Seizures associated with alcohol intake: to abstain or not to abstain that is the question

A reader of my blog wrote in to me. As has been the trend, I try to answer each and every question though lately I have to admit I have fallen back in this quest mostly due to constraint of time. I promise to be more timely in my replies going forward.

 

Here is his question. My answer to it follows:

 

HI, I was 21 when I had a seizure, following a weekend long music festival and drinking heavily and consuming amphetamines. Had about 5 or 6 following this up to the age of 25, mostly following drinking heavily and sometimes consuming amphetamines and/or diazepam. Have not taken any illegal substances since and now in my 30′s. Still drink regularly. No seizures and spent a few years taking a very low dose-100/200mg of epilim chrono(sodium valporate). Have not taken medication for 4 yrs approx. A junior doctor told me(while the consultant had left the room to fetch something) that he had studied this for his theses and it was very common for young adult males to “develop” seizures but assured me I would grow out of it, which appears so far(touch wood) to be true. Is there any truth in this? Is my case prob related to drink/illegal substance misuse?

 

S

 

 

Brain diseases reply:

 

Dear S,

Thank you for writing in to me at www.braindiseases.wordpress.com. I shall answer your question to me in a unique way. Here we go.

 

As a neurologist with interest in epilepsy I frequently encounter patients with history similar to yours. After a night of heavy drinking (usually different types of alcohol are consumed over a short course of time), at times along with other illicit drugs such as cocaine, amphetamines and more commonly prescription drugs such as Xanax and Valium (diazepam), lo and behold the person is witnessed to have a generalized convulsion soon there after (either that night itself or early next morning). The first encounter these patients have with the health care system is in the ER to which they present or are brought to by the EMS for evaluation. Now imagine that you are a physician in the ER and evaluate such a patient in the middle of the night. You are pressed for time. What shall be your assessment and plan? You shall order a few basic blood tests and a CT scan of the brain. CT scan comes back normal and the basic labs are normal too. Most of the times these patients are discharged from the ER after starting them on an anticonvulsant  (sodium valproate, phenytoin (Dilantin) and levetiracetam (Keppra) are the most commonly chosen drugs) with advice to follow up with a neurologist like me.

 

Now you may think that this “case” is closed but that is a fallacy.

 

Many questions remain unanswered:

 

  1. Was the seizure indeed induced by alcohol and the combination of illicit drugs? How sure are we of this fact? :  if this is indeed a seizure induced by alcohol and illicit drug use then surely the patient does not need an anticonvulsant drug. If he stops drinking/binging and stops illicit drug use he shall not have any more seizures.
  2. How long should the anticonvulsant medication continue?
  3. Can he drink a “little” amount or is alcohol completely off the bargaining table? Does he have to abstain for life?
  4. Who was the actual culprit—alcohol alone Vs alcohol in excess Vs alcohol and illicit drug combination Vs illicit drug by itself?
  5. Does the patient have an underlying seizure disorder (tendency to have seizure/ underlying epilepsy) and that alcohol/illicit drug combo was just the fuse. Such a patient of course shall warrant treatment with an anticonvulsant. Again more questions: which anticonvulsant and for how long? Does he need to be treated for life? If he takes an anticonvulsant can he again start drinking?

 

There is no one right answer to the above questions. No one size fits all model here. The answer to each has to be personalized to the patient at hand. Fortunately to answer the above questions as a neurologist I do not need expensive tests. All I need to do is to spend time with the patient and get a thorough history. In some cases I may order an electroencephalogram (EEG).

 

The rest is easy. Hope you found my answers insightful.

 

Nitin Sethi, MD

Alcohol and seizures: a few questions and their answers.

One of the readers of my blog asked me a few questions. His questions and my answers to them follow.

Hello Dr Sethi! To begin with, I’d like to thank you for clarifying and educate us about seizures.(esp. rum fits, alcohol withdrawal seizures and Dts seizures)

I have some questions:

1. How would I differentiate between epilepsy and alcoholic fits? Ignoring any test(EEG,CT), i mean based on the clinical manifestation?eg. duration of fits?the sequence of occurence (pattern of seizure)?etc…

2. how would i differentiate between epilepsy and the ‘fits’ that is seen in patients with hysteria (conversion disorder)?

