Seizures: a question and an answer
One of the readers of my blog wrote to me recently. His question and my reply to it follows. I think some of you may find it helpful.
Nitin Sethi, MD
Alcohol and seizures: a question and an answer
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?
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.
Nitin Sethi, MD
Seizures associated with excessive alcohol intake-why me?
One of the readers of my blog asked a question about alcohol induced seizures. His question and my reply to it follows. I have removed the name to maintain confidentality as always.
Hi; I wanted to read up about alcohol induced seizures because I have a question(s) for you, but I guess I should give you a little background first. I have had 7 of them, never had a problem before. The first one I do remember…I was drinking heavily ( Vodka ) and had done some recreational drugs too. I was in the kitchen and my bottom jaw “stuck” out and my hands clinched tight! My brain said “lay down” so I did and that’s as much as I remember. My soon to be wife and my son told me that my lips turned blue, eyes rolled up and I “wet” myself.Needless to say they called 9-11 but I refused to go.The other 6 six I do not remember…although the last one happened in the street and I got 3 staples in the head as a result.My Dad was an alcoholic so I never really drank growing up.However,when my son’s mother and I split when he was 2 ( he is 16 now ) I started to drink more, I had socially here and there but not like this.The seizures started about 3+ years ago I would “guesstimate”.I tried rehab 3 times – no good.At my “peak” I was drinking a gallon of Vodka a day.( I am not making any of this up! ).I have had massive panic attacks,spent hours ( every 20 min.) over the toilet,my blood pressure was through the roof and on and on.The “nail in the coffin” for me was one day I had my “other half” leave work to bring me my fix because I couldn’t handle the with-drawls any longer that morning. I drank about a pint and had pain in my chest,irregular breathing and I honestly felt like I was going to die!!My neighbor took me to emergency.When my “other half” got wind of it and showed up I was in horrible shape. The Doctor told her my blood-alcohol was .335 and he wanted to know how come I was even still functioning.( I know nothing of the point scale but I assume that was pretty bad ).I spent 3 days there, 2 on a heart monitor.They gave me Valume ( I don’t think I spelled that right ) and I don’t know what else.I had been given Librium in the past but they did not give me any, nor did I have any seizures while I was there.I was however really scared.When I came home I swore to my family that that was it……..it will 2 years in April !!! I drink a lot of coffee ( w/milk and sugar of course )and I like my ice cream!I build and paint models to “occupy” myself around the house but I do still think about it ( drinking ) here and there.I’m really not to worried about starting again…all I have to do is think about what I put the people I love through and that pretty much ” kills ” any craving,but I am fully aware that I will always be an Alcoholic. I do have an excessive personality, I really can’t do anything in moderation and I have insomnia ( in other words I am VERY high strung to begin with ).I will say that life is sooooo much better now but I do have a couple of questions……Why all of a sudden? 20+ years of “partying” and then one night “boom”( or did I answer my own question? ).It did take awhile to get to a gallon a day ( a few years in fact ). On a bigger scale….what I really would like to know is am I done having them? I think about them once and awhile and it kind of scares me to think I could be out doing something and have another one.I abstain from alcohol and everything else, but I do miss being able to “socialize” like everyone else.I don’t mind when people drink around me, it doesn’t tempt me or anything ( plus I know what they are going to feel like later! ) but I guess I put myself in that “boat”. Am I done having them??? I haven’t had one since I stopped drinking although one night at work shortly after I stopped I did have some kind of “panic attack”( light head,scared,sweating,dizzy-I just went home ) been O.K since but that is what got me wondering if I am truly done w/them.( I cannot associate any pain or anything w/having them – just waking up disoriented in an ambulance or wherever else, but again….I am clean and sober and will stay that way so can I assume that there won’t be anymore?
And to anyone reading this….I am no expert on this and believe me, I don’t tell ANYONE how to live their life but – if your to the point of having seizures from drinking like I did – time to quit the game and walk away! I was playing a game that almost cost me my life – wasn’t worth it!
Thank you for your time reading this and I look forward to your response.
