Tag: epilepsy

Seizures due to hypoglycemia (low blood sugar)

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Seizures in the setting of hypoglycemia are well described. The brain needs sugar to function and when the blood sugar falls “too low”, one of the things that can happen is that the patient may have a seizure (this is usually a generalized convulsion-a tonic-clonic or Grand Mal seizure). There is no one level of blood sugar below which one has a seizure (rather the level varies from person to person). Let me explain that with an example. Lets assume you are a diabetic and you take your insulin shot but for once forget to take a meal (maybe you are a hard working executive on the run). You have a convulsion while at work and are taken to the nearest ER. There your blood sugar at the time of presentation is recorded to be 60 mg/dl. There might be another similar patient whose blood sugar falls to 52mg/dl yet he does not have a convulsion. So there is no set limit below which the brain shall have a seizure but speaking in broader terms usually the brain does not tolerate blood sugar below 60mg/dl and below 40 mg/dl most patients shall be symptomatic (either have a convulsion or be confused and obtunded. The term used for this constellation of neurological signs and symptoms as a result of hypoglycemia is NEUROHYPOGLYCEMIA).

The good news though is that seizures due to hypoglycemia are readily treatable. In the ER we load the patient with glucose (usually this is given via an intravenous drip as the patient is obtunded and confused and cannot accept anything from the mouth). The blood sugar quickly rises and the seizures stop. Patients who suffer from hypoglycemic seizures do not need to be on an anti-epileptic drug. These patients do not have epilepsy. If their blood sugar does not fall down again, they will not have another seizure.

Rather a meticulous search should be conducted to find out the cause of hypoglycemia:

-is the patient a diabetic who took too much insulin by mistake?

 -did he miss his meal but took his insulin?

-is there any other cause of hypoglycemia such an insulin secreting tumor?

-is the patient septic?

Hypoglycemic seizures are most commonly seen in diabetics. This emphasizes the importance of good glycemic control in this vulnerable population.

Nitin Sethi, MD

Complex partial seizures/ temporal lobe epilepsy

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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 associated with alcohol intake

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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

Erectile dysfunction-some neurological causes

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I thought I would discuss some neurological causes of erectile dysfunction and decreased libido. There are many neurological diseases which are associated with erectile dysfunction and may also result in decreased libido. One of the most common is diabetic autonomic neuropathy. Diabetic patients especially those who have autonomic neuropathy (dysautonomia) frequently have erectile dyfunction. Supprisingly many do not volunteer this information, unless their doctor asks about it. They may complain of other symptoms of neuropathy like pain and numbess in their hands and feet but may not volunteer the history that they are having erectile dysfunction. Many patients do not realize that their erectile problems are a part and parcel of their uncontrolled diabetes.

Erectile problems and decrease libido is also frequently seen in patients who have multiple sclerosis. Fortunately this aspect of MS is now been given increasing recognition by doctors and a discussion is initiated with the patient at some stage of their treatment. Women with MS may have complaints of decreased vaginal lubrication, loss of vaginal muscle tone and diminished clitoral engorgement.
All this can lead to a decrease or loss of sex drive. Decreased or unpleasant genital sensations may lead to a diminished capacity for orgasm. Men with MS experience  erectile dysfunction and a decrease in or loss of ejaculatory force or frequency.

Erectile dysfunction and sexual difficulties are also a part and parcel of certain neurodegenerative conditions like multi system atrophy especially a syndrome called Shy Drager Syndrome in which autonomic failure is prominent. Parkinsons disease and patients with degenerative dementias may also have some of these problems. In these patients the cause is usually multifactorial.

Patients with epilepsy also frequently have sexual dysfunction. Again the causes are multifactorial but one important reversible cause is drug side-effects. Some anti-epileptic drugs and antidepressants frequently cause sexual dysfunction as a side-effect.

The good news is that sexual dysfunction is now more readily recognized as a part and parcel of certain neurological disorders. Neurologists are nowdays more adept in asking patients about it. It is important that patients volunteer information if they are experiencing sexual dysfunction as many of the causes are treatable. Drugs with sexual dysfunction as a side-effect can be stopped and replaced with other drugs. Also some of the symptoms can be ameriolated by using medications like sildenafil (Viagra).