3. is treatment necessary for alcohol fits? or just allow the patient to relax in the recovery position and let the fit go away?

4. how would you distinguish between: alcohol withdrawal syndrome and DT? is there any special cardinal symptom that will give me a clue that the patient is in DT.?

Thank you very much Dr Sethi. looking forward to hear from you.

Dr. Ronny Gooriah (doing Internship)

Dear Dr. Gooriah,
thank you for writing in to me. I am glad you found the information presented useful. Now without further delay, let me answer your questions.

1. If I understood your question you want to know how to differentiate between seizures caused by alcohol (alcohol fits) from seizures/epilepsy caused by other conditions. As you may be well aware of, epilepsy is a condition which predisposes the patient to multiple convulsions in his/her lifetime. There are numerous causes of epilepsy. Broadly speaking epilepsy can be idiopathic , symptomatic or cryptogenic. Seizures may also occur secondary to a medical condition which may or may not involve the brain like for example a brain tumor, head trauma, meningitis or encephalitis and in the setting of multiorgan failure such as sepsis, renal or hepatic failure. There is no absolute way of differentiating a seizure caused by alcohol (excessive use or sudden stoppage) from epilepsy (whether idiopathic, symptomatic or cryptogenic) specially early in the course of the disease. One needs to take a thorough history which should include a history of alcohol intake. How much? what kind? over what time frame were the drinks consumed? were drinks mixed? were recreational drugs taken along with the alcohol and so forth. Other history which may be helpful in determining if the patient has epilepsy include: a history of febrile convulsions, family history of seizures, history of meningitis or encephalitis, history of significant head trauma and if seizures have occured in settings where the patient was not abusing alcohol. The answer to all these questions and the results of tests such as EEG and neuroimaging (MRI brain) shall help in determining whether the patient has epilepsy per se or whether all his seizures can be attributed to alcohol.

2. Nonepileptic events (pseudoseizures) may occur as a manifestation of a somatoform or conversion disorder. These patients have events that look like seizures (sudden shaking of the body and the patient may appear to suffer loss of consciousness) but there is no EEG correlate to these events. Meaning that the EEG shows the patient is not having a seizure. Patients who exhibit nonepileptic events (some doctors refer to them as hysterical convulsions) usually fall in two categories. Either they are doing this for a secondary gain (seeking attention, disability or financial compensation aka they are malingering) or these events are really not under their conscious control (usually these patients are under severe mental stress or may have history of physical or sexual abuse). A trained eye (such as a neurologist) simply by looking at the clinical event shall at times be able to determine if it is a true seizure or a pseudoseizure/ hysterical convulsion. At times though the differentiation is indeed difficult (if solely based on the description of the event). A video-EEG in these cases is extremely helpful. As the name suggests the patient is attached to a EEG machine while under video surveillance. The idea is to capture a typical seizure on the camera and look at the EEG at the same time.

3. If the patient suffers a single alcohol related seizure, no treatment may be necessary apart from simple observation and making sure the patient does not hurt himself. On the other hand if the patient suffers a flurry of seizures one after the other, you may have to give medications to stop the seizures at least acutely. Whether such patients warrant long term anticonvulsant therapy is another issue and needs careful consideration.

4. Patients who are in DT or have impending DT usually have dysautonomia. They are frequently tachycardic or have irregular heart rate, their blood pressure may be high and have wide swings, they may have profuse sweating and are disoriented, confused and agitated (hence the word delirium). DT has a high mortality and hence these patients need close supervision and aggressive treatment usually in an intensive care setting.

I hope I have answered your questions to your satisfaction.

