the effects of electrical stimulation of the human brain, with relevance to the site of onset of focal seizures, culminated in the detailed mapping of functional localization of the parts of the body in the motor and sensory regions of the cortex, by the Canadian neurosurgeon Wilder Penfield and his colleagues in the 1930s.

Deliberate induction of epileptic seizures was used during the twentieth century in attempts to treat mental illness. Camphor, which had been observed to precipitate attacks in epileptic patients, was introduced to induce shocks, but it produced such violent convulsions that bones were broken, and symptoms remained unaffected. Insulin shock therapy inducing seizures by the lowering of blood sugar was used with some success in schizophrenics. Electroconvulsive therapy (ECT), first applied in the late 1930s, and nowadays performed under anaesthesia, remains in use and is effective in the treatment of depressive illness.

Epilepsy would now be defined as a paroxysmal and transitory disturbance of the functions of the brain, involving repetitive discharges in large groups of brain cells, and commonly causing convulsions. The disturbance develops suddenly, ceases spontaneously, and is subject to recurrence. The current understanding of epileptiform activity in the brain, its types, nature, and mechanisms, is described under ‘convulsions’.

— E. M. Tansey, Sheila Jennett

See also convulsions; craniotomy; EEG; magnetic brain stimulation.

An established tendency to recurrent fits which may vary in seriousness; they are brought about by sudden abnormal discharges from brain cells.

Epileptics can participate in many sports. Exercise does not increase the risk of having a seizure. On the contrary, there is strong evidence to suggest that a regular physical exercise programme may be helpful in seizure control. The British Epilepsy Association advises only against sports in which a blow to the head is likely, and underwater sports, motor racing, or climbing, when an epileptic fit could be fatal. About 2 per cent of the population suffer from epilepsy. In most cases, it is adequately controlled by medication.

Definition

Epilepsy is a condition characterized by recurrent seizures that may include repetitive muscle jerking called convulsions. A seizure is a sudden disruption of the brain's normal electrical activity accompanied by altered consciousness and/or other neurological and behavioral manifestations.

Description

Epilepsy affects 1–2% of the population of the United States. Although epilepsy is as common in adults over 60 as in children under 10, 25% of all cases develop before the age of five. One in every two cases develops before the age of 25. About 125,000 new cases of epilepsy are diagnosed each year, and a significant number of children and adults that have not been diagnosed or treated have epilepsy.

Most seizures are benign, but a seizure that lasts a long time can lead to status epilepticus, a life-threatening condition characterized by continuous seizures, sustained loss of consciousness, and respiratory distress. Nonconvulsive epilepsy can impair physical coordination, vision, and other senses. Undiagnosed seizures can lead to conditions that are more serious and more difficult to manage.

Types of Seizures

Generalized epileptic seizures occur when electrical abnormalities exist throughout the brain. A partial seizure does not involve the entire brain. A partial seizure begins in an area called an epileptic focus, but may spread to other parts of the brain and cause a generalized seizure. Some people who have epilepsy have more than one type of seizure.

Motor attacks cause parts of the body to jerk repeatedly. A motor attack usually lasts less than an hour and may last only a few minutes. Sensory seizures begin with numbness or tingling in one area. The sensation may move along one side of the body or the back before subsiding.

Visual seizures that affect the area of the brain that controls sight cause people to hallucinate. Auditory seizures affect the part of the brain that controls hearing and cause the patient to imagine hearing voices, music, and other sounds. Other types of seizures can cause confusion, upset stomach, or emotional distress.

PARTIAL SEIZURES. Simple partial seizures do not spread from the focal area where they arise. Symptoms are determined by the part of the brain affected. The patient usually remains conscious during the seizure and can later describe it in detail.

COMPLEX PARTIAL SEIZURES. A distinctive smell, taste, or other unusual sensation (aura) may signal the start of a complex partial seizure.