Personal Regards,

Nitin Sethi, MD

Mind-body interventions: applications in neurology

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A comprehensive review  on mind-body interventions and its application in various neurological disorders was recently published in Neurology. The authors Wahbeh, Elas and Oken searched Medline and PsychoInfo databases to identify clinical trials, reviews and published evidence on mind-body therapies and neurological diseases.

Meditation, relaxation, breathing exercises, yoga, tai-chi, qigong, hypnosis and biofeedback are some of the mind-body interventions that have been used in various neurological conditions like general pain, back and neck pain, carpel tunnel syndrome, headaches (migraine and tension), fibromyalgia, multiple sclerosis, epilepsy, neuromuscular diseases, stroke, falls with aging, Parkinson disease, stroke and attention deficit hyperactivity disorder (ADHD).

The authors do a good job in shifting through all the data to try to identify the effectiveness of mind-body interventions. As they point out in their discussion , many patients as many as 62% use complementary and alternative medicine therapies (CAM). Some with and many without the knowledge of their physicians. One of the reason why CAM therapies are popular is that they are relatively easy to implement, cheap (though many patients have to pay out of their pocket. Some insurance companies shall reimburse if you have a letter from your doctor) and more importantly as the authors point out it makes the patients feel empowered. They feel that they are in control of some of the decision making in their disease process and treatment. Moreover it gives a sense of general well being.

The authors righly point out that is difficult to scientifically judge whether these interventions are all effective. The reason for this is that many of the studies included small number of subjects and some of them did not have a control group. Moreover it is hard to blind these studies so as to avoid a placebo effect. Like suppose I want to study whether acupuncture is effective for lower back pain. One group I give acupuncture. Ideally I should have a control, a group which receives sham acupuncture so as to null the placebo effect. Now this is difficult to implement.

Th authors in their review conclude that there are several neurological conditions where the evidence in favor of mind-body therapies is quite strong such as migraine headaches. In other conditions the evidence is limited due to small clincial trials and inadequate control group.

It is reasonable to conclude that CAM therapies like yoga, tai-chi and qigong improve balance in the elderly and decrease the incidence of falls. Moreover they give a sense of well being and happiness. Meditation exercises whether it is mindfulness meditation, transcendental meditation or concentration meditation with the repetition of a word like Om or a mantra

“Hare Krishna Hare Krishna

Krishna Krishna Hare Hare 

Hare Rama Hare Rama

Rama Rama Hare Hare”

all help in relaxation and reducing stress. This may decrease blood pressure and reduce the incidence of strokes and heart attacks. Brain changes have been observes during meditation in EEG and imaging studies and there is evidence that these exercises have wide spread effects on the endocrine and immune systems as well neurotransmitters. Hatha yoga may help in improving mobility and balance and thus decreasing fall risk. As the authors point out righly Bikram yoga  which is carried out in very hot temperatures is likely not good for patients with MS, as it may worsen their weakness. This is called Uhthoff phenomena.

There is also some evidence to suggest benefits of these interventions in patients who have chronic lower back and neck pain, those with fibromyalgia, osteoarthritis as well as carpel tunnel syndrome (some studies suggest benefit while others do not).

My advise to patients who want to try out CAM therapies for various neurological conditions is to take their doctors into confidence. It is likely that some of these therapies when used along with allopathic medicines shall give added benefits and likely make you feel better. Like with any other therapy one must find a knowledgeable practitioner who knows what he or she is doing.

Then one can truly reap the benefits of these ancient therapies.

Personal Regards,

Nitin Sethi, MD

Driving with epilepsy: when to start?

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One of the big ways in which epilepsy and seizures negatively affect quality of life is by the restrictions they impose on driving. So should patients with epilepsy be allowed to drive and if so when? Is it safe from them to drive?

All these are genuine questions for which patients frequently seek answers. Well lets tackle them one by one. Normally if you have a new onset seizure (your first seizure ever) and present to the hospital, your doctor shall ask you not to drive at least till the seizure work up is complete. The seizure workup shall determine what is the cause of your seizure, do you need to be on a seizure medication, if yes for how long and what are the chances that you are going to have another seizure.