Personal Regards,

Nitin Sethi, MD

Alcohol and seizures: a question and an answer

T

HI
My Father is an aolcoholic and last Sept he was admitted to hospital after a fall when drunk – whilst in hospital he had a fit – understandable he was cold turkey whilst there. He was treated and sent home. Since Dec he has reduced his drinking and now generally consistantly drinks 1 bottle red wine a day – yes this is still too much but about 50% what he used to drink – he reduced gradually and has maintained this intake for a few months now.
What I find strange is that all i can find about these alcohol withdrawl fits relates to 2-3 days without alcohol – Dad had a fit a few mornings ago after a normal day and normal alcohol consumption levels. The hospital saw alcohol in his notes and packed him off home again with some Vitamin B tablets.
How many alcoholics normally get fits whilst they are still drinking? How normal is this? He is eating better these days than he was but still could do with eating more. He borderline underweight and 74 years old – he has been dependant for more years than I can imagine but probably the last 12 years have been the worst. He does not drink in the morning but the first drink in the day is normally 3/4pm and last drink 6/7pm before bed. This one bottle of wine is often enough for him to fall when on his way to bed or even a few hours later I have had to carry him back to bed if he falls in the bathroom. His body just doesnt seem to be able to cope with alcohol any more – less alcohol to get drunk – is this why he is having the fits?
My apologies for long winded questions but the question needed some context to make sense I think. Any I am not delusional about his alcohol intake – I monitor it and he has no other way or place to stash any.

Thank you so much in advance

P.S. the fit was 6.30 am Thursday and now Sat pm he is still very unsteady and his memory is worse than before. What is the normal recovery from these fits?

 

Braindiseases

Dear T,
thank you for writing in to me about your father. There is no one set limit above which alcohol can induce a seizure. The limit varies from person to person. Rum fits (seizures which occur at the height of binging) of course occur when one consumes too much alcohol in too short time. Alcohol withdrawal seizures classically occur 24-48 hours after the last drink (they occur in people who are chronic alcoholics/ people who consume heavy alcohol on a daily basis and who then suddenly stop drinking). Again not every chronic heavy drinker gets alcohol withdrawal seizure if he/she stops drinking suddenly. Usually it is the person who is chronically malnourished and dehydrated who is more predisposed to an alcohol withdrawal seizure in the setting of sudden cessation of drinking. These people as you can well imagine are deficient in multiple vitamins and minerals (commonly the B group of vitamins such as Vitamin B1, B2, B6, folic acid and B12). Their electrolytes are also more likely to be off (meaning they serum sodium, potassium, magnesium is low). They may also have alcoholic liver disease (alcoholic steatosis or fatty liver, alcoholic hepatitis and finally cirrhosis). During their prolonged drinking years they may also fallen down and struck their head. So it is a combination of factors (meaning the overall health status) and not just the sudden cessation of drinking which predisposes some alcoholics to alcohol withdrawal seizures.
Finally over the course of years of heavy drinking, some alcoholics develop epilepsy. The reason for this may be any of the above I have listed. My personal feeling is that these patients likely have underlying epilepsy and alcohol (in excess or sudden cessation after years of drinking) just helps to unmask it.
Now let me answer your last question about time frame of recovery. Again if his pre-existing neurological status is compromised (his memory is already bad after years of drinking, his general medical condition is poor or if he has coexisting medical problems such as chronic lung or liver disease, diabetes or congestive heart failure) his recovery from a convulsion shall be slow as compared to a young person with no pre-existing medical problems.
I hope I have addressed some of your concerns. I wish you both my very best.

Personal Regards,

Nitin Sethi, MD

Alcohol and seizures: few questions and their answers

One of the readers of my blog asked me a few very specific questions with respect to alcohol intake and seizures.  Many times your excellent questions and my answers to them get lost in the sea of information here. So I decided to post her questions and my reply to them as a main post. I feel many of you shall find them informative.  I have removed the reader’s name and email id.

T

35 y/o m with no significant medical hx has been a chronic binge drinker since the age of 20. Alcohol intake has increased more through the years (1-2 pints of whiskey 3-4 times/week including minimal beer intake). 3 years ago after a weekend of binging, which included cocaine, he had his first clonic-tonic seizure (that was witnessed). ER doc said it was d/t the cocaine. Since then he had stopped using cocaine but continued to have seizures after binging. It has been 3 years of multiple untreated gran mal, partial and/or focal seizures. It mostly happens a few days after stopping the liquor and/or when sleep deprived.

One evening while driving and NOT drinking, he crashed his car and does not remember any of it. At this point he has stopped drinking. 20 days clean and has had 1-2 focal seizures during sleep. How long does AWS last? Do you think his brain is affected by having so many untreated seizures? Should he get on anti-epilectic meds? If these are provoked seizures will an EEG even be worth it? The family has no history of epilepsy. Will his driving be affected? As a physician, do you have to report to the state if someone has provoked seizures or would this be a HIPA violation? Does taking the recommended dose of Nyquil have any affect on provoking a seizure during withdrawal? Would he have a high risk of reoccurrance?