Thank you for writing in to me. As the name of my post suggests the seizure/ convulsion in the above case is usually temporally associated with excessive alcohol use. I shall use your question to discuss alcohol induced seizures at length namely under the following points:
“I can drink but know exactly when to stop”: people frequently have this misconception (these are people who usually suffer from a drinking problem aka alcoholics but still feel they have their drinking under control). Now what is “excessive” for one may be the “norm” for another. So there is no hard and fixed limit about exactly how much alcohol can be “safely consumed” without provoking a seizure. Some people can drink like a fish and still not suffer a convulsion and there are others who have suffered an alcohol induced convulsion after just a “few” drinks. In my experience some people are particulary good in knowing when to stop. They shall drink right up to the limit but then stop and “be okay”. That said I feel this is playing with fire and if you are drinking right up the edge, you are playing Russian roulette.
Another misconception that I have encountered is that people frequently feel that if they drink top shelf vodka or scotch or more commonly wine they are immune from suffering the ill-effects of excessive alcohol intake aka a seizure. Again it is not the type of alcohol which is consumed that makes you prone to have a convulsion, it is the absolute amount consumed. So if you drink bottle after bottle of wine, you are just as likely to suffer a convulsion as when you consume excessive amounts of some bottle shelf vodka. Obviously it goes without saying that one can ‘safely” cosume more bottle of light beer than an alcoholic beverage with a higher quantity of absolute alcohol.
When a person has suffered a convulsion in the field is brought to the emergency room, doctors as a rule usually check the blood alcohol level. This gives a fair indication about exactly how much alcohol was consumed and helps us in determing if excessive alcohol ingestion played a role in the seizure. The absolute blood alcohol level though is just a number and other things have to be considered before a seizure is attributed to excessive alcohol inake:
how long ago was the last drink consumed? (alcohol is rather quickly metabolized and hence one may obtain a falsely low reading if the blood level is checked after some time has lapsed since the last drink).
over what time frame was the alcohol consumed ?(you are more likely to suffer a convulsion if you consume excessive amounts over a very short interval of time–aka if you are binge drinking). The caveat to that is alcohol withdrawal seizure if which a person who is a chronic alcoholic abruptly ceases drinking and suffers a withdrawal seizure. This usually occurs 24-48 hours after the last drink was consumed.
whether the drinks were mixed? one is more likely to suffer a convulsion in the setting of consuming many different types of drink (vodka, rum, whisky, beer) in one sitting. Again my personal impression is that this is not because one consumed different kinds of drinks, it is because when drinks are mixed you are more likely to consume more alcohol and not get a warning about when to stop.
whether there was use of illicit drugs along with the alcohol? combining alcohol and illicit drugs like cocaine, heroin and even prescription drugs like Xanax (a common drug of abuse), valium, Adderall, anti-depressants such as Wellbutrin, and even some over the counter so called safe herbal medications to lose weight can build the perfect storm to provoke a convulsion.
whether there were other precipitating factors? factors like been sleep deprived, dehydrated, drinking on an empty stomach all help in adding their two cents to build the perfect storm leading to an alcohol induced convulsion.
is there an underlying tendency/predisposition to have a convulsion? this concept is a little difficult to explain but let me attempt to explain with an example. Let us assume you have underlying epilepsy. You are then more likely to suffer a convulsion in the setting of excessive alcohol use that say a person who does not have underlying predisposition to have a seizure. You may both consume the same drinks and the same amount of alcohol, still you remain at higher risk of suffering a convulsion than the other person.
I thank you for your question and wish you good health in the New Year 2011. It takes immense strength of character and determination to walk away a winner from an alcohol addiction.
Nitin Sethi, MD
Seizures due to hypoglycemia–a couple of questions and answers.
I got a few insightful questions from my readers which I am sharing here. My reply to them follows.