If the cause of seizure is found to be reversible, lets say for example you are diabetic and have a seizure when your blood sugar suddenly fell down as you took your insulin shot but missed a meal. Now this is a reversible cause of seizure and the patient does not have epilepsy. If his blood sugar does not fall down again, he may never have a second seizure. In this case the answer is simple and yes the patient can drive.

Lets take another example, a patient has poorly controlled epilepsy and is brought to the hospital after a seizure at work. In this case, the doctor shall rightly advise the patient not to drive. A patient like this is liable to have another seizure and may injure himself or hurt others if he is behind the wheel.

But this does not mean, that a patient with epilepsy can never drive. If your seizures have been well controlled on medication for a period of 2 years, you may discuss driving again with your doctor. Drving laws with respect to epilepsy vary from state to state in USA. In the state of New York, as a physician I am not mandated by law to report my patient with epilepsy to the DMV. It is left to the patient’s own good judgement that he or she shall surrender their driving license and not drive. In the state of New Jersy though, physicians are mandated by law to report seizure patients to the DMV.

You should be aware of the laws in your state and should discuss the same with your doctor. Most of the bylaws can be found on the DMV website and are listed for each state.

I hope you found this information useful. Its wednesday night and the clock strikes 10pm. I think my bed is calling. Have a good night everyone.

Personal Regards,

Nitin Sethi, MD

Seizures in children: febrile convulsions

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In this post I would like to talk about seizures in children. Seizures are among the most common conditions for which pediatric neurologists are consulted. Seizures in children differ from seizures in adults. Also the etiology of seizures in children differs from that in adults. There are many epilepsy syndromes which have been described in the pediatric age group, each has its own natural history and prognosis.

Typical febrile convulsion: as the name suggests this is a seizure (convulsion) associated with fever. Febrile seizures/ convulsions are mostly seen in the age group of 6 months to 6 years of age. Classically the child has high fever (may be on account of a sore throat or any other condition), as the fever is rising, the child is noted to have a brief seizure/ convulsion. I used the word brief because in its typical form a febrile seizure is brief lasting for a few seconds to minutes. Also in a typical febrile seizure, the seizure is a generalized tonic clonic seizure (the child stiffens up and then shakes). Typical febrile seizure has a good prognosis and does not lead to epilepsy later on in life. As a result these children need not be treated with anti-epileptic drugs. Children outgrow the seizures after the age of 6 years or so. All we advise parents is to keep the fever down. At times the neurologist might prescribe rectal diazepam. This is marketed under the name Diastat. Rectal diazepam is a benzodiazepine drug which can be given by the rectal route. Parents can give it by themselves, the drug is rapidly absorbed across the rectal mucosa and may abort a prolonged febrile convulsion. Usually febrile seizures run in the family and if a careful history is taken, one finds that one of the child’s parents too had febrile seizures as a child.

Atypical febrile convulsion: a febrile seizure is said to be atypical when either it is very prolonged (remember I said febrile seizures are usually brief) or when it is not generalized but rather focal (one arm or limb shakes not the whole body).  Sometime the seizure may occur without fever or even with temperature less than 100 F. Atypical febrile seizures may lead to epilepsy later in life and hence these children have to be closely followed. If a child has multiple febrile seizures or has a seizure everytime he or she has fever, your doctor may recommend an anti-epileptic drug for a short time. The drug most commonly used in this age group is phenobarbital. Phenobarbital is a safe drug which has been around for awhile now. Its most common side-effect is sedation.

Dr. Sethi

Seizures, convulsion, fit, epilepsy

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  • 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?

    8) 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!!!

    Personal Regards,

    Dr. S

      

    Seizures/ convulsions/fits/Epilepsy

      

    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.

     

    Dr. S

     

    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.

     

    Personal Regards,

    Dr. S

     

    Seizures/fits/convulsions/ epilepsy

     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.

    Dr. S

    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.

    Personal Regards,

    Dr. S

      

Questions about epilepsy?

Ask Dr S:

neurologistnyc@yahoo.com

 

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