Thank you for your time and advice.
T

braindiseases Dear T,
thank you for writing in. You ask specific questions and hence I shall answer them likewise.

Q: How long does AWS last?

A: acute alcohol withdrawal seizures occur about 24 to 48 hours after the last drink. Delirium tremens (during which the patients may have a flurry of seizures) peaks 72 hours after the last drink. We usually like to put patients on Librium or Ativan (lorazepam) to prevent AWS till we see no signs of autonomic instability (such as variations in blood pressure and heart rate), tremors and so forth.

Q: Do you think his brain is affected by having so many untreated seizures? Should he get on anti-epilectic meds? If these are provoked seizures will an EEG even be worth it?

A: while there is no study which clearly shows that the brain is damaged by seizures permanently (and I do not mean status epilepticus–where in neuronal death does occur unless seizures are controlled quickly), ongoing untreated seizures certainly are not desirable.
Whether he needs to be on long term anti-convulsant is a question that can only be answered after reviewing his history at length and after taking into consideration test results such as EEG and MRI brain.
We are assuming his seizures are provoked. It is also possible that he has an inherent epileptogenicity and the alcohol brings it out. Also during this long history,. he may have fallen and now have a secondary seizure focus in the brain. So yes the EEG is worthwhile.

Q: The family has no history of epilepsy. Will his driving be affected? As a physician, do you have to report to the state if someone has provoked seizures or would this be a HIPA violation?

A: The laws with respect to driving and epilepsy vary from state to state. In the state of NY where I practice, I am NOT mandated by law to report to the DMV (department of motor vehicles) that my patient has a seizure disorder. All I have to do is tell the patient that the law in NY is that ” you have to be seizure free on medications for one year before you can drive”. I do this and I document in the chart that I told the patient about not driving. It is left to the patient’s own good judgement that they shall heed my advise and not drive. In the state of NJ, the physician is mandated by law to report this to the DMV. The duration of time you have to be seizure free before you can drive also varies from state to state. The DMV website or the American Epilepsy Society website are good resources for more information.
Now suppose you come to know the patient is still driving (inspite of your advise). Moreover he is driving a school bus. What do you do then? Hmmm tricky and messy situation. Lives are at stake here. I shall confront (maybe not confront but approach) the patient with this information. If he still continues to drive, my responsibility to the public at large exceeds patient confidentality (HIPAA privacy rules). I can then approach the DMV directly.

Q: Does taking the recommended dose of Nyquil have any affect on provoking a seizure during withdrawal? Would he have a high risk of reoccurrance.

A: many medications can lower seizure threshold. I would double check on all his medications to see if he is taking anything which lowers his seizure threshold. The risk of recurrence can only be determined after a detailed history and taking tests like EEG and MRI brain into consideration.

Hope this helps.

Personal Regards,
Nitin Sethi, MD

Alcoholic neuropathy

Continuing with the posts on the neurological manifestations of alcoholism, I shall cover the topic of alcoholic neuropathy here. Simply put alcohol is a neurotoxin especially when it is consumed in excess. People who consume large amounts of alcohol on a chronic (daily) basis frequently develop neuropathy. It does not depend upon the kind of alcohol consumed (top of the shelf Scotch whisky Vs a cheap rum) rather it depends upon the amount and frequency of use. Patients develop a predominantly sensory neuropathy and have complaints of pain, burning, tingling, pins and needle sensation in the feet and sometimes in the finger tips. Rarely if the neuropathy is severe patients may also develop peripheral weakness (motor symptoms).

Alcoholic neuropathy is also thought to be not entirely due to alcohol, rather it is a nutritional neuropathy and occurs due to lack of essential nutrients and vitamins in the marginal diets of alcoholics. It is uncertain whether the neuropathy would develop in an alcoholic who supplements his diet with essential nutrients and vitamins. Alcoholic neuropathy is more commonly seen in patients who have other neuropathic conditions like diabetes. In this subgroup of patients, alcohol acts as an additional neurotoxin and makes the neuropathy worse. The same principle applies to cancer patients been treated with neurotoxic chemotherapy medications or an HIV patient been treated with neurotoxic antiretroviral medications.

Thus the message is simple.