Complex partial seizures start as simple partial seizures, but move beyond the focal area and cause loss of consciousness. Complex partial seizures can become major motor seizures. Although a person having a complex partial seizure may not seem to be unconscious, he or she does not know what is happening and may behave inappropriately. He or she will not remember the seizure, but may seem confused or intoxicated for a few minutes after it ends.

Causes & Symptoms

The origin of 50–70% of all cases of epilepsy is unknown. Epilepsy sometimes results from trauma at birth. Such causes include insufficient oxygen to the brain; head injury; heavy bleeding or incompatibility between a woman's blood and the blood of her newborn baby; and infection immediately before, after, or at the time of birth.

Other causes of epilepsy include:

• head trauma resulting from a car accident, gunshot wound, or other injury
• alcoholism
• brain abscess or inflammation of membranes covering the brain or spinal cord
• phenylketonuria (PKU), a disease that is present at birth, is often characterized by seizures, and can result in mental retardation
• other inherited disorders
• infectious diseases such as measles, mumps, and diphtheria
• degenerative disease
• lead poisoning, mercury poisoning, carbon monoxide poisoning, or ingestion of some other poisonous substance
• genetic factors

Status epilepticus, a condition in which a person suffers from continuous seizures and may have trouble breathing, can be caused by:

• suddenly discontinuing antiseizure medication
• hypoxic or metabolic encephalopathy (brain disease resulting from lack of oxygen or malfunctioning of other physical or chemical processes)
• acute head injury
• infection spread from blood (for example, meningitis or encephalitis) caused by inflammation of the brain or the membranes that cover it

Diagnosis

Personal and family medical history, description of seizure activity, and physical and neurological examinations help primary care physicians, neurologists, and epileptologists diagnose this disorder. Doctors rule out conditions that cause symptoms that resemble epilepsy, including small strokes (transient ischemic attacks, or TIAs), fainting (syncope), pseudoseizures, and sleep attacks (narcolepsy).

Neuropsychological testing uncovers learning or memory problems. Neuroimaging provides views of brain areas involved in seizure activity.

The electroencephalogram (EEG) is the main test used to diagnose epilepsy. EEGs use electrodes placed on or within the skull to record the brain's electrical activity and pinpoint the exact location of abnormal discharges.

The patient may be asked to remain motionless during a short-term EEG or to go about his normal activities during extended monitoring. Some patients are deprived of sleep or exposed to seizure triggers, such as rapid, deep breathing (hyperventilation) or flashing lights (photic stimulation). In some cases, people may be hospitalized for EEG monitorings that can last as long as two weeks. Video EEGs also document what the patient was doing when the seizure occurred and how the seizure changed his or her behavior.

Other techniques used to diagnose epilepsy include:

• Magnetic resonance imaging (MRI), which provides clear, detailed images of the brain. Functional MRI (fMRI), performed while the patient does various tasks, can measure shifts in electrical intensity and blood flow and indicate which brain region each activity affects.
• Positron emission tomography (PET) and single photon emission tomography (SPECT) monitor blood flow and chemical activity in the brain area being tested. PET and SPECT are very effective in locating the brain region where metabolic changes take place between seizures.

Treatment

Relaxation Techniques

Stress increases seizure activity in 30% of people who have epilepsy. Relaxation techniques can provide some sense of control over the disorder, but they should never be used instead of antiseizure medication or without the approval of the patient's doctor. Yoga, meditation, and favorite pastimes help some people relax and manage stress more successfully. Biofeedback can teach adults and older adolescents how to recognize an aura and what to do to stop its spread. Children under 14 usually are not able to understand and apply principles of biofeedback.

Acupuncture

Acupuncture treatments (acupuncture needles inserted for a few minutes or left in place for as long as 30 minutes) make some people feel pleasantly relaxed.

Acupressure

Acupressure can have the same effect on children or on adults who dislike needles.

