Is it a seizure or is it syncope: going over the basics again

Is it a seizure or is it syncope: going over the basics again

Nitin K. Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

 

I have written about this before but thought this would be a good time to go over the basics again. So let us begin with an example. Our main actor (lets call him John) is working in his office. The clock strikes 12 and he decides to step outside to smoke.  It has been a tough day at work for John.  Went out with a couple of friends last night and had one too many Jack Daniels on the rocks (with a slice of lime!!!).  This liberal indulgence in the bubby resulted in John waking up dehydrated and with the worst hangover of his life. That combined with a cold he is still nursing and you can imagine John is a very unhappy camper.

So John  steps out to smoke. Lights up and takes a deep puff. Ahhhhhhhhhhhhhh. And then it happens. He feels light headed, dizzy, his vision starts to grey and before he knows it he is on the floor.  His friend who sees him fall, rushes to help him. By the time he reaches John, John is already coming around. He attempts to get up on his feet and asks his friend what happened. He is alert and oriented and apart from a bruised ego, he feels well.

 

Now lets go to case scenario number 2. John is again our main actor. In this case though John is having a good day. He slept well the night before and steps out to have a smoke. He lights up. Ahhhhhhhhhhh. Life sure feels good. And then it happens. He stiffens up. A cry is heard (we call this the epileptic cry) and then he takes a hard fall to the ground.  After falling to the ground, he is noted to “shake” by his friend who has since rushed to his side ( I saw him shaking–both arms and legs, it was horrible. He was foaming at the mouth and I thought he was going to die is how his friend describes the event to the EMS later on!!!). After a minute, John stops shaking but he does not come around immediately. He remains confused and disoriented till the arrival of the EMS 15 minutes later. John later tells the doctor in the ER that he has bitten his tongue and lost control of his bladder (wet his pants) during the episode.

So after presenting these two case scenarios, my question to you is in which scenario did John have a syncope (fainting episode) and which was a seizure?

In the next post we shall pick up John’s story from the ER. Hopefully we can make him feel better.

 

Sudden Unexpected Death In Epilepsy

Sudden Unexpected Death In Epilepsy

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10021

I recently read about the tragic death of John Travolta’s son from a reported seizure while on a family vacation. The news got extensive coverage on prime time television networks but unfortunately none of the news segments provided any credible information about death from a seizure or epilepsy in general.  While I respect medical journalists and the work they do, I feel they owe a bigger moral obligation not just in getting news across to the public but also going a step forward in researching the topic and utilizing the news story  to spread awareness about a disease. The tragic death of Mr. Travolta’s son limelights epilepsy and its at times unexpected tragic consequences.

When people think of a seizure or epilepsy, death as a possible consequence does not come to mind as conjured by other illnesses like cancer. Seizures usually are discreet episodes, guaranteed they are frightening to witness (if you happen to be a family member or a bystander). The patient falls down (if standing at the time of seizure onset), shakes and jerks violently, eyes roll up, drools and may bite his or her tongue. After a minute or two (which for the caregiver or bystander may seem like an eternity), the person stops shaking and may infact appear to fall asleep and breathe loudly. Emergency medical staff are there by then and take the person to the hospital.

ALL’S WELL THAT ENDS WELL YOU MAY SAY!!!

Well yes and no. As I tell most of my patients and their concerned family members, most seizures end on their own and do not need any “active intervention” (meaning giving them some drug to stop the seizure). By the time EMS arrive, the seizure is already over and the patient is confused and disoriented (we call this the post-ictal stage meaning the stage after the ictus/seizure is over). There are a few patients in whom the seizure may not stop or in whom one seizure is followed in rapid succession by another seizure without regaining consciousness in between. These patients are said to be in “status epilepticus” and need urgent medical attention to abort the onoing seizures. These are the patients who the EMS give intravenous medications to stop the seizure (you can read about this more on my website http://braindiseases.info), once these patients reach the ER, intravenous medications to abort the seizure are administered.

But coming back to where I started most seizures do abort on their own. That is what I tell my patients and their caregivers. As a physician the seizure itself does not worry me so much, it is the circumstances surrounding the seizure which can prove to be fatal. When a person is having a seizure, his or her brain is malfunctioning (think of it as a massive short circuit in the neural pathways), he is thus unable to fend for himself.  Seizures are usually associated with a loss of body tone, a standing patient thus may fall and injure himself. A hard fall on the head may result in a fatal head injury due to intracranial hemorrhage. A person standing next to a subway line in New York City may fall onto the tracks after a seizure episode and get hit by an oncoming train, he or she may suffer a fatal car crash if the seizure happens to occur while they are driving (this of course poses a risk to other motorists and pedestrians who share the road. There are rules with respect to driving with epilepsy and these vary from state to state). Deaths have occurred due to submersion and drowning if the patient has a seizure while swimming or while taking a bath in a tub.

So what I tell my patients is this

“YOU DO NOT WANT TO GET CAUGHT WITH A SEIZURE AT THE WRONG PLACE AND AT THE WRONG TIME”.

There is a further entity called “Sudden Unexplained Death in Epilepsy” also called SUDEP. SUDEP refers to patients with epilepsy/ seizure disorder who are found dead due to no “apparent reason”.  These usually are epilepsy patients who on the surface seem to be fine and one day are found dead. At times they may go to bed okay but are found in bed dead the next morning. A lot of research and studies have looked into SUDEP to try to determine its etiology and thus help in better identification of those epilepsy patients who are more prone to SUDEP. While we still do not know what causes SUDEP, we now do know certain facts.

There is neural control of heart rate (meaning parts in the brain control our heart rate). Hence seizures which arise from certain areas in the brain such as the insular cortex may at times be accompanied with bradycardia (that is the heart slows down and in extreme cases may even stop for a few seconds to minutes). Thus ictal bradycardia or ictal asystole may be one of the mechanism underlying SUDEP.  In other documented cases of SUDEP, patient was found to have severe laryngeal muscle spasm  thus impairing respiratory effort.

So who are the patients who are at high risk for SUDEP? These are usually patients who have poorly controlled epilepsy (seizure control is inadequate on current therapy). Patients who have seizures associated with ictal bradycardia and/or laryngeal spasm remain at exceptionally high risk.

Epilepsy is a relatively common neurological disorder. It imposes a high price in terms of socio-economic costs and quality of life issues. Every attempt should be made to attain good seizure control (thankfully we now have many options both medical therapy ( anti-seizure medications) as well as surgical, you can read about them on my website http://braindiseases.info).

The battle is still to be won but together we can!!!

Seizures in children: febrile convulsions

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