Epilepsy

What epilepsy is

The brain works through regular electrical impulses of neurons. In an epileptic seizure a group of neurons discharges simultaneously and excessively, temporarily disrupting the function of the corresponding area. According to the definition of the International League Against Epilepsy (ILAE), epilepsy is diagnosed when there are two or more unprovoked seizures more than 24 hours apart, or a single unprovoked seizure when the risk of recurrence is high (over 60%, for example when tests show a lesion or typical epileptic activity), or when an epilepsy syndrome is recognized.

It must be distinguished from provoked seizures, caused by a temporary factor: hypoglycemia, severe electrolyte disturbances, fever in children, withdrawal from alcohol or drugs, severe sleep deprivation, a recent head injury or an acute brain infection. These do not constitute epilepsy and are treated by treating the cause.

The causes of epilepsy are divided into: structural (a result of stroke, trauma, tumor, hippocampal sclerosis), genetic, infectious, metabolic, immune and unknown, the last being very frequent. Epilepsy can begin at any age, with two peaks: in childhood and after age 60–65, when stroke and neurodegenerative diseases are the main causes.

How a seizure can appear

A seizure may be focal (starting in one area of the brain) or generalized (involving both hemispheres from the start):

• Tonic-clonic seizure (the well-known “grand mal”): loss of consciousness, stiffening of the body (tonic phase), then rhythmic jerking of the limbs (clonic phase), often with tongue biting, loss of urine, and confusion and drowsiness afterwards (postictal phase).
• Absence seizure: a brief interruption of consciousness with staring, without falling, typical in children.
• Myoclonic seizure: brief, sudden muscle jerks.
• Focal seizure: unusual sensations (a smell, fear, “déjà vu”), involuntary movements of one part of the body, or staring with automatisms (chewing, plucking at clothes) and altered awareness. When awareness is preserved, the person remembers the seizure.

Not every faint or episode of shaking is an epileptic seizure. Syncope (a faint from a fall in blood flow to the brain) can produce a few brief jerks but lasts less and recovery is quick; sometimes the distinction needs cardiology assessment (see Holter ECG). There is also a group of psychogenic seizures, which are not caused by electrical discharges and are treated differently.

How to help during a seizure

• Note the time the seizure begins and remove dangerous objects.
• Protect the head with something soft (a folded jacket).
• Do not hold the person down and do not put anything in the mouth; it is not true that the tongue can be swallowed.
• After the convulsions stop, turn the person onto their side (recovery position) if they are breathing and stay close until consciousness returns.
• Do not give food or drink until they have fully recovered.
• Call 127 as in the emergency box. A seizure lasting more than 5 minutes, or repeating without return of consciousness, is status epilepticus, a life-threatening emergency.

Rescue medicines (for example midazolam given in the cheek or nose) are used only according to the plan prescribed by the doctor and by people trained to give them.

How the assessment is done

The neurologist reviews the description of the episode, the account of people who were present (very valuable, because the patient often does not remember the seizure) and the neurological examination. After a first seizure, blood tests (glucose, electrolytes) and an ECG exclude provoked and cardiac causes. An EEG (recording of the brain’s electrical activity) and brain MRI are recommended at the relevant service; they help define the type of seizure and its cause and assess the risk of recurrence.

A normal EEG does not exclude epilepsy, because discharges may not be captured during the recording; it is sometimes repeated or prolonged. Results are always interpreted together with the clinical history.

How it is treated and followed

The basic treatment is anti-seizure medicines (ASMs). The choice depends on the seizure type, age, sex, coexisting disease and other drugs; drugs such as lamotrigine, levetiracetam, carbamazepine, oxcarbazepine, valproate or ethosuximide (for absences) are used. About 70% of patients become seizure-free with one or two suitable drugs. If seizures continue after two suitable drugs at adequate doses (drug-resistant epilepsy), the patient is referred to a specialized epilepsy center for assessment of surgery, vagus nerve stimulation or a ketogenic diet.

Do not stop treatment suddenly: abrupt withdrawal is one of the main causes of seizures and of status epilepticus. After two years without seizures, a gradual reduction of the dose may be discussed, by the specialist only. Drugs are reviewed for effect, tolerance and interactions: some ASMs (carbamazepine, phenytoin) reduce the effect of hormonal contraceptives, warfarin and the newer anticoagulants, so any new drug should be reported to the doctor.

Keep a seizure diary and discuss sleep, alcohol and other factors that may trigger them. Women of childbearing age should plan pregnancy in advance with the specialist: some drugs, especially valproate, carry a high risk of malformations and of harm to the child’s development and must be changed before conception; folic acid is recommended. With good follow-up, most women have normal pregnancies. Regular check-ups, every 6 months to a year or sooner when the doctor considers it reasonable, assess the effect and side effects of drugs.

Daily safety

After a new seizure, do not drive until you have been assessed; legal rules on driving after a seizure vary and depend on the seizure-free period. Discuss with your doctor safety when swimming (swimming alone is forbidden), bathing (prefer a shower to a bath), working at height and using dangerous equipment. Restrictions are tailored to the case and are not the same for everyone: many people with controlled epilepsy work and live normally. A rarer risk is sudden unexpected death in epilepsy (SUDEP), a risk that falls when seizures are well controlled and drugs are taken regularly.

Care at Tirana Polyclinic: we offer neurology consultation, follow-up and interpretation of EEG results, tests and imaging performed at other services.