Aromatherapy

Aromatherapy involves mixing aromatic plant oils into water or other oils and massaging them into the skin or using a special burner to waft their fragrance throughout the room. Aromatherapy oils affect the body and the brain, and undiluted oils should never be applied directly to the skin. Ylang ylang, chamomile, or lavender can create a soothing mood. People who have epilepsy should not use rosemary, hyssop, citrus (such as lemon), sage, or sweet fennel, which seem to stimulate the brain.

Nutritional Therapy

KETOGENIC DIET. A special high-fat, low-protein, low-carbohydrate diet is sometimes used to treat patients whose severe seizures have not responded to other treatment. Calculated according to age, height, and weight, the ketogenic diet induces mild starvation and dehydration. This forces the body to create an excessive supply of ketones, natural chemicals with seizure-suppressing properties.

The goal of this controversial approach is to maintain or improve seizure control while reducing medication. The ketogenic diet works best with children between the ages of one and 10. It is introduced over a period of several days, and most children are hospitalized during the early stages of treatment.

If a child following this diet remains seizure-free for at least six months, increased amounts of carbohydrates and protein are gradually added. If the child shows no improvement after three months, the diet is gradually discontinued. A 2003 study of the diet and its effect on growth noted that if used, clinicians should recommend adequate intake of energy and protein and a higher proportion of unsaturated to saturated dietary fats. The report also recommended use of vitamin and mineral supplements with the diet.

Introduced in the 1920s, the ketogenic diet has had limited, short–term success in controlling seizure activity. Its use exposes patients to such potentially harmful side effects as:

• staphylococcal infections
• stunted or delayed growth
• low blood sugar (hypoglycemia)
• excess fat in the blood (hyperlipidemia)
• disease resulting from calcium deposits in the urinary tract (urolithiasis)
• disease of the optic nerve (optic neuropathy)

Homeopathy

Homeopathic therapy also can work for people with seizures, especially constitutional homeopathic treatment that acts at the deepest levels to address the needs of the individual person.

Allopathic Treatment

The goal of epilepsy treatment is to eliminate seizures or make the symptoms less frequent and less severe. Long-term anticonvulsant drug therapy is the most common form of epilepsy treatment.

Medication

A combination of drugs may be needed to control some symptoms, but most patients who have epilepsy take one of the following medications:

• Dilantin (phenytoin)
• Tegretol (carbamazepine)
• Barbita (phenobarbital)
• Mysoline (primidone)
• Depakene (valproic acid, sodium valproate)
• Klonopin (clonazepam)
• Zarontin (ethosuximide)

Dilantin, Tegretol, Barbita, and Mysoline are used to manage or control generalized tonic-clonic and complex partial seizures. Depakene, Klonopin, and Zarontin are prescribed for patients who have absence seizures.

Neurontin (gabapentin), Lamictal (lamotrigine), and topiramate (Topamax) are among medications more recently approved in the United States to treat adults who have partial seizures or partial and grand mal seizures. Another new medication called Levetiracetam (Keppra) has been approved and shows particularly good results in reducing partial seizures among elderly patients with few side effects. This is important, because elderly patients often have other conditions and must take other medications that might interact with seizure medications. In 2003, Keppra's manufacturer was working on a new antiepilectic drug from the same chemical family as Keppra that should be more potent and effective. Available medications frequently change, and the physician will determine the best treatment for an individual patient. A 2003 report found that monotherapy, or using just one medication rather than a combination, works better for most patients. The less complicated the treatment, the more likely the patient will comply and better manager the seizure disorder.

Even an epileptic patient whose seizures are well controlled should have regular blood tests to measure levels of antiseizure medication in his or her system and to check to see if the medication is causing any changes in his or her blood or liver. A doctor should be notified if any signs of drug toxicity appear, including uncontrolled eye movements; sluggishness, dizziness, or hyperactivity; inability to see clearly or speak distinctly; nausea or vomiting; or sleep problems.