Drink alcohol in moderation applies to all of us.

People who have diabetes should avoid alcohol if possible or if that is not possible consume as little.

Patients been treated with neurotoxic medications should also avoid alcohol.

Supplement your diet with at least one to two tablets of a good multivitamin every day.

Alcoholic neuropathy is treated much the same as any other neuropathy (see my post on diabetic neuropathy http://braindiseases.info)

Nitin Sethi, MD

Alcohol induced dementia/ alcoholic neurodegeneration

Continuing with the effects of alcohol on the brain, in this post I shall dicuss a frequently asked question by people who consume alcohol, does it cause neurodegeneration? Does alcohol kill neurons/ brain cells?

Let us discuss the entity called alcoholic cerebellar and cerebral degeneration. We now sufficient data to suggest that excessive consumption of alcohol does damage the brain.  Some parts of the brain are more specifically affected, these include the cerebellum. The cerebellum is the part of the brain which controls coordination, balance, gait as well has motor memory (memory for common motor actions performed by the brain). In the cerebellum are cells called the Purkinje cells which are selectively destroyed by alcohol ( the part of the cerebellum most commonly affected is the midline of the cerebellum between the two cerebellar hemispheres. This part is called the vermis of the cerebellum). So in alcoholic cerebellar degeneration we see vermian cerebellar atrophy in CT scan and MRI scans and also grossly if an autopsy is carried out).

So how does vermian atrophy present clinically?

Patients with alcoholic cerebellar degeneration have problems with gait and balance. Their coordination is off and they are prone to frequent falls (we have all seen the walk of a drunkard. While the clinical signs may not be so overt, on clinical examination we can usually pick up the signs of cerebellar dysfunction). Since these patients are prone to falls, they frequently land up in the ERs with head injuries (intracerebral hematoma, epidural and subdural hematoma). See my post on neurotrauma http://braindiseases.info).

Alcohol induced dementia: while this entity is not so well defined as alcoholic cerebellar degeneration, there is ample evidence to suggest that too much alcohol damages the cerebrum and can cause cognitive and memory problems. The thinking is that this is not entirely due to alcohol only. When someone abuses alcohol, he or she also does not consume a good diet and soon becomes deficient in essential nutrients and vitamins such as vitamin  B12 and folic acid. So alcohol induced cerebral degeneration is likely due to nutritional deficiencies.

No one quite knows the answer that if you supplement your diet with vitamins and essential nutrients even in the face of heavy and chronic alcohol consumption, would that prevent the development of alcoholic cerebral and cerebellar degeration. Infact in certain countries of the world a plan was put forward to fortify all alcoholic beverages with vitamins and essential nutrients. One of the problems with this proposal is that it alters the taste of the alcohol. Your rum does not taste like rum anymore!!!

In any case I advise my patients to always drink in moderation and to take 1to 2 tablets of a good multivitamin every day apart from a wholesome and nutritious diet.

Nitin Sethi, MD

Seizures associated with alcohol intake

In this post I thought I shall discuss the effects of alcohol on the brain especially with respect to seizures. Many people drink socially , a drink or two after work is not only relaxing but also enjoyable. But who is an alcoholic or rather when does one have a drinking problem? We doctors use the CAGE criteria as a rather simple questionaire to determine if someone has a drinking problem.

“CAGE” where each letter has a question attached to it and the person has to answer yes or no. Let me elaborate a little.

C–stands for “cutting down”–have you ever felt the need to cut down on your drinking?

A–stands for “anger”—have you ever felt angry if someone has questioned your drinking habit?

G–stands for “guilt”—have you ever felt guilty about your drinking?

E– stands for “eyeopener”–have you ever taken a drink first thing in the morning?

If the person answers yes to these questions, he or she may have a drinking problem. What though is the effect of heavy alcohol drinking on the brain? Does it actually kill brain cells (neurons)? Does it lead to dementia? Can too many drinks cause a seizure?

Alcohol contrary to popular beliefs is a CNS depressant and not a stimulant. Alcohol is rather rapidly absorbed through the lining of the stomach and enters the blood stream from where it is carried to the brain. In the brain, it acts on the neurons and initially causes a loss of inhibition. You loosen up, your speech flows more smoothly and soon you become the life of the party. Well as you continue to drink, alcohol then starts depressing the central nervous system (CNS) . People usually fall asleep soon after consuming alcohol.

But let us get back to how chronic alcohol intake affects the CNS especially with respect to seizures.

I shall discuss this one by one.

Alcohol induced seizures

 

 Heavy alcohol consumption can induce seizures. Alcohol induced seizures are of different types. One is what is commonly referred to as “rum fits”. Let me explain with an example. You are out with your friends celebrating a promotion. Your drink for the night is beer. Your normal “limit” is say 4 beers. But hey you are celebrating and so you end up binging. Before you know it you are on your 10th beer of the night. Right as you are having your 11th beer, your eyes roll up and you have a big generalized tonic-clonic convulsion (see my posts on epilepsy on my website http://braindiseases.info) . This kind of seizure which occurs at the height of binging is what has been referred to as a “rum” fit. I guess it was first described with respect to rum. Any of us can have a rum fit if we drink too much alcohol. You do not need to be an epileptic to have a rum fit, though I feel these kinds of seizures associated with alcohol binging are more common in patients who have an underlying seizure tendency. Thus if you are an epileptic you are more likely to have a rum fit if you overindulge in alcohol as regards to someone who does not have a seizure tendency. Hence I always advise my seizure patients to drink alcohol in moderation. You can drink and by all means enjoy your occasional drink but do not overindulge in this pleasure. Know when to say no and walk out of the bar.

Another type of seizure associated with alcohol is what is called “Alcohol Withdrawal Seizure”. Here the seizure occurs in a different scenario. Usually the person is one who is a chronic alcohol drinker, one who is dependent on alcohol and feels uneasy and restless if he does not drink everyday. Let us now assume he suddenly stops drinking for whatever reason. Maybe he runs out of money and cannot buy alcohol. Usually 24 to 48 hours after his last drink, this patient may have a generalized tonic clonic convulsion. As this seizure occurs in the setting of a withdrawal from alcohol, it is called alcohol withdrawal seizure. It is important that heavy and chronic alcohol drinkers keep this is mind and do not suddenly stop drinking. If a person does decide to quit alcohol he should do it under medical supervision.

Now for the third setting in which seizures might occur with alcohol. Again we have a person who is an alcoholic (heavy and chronic alcohol user). Again for some reason he suddenly stops drinking. Uusally after 72 hours, he starts becoming delirious (confused), he has autonomic dysfunction and is tachycardic, sweating profusely, his blood pressure is up. Such a patient is said to be in what we refer to as “delirium tremens” (DT) . Patient who are in DT may have a flurry of seizures one after the other. DT is a life threatening condition and a patient may die if not treated in time. Usually patients are admitted to the intensive care unit of the hospital. We hydrate them aggressively, we give them medications to calm them down. Lorazepam (Ativan) or other benzodiazepines like chordiazepoxide (Librium) are given to prevent seizures and treat acute alcohol withdrawal.

Patients who have had a rum fit, an alcohol withdrawal seizure or even DT do not warrant long term treatment with an antiepileptic drug. These patients do not have epilepsy. If they abstain from drinking in the future it is more than likely that they may never have a seizure again in their lifetime. However there are a few patients whom we feel have a high risk for seizure recurrence, in such patients we may prescribe antiepileptic drug therapy for some time (the duration of the therapy varies depending upon the history, examination findings and the results of investigations like EEG and CT scan or MRI brain)

I have tried to give an overview of the kinds of seizures associated with alcohol intake. Like I stated earlier one need not be an epileptic to have seizures associated with alcohol intake. I try to explain this to my patients as follows. The brain has a threshold for the amount of alcohol it can tolerate. This threshold varies from person to person. If you drink above that threshold, the brain does not like it and one way it reacts is by having a seizure. This “threshold” is lower in patients who have an underlying seizure tendency. In these epileptic patients, a small amount of alcohol may induce a seizure. Also if you mix your drinks or combine alcohol consumption with other recreational drugs like cocaine you are creating the ideal grounds to have a seizure. Certain medicines like antibiotics also lower your seizure threshold and hence should not be used along with alcohol.

Patients with epilepsy should discuss about alcohol consumption with their doctors because at times we doctors do not initiate this discussion of our own. If you have seizures my advise to you would be to drink in moderation and not exceed your limits.

Nitin Sethi, MD