Post traumatic epilepsy: a question and an answer
One of the readers of my blog asked me a question regarding her son. I am reproducing her question here. My answer to it follows.
my son was involved in a car crash 3 years ago aged 17 years and required brain surgery to remove a bloodclot. He recovered well with no ill effects. He had his first fit in November 2009. He had another 2 that same month. CT and MRI scans clear but eeg showed slight abnomal waves over area of surgery. Neuroligist said our choice if wanted to be on medication. Last fit was 27th November 2009 but he has just had another on 8th February whilst flying to holiday Do you thnk meds should be started to prevent further fits.
thank you for writing in to me. Your son’s condition is consistent with what is called post traumatic epilepsy. Let me attempt to explain this a little further. Your son obviously was not born with a seizure disorder (epilepsy). He was apparently well till he was involved in a motor vehicle accident (MVA). As a result of the MVA, he suffered head injury and from what you decribe an intracranial hematoma (blood clot) which required evacuation (removal of the blood clot surgically). He had an uneventful recovery but soon there-after had his first convulsion (you do not mention the time interval between the head trauma and the first convulsion).
As the name suggests post traumatic epilepsy refers to epilepsy/ seizure disorder which occurs after head trauma. Usually for post traumatic epilepsy to occur, the head trauma has to be significant such as a motor vehicle accident with significant intracranial hemorrhage or head injuries sustained in the battle field. Many of our soldiers returning from the battlefields of Afghanistan and Iraq suffer bullet shot injuries to the head (these as you can imagine are penetrating head injuries and cause significant brain damage as the high velocity bullet traverses through the skull). IED (improvised explosive devices) related blast injuries cause closed but still significant head trauma and are the signature injury of these two wars. Many of these brave men and women later develop post traumatic seizure disorder/ epilepsy. In other words minor bumps to the head (example you walk into a door) do not cause post-traumatic epilepsy.
There are three types of post traumatic epilepsy. Immediate, early and delayed. Let me explain this at length. Let us assume you are involved in an accident. Your head strikes the ground or steering wheel hard. You have a seizure soon after the impact. This is called immediate or impact seizure. This type of seizure does not lead to seizures later in life and hence such a patient does not warrant to be on long term anti-convulsant therapy.
Early post traumatic seizures are those which occur within 6 months of injury while late post traumatic seizures are those which occur after 6 months. Remember you can have your first post traumatic seizure as long as 5 years after the head injury. In other words if 18 months go by and the person has not had a seizure then likely he shall not have seizures as a result of head trauma. Patients who have early and late post traumatic epilepsy may warrant treatment with anti-convulsants. This is because the brain has suffered a scar (as a result of the head injury) and it is this scar tissue (consisting of damaged brain tissue) which then misfires and acts as a seizure focus (point in the brain where the seizure originates from).
In the case of your son, since he has suffered multiple convulsions since his head injury, he likely needs to be on an anti-convulsant. This decision though shall be made by his neurologist after consideration of factors which I mentioned earlier in my post. EEG may or may not be helpful in this regard (a normal EEG does not rule out seizure disorder and vice versa not every patient with a seizure disorder has an abnormal EEG).
I hope this is helpful to you. I wish him my very best.
Nitin Sethi, MD
Non epileptic seizures or pseudoseizures
Non epileptic seizures or pseudoseizures-what are they and what is to be done about them?
Nitin K Sethi, MD
Assistant Professor of Neurology
New York-Presbyterian Hospital
Weill Cornell Medical Center
New York, NY
I thought in this post of mine, I shall discuss pseudoseizures. As the name suggests pseudoseizures means “not true seizures”. We nowdays prefer to refer to them as non-epileptic events (NEE).
So what do we mean when we say someone has pseudoseizures? Let me illustrate with the aid of an example. A patient lets say Ms.XYZ comes to me for initial consultation for her seizure disorder. History is as follows. She has had 2 episodes where-in she was witnessed to have violent jerking movements of her arms and legs. First episode occurred in school after she got into a heated verbal argument with her best friend while the second occurred after a similar confrontation at home with her mother. None of these events were preceded by any aura. As per history she did not bite her tongue or have loss of bladder control though she says she felt tired after the events.
Hmm sounds suspicious for seizures you might rightly say. I tell her I would like to bring her into the hospital to do a video-EEG study to better characterize her seizure type (see my posts on seizure types at http://braindiseases.info). She agrees to the study.
EEG recording is initiated and is read as normal after 24 hours. The next day in the hospital, I tell her and her mother about the results of the normal EEG. A few hours after my discussion with the family, she is noted by the nursing staff to have a violent “seizure”. I review her EEG. On the camera I notice her to suddenly stiffen and then have violent out of phase (uncoordinated) flinging movements of the arms and legs. Her head moves from side to side and I overhear her yelling “too much, too much, let me go!!! let me go!!!). The event occurs while her mother and her best friend are by her bedside.
I look at the time locked EEG (EEG synchronized with the video in real time). While she is clinically having a “seizure”, her brain waves are normal (the brain is not having a seizure). A correct diagnosis of pseudoseizures (non-epileptic event) is made and she is discharged home with advise to follow up with a psychiatrist.
So what is a pseudoseizure?
1. It is not a true seizure but rather an episode or episodes which clinically look like seizures but are not accompanied by any EEG changes.
2. It usually has a psychological basis. In my experience I commonly see them in people who are passing through tremendous stress be it interpersonal relationships or at the job.
3. A person may have pseudoseizures to achieve a secondary gain (in the case of our patient, attention and love from her mother and best friend).
4. Pseudoseizures are not treated like seizures. These patients do not need anti-seizure medications. They rather at times need a psychiatrist to explore the underlying reasons for the NEE (conflicts in family etc).
5. Some patients who have true seizures (epilepsy) may also have pseudoseizures.
Complex partial seizures/ temporal lobe epilepsy
One of the most common type of seizures seen in the adult population is what are called complex partial seizures. As the name suggests these are partial seizures meaning that only a part of the brain has the seizure (remember in generalized seizures the whole brain has the seizure and hence the patient clinically has a convulsion, read my posts on epilepsy and seizures at http://braindiseases.info). Complex partial seizures differ from simple partial seizures. While in simple partial seizures there is no disturbance in the patient’s level of consciousness (the patient is awake and alert), in complex partial seizures there is an impairment in the level of consciousness. The patient may have his or her eyes open but usually is unable to respond or communicate. He may or may not comprehend if you try to speak to him during a seizure episode.
As many of the complex partial seizures arise from the temporal lobes in the brain, epilepsy of this kind is also referred to as temporal lobe epilepsy (TLE). That said and done complex partial seizures may also arise from the frontal lobes. Seizures arising from the frontal lobes can present with bizzare clinical manifestations, patient may become hyperactive during the seizure and have strange bicycling like movements of the legs. Complex partial seizures are at times associated with an aura. A simple way to define aura is what happens usually before the seizure. Prior to the onset of a seizure, the patient may experience gustatory or olfactory auras (smell of burning rubber, metallic taste in the mouth are the different classical auras mentioned in the textbooks of neurology). Other patients may mention they “feel wierd” or “dizzy”. Others mention a rising sensation in the stomach.
During the seizure apart from impairment in the level of consciousness, patients frequently exhibit what we refer to as automatisms. These are semi-purposeful movements. Examples include lip-smacking, chewing movements, tongue protusion, picking at the clothes (semi-purposeful movements of the hands). These patients may or may not have a “convulsion”. If the seizure spreads and becomes generalized then they go into a convulsion (such seizures are referred to as partial with secondary generalization).
If an adult presents with a new onset complex partial seizure, neuroimaging is warranted. This is because a new onset complex partial seizure raises the suspicion for an underlying structural lesion in the brain such as a cyst or a tumor (though I want to emphasize here that the most common cause of new onset seizures in the elderly is vascular, meaning a previous stroke).
Work-up for TLE includes an EEG, if needed a long term EEG recording (we call this a video-EEG study), imaging studies like CT scan (though the study of choice is what is called a MRI scan of the brain done under the epilepsy protocol). Thin slices are taken to look at the temporal lobes and hippocampus to make sure there is no structural lesion there nor is there any evidence for mesial temporal sclerosis (MTS).
There are many effective drugs for complex partial seizures/TLE. The most commonly used are carbamazepine (Tegretol) and oxcarbazepine (trileptal). If the seizures are refractory to medications, these patients can be worked up for epilepsy surgery (see my post on epilepsy surgery at http://braindiseases.info).
Nitin Sethi, MD
Seizures, convulsion, fit, epilepsy
Seizures/ Convulsions/ Fits/ Epilepsy
Let us now talk a little about seizures. Seizures are among the most common neurological conditions encountered by physicians. What is a seizure? Simply put it is a short-circuit of your brain. Brain cells also called neurons communicate with each other via electrical charges. This communication process is highly organized and smooth most of the times. Rarely for various reasons ,which I shall elaborate later on in the article, things go awry and the result is a seizure ( lots of brain cells firing at the same time in a disorganized manner). So seizure is nothing but a hypersynchronous discharge of brain cells.
Is there any difference between a seizure and a convulsion? Well the answer is yes and no. The terms can be used interchangeably and essentially mean the same thing. But usually as neurologists when we use the term convulsion we mean the patient was “shaking” visibly. The type of seizure you see in a movie–lot of thrashing around, person losing consciousness, falling down, drooling, biting his tongue or lips, losing control of his bladder ( many people may pee on themselves during a big convulsion) and then is confused and disoriented as help arrives. Pretty dramatic, you cannot miss it. You see someone doing that and you know he is having a convulsion and you call for help.
Seizures though can be very subtle, so subtle that even an attentive and doting parent might miss it. Short arrest of behavior ( staring spells), losing train of thought in the middle of a sentence, sudden speech arrest, short rapid jerks of the arms and legs on waking up in the morning, a strange smell ( the classical smell described is that of burning rubber), abnormal behavior at night while sleeping: these may all represent seizures.
It is important to recognize these myriad manifestations of seizures. Sometimes these may be missed and people continue to suffer from seizures for years.
So that brings me to the next point I want to discuss with you. HOW DO WE DIAGNOSE SEIZURES?? Easy, most of the time it is by a good history. A thorough history taken by a physician ( need not be a neurologist or an epileptologist) can usually give the physician a pretty good idea if you indeed did have a seizure. So when asked try to give as thorough a history as possible: how did the episode start? what were you doing at that time? did it occur during sleep? did you smell something strange? did you lose consciousness and completely black out or were you just confused and disoriented? could you understand people around you at that time? did you shake? if yes did the whole body shake or one side shook? did you bit your tongue or pee on yourself? were you confused after the episode and if yes how long did it take for you to come back to normal?
As you can see lots and lots of questions. Sometimes you may not know the answer to all of them by yourself ( you were passed out, how can you know!!!!) well in that case we try to get information from family and friends, a bystander who saw the episode, the emergency medical service people who were called to help you.
Once your physician feels that you may have had a seizure, then come the questions:
1) Why did you have a seizure and what was the cause of the seizure.
2) what kind of seizure was it ?( I shall come to this later)
3) was the seizure a one time event or can it occur again?
4) Does it need to be treated?
5) if it warrants treatment what medication is required?
6) will the medication ensure that you do not have a seizure again?
7) how long do you need to take this medication?
can you drive? does the seizure place any restriction on your lifestyle?
9) if the medication does not work: what do you do then?
I shall tackle these questions one by one. Enough information for now, I need a break!!!
So we take off from where we left and discuss about the different types of seizures. Broadly there are two types of seizures: generalized and partial.
1) Generalized seizures as the name suggests come from the whole brain, that is the whole brain malfunctions and misfires. As the whole brain is malfunctioning it is but natural that the person shall lose consciousness and is amnestic for the event and for some period of time afterwards. These are the classical big seizures you see in movies with the falling, frailing arms and legs and tongue biting. What many people do not know is that generalized seizures can be more subtle: staring spells seen in children are a type of generalized seizures called Absence Seizures.
2) Partial seizures or focal seizures as the name suggests come from one part of the brain i.e. only a part of the brain has the seizure. As a result consciousness is usually retained albeit it may be impaired. The patient may have his or her eyes open and one part of his body the arm or leg may be shaking but he is not able to respond adequately if you call out to him. Focal seizures are further subdivided depending upon whether the manifestations are primarily motor, sensory, autonomic or psychic.
3) Partial seizure with secondary generalization: the name is self explainatory. The seizure starts off from a focal area in the brain and then spreads and soon the whole brain is involved. Most of the seizures are partial with secondary generalization but patients and even attentive bystanders might not volunteer the history that initial symptoms were focal. It is very important you tell your doctor exactly what happened right at seizure onset: did you smell something strange? did you have a funny taste in your mouth or a strange sensation in your belly? did one part of the body shake first and then the seizure spread to other body parts. The strange feelings noted at seizure onset are called auras and they help us in localizing where in your brain did the seizure come from. It is very very important that you give a good history about this because the medications used to treat generalized seizures are at times different from the ones effective against partial seizures. I shall come back to the medications at a later date.
Numerous other types of seizures have been described especially in children and there quite a few epileptic syndromes seen in the pediatric age-groups. I shall comment on these briefly as we go along.
Enough typing for now. Its freezing outside here in New York City and I think I need a cup of coffee to jump start my brain.
Seizures/ Convulsions/ Fits/Epilepsy
Now that we know a little something about seizures in general, lets turn to managment of seizures and epilepsy. As a work-up of why one had a seizure and to determine its cause, your physician may order a few tests. The mostly commonly ordered tests include something called an electroencephalogram or EEG in short and an imaging test of the brain either a CT scan also called a CAT scan or more commonly a MRI scan (MRI stands for magnetic resonance imaging).
Let us talk a little about these tests. An EEG is actually very similar to an EKG (electrocardiogram). Basically electrodes are placed on the surface of your head (completely painless procedure) and then one looks at the brain waves for about 30 mins and tries to find out if and where does the brain misfire. An imaging study like a CT scan or MRI scan is done to rule out the presence of anything structural inside the brain that might be the cause of the seizure like a brain tumor or a vascular anomaly. It is important to rule out a structural cause for a seizure as its presence guides the managment.
You have something inside the brain which does not belong there, you may need a neurosurgical opinion to get it out. Most of the times in people who have epilepsy no structural cause is found on neuroimaging and then the treatment turns to how to manage/control/prevent further seizures. It is thought in these patients the problem is at the cellular level, something which we cannot see on imaging studies. If there is nothing to be seen, there is nothing to be taken out.
Let me lay down some basic tenents of treatment:
1. A single provoked seizure may not warrant treatment. What does that mean? Well basically if you had a seizure which was because of something you did like used a drug of abuse (cocaine etc), alcohol in excess ( a drinking binge with the buddies may cause what we doctors call “rum fit”), did not sleep for a couple of nights, some antibiotics and anti-depressants have been known to cause a seizure: then you may not need to be treated. Just do not abuse the drug again and you shall be fine. No more seizures no need to be on long term anti-seizure medications.
2. A single unprovoked seizure may not warrant treatment. Sometimes a person may have a single seizure for which no provoking cause can be found inspite of a thorough search for one. Your EEG and scan is normal.Your doctor may decide just to observe you and not start any drug treatment. Why you may ask we do this? Well the reason is simple. Studies have shown that as many as 70% of single unprovoked seizures may not recur ever. So why treat someone with anti-seizure medications with their risk of side-effects. It is better at times to just watch. If seizures recur your doctor at that time might decide to treat you.
We shall stop now, the sun is out, central park is calling, I am going to head out for a run.
Management/ treatment of seizures: let us now turn to the treatment of seizures. I shall discuss this broadly under two headings:
1) acute management of seizures: what do you do and what happens in the hospital setting if one has a seizure?
2) management of seizures over the longer term or rather I should say ongoing treatment of someone who has epilepsy.
Let us start with acute management of seizures. Some of us have seen people around us have a seizure either at home, outside or in the workplace. What do you do? Whom do you call? Is the person who is having a seizure going to die if we do not do something? Crude as it may sound here, the seizure itself never kills a patient it is the circumstances surrounding the seizure which may prove lethal. Let me explain further. Most of the seizures stop by themselves in a few minutes (though it may seem hours to the person witnessing the seizure). More often than not, the seizure has already stopped by the time EMS (emergency medical services) arrive on the scene. The patient has stopped shaking and is just confused or may have even fallen asleep. So more often than not there is no active intervention needed on the part of the EMS. All they may do is check the patient’s vitals, maybe give him some supplemental oxygen and then transport him to the nearest hospital for further evaluation. There that was simple wasn’t it? However let me paint another scenario. Person is standing by the side of the subway track waiting for the train. Has a seizure and falls onto the tracks. Cracks his skull open, may get run over by the train if not pulled out by someone. There-in lies the problem with seizures and epilepsy and which patients find the most unsettling. The uncertainity, the possibility of having a seizure at the wrong place and at the wrong time. Deaths have occurred when people have had a seizure while driving, swimming or even while taking a bath in the tub.
So if you see someone having a seizure, do not panic and follow some simple guidelines. I shall list them out for you.
1. Do not try to physically restrain the patient. You try to hold down his arms or legs you may cause more harm than good like a dislocated shoulder.
2. Just try to ensure that the patient is not hurting himself: like if he is hitting his head on the hard floor while having a seizure you may try to gently hold his head or put a cushion under it.
3. Remove anything from the surroundings which has the potential for causing injury: things like a hot stove, sharps,
4. Do not put anything like a spoon or your finger into the patient’s mouth to prevent it from shaking. The patient may bite your finger off or may choke.
5. If possible gently turn the patient’s head to the side, this causes the tongue to fall away opening the airway and lets the oral secretions (saliva) drip out from the side of the mouth and prevents aspiration.
6. I have encountered people with certain misconceptions like having the patient smell something pungent (smelling salts, a stinking shoe) aborts the seizure. These things do not work, you are wasting your time and not helping the patient.
7. Once you have made certain the patient is safe, better to utilize the time to call EMS. Tell them clearly what you saw and did. Give a good history. Usually once the seizure stops the patient is not immediately responsive, you may hear sonorous respirations as if he is in a deep sleep.
Time for a break!!! This took longer than I thought.
So lets pick up from where we left off a couple of days ago. Lets talk about the acute managment of a seizure in the hospital setting. A person is brought to the hospital by the EMS and is still having a convulsion as he is wheeled into the ER. We call this Status Epilepticus ( a potentially life threatening condition when a patient has been having a seizure for greater than 30 mins or has had multiple seizures in near about the same amount of time without regaining consciousness inbetween).
There are a couple of things which doctors do in this setting. I shall list them out.
1) Protect the airway, check the vitals, maintain the circulation and oxygenation/breathing (ABC). We make sure that the patient is breathing and oxygenating well ( no obstruction to his airways), sometimes when the patient is not breathing well on his own, the doctors might put a tube down the throat into the trachea and put the patient on a ventilator ( a machine which does the work of breathing for the patient until he/she can breathe on his own). If the blood pressure is low, intravenous fluids may be administered.
2) A quick search is made for the cause/etiology of seizures. Blood is checked for the blood sugar level, electrolytes ( sodium, calcium, magnesium etc). One of the common causes of seizures especially in people with diabetes is low blood sugar. Either the patient takes too much of his diabetic pills/ insulin or the patient may have missed a meal letting his blood sugar fall to a dangerously low level.
In such a case intravenous dextrose ( a form of sugar) stops the seizure immediately.
3) To stop the seizure acutely certain medications may be administered. These commonly belong to the benzodiazepines group of medications with names like Diazepam (valium) or Lorazepam (ativan) followed by a longer acting anti-seizure medication like Dilantin (phenytoin).
4) Once the seizure stops the work-up begins to find the etiology of the seizure ( remember the MRI and EEG I talked about before).
Depending upon the cause of the seizure, its risk of recurrence, the type of seizure ( partial Vs generalized), the doctor may prescribe an anti-seizure medication ( we call them anti-epileptic drugs or AEDs). There are many different AEDs in the market. Each drug has its own mechanism of action, the kind of seizures it is most effective in controlling, side-effect profile and recommended dosage for seizure control.
Your doctor shall discuss this with you in detail. Please remember a number of AEDs can potentially interact with other medications which you may be taking for blood pressure etc. So remember to tell your doctor a complete list of your medications. Also some AEDs lower the efficacy of birth control pills, thus women with epilepsy may be advised to use alternate methods of contraception.
An important point here especially for pregnant women with epilepsy. Some AEDs have been linked to cause major congenital malformations in babies like cleft lip, cleft palate and spinal column deformities (spina bifida). Pregnant women with epilepsy remain a high risk group-they need close supervision by a doctor well versed with the use of AEDs during pregnancy. Some AEDs are best avoided in pregnancy while others have a relatively safer track record when it comes to the incidence of major congenital malformations.
I hope this small discourse on seizure is informative. I shall tackle brain tumors next.
Questions about epilepsy?
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