Status epilepticus requires emergency treatment, usually with Valium (Ativan), Dilantin, or Barbita. An intravenous dextrose (sugar) solution is given to a patient whose condition is due to low blood sugar, and a vitamin B₁ preparation is administered intravenously when status epilepticus results from chronic alcohol withdrawal. Because dextrose and thiamine are essentially harmless and because delay in treatment can be disastrous, these medications are given routinely, as it is usually difficult to obtain an adequate history from a patient suffering from status epilepticus.

Intractable seizures are seizures that cannot be controlled with medication or without sedation or other unacceptable side effects. Surgery may be used to eliminate or control intractable seizures.

Surgery

Surgery can be used to treat patients whose intractable seizures stem from small focal lesions that can be removed without endangering the patient, changing the patient's personality, dulling the patient's senses, or reducing the patient's ability to function.

A physical examination is conducted to verify that a patient's seizures are caused by epilepsy, and surgery is not used to treat patients with severe psychiatric disturbances or medical problems that raise risk factors to unacceptable levels.

Surgery is never recommended unless:

• The best available antiseizure medications have failed to control the patient's symptoms satisfactorily.
• The origin of the patient's seizures has been precisely located.
• There is good reason to believe that surgery will significantly improve the patient's health and quality of life.

Every patient considering epilepsy surgery is carefully evaluated by one or more neurologists, neurosurgeons, neuropsychologists, and/or social workers. A psychiatrist, chaplain, or other spiritual advisor may help the patient and his family cope with the stresses that occur during and after the selection process.

TYPES OF SURGERY. Surgical techniques used to treat intractable epilepsy include:

• Lesionectomy. Removing the lesion (diseased brain tissue) and some surrounding brain tissue is very effective in controlling seizures. Lesionectomy is generally more successful than surgery performed on patients whose seizures are not caused by clearly defined lesions, but removing only part of the lesion lessens the effectiveness of the procedure.
• Temporal resections. Removing part of the temporal lobe and the part of the brain associated with feelings, memory, and emotions (the hippocampus) provides good or excellent seizure control in 75–80% of properly selected patients with appropriate types of temporal lobe epilepsy. Some patients experience post-operative speech and memory problems.
• Extra-temporal resection. This procedure involves removing some or all of the frontal lobe, the part of the brain directly behind the forehead. The frontal lobe helps regulate movement, planning, judgment, and personality. Special care must be taken to prevent post-operative problems with movement and speech. Extra-temporal resection is most successful in patients whose seizures are not widespread.
• Hemispherectomy. This method of removing brain tissue is restricted to patients with severe epilepsy and abnormal discharges that often extend from one side of the brain to the other. Hemispherectomies are most often performed on infants or young children who have had an extensive brain disease or disorder since birth or from a very young age.
• Corpus callosotomy. This procedure, an alternative to hemispherectomy in patients with congenital hemiplegia, removes some or all of the white matter that separates the two halves of the brain. Corpus callosotomy is performed almost exclusively on children who are frequently injured during falls caused by seizures. If removing two–thirds of the corpus callosum does not produce lasting improvement in the patient's condition, the remaining one-third will be removed during another operation.
• Multiple subpial transection. This procedure is used to control the spread of seizures that originate in or affect the "eloquent" cortex, the area of the brain responsible for complex thought and reasoning.

Other Forms of Treatment

VAGUS NERVE STIMULATION. Approved for adults and adolescents (over 16 years old) with intractable seizures, vagus nerve stimulation (VNS) uses a pacemaker-like device implanted under the skin in the upper left chest, to provide intermittent stimulation to the vagus nerve. Stretching from the side of the neck into the brain, the vagus nerve affects swallowing, speech, breathing, and many other functions, and VNS may prevent or shorten some seizures.

First Aid for Seizures

A person with epilepsy having a seizure should not be restrained, but sharp or dangerous objects should be moved out of reach. Anyone having a complex partial seizure can be warned away from danger by someone calling his/her name in a clear, calm voice.

A person with epilepsy having a grand mal seizure should be helped to lie down, and those aiding the patient should contact emergency medical personnel. Tight clothing should be loosened. A soft, flat object like a towel or the palm of a hand should be placed under the person's head. Forcing a hard object into the mouth of someone having a grand mal seizure could cause injuries or breathing problems. If the person's mouth is open, placing a folded cloth or other soft object between his or her teeth will protect the tongue. Turning the patient's head to the side will help with breathing. After a grand mal seizure has ended, the person who had the seizure should be told what has happened and reminded of where he or she is.

Expected Results

People who have epilepsy have a higher than average rate of suicide; sudden, unexplained death; and drowning and other accidental fatalities.

Benign focal epilepsy of childhood and some absence seizures may disappear in time, but remission is unlikely if seizures occur several times a day, several times in a 48-hour period, or more frequently than in the past.

Epilepsy can be partially or completely controlled if the individual takes antiseizure medication according to directions; avoids seizure-inducing sights, sounds, and other triggers; gets enough sleep; and eats regular, balanced meals.

Anyone who has epilepsy should wear a bracelet or necklace identifying the seizure disorder and listing the medication he or she takes.

Prevention

Eating properly, getting enough sleep, and controlling stress and fevers can help prevent seizures. A person who has epilepsy should be careful not to hyperventilate. Those who experience auras should find a safe place to lie down and stay until the seizure passes. Anticonvulsant medications should not be stopped suddenly and, if other medications are prescribed or discontinued, the doctor treating the seizures should be notified. In some conditions, such as severe head injury, brain surgery, or subarachnoid hemorrhage, anticonvulsant medications may be given to the patient to prevent seizures.

Resources

Books

"Seizures." Reader's Digest Guide to Medical Cures & Treatments : A Complete A-to-Z Sourcebook of Medical Treatments, Alternative Opinions, and Home Remedies. Canada: The Reader's Digest Association, Inc., 1996.

Shaw, Michael, ed. Everything You Need to Know about Diseases. Springhouse, PA: Springhouse Corporation, 1996.

Periodicals

Batchelor, Lori, et al. "An Interdisciplinary Approach to Implementing the Ketogenic Diet for the Treatment of Seizures." Pediatric Nursing (September/October 1997): 465–471.

"Data Analysis Shows Keppra Reduced Partial Seizures in Elderly Patients." Clinical Trials Week (April 28, 2003): 26.

Dichter, M.A., and M.J. Brodie. "Drug Therapy: New Antiepileptic Drugs." The New England Journal of Medicine (15 June 1996): 1583-1588.

Dilorio, Colleen, et al. "The Epilelpsy Medication and Treatment Complexity Index: Reliability and Validity Testing." Journal of Neuroscience Nursing (June 2003): 155–158.

"Epilepsy Surgery and Vagus Nerve Stimulation Are Effective When Drugs Fail." Medical Devices & Surgical Technology Week (May 4, 2003): 33.

Finn, Robert. "Partial Seizures Double Risk of Sleep Disturbances (Consider in Diagnosis, Management)." Clinical Psychiatry News (June 2003): 36–41.

Lannox, Susan L. "Epilepsy Surgery for Partial Seizures." Pediatric Nursing (September–October 1997): 453-458.

Liu, Yeou-Mei Christiana, et al. "A Prospetive Study: Growth and Nutritional Status of Children Treated With the Ketogenic Diet." Journal of the American Dietetic Association (June 2003): 707.

McDonald, Melori E. "Use of the Ketogenic Diet in Treating Children with Seizures." Pediatric Nursing (September-October 1997): 461-463.

"New Drug Candidate Shows Promise." Clinical Trials Week (April 7, 2003): 26.

Organizations

American Epilepsy Society. 638 Prospect Avenue, Hartford, CT 06105-4298. (205) 232-4825.

Epilepsy Concern International Service Group. 1282 Wynnewood Drive, West Palm Beach, FL 33417. (407) 683–0044.

Epilepsy Foundation of America. 4251